Hospital rules-based system: The next generation of medical informatics for patient safety

Positive Patient Postoperative Outcomes with Pharmacotherapy: A Narrative Review including Perioperative-Specialty Pharmacist Interviews

The influence of pharmacotherapy regimens on surgical patient outcomes is increasingly appreciated in the era of enhanced recovery protocols and institutional focus on reducing postoperative complications. Specifics related to medication selection, dosing, frequency of administration, and duration of therapy are evolving to optimize pharmacotherapeutic regimens for many enhanced recovery protocolized elements. This review provides a summary of recent pharmacotherapeutic strategies, including those configured within electronic health record (EHR) applications and functionalities, that are associated with the minimization of the frequency and severity of postoperative complications (POCs), shortened hospital length of stay (LOS), reduced readmission rates, and cost or revenue impacts. Further, it will highlight preventive pharmacotherapy regimens that are correlated with improved patient preparation, especially those related to surgical site infection (SSI), venous thromboembolism (VTE), nausea and vomiting (PONV), postoperative ileus (POI), and emergence delirium (PoD) as well as less commonly encountered POCs such as acute kidney injury (AKI) and atrial fibrillation (AF). The importance of interprofessional collaboration in all periprocedural phases, focusing on medication management through shared responsibilities for drug therapy outcomes, will be emphasized. Finally, examples of collaborative care through shared mental models of drug stewardship and non-medical practice agreements to improve operative throughput, reduce operative stress, and increase patient satisfaction are illustrated.

Optimizing Clinical Monitoring Tools to Enhance Patient Review by Pharmacists

BACKGROUND

The Clinical Monitoring List (CML) is a real-time scoring system and intervention tool used by Mayo Clinic pharmacists caring for hospitalized patients.

OBJECTIVE

The study aimed to describe the iterative development and implementation of pharmacist clinical monitoring tools within the electronic health record at a multicampus health system enterprise.

METHODS

Between October 2018 and January 2019, pharmacists across the enterprise were surveyed to determine opportunities and gaps in CML functionality. Responses were received from 39% (n = 162) of actively staffing inpatient pharmacists. Survey responses identified three main gaps in CML functionality: (1) the desire for automated checklists of tasks, (2) additional rule logic closely aligning with clinical practice guidelines, and (3) the ability to dismiss and defer rules. The failure mode and effect analysis were used to assess risk areas within the CML. To address identified gaps, two A/B testing pilots were undertaken. The first pilot analyzed the effect of updated CML rule logic on pharmacist satisfaction in the domains of automated checklists and guideline alignment. The second pilot assessed the utility of a Clinical Monitoring Navigator (CMN) functioning in conjunction with the CML to display rules with selections to dismiss or defer rules until a user-specified date. The CMN is a workspace to guide clinical end user workflows; permitting the review and actions to be completed within one screen using EHR functionality.

RESULTS

A total of 27 pharmacists across a broad range of practice specialties were selected for two separate two-week pilot tests. Upon pilot completion, participants were surveyed to assess the effect of updates on performance gaps.

CONCLUSION

Findings from the enterprise-wide survey and A/B pilot tests were used to inform final build decisions and planned enterprise-wide updated CML and CMN launch. This project serves as an example of the utility of end-user feedback and pilot testing to inform project decisions, optimize usability, and streamline build activities.

Unfractionated heparin infusion for treatment of venous thromboembolism based on actual body weight without dose capping

