Assessment of Outcomes in Patients with Heart Failure and End-Stage Kidney Disease after Fluid Resuscitation for Sepsis and Septic Shock.

BACKGROUND: Sepsis fluid resuscitation is controversial, especially for patients with volume overload risk. The Surviving Sepsis Campaign recommends a 30-mL/kg crystalloid fluid bolus for patients with sepsis-induced hypoperfusion. Criticism of this approach includes excessive fluid resuscitation in certain patients. OBJECTIVE: The aim of this study was to assess the efficacy and safety of guideline-concordant fluid resuscitation in patients with sepsis and heart failure (HF) or end-stage kidney disease (ESKD). METHODS: A retrospective cohort study was conducted in patients with sepsis who qualified for guideline-directed fluid resuscitation and concomitant HF or ESKD. Those receiving crystalloid fluid boluses of at least 30 mL/kg within 3 h of sepsis diagnosis were placed in the concordant group and all others in the nonconcordant group. The primary outcome was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) and hospital length of stay (LOS); vasoactive medications and net volume over 24 h; new mechanical ventilation, new or increased volume removal, and acute kidney injury within 48 h; and shock-free survival at 7 days. RESULTS: One hundred twenty-five patients were included in each group. In-hospital mortality was 34.4% in the concordant group and 44.8% in the nonconcordant group (p = 0.1205). The concordant group had a shorter ICU LOS (7.6 vs. 10.5 days; p = 0.0214) and hospital LOS (12.9 vs. 18.3 days; p = 0.0163), but increased new mechanical ventilation (37.6 vs. 20.8%; p = 0.0052). No differences in other outcomes were observed. CONCLUSIONS: Receipt of a 30-mL/kg fluid bolus did not affect outcomes in a cohort of patients with mixed types of HF and sepsis-induced hypoperfusion.

Managing Grief for Pharmacy Leaders.

Grief is everywhere and affects individuals and teams in many different ways. The negative effects may not only be felt by the individual, but they can disrupt a team or an entire organization. While grief is common, understanding how to interact with others who are grieving is not. As leaders within healthcare institutions, pharmacists encounter many individuals and teams that are experiencing grief. The sources of grief can arise from pharmacy team members, other healthcare providers, patients, or our own personal experiences. This literature review introduces grief, where it comes from, and how it is emotionally and physically expressed in individuals. It discusses grief's disruptive nature and how to effectively communicate with those grieving to limit disturbances to individual, team, and organizational performance. Understanding what grief is, how it manifests in individuals and teams, and how to navigate a grieving workplace are vital skills for pharmacy leaders and will enable a more productive workplace.

Conscientious Objection: A Review of State Pharmacy Laws and Regulations.

Most states have adopted conscience clauses since the Roe v. Wade paradigm in the 1970s; however, not all clauses are respective to pharmacists. The purpose of this report is to quantify the presence of conscientious objection among US states with respect to pharmacist's right to refuse to dispense. Fifty Boards of Pharmacy administrative codes were consulted for review. If Web sites were ambiguous or undeterminable, E-mail requests were sent on active legislation per National Association of Boards of Pharmacy contact information. Eleven states have conscience clauses present in their pharmacy administrative code-nearly double than last published in 2006. Requirements vary throughout the states including drug-specific limitations, requirement in writing, or notification in advance. Some states alternatively require duty to dispense. Less than one-fourth of United States boards of pharmacy provide a conscience clause or similar intended language in laws or policies. Within those states, pharmacists have a right to refuse to perform certain services based on religious, ethical, or moral objections. Imprecise language throughout the nation allows the rights to vary widely.

A Survey of Opioid Medication Stewardship Practices at Academic Medical Centers.

