Black soil blindness: a new mycotoxicosis of cattle grazing Corallocytostroma-infected Mitchell grass (Astrebla spp).

A new, fatal mycotoxicosis of cattle has been recognised in north-western Australia. A feeding trial confirmed the toxicity of a previously unknown species of Corallocytostroma that grows on Mitchell grass (Astrebla spp). The disease has been colloquially named 'black soil blindness' because its most prominent features are its confinement to pastures on black soil, and blindness and death of affected animals. Over 500 cattle have died and considerable subclinical disease in present. Above average wet season rainfall and extended growing seasons may explain the emergence of the fungus. The disease is important because cattle production in large areas of Australia utilise Mitchell grass pastures.

An update on ready-to-use intravenous delivery systems.

The advent of ready-to-use intravenous (IV) delivery systems, particularly small-volume parenterals less than 250 mL has contributed greatly to pharmacy and patient care. Since their introduction in the late 1970s, the availability and variety of systems have increased. The purpose of this article is to update practitioners on small-volume parenterals systems that have a large product availability requiring little manipulation to make the system patient-specific. Additional benefits such as extended stability, potential for decreasing waste of products, as well improved end-quality are also discussed. With the benefits described that these systems have over the traditional method of preparing small-volume parenterals, there is still hesitation to fully utilize these systems. The primary reason for this seems to be the issue of cost. With various rebate incentive programs offered by manufacturers as well as the benefits that the systems provide, ready-to-use IV delivery systems are comparable in price to the traditional method of preparing small-volume parenteral agents.

Patient care contributions of clinical pharmacists in four ambulatory care clinics.

This study investigates both cost-avoidance and improvement in the quality of care and patient outcome attributed to pharmacist intervention in four ambulatory care clinics. Four clinical pharmacists reported 199 interventions made in the pharmacotherapeutic management of 87 ambulatory clinic patients in 1 month. The majority of interventions were based on acceptable professional practices as ranked by peer reviewers. Positive impact of the interventions on patient outcome based on objective and subjective data was documented in 49% of the interventions. Forty-two percent of the interventions improved the process of care with no measurable impact on patient outcome. Cost avoidance was calculated according to interventions made at different steps of the drug use process. Net cost avoidance figures projected to 1 year amounted to $221,056.

Development and implementation of a strategic-planning process at a university hospital.

The development and implementation of a long-range strategic plan for the pharmacy department at a university hospital is described. Because of rapidly occurring changes in health-care delivery, financing, and education, the pharmacy department at the University of Illinois Hospitals decided to create a strategic plan that would stimulate growth, be responsive to a changing health-care environment, and emphasize the department's philosophy of striving for professional leadership in education, research, and innovation. Actual strategy development was done during a three-day administrative retreat, which was conducted according to a structured agenda that facilitated extensive brainstorming and discussion. As a result, the department developed eight major strategies that have been directing its growth and development over the last four years. Each strategy had an implementation plan that included substrategies with statements of specific results that were expected, an action plan (a list of specific tasks to be accomplished), and a general statement summarizing the benefits of each substrategy. Annual meetings were held to review the continued appropriateness of these strategies. Implementation of the strategic plan has resulted in major improvements in drug cost containment, improved ambulatory-care pharmaceutical services, a results-oriented performance-appraisal system, more support for clinical education programs, and a substantial increase in support for research. The strategic plan has allowed the department to constructively participate in two downsizing events within the hospital without major adverse effects on its own services and programs. Use of the strategic-planning process should be considered by other hospital pharmacy departments as a means of responding to the external and internal forces of change that currently affect most hospitals.

Cost justification of clinical pharmacy services on a general surgery team: focus on diagnosis-related group cases.

We used a novel approach to cost-justify clinical pharmacy services on a general surgery team in nine diagnosis-related group cases. The clinical pharmacist monitored nine patients longitudinally on a general surgery team from admission to discharge and intervened in their therapeutic management. Each recommendation was analyzed for rationale, acceptance, perceived impact on quality and/or cost of patient care, whether self-initiated or solicited, and impact on patient outcome. Types of recommendations and outcomes were categorized by process and outcome measurement criteria. Total cost avoidance per patient was calculated using costs of drug therapy, laboratory tests, and length of stay. Accounting for cost of clinical pharmacy services, net cost avoidance per patient was calculated. The clinical pharmacist made 101 recommendations on nine patients. Physicians accepted 82 percent of the recommendations; 77 percent of the recommendations were self-initiated and 23 percent were solicited. Recommendations had a perceived impact on cost, quality, or both at 13, 31, and 56 percent, respectively. Most recommendations (79 percent) brought patient therapy to a level of conformance with current standards of practice as documented in the medical literature. Recommendations that potentially preserved a major organ function by preventing drug-induced toxicity or the exacerbation of existing problems constituted 16 percent of the total. None of the accepted recommendations adversely affected patient outcome and 23 percent directly resulted in a measurable positive outcome in patient care. A total of four hospital days was potentially saved for two cases. Based on objective outcome criteria, a 1.9-day increase in therapeutic control was documented per patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of the contribution of clinical pharmacists: inpatient care and cost reduction.