Controversy exists regarding the use of dose capping of weight-based unfractionated heparin (UFH) infusions in obese and morbidly obese patients. The primary objective of this study was to compare time to first therapeutic activated partial thromboplastin time (aPTT) in hospitalized patients receiving UFH for acute venous thromboembolism (VTE) among three body mass index (BMI) cohorts: non-obese (< 30 kg/m2), obese (30–39.9 kg/m2), and morbidly obese (⩾ 40 kg/m2). In this single-center, retrospective cohort study, patients were included if they ⩾ 18 years of age, had a documented VTE, and were on an infusion of UFH for at least 24 hours. Weight-based UFH doses were calculated using actual body weight. A total of 423 patients met the inclusion criteria, with 230 (54.4%), 146 (34.5%), and 47 (11.1%) patients in the non-obese, obese, and morbidly obese cohorts, respectively. Median times to therapeutic aPTT were 16.4, 16.6, and 17.1 hours in each cohort. Within 24 hours, the cumulative incidence rates for therapeutic aPTT were 70.7% for the non-obese group, 69.9% for the obese group, and 61.7% for the morbidly obese group (obese vs non-obese: HR = 1.02, 95% CI: 0.82–1.26, p = 0.88; morbidly obese vs non-obese: HR = 0.87, 95% CI: 0.62–1.21, p = 0.41). There was no significant difference in major bleeding events between BMI groups (obese vs non-obese, p = 0.91; morbidly obese vs non-obese, p = 0.98). Based on our study, heparin dosing based on actual body weight without a dose cap is safe and effective.

Management of Parenteral Nutrition in Hospitalized Adult Patients [Formula: see text]

Despite the high prevalence of malnutrition in adult hospitalized patients, surveys continue to report that many clinicians are undertrained in clinical nutrition, making targeted nutrition education for clinicians essential for best patient care. Clinical practice models also continue to evolve, with more disciplines prescribing parenteral nutrition (PN) or managing the cases of patients who are receiving it, further adding to the need for proficiency in general PN skills. This tutorial focuses on the daily management of adult hospitalized patients already receiving PN and reviews the following topics: (1) PN basics, including the determination of energy and volume requirements; (2) PN macronutrient content (protein, dextrose, and intravenous fat emulsion); (3) PN micronutrient content (electrolytes, minerals, vitamins, and trace elements); (4) alteration of PN for special situations, such as obesity, hyperglycemia, hypertriglyceridemia, refeeding, and hepatic/renal disease; (5) daily monitoring and adjustment of PN formula; and (6) PN-related complications (PN-associated liver disease and catheter-related complications).

Clinical and laboratory considerations for the rapid detection of carbapenem-resistant Enterobacteriaceae

Carbapenem resistance among the Enterobacteriaceae has become a significant clinical and public health dilemma. Rapid administration of effective antimicrobials and implementation of supplemental infection control practices is required to both improve patient outcomes and limit the spread of these highly resistant organisms. However, carbapenem-resistant Enterobacteriaceae (CRE)-infected patients are predominantly identified by routine culture methods, which take days to perform. Rapid genomic and phenotypic methods are currently available to accelerate the identification of carbapenemase-producing CRE. Effective use of these technologies is reliant on close collaboration between clinical microbiology, infection prevention, antimicrobial stewardship and infectious diseases specialists. This review discusses the performance characteristics of these technologies to date, and describes strategies for their optimal implementation.

Randomized Trial of Rapid Multiplex Polymerase Chain Reaction-Based Blood Culture Identification and Susceptibility Testing

BACKGROUND

The value of rapid, panel-based molecular diagnostics for positive blood culture bottles (BCBs) has not been rigorously assessed. We performed a prospective randomized controlled trial evaluating outcomes associated with rapid multiplex PCR (rmPCR) detection of bacteria, fungi, and resistance genes directly from positive BCBs.

METHODS

A total of 617 patients with positive BCBs underwent stratified randomization into 3 arms: standard BCB processing (control, n = 207), rmPCR reported with templated comments (rmPCR, n = 198), or rmPCR reported with templated comments and real-time audit and feedback of antimicrobial orders by an antimicrobial stewardship team (rmPCR/AS, n = 212). The primary outcome was antimicrobial therapy duration. Secondary outcomes were time to antimicrobial de-escalation or escalation, length of stay (LOS), mortality, and cost.

