Development and implementation of a clinical decision support-based initiative to drive intravenous fluid prescribing.

OBJECTIVE: Studies suggest superior outcomes with use of intravenous (IV) balanced fluids compared to normal saline (NS). However, significant fluid prescribing variability persists, highlighting the knowledge-to-practice gap. We sought to identify contributors to prescribing variation and utilize a clinical decision support system (CDSS) to increase institutional balanced fluid prescribing. MATERIALS AND METHODS: This single-center informatics-enabled quality improvement initiative for patients hospitalized or treated in the emergency department included stepwise interventions of 1) identification of design factors within the computerized provider order entry (CPOE) of our electronic health record (EHR) that contribute to preferential NS ordering, 2) clinician education, 3) fluid stocking modifications, 4) re-design and implementation of a CDSS-integrated IV fluid ordering panel, and 5) comparison of fluid prescribing before and after the intervention. EHR-derived prescribing data was analyzed via single interrupted time series. RESULTS: Pre-intervention (3/2019-9/2019), balanced fluids comprised 33% of isotonic fluid orders, with gradual uptake (1.4%/month) of balanced fluid prescribing. Clinician education (10/2019-2/2020) yielded a modest (4.4%/month, 95% CI 1.6-7.2, p = 0.01) proportional increase in balanced fluid prescribing, while CPOE redesign (3/2020) yielded an immediate (20.7%, 95% CI 17.7-23.6, p < 0.0001) and sustained increase (72% of fluid orders in 12/2020). The intervention proved most effective among those with lower baseline balanced fluids utilization, including emergency medicine (57% increase, 95% CI 0.7-1.8, p < 0.0001) and internal medicine/subspecialties (18% increase, 95% CI 14.4-21.3, p < 0.0001) clinicians and substantially reduced institutional prescribing variation. CONCLUSION: Integration of CDSS into an EHR yielded a robust and sustained increase in balanced fluid prescribing. This impact far exceeded that of clinician education highlighting the importance of CDSS.

Evaluation and optimization of take-home naloxone in an academic medical center.

With the United States in the midst of an opioid overdose epidemic, efforts to reduce overdose deaths have increased. Expanding access to the opioid antagonist naloxone can combat the epidemic. A pilot project in a psychiatric hospital resulted in the development of a screening tool in the electronic medical record (EMR) to help pharmacists identify adult inpatients at high risk of opioid overdose. Pharmacists can facilitate these patients being discharged with take-home naloxone. The purpose of this project was to optimize the screening tool for nonpsychiatric adult inpatient areas. Prior to implementation, a team of pharmacists familiar with the screening tool and take-home naloxone met with stakeholders to assess need for modification of the tool, determine barriers to implementation, and provide insight into the new service. In addition to expanding the tool into nonpsychiatric areas, a morphine-equivalents calculator was developed to identify patients receiving at least 100 mg of morphine equivalents per day to capture an additional at-risk population. Four short educational videos were developed to provide training to pharmacists. Initial performance of the screening tool was evaluated in general medicine patients over a 5-day period. Out of 44 admissions, 8 (18.2%) screened positive. The majority of those patients (5/8, 62.5%) screened positive for morphine equivalents greater than 100 mg. Anecdotally, the educational videos have been well received by pharmacy staff. Opioid overdose risk factors can be applied to nonpsychiatric inpatients for screening purposes in the EMR. Educational videos can be used to disseminate information to pharmacists on take-home naloxone and opioid overdose.

Evaluating pharmacy leader development through the seven action logics.