Purpose: The results of a survey of academic medical centers assessing the presence and description of opioid stewardship activities. Methods: Academic medical centers within the Vizient University Health System Consortium Pharmacy Network were asked to complete a survey related to opioid stewardship activities. The survey consisted of 30 questions aimed at identifying current opioid stewardship practices among hospitals and health systems. Results: There were 27 respondents to the survey. Only 42.3% of respondents have opioid stewardship activities in place. Opioid stewardship practices are primarily linked to either formal consult services or the role of a clinical pharmacy specialist. Very few institutions have opioid stewardship embedded into the daily practice of clinical pharmacists. Just over half of respondents have pharmacists as part of a pain consult team. Principle roles of pharmacists on consult teams include provider education, patient education, and optimization of therapy outside of a collaborative practice or prescribing role. Over half of the respondents participating in stewardship maintain a pharmacist's role in monitoring surgery and postoperative opioid prescribing. The majority of respondents have opioid medication policies in place to address range orders, smart pump programming of opioids, limits on meperidine use, and cumulative limits on acetaminophen dosing. Conclusion: There are limited examples of pharmacy services related to opioid stewardship. The authors believe this is a pharmacy practice model that will evolve with the national attention to the opioid epidemic and new Joint Commission Standards.

Implementation of a workflow system with electronic verification for preparation of oral syringes.

PURPOSE: The implementation of a commercially available, Web-based, barcode-enabled workflow management system for filling and checking patient-specific oral syringes at the Cleveland Clinic is described. SUMMARY: Historically, the process for preparing oral syringes has been a manual, repetitive procedure at Cleveland Clinic. Within this process, paper logs are the sole source of information. These logs can be difficult to locate or interpret. It remains a rote process with numerous manual steps offering opportunity for human error. Traditionally, automation, such as barcode scanning, has not been available during oral syringe preparation and checking. Based on increasing regulatory demands and documentation gaps identified, solutions were explored in the pharmacy's nonsterile compounding environment. An electronic verification workflow system was developed, implemented, and evaluated with a focused assessment of throughput and patient safety relative to oral syringe preparation. This was a retrospective study conducted in an academic, tertiary, acute care medical center. Analysis was completed at 3 months to evaluate efficiencies. Data regarding experiences at the Cleveland Clinic shows promising benefits with regards to United States Pharmacopeia chapter 795 compliance, the pursuit of incorporating advanced informatics and automation in manual processes, and standardization of workflow within an enterprise setting. CONCLUSION: Implementation of an electronic workflow verification system that integrates barcode verification and image-capture capabilities has maintained regulatory compliance in the nonsterile compounding environment including preparation of oral syringe doses without impacting throughput.

Development of an operational productivity tool within a cancer treatment center pharmacy.

PURPOSE: The development and implementation of an operational productivity tool in an academic cancer treatment center are described. SUMMARY: Based on the increasing complexity of care delivery within the oncology setting, solutions were explored within Cleveland Clinic pharmacy's productivity model. Data were electronically captured based on orders processed through the outpatient oncology setting, including hazardous and nonhazardous medications. Based on current workflow, inpatient and outpatient orders were reviewed in productivity metrics. The metric defining the variability of the workload itself was weighted dispense type as it was the best representation of a mixed-skill workflow. After conducting workflow process mapping, discrete measurable steps were assessed and evaluated daily. Operational components of interest included pharmacist verification activities and technician compounding activities. Historical production data were sampled for assigning relative value units (RVUs) respective to time to normalize workload into a common unit (i.e., 1 hour) and to relate work demand in a highly variable setting. RVUs were assigned and delineated by cognitive and distributive activities for pharmacists and technicians, respectively. The Cleveland Clinic department of pharmacy developed a productivity tool to retrospectively measure workload involving time to review, verify, reconstitute, admix, and deliver chemotherapeutic agents. The weighting of each medication allowed for precise and meaningful evaluation of productivity. With RVUs assigned to 2 years of operational metrics, there now exists an opportunity to monitor performance trends within the cancer treatment center pharmacy. The data are readily retrievable within the electronic health record. CONCLUSION: The productivity data provided precise information to assess trends in operations within the pharmacy of an outpatient cancer treatment center.