RESULTS

Time from BCB Gram stain to microorganism identification was shorter in the intervention group (1.3 hours) vs control (22.3 hours) (P < .001). Compared to the control group, both intervention groups had decreased broad-spectrum piperacillin-tazobactam (control 56 hours, rmPCR 44 hours, rmPCR/AS 45 hours; P = .01) and increased narrow-spectrum β-lactam (control 42 hours, rmPCR 71 hours, rmPCR/AS 85 hours; P = .04) use, and less treatment of contaminants (control 25%, rmPCR 11%, rmPCR/AS 8%; P = .015). Time from Gram stain to appropriate antimicrobial de-escalation or escalation was shortest in the rmPCR/AS group (de-escalation: rmPCR/AS 21 hours, control 34 hours, rmPCR 38 hours, P < .001; escalation: rmPCR/AS 5 hours, control 24 hours, rmPCR 6 hours, P = .04). Groups did not differ in mortality, LOS, or cost.

CONCLUSIONS

rmPCR reported with templated comments reduced treatment of contaminants and use of broad-spectrum antimicrobials. Addition of antimicrobial stewardship enhanced antimicrobial de-escalation.

CLINICAL TRIALS REGISTRATION

NCT01898208.

Overestimation of Glomerular Filtration Rate Among Critically Ill Adults With Hospital-Acquired Oligoanuric Acute Kidney Injury

BACKGROUND

Medication use in the intensive care unit (ICU) depends on creatinine-based glomerular filtration rate (GFR) estimates. Urine output deterioration may precede the creatinine rise resulting in delayed recognition of GFR reductions. Our objective was to quantify the disparity between estimated GFR (eGFR) and true GFR in ICU patients with hospital-acquired oligoanuric acute kidney injury (hAKI).

METHODS

This single-center cohort study examined adults who met the Acute Kidney Injury Network stage III urine output criterion ≥48 hours after ICU admission. True GFR was ≤15 mL/min/1.73 m(2), and eGFR was described by 6 different creatinine-based equations. True GFR and eGFR were compared on the day of hAKI diagnosis and followed for 4 days using multivariable linear regression with generalized estimating equations, adjusting for day and method.

RESULTS

Of the 691 patients screened, we enrolled 61 patients. After adjustment for multiple comparisons and day, there were significant differences in eGFR between the estimation methods and true GFR (P < .001). After day adjustment, eGFR overestimated true GFR by 17 to 50 mL/min/1.73 m(2) and overestimation persisted through the fourth day of hAKI (P ≤ .001).

CONCLUSION

Creatinine-based equations overestimated GFR in ICU patients with hAKI. This study highlights a population at risk of medication misadventures in whom systems optimization should be considered.

Rates and appropriateness of antimicrobial prescribing at an academic children's hospital, 2007-2010

OBJECTIVE AND DESIGN

Antimicrobial use in hospitalized children has not been well described. To identify targets for antimicrobial stewardship interventions, we retrospectively examined pediatric utilization rates for 48 antimicrobials from 2007 to 2010 as well as appropriateness of vancomycin and cefepime use in 2010.

PATIENTS AND SETTING

All children hospitalized between 2007 and 2010 at the Mayo Clinic Children's Hospital, a 120-bed facility within a larger adult hospital in Rochester, Minnesota.

METHODS

We calculated antimicrobial utilization rates in days of therapy per 1,000 patient-days. Details of vancomycin and cefepime use in 2010 were abstracted by chart review. Two pediatric infectious disease physicians independently assessed appropriateness of antibiotic use.

