Propofol-induced interference with activated partial thromboplastin time-based monitoring of therapeutic heparin anticoagulation.

PURPOSE: The activated partial thromboplastin time (aPTT) is a coagulation assay commonly utilized for monitoring therapeutic heparin anticoagulation. aPTT methods based on optical detection are vulnerable to spectral interference from hemolysis, icterus, lipemia, and other substances. Intravenous lipid emulsions of primarily 20% have been shown to interfere with multiple clinical laboratory assays, including those measuring aPTT by optical methods, but there is limited data on propofol's effect. The primary objective of this study was to determine the rate of interference of propofol with aPTT measurements in patients receiving both propofol and intravenous heparin. METHODS: A retrospective observational cohort study of intensive care unit patients who received concomitant propofol and heparin infusions (N = 38 patients) and whose heparin therapy was monitored by aPTT (N = 531 aPTTs) was conducted. Review of the electronic medical record was completed to obtain relevant clinical and laboratory data, while the laboratory information system was queried for analytical interference with the aPTT assay. RESULTS: A total of 109 aPTTs (21%) spanning 21 patients (55%) had documented aPTT interference. All 21 patients had at least one aPTT requiring ultracentrifugation prior to reporting, and 12 aPTTs from 4 patients were unreportable due to interference. Patients with and without aPTT interference received similar doses of propofol. None of the cases of aPTT interference were caused by hemolysis or hyperbilirubinemia. CONCLUSION: A potential medication-assay interaction was observed in approximately half of patients who received concomitant propofol and heparin infusions and had aPTT measured for anticoagulation management. Sample ultracentrifugation removes the optical interference in most cases but significantly prolongs aPTT reporting and delays appropriate adjustments to heparin dosing.

Long-Term Impacts of a Targeted Intervention in the Emergency Department on Inpatient Prescribing Practices.

Background: In 2009, researchers successfully implemented an intervention to decrease the inappropriate prescribing of multivitamin infusions (MVIs) in the emergency department (ED) for patients presenting with alcohol-related illnesses. Objective: The purposes of our study were to determine the impact of the 2009 intervention on hospital-wide prescribing practices of vitamin therapies for alcohol-related illnesses, and to evaluate its long-term sustainability. Methods: A retrospective observational cohort study was conducted at a 60,000-visit ED, 811-bed academically-affiliated tertiary referral hospital with an average census of 515 and 714 patients in 2009 and 2019, respectively. Patients were included if they presented to the ED from 2009 to 2019 with an alcohol-related illness as defined by ICD-9 and ICD-10 codes. The primary outcome was the change in the monthly average of MVIs ordered inpatient within the first four months compared to the last four months of the study period. Secondary outcomes included changes in the mean distribution (MD) per month of thiamine administrations in the ED and inpatient setting, and MVIs ordered in the ED. Results: The MD of MVIs ordered per month decreased by 3.5% (95% CI -5.3, -1.7) in the inpatient setting and decreased by 1.4% (95% CI -2.5, -.3) in the ED from the beginning to the end of our study period. Conclusions: This study suggests the effects of an intervention made in the ED sustained impact over a 10-year timeframe, and decreased the use of MVIs in both the ED and hospital-wide.

Guideline adherence for the management of emergency department patients with febrile neutropenia and no infection source: Is there room for improvement?

INTRODUCTION: Febrile neutropenia is an oncologic emergency associated with significant morbidity and mortality. The objective of our study was to assess guideline adherence and clinical outcomes associated with the management of high- and low-risk febrile neutropenia patients presenting to the emergency department. METHODS: A retrospective observational cohort study was conducted at a 60,000-visit emergency department at an academically-affiliated tertiary referral hospital. Patients were identified as low- or high-risk using the guideline-recommended Multinational Association for Supportive Care in Cancer score. The primary outcome was the proportion of cases in which the management was concordant with applicable febrile neutropenia guidelines. Guideline adherence was defined as hospital admission and intravenous antimicrobial therapy for high-risk patients and discharge home with oral antimicrobial therapy for low-risk patients. Secondary outcomes included appropriate vancomycin administration, hospital length of stay, rates of acute kidney injury, in-hospital Clostridium difficile infection rates, and 30-day mortality. RESULTS: Of the 237 patients included, 94 (39.7%) were low-risk patients and 143 (60.3%) were high-risk patients. Guideline adherence occurred in 96.8% of high-risk patients and 0.4% of low-risk patients. Mean hospital length of stay of the low-risk group was 5 ± 5.0 days compared to 7.2 ± 7.3 days in the high-risk group. Vancomycin was often inappropriately given in 69.5% of high-risk patients. Clostridium difficile occurred in 15 (10.3%) adherent and 4 (4.4%) non-adherent patients. By 30 days, 4 (4.3%) low-risk and 15 (10.7%) high-risk patients died. CONCLUSION: Adherence to the febrile neutropenia guidelines was low resulting in unnecessary hospital admissions of low-risk patients and frequent over-prescription of empirical vancomycin.

What does a pharmacist do? A time and motion study.

BACKGROUND: Pharmacists work in many different settings and have various responsibilities. However, pharmacists are expensive and need to be used efficiently. Previous studies have shown that prescription preparation, clinician interaction, and medical record evaluation take a large part of a pharmacist's day. Additionally, it is also estimated that almost half of their time is considered "non-value added," or that their tasks could be performed by a non-pharmacist. OBJECTIVE: To observe pharmacists in multiple practice settings and record their activities to gauge inefficiencies. METHODS: Time and motion methods were used to observe how pharmacists in retail, clinical, hospital, ambulatory, and academic settings perform daily tasks. Data was collected every 5 min for a total of 18 h from each setting, and sorted into 20 general categories of pharmacists' tasks. RESULTS: Pharmacists spend more time verifying prescriptions than any other activity, accounting for 31% of their time. Other common activities were patient education, charting, counseling, and chart review. CONCLUSION: Although most of pharmacists' daily activities add value to the healthcare team, there are ways to use their time more efficiently. Along with delegating tasks to other pharmacy personnel, new initiatives designed to help pharmacists increase time spent on value-added tasks are recommended.