Involvement of a pharmacy department in a hospital's transition to patient-centered care.

This article will describe our hospital's transition to a patient-centered care environment as a response to rising costs within the hospitals and a desire to improve the quality of patient care through systems improvement. The involvement of pharmacy managers in the new organizational structure will be detailed, as well as their new roles and responsibilities as care center leaders. The traditional pharmacy management structure has been replaced by a team approach to decision making and problem solving. Challenges exist to the pharmacy managers as they reorganize to accommodate new responsibilities within the care centers. Opportunities exist within this setting to support pharmaceutical care.

Pharmacy-controlled documentation of drug allergies.

The implementation of a pharmacy-enforced policy for documenting drug allergies is described. After two incidents at a 600-bed teaching hospital in which patients experienced severe allergic reactions to drugs, an audit was conducted to evaluate the existing drug allergy documentation policy. Physicians documented allergies in medical charts and treatment orders for 68% and 78% of patients, respectively; no initial drug orders contained this information. Nurses documented allergies in admission assessments, medication records, and charts for 71%, 61%, and 15% of patients, respectively. Only 2% of pharmacy computerized drug profiles contained allergy information. A new policy for drug allergy documentation was instituted. Physicians provide allergy information on the first written drug order. Nurses independently solicit allergy information and check it against that provided by the physician. Pharmacists enter the information into the patient's drug profile. If the information has not been obtained, the drug is not dispensed. Repeat audits two months and one year after the policy was put in place showed significant improvements in the completeness and accuracy of drug allergy documentation by pharmacists and physicians. In general, documentation by nurses did not improve to the degree found for pharmacists and physicians. A policy that gave pharmacists the primary responsibility for ensuring that drug allergy information was obtained before drugs were dispensed was effective in improving allergy documentation by physicians and pharmacists.

The application of computerized clinical files to hospital pharmacy practice.

As more hospital pharmacies move in the direction of computer access, the profession must identify more clinical applications for computer programming. The roles of the hospital pharmacist and pharmacy technician are changing, and the profession is moving in the direction of increased clinical involvement. The computer is becoming the mainstay of hospital pharmacy practice. Enhancement of computer technology is essential to assist the hospital pharmacist in assimilating all relevant data in order to provide optimal oversight of drug therapy. As more data become available on drugs, optimal use of drugs, and factors which place the patient at risk for developing reactions to drugs, we must place less reliance on committing all facts to memory and recognize that the computer is a necessary solution to optimizing patient care.

Changing use patterns of plasma volume expanders through educational intervention.

Use patterns of the plasma volume expanders albumin and hetastarch were evaluated before and after an educational program promoting the preferential use of hetastarch was implemented in a 700-bed teaching hospital. The high acquisition cost and periodic shortages of 5% albumin injection prompted the implementation in March 1985 of a target drug program that would encourage the use of 6% hetastarch injection in place of albumin whenever possible. Purchases of albumin and hetastarch were monitored from August 1984 to March 1985 and again from April to November 1985 to determine how much and where these agents were being used. Criteria and guidelines for the use of plasma volume expanders were developed by the pharmacy with physician input. Senior attending physicians who had been identified as primary decision makers in the clinical use of albumin were asked to abide by the guidelines; also, pharmacists conducted inservice educational programs on the use of hetastarch. Patterns of albumin and hetastarch use changed significantly (p less than 0.05) after the educational program was implemented. From August 1984 to March 1985, the mean number of units of albumin and hetastarch purchased monthly were 325.5 and 0.4, respectively. These numbers changed to 195.3 and 163.1 units, respectively, from April to November 1985. The monthly cost avoidance associated with this change was $5127, which extrapolates to $61,526 annually. An educational program can be effective in controlling hospital expenditures for plasma volume expanders. However, clinicians should be aware of the potential adverse effects of hetastarch and should avoid using it in excessive amounts or in patients with underlying coagulopathies.

Stability and cost analysis of clindamycin-gentamicin admixtures given every eight hours.

Stability and costs of a mixture of clindamycin and gentamicin in a single carrier solution for every-eight-hour i.v. administration were analyzed. Duplicate solutions containing clindamycin 900 mg (as the phosphate salt) and gentamicin 100 mg (as the sulfate salt) in 5% dextrose injection 150 mL in flexible plastic containers were prepared. Samples withdrawn at 0-24 hours were visually inspected and assayed for content of both drugs. Clindamycin concentrations were determined by high-performance liquid chromatography and gentamicin concentrations by fluorescence-polarization immunoassay. Preparation and administration times were measured in two trials to determine cost differences between every-eight-hour administration of the two-antibiotic mixture and separate administration of the two drugs (four daily doses of clindamycin and three of gentamicin). No precipitate was seen. Concentrations of both drugs after 24 hours were greater than 90% of initial concentrations. Total daily costs (per patient) for labor, drug, and carrier solution were $3.08 less when the two drugs were mixed and administered every eight hours. At the concentrations studied, clindamycin and gentamicin mixed together in 5% dextrose injection are stable for 24 hours. Administration of this drug mixture every eight hours is safe and less costly than separate administration of the two drugs.

A method for familiarizing nurses with the hospital formulary.

A slide-tape audiovisual program was developed by a university-based drug information center for the purpose of familiarizing the nursing staff with our institution's formulary. The formulary contains useful information on medications stocked by our pharmacy, including costs, dosage forms, policies and procedures governing the pharmacy department, and many useful tables and figures. It was felt that the nursing staff was not aware of these components and thus, was not optimally utilizing the formulary. Nurses taking a test after the slide-tape presentation scored higher on the average than nurses from similar nursing stations who had not seen the presentation. These results, as well as the positive subjective responses from the individual nurses regarding the presentation, indicate that the slide-tape format is an effective means of acquainting the nursing staff with the hospital formulary. It is anticipated that this new awareness of the formulary will result in its more efficient use and further promote the pharmacy department as an information provider.

Controlling moxalactam and cefotaxime use with a target drug program.

A target drug program was utilized to prevent increasing costs associated with inappropriate use of moxalactam and cefotaxime. The cost saving abilities of pharmacists in this regard were calculated. Pharmacists consulted with physicians each time these drugs were prescribed to encourage cefazolin substitution when appropriate. Records of all cephalosporin piggyback doses dispensed were maintained along with quarterly purchase data. Excess costs of utilizing third generation cephalosporins in place of cefazolin were calculated for various usage levels. Actual third-generation usage was compared to usage predicted if no target program was in place, and cost saving was calculated. During the study period, combined moxalactam and cefotaxime use averaged 3.2% of total cephalosporin use at a cost of $4109 per month. Based on an expected predicted usage of 20% to 40%, an annualized cost savings of $91,071 to $202,815 was achieved. Clinical pharmacists were very effective in preventing inappropriate use of moxalactam and cefotaxime, preventing a rise in drug costs.