RESULTS

From 2007 to 2010, 9,880 of 17,242 (57%) hospitalized children received 1 or more antimicrobials. Antimicrobials (days of therapy per 1,000 patient-days) used most frequently in 2010 were cefazolin (97.8), vancomycin (97.1), fluconazole (76.4), piperacillin-tazobactam (70.7), and cefepime (67.6). Utilization rates increased significantly from 2007 to 2010 for 10 antimicrobials, including vancomycin, fluconazole, piperacillin-tazobactam, cefepime, trimethoprim-sulfamethoxazole, caspofungin, and cefotaxime. In 2010, inappropriate use of vancomycin and cefepime was greater in the pediatric intensive care unit than ward (vancomycin: 17.8% vs 6.4%, P = .001; cefepime: 9.2% vs 3.9%, P = .142) and on surgical versus medical services (vancomycin: 20.5% vs 8.0%, P = .001; cefepime: 19.4% vs 3.4%, P ≤ .001). The most common reason for inappropriate antibiotic use was failure to discontinue or de-escalate therapy.

CONCLUSIONS

In our children's hospital, use of 10 antimicrobials increased during the study period. Inappropriate use of vancomycin and cefepime was greatest on the critical care and surgical services, largely as a result of failure to de-escalate therapy, suggesting targets for future antimicrobial stewardship interventions.

Detecting delayed microbiology results after hospital discharge: improving patient safety through an automated medical informatics tool

We developed a computerized medical informatics tool to identify patients who had a culture performed on a sterile body site specimen during their hospitalization that subsequently turned positive after hospital dismissal. During a 13-month period, 533 patients had a positive culture identified by our Computer-Based Antimicrobial Monitoring (CBAM) program after hospital dismissal, and 112 (21%) of these culture results necessitated an intervention and communication with the primary health care professional. Thirty-two (29%) of positive cultures were from the blood. Thirty-eight (34%) of the CBAM interventions with available outcome data resulted in initiation of, change in, or prolongation of outpatient antimicrobial therapy. The CBAM program serves an important role in optimizing patient care and communication with the health care professional during the transition from inpatient to outpatient management.

ACEi/ARB for systolic heart failure: closing the quality gap with a sustainable intervention at an academic medical center

BACKGROUND

National guidelines recommend angiotensin converting enzyme inhibitor (ACEi) or angiotensinogen receptor blocker (ARB) therapy for patients with left ventricular systolic dysfunction (LVSD), including those with symptomatic heart failure (HF). However, guideline adherence has not been optimal. The goal of this quality improvement project is to devise and implement a sustainable care-delivery model in a 920-bed academic hospital center that would improve ACEi/ARB adherence before hospital discharge.

METHODS

The Model of intervention is: (1) a computer-based daily screening program; (2) inpatient pharmacist e-flag message; and (3) alerts for inpatient care teams. Its operating algorithm: If eligible adult HF/LVSD inpatients are not on ACEi or ARB nor documentation of contraindications, a flag alert is generated; deficiency is confirmed by a pharmacist and conveyed to the patient-care teams; if alert is acted on and care brought into adherence, the screening program would not re-flag the same patients the succeeding day; if not, the patients would be re-flagged daily until reaching adherence. We compared ACEi/ARB adherence before, during, and after the intervention.

RESULTS

Baseline performance (percentage of eligible HF/LVSD patients receiving ACEi/ARB) was 87.5%. After implementation of the Model the ACEi/ARB adherence rate at the time of hospital discharge rose to 96.7% (P < 0.002) and was sustained for 21 months without needing additional personnel.

CONCLUSIONS

A carefully designed, computer-based care-delivery model is highly efficient and sustainable for enhancing ACEi/ARB adherence.

A model for medication safety event detection

BACKGROUND

Hospital medication safety event detection predominantly emphasizes the identification of preventable adverse drug events (ADEs) through self-reports. These relatively rare events only provide insight into patient harm and self-reports identify only a small portion of ADEs. A broader system-focused approach to medication safety event detection that uses an array of event detection methods is recommended. This approach illuminates medication system deficits and supports improvement strategies that can prevent future patient risk.

OBJECTIVE

To: (i) describe a system-focused approach to hospital medication safety event detection, and (ii) present a case illustration of approach application. SYSTEM-FOCUSED MODEL AND METHODOLOGY: A three-level medication safety event detection model that ranges from a narrow harm-focused to broader system-focused approach is described. A standardized cross-level methodology to detect medication safety events is presented.