Clinical pharmacists in this study hospital reported 1027 interventions in patient drug therapy over two time periods of three and two weeks, respectively. These interventions were subjected to self and peer reviews and to cost-avoidance evaluation. The most frequent type of intervention was recommendations related to drug selection (29.6 percent). Recommendations were not implemented by physicians in only 10.2 percent of the cases. The perceived impact of these interventions on the quality, cost, or both was found by the peer reviewers to occur in 58.5, 16.1 and 25.6 percent of the cases, respectively. Also, when peer reviewed for clinical significance, 983 of these interventions were judged to improve drug therapy to an acceptable level based on the professional literature, and 36 were deemed very significant in terms of saving patients' lives or preserving major organ functions. Of the 983 interventions rendering drug therapy to an appropriate level, 398 were deemed to have cost-avoidance impact; of this number a 25 percent random sample was subjected to cost-avoidance evaluation. Realized cost-avoidance averaged $242 for each intervention implemented. When extrapolated annually, $364,900 was the net realized cost-avoidance after discounting for the cost of providing clinical pharmacy services. An average cost-avoidance of $860.50 was calculated for each intervention made by pharmacists, but not followed by physicians, for an annual potential cost-avoidance of $532,650. In all, clinical pharmacists had the potential to save $897,550 annually in hospital resources if all their interventions had been accepted and implemented.

Interdisciplinary committee on infusion-control devices: containing related-product costs.

A program for decreasing expenditures for i.v. sets and related items at a 530-bed university teaching hospital is described. A multidisciplinary committee originally formed to evaluate infusion-control devices (ICDs) developed a cost-containment strategy for reducing the number of accessories and amount of equipment used in i.v. therapy and for reducing inappropriate use of these items. Major problems identified in an audit were excessive use of secondary sets; inappropriate use of add-on flow-control devices, extension sets, and metered-chamber sets; and use of the wrong type of i.v. set with ICDs. New procedural guidelines, inservice-education programs, evaluation of new and different i.v. products, and increased enforcement of policies and procedures by the pharmacy department were implemented to address these problems. For fiscal year 1986, the bid process for i.v. equipment was divided into 10 sections so that manufacturers who may not have been able to bid on every item could bid only on individual sections if they desired. A follow-up audit six months after implementation of the strategy showed increased compliance with guidelines for use of i.v. sets and devices. Compared with the previous year, data for fiscal year 1986 showed total savings of $142,223 attributable to decreased use of i.v. equipment. The competitive-bid process saved $54,942; the total amount saved was $197,165. The trend of appropriate use as a result of adherence to the guidelines continued through fiscal year 1987. This multidisciplinary cost-containment approach was effective in reducing expenditures for i.v. sets and equipment.

Interdisciplinary committee on infusion-control devices: evaluating new products.

Evaluation and selection of volumetric infusion-control devices (ICDs) by an interdisciplinary committee in a university teaching hospital is described. The committee, which was originally formed to evaluate problems with the existing system of ICD management, determined that the ICDs in use at the hospital were outdated. After gathering information on the types of ICDs available and identifying options for replacing the existing equipment, the committee decided to replace some of the devices with new volumetric ICDs. A six-page evaluation form was mailed to ICD manufacturers, and representatives from 16 manufacturers were invited to demonstrate their devices to the committee members. Five manufacturers were then invited to participate in a two-week, inhouse comparative trial, during which the devices were objectively evaluated by nurses, the bioinstrumentation department, and the ICD committee. The results of that evaluation were used to construct bid specifications. The decision of which ICDs to purchase was based on cost factors and the degree to which the devices met the specifications. The use of a multidisciplinary committee to evaluate and select new ICDs was an effective strategy. The devices that were purchased represented improvements in patient safety and cost-effectiveness.

Interdisciplinary committee on infusion-control devices: managing product use.