PURPOSE: Pharmacy leader development over time was analyzed using the seven action logics. METHODS: As part of an ongoing leadership seminar series, students were required to select a visionary pharmacy leader and conduct a structured interview to evaluate pharmacy leaders' action logics. A standardized questionnaire comprising 13 questions was created by the class. Questions addressed leadership qualities during the leaders' early years, education years, and work years. Transcripts were then coded by two separate trained investigators based on the leader's stage of life to provide a score for each action logic individually over time. Kappa coefficient was used to evaluate interrater agreement. RESULTS: A total of 14 leaders were interviewed. All leaders were currently employed and had won national awards for their contributions to pharmacy practice. Overall, there was 82% agreement between the two evaluators' scores for the various characteristics. Action logics changed based on the leaders' life stage. Using aggregate data from all leader interviews, a progression from lower-order action logics (opportunist, diplomat, expert) to higher-order action logics (strategist, alchemist) was found. Ten leaders (71%) were diplomats during their early years. Six leaders (43%) were experts during their education years, and 4 (29%) were strategists or alchemists. During the third life stage analyzed (the work years), 6 leaders (43%) were strategists, and 2 were alchemists. During their work years, all leaders had a percentage of their answers coded as alchemist (range, 5-22%). CONCLUSION: Throughout their professional careers, pharmacy leaders continually develop skills through formal education and mentorship that follow action logics.

Pharmacy Practice Model Initiative task force report: Improving participation in a survey on hospital pharmacy practices in Texas.

PURPOSE: Results of an initiative to increase participation in a survey on hospital pharmacy practices are reported. METHODS: In an initiative led by pharmacy residents at the University of Houston College of Pharmacy, a task force was created to boost the rate of response to the Hospital-Assessment Survey (HSA), an online benchmarking tool developed as part of the ASHP-sponsored Pharmacy Practice Model Initiative (PPMI). Under the guidance of leaders from ASHP's Texas affiliate and state health-system pharmacy leaders, an 11-member team of residents targeted Texas hospitals that had not responded to the HSA as of December 2013 and used phone and e-mail methods to encourage survey participation. Data obtained from newly responding institutions were aggregated with previously collected data on Texas facilities and compared with national data. RESULTS: During the 11-week initiative, 66 new HSA responses were received from Texas hospitals, raising the total number of respondents to 89 and boosting the overall participation rate from 4.3% to 16.7% (p <0.001). Analysis of the survey data indicated broad similarities among small and large Texas hospitals with regard to six optimal practice characteristics. Pharmacy practice models and characteristics in Texas overall were largely consistent with national statistics. CONCLUSION: The involvement of the PPMI task force was associated with a substantial increase in the survey response rate. The survey results indicated that, with a few exceptions, practice models and the use of optimal practices were similar at Texas hospitals of various sizes and between Texas hospitals overall and sampled hospitals nationwide.

Expansion of clinical pharmacy through increased use of outpatient pharmacists for anticoagulation services.

PURPOSE: The expansion of clinical pharmacy services through increased use of outpatient pharmacists for anticoagulation services is described. SUMMARY: Due to the high demand for clinical pharmacist services by patients and medical staff at Harris Health System in Houston, Texas, and the strict budgetary restrictions to improve the quality of care through cost-neutral services, a new telephone anticoagulation monitoring service, provided by clinical pharmacists, was established at four of the busiest anticoagulation ambulatory care centers within the system. One clinical staff pharmacist was trained in each of the four clinics by a clinical pharmacy specialist. Each pharmacist received roughly two weeks of training to provide this service. Implementation of the new anticoagulation monitoring service occurred on April 1, 2013. Data collected between October 2011 and April 2014 revealed significantly more visits per month for the clinical pharmacy service after the implementation of the telephone anticoagulation monitoring service (p=0.011). Redistribution of workflow resulted in a 16% increase in clinical pharmacy patient volume at the ambulatory care clinics (p=0.011). The percentage of International Normalized Ratio values in the therapeutic range, the proportion of hospitalizations due to thromboembolic or bleeding events, work hours per prescription volume, project completion rates, and the number of students precepted did not significantly differ between groups. CONCLUSION: The implementation of a clinical pharmacy telephone service for patients receiving anticoagulation at an outpatient center resulted in increased patient clinic visits without adversely affecting patient outcomes or increasing personnel or costs.