CASE ILLUSTRATION

A Level 3 system-focused methodology that incorporated both voluntary and non-voluntary event detection strategies was used in 17 critical care (n = 4), intermediate care (n = 7) and medical-surgical units (n = 6) across two hospitals. A total of 431 events were detected: 78 (18.1%) ADEs and 353 (81.9%) potential ADEs. Of the 353 PADEs, 302 (70.0%) were non-intercepted events. Non-voluntary detection methods yielded the majority of events (367, 85.1%).

CONCLUSIONS

The incidence of ADEs was low when compared with non-intercepted PADEs. This was indicative of medication safety system failures that placed patients at risk for potential harm. Non-voluntary detection methods were much more effective at detecting events than traditional self-report methods.

Effect of body mass index on bleeding frequency and activated partial thromboplastin time in weight-based dosing of unfractionated heparin: a retrospective cohort study

OBJECTIVE

To assess bleeding and activated partial thromboplastin time (APTT) in relation to body mass index (BMI) in patients prescribed weight-based dosing of intravenous unfractionated heparin (UFH) for cardiac indications without a maximum (dose-capped) initial bolus or capped initial infusion rate.

PATIENTS AND METHODS

Consecutive patients admitted to an academic medical center from February 1, 2002, through November 31, 2003, who were treated with a UFH nomogram consisting of a 60-U/kg intravenous bolus plus an initial continuous intravenous infusion of 12 U/kg hourly and titrated to a goal APTT range corresponding to thromboplastin-adjusted target heparin levels of 0.3 to 0.7 U/mL by anti-Xa assay were evaluated for this retrospective cohort study. Patients were excluded if they concomitantly received a fibrinolytic, glycoprotein IIb/IIIa inhibitor, or any other antithrombotic agent (except warfarin). Study patients were divided into quartiles by BMI.

RESULTS

Of the 1054 patients included in the study, 807 (76.6%) had an initial bolus dose higher than 4000 U, and 477 (45.3%) had an initial infusion rate higher than 1000 U/h. Despite a significant difference among BMI quartiles in proportion of supratherapeutic first APTT values (P<.001), no statistically significant difference was found in bleeding frequency (P=.26) or frequency of first APTT within the goal range (P=.27). Logistic regression analyses revealed that BMI was not a significant predictor of bleeding or first APTT within the goal range.

CONCLUSION

We did not find any difference in the proportion of first APTT values in the goal range or an increased risk of bleeding in obese patients treated with UFH without a capped initial dose. Our data demonstrate the safe use of weight-based UFH without a capped initial bolus dose or capped initial infusion rate in patients with medical cardiac conditions.

Decision support systems for antibiotic prescribing

PURPOSE OF REVIEW

To explore recent developments in computerized evidence-based guidelines and decision support systems that have been designed to improve the effectiveness and efficiency of antibiotic prescribing.

RECENT FINDINGS

The most frequently utilized decision support systems are electronic guidelines and protocols, especially for empirical selection of antibiotics. The majority of decision support systems result in improvement in clinical performance and, in at least half of the published trials, in patient outcomes. Despite the reported successes of individual applications, the safety of electronic prescribing systems in routine practice has been identified recently as an issue of potential concern. Bioinformatics-assisted prescribing may contribute to reducing the complexities of prescribing combinations of antimicrobials in the era of multidrug resistance.

SUMMARY

The reemerging interest in prescribing decision support reflects the recent change in emphasis from support for diagnostic decisions towards support for patient management and from systems targeting a broad range of clinical diagnoses to task specific and condition-specific decision aids.

Effectiveness of a clinical decision support system to identify heparin induced thrombocytopenia

BACKGROUND

Subtle decreases in platelet count may impede timely recognition of heparin-induced thrombocytopenia (HIT), placing the patient at increased risk of thrombotic events.

OBJECTIVE

A clinical decision support system (CDSS) was developed to alert physicians using computerized provider order entry when a patient with an active order for heparin experienced platelet count decreases consistent with HIT.