The development of an interdisciplinary approach to the management of infusion-control devices (ICDs) in a university teaching hospital is described. An ICD committee composed of staff from the pharmacy, nursing, bioinstrumentation, and materiel management departments was created to identify and solve problems with the existing system of ICD management. These problems included untimely delivery of malfunctioning ICDs to the bioinstrumentation department for repairs, chronic shortages of ICDs, inappropriate use of these devices, and lost charges for ICDs and cassettes. The committee decided on joint control of the ICD program by the pharmacy and nursing departments. Guidelines for appropriate use of ICDs were developed and distributed to all nursing units and pharmacy satellites. The pharmacist was responsible for screening requests for ICDs to determine whether they conformed to those guidelines. New policies for delivery of malfunctioning ICDs to the bioinstrumentation department resulted in improved turnaround time for repairs. Responsibility for billing was shared by the pharmacy and nursing departments. These changes resulted in increased availability of ICDs for patient use and an increased charge capture of $247,000 per year. Through the combined efforts of the pharmacy and nursing departments in this institution, the distribution and collection of ICDs has been made more efficient and lost patient charges have decreased.

Contribution of clinical pharmacists to cefazolin utilization.

Cefazolin utilization guidelines were established by representatives of major participants in the patient care process in a 520-bed teaching hospital. Patients admitted to certain hospital units and placed on cefazolin therapy were concurrently monitored for compliance with guidelines by clinical pharmacists (experimental group), while patients admitted to similar units were not monitored for guideline compliance (control group). When therapy, in the experimental group, was deemed noncompliant to the established guidelines, the pharmacist alerted the physician and made recommendations to correct the deficiency. The percent increase in compliance with guidelines attributed to clinical pharmacist intervention was then measured. Clinical pharmacy monitoring for the experimental group increased the rate of compliance with guidelines and decreased the overall cost of patient care. The projected net annual savings in cefazolin cost was calculated to be $7,913.00.

A model for inpatient clinical pharmacy practice and reimbursement.

The development and expansion of clinical pharmacy over the past 15 years have resulted in several debates. One debate that was very lively in the late 1970s concerned proper reimbursement for clinical pharmacy services. Although this debate is less heated now, its importance is even more significant with today's major changes in health care reimbursement. This article reviews the key reasons for the original debate and discusses how recent changes have increased and added direction to the debate. A model is presented that the authors believe represents the key to the increasing acceptance of the pharmacist's clinical role.

Microcosting method for small-volume injectables.

The costs of preparing different small-volume injectables (SVIs) in a centralized i.v. admixture pharmacy in a 650-bed teaching hospital were calculated using a microcosting method. The types of SVIs produced and methods of preparation were identified. Time-and-motion and work-sampling studies were performed to determine the amount of pharmacist and technician time spent in SVI production, auxiliary activities, and nonproductive activities. The costs of material and equipment used were calculated, and waste-cost factors based on percentages of wasted SVIs were determined. To determine the final cost per unit prepared, the calculated costs were added and multiplied by the appropriate waste factors. On the average, it took 5.57 minutes of total personnel time to prepare an SVI. It took an average of 192.4 seconds and 16.6 seconds for the technicians and pharmacists, respectively, to reconstitute a vial of powder and prepare an SVI in a minibag. Bulk prepacked items and admixtures prepared from vials of powder for reconstitution and stored in minibags were, respectively, the least and most expensive SVIs. By using microcosting methods to determine the cost of preparing SVIs, this institution discovered that the cost figures were much higher than it had anticipated. These data can be used to improve productivity and cost efficiency and to compare the costs of in-house and commercially available preparations.

Decision analysis applied to the purchase of frozen premixed intravenous admixtures.

A structured decision-analysis model was used to evaluate frozen premixed cefazolin admixtures. Decision analysis is a process of stating the desired outcome, establishing and weighting evaluation criteria, identifying options for reaching the outcome, evaluating and numerically ranking each option for each criterion, multiplying the ranking by the weight for each criterion, and calculating total points for each option. It was used to compare objectively frozen premixed cefazolin admixtures with batch reconstitution from vials and reconstitution of lyophilized, ready-to-mix containers. In this institution the model numerically demonstrated a distinct preference for the premixed frozen admixture over these other alternatives. A comparison of these results with the total cost impact of each option resulted in a decision to purchase the frozen premixed solution. The advantages of the frozen premixed solution that contributed most to this decision were decreased waste and personnel time. The latter was especially important since it allowed for the reallocation of personnel resources to other potentially cost-reducing clinical functions. Decision analysis proved to be an effective tool for formalizing the process of selecting among various alternatives to reach a desired outcome in this hospital pharmacy.