METHODS

Comparisons for timeliness of HIT identification and treatment were evaluated for the year preceding and year following implementation of the CDSS in patients with laboratory confirmation of HIT.

RESULTS

During the intervention time period, the CDSS alert occurred 41,922 times identifying 2,036 patients who had 2,338 inpatient admissions. The CDSS had no significant impact on time from fall in platelet count to HIT laboratory testing (control 2.3 days vs intervention 3.0 days P = 0.30) and therapy (control 19.3 days vs intervention 15.0 days P = 0.45), and appeared to delay discontinuation of heparin products (control 1.3 days vs. intervention 2.9 days P = 0.04). However, discontinuation of heparin following shorter exposure duration and after smaller decrease in platelet count occurred during the intervention period. The HIT CDSS sensitivity and specificity were each 87% with a negative predictive value of 99.9% and positive predictive value of 2.3%.

CONCLUSIONS

Implementation of a CDSS did not appear to improve the ability to detect and respond to potential HIT, but resulted in increased laboratory testing and changes in clinician reactions to decreasing platelet counts that deserve further study.

Computer-Based Monitoring as a Tool for Antimicrobial De-Escalation

Purpose

Multiple studies have found an association between the prompt initiation of empirically-appropriate antimicrobial therapy and improved patient outcomes. Such empiric-antimicrobial therapy is often broad; however, once the patient's infectious syndrome, microbiology, and susceptibilities are more defined, it is important to refine antimicrobial therapy. Despite the potential benefits of an “antimicrobial de-escalation” approach, it may be difficult to enforce in clinical practice. Mayo Clinic's Computer-Based Antimicrobial Monitoring System (CBAM) is a medical-informatics tool that was used to assist in this endeavor. This study evaluates the hypothesis that CBAM can enhance the de-escalation of vancomycin and broad-spectrum combination antimicrobial therapy.

Methods

Hospitalized patients at the Mayo Clinic were screened from January through June 2006 using rule-based algorithms incorporated by CBAM. Interventions were performed by physicians and pharmacists as pertinent. These patients were compared with a historical group of patients obtained by CBAM reporting capabilities. De-escalation rates and mean duration of antimicrobial therapy were compared between groups.

Results

Vancomycin de-escalation rates significantly improved from 33% to 68% with intervention ( P = 0.001). In addition, the average duration of therapy was decreased from 10.4 ± 7.3 days to 7.7 ± 2.4 days among patients who underwent vancomycin de-escalation per recommendation ( P = 0.014).

Conclusions

Utilizing the Mayo Clinic's CBAM system to identify potential patients for de-escalation is a unique approach and was successful at improving adherence to vancomycin de-escalation.

[Pharmaceutical services for inpatients provided by hospital pharmacies in Brazil: a review of the literature]

This paper discusses the literature on hospital pharmacy services for in-patients in Brazil, seeking a broader view of its characteristics and priorities. Seventeen papers were located in the Medline and Lilacs databases that complied with the pre-defined inclusion/exclusion criteria. Most of them were related to teaching and research, logistics and compounding, based on observations in public hospitals in Southeast Brazil. Few studies focused on core activities such as management and selection. The academic syllabus through which pharmacy students are trained may underlie the perception that compounding is the preponderant aspect of hospital pharmacy services, although this is required in only a few institutions. Added to this is poor compliance by pharmacy activities with established norms and standards and the lack of an indexed Brazilian publication in this field. As there were far more studies of the public sector than its private counterpart, it seems as though there is either greater freedom of action in the former or less scientific output in the latter, quantified by published studies.

Duke Surgery Patient Safety: an open-source application for anonymous reporting of adverse and near-miss surgical events

BACKGROUND

Studies have shown that 4% of hospitalized patients suffer from an adverse event caused by the medical treatment administered. Some institutions have created systems to encourage medical workers to report these adverse events. However, these systems often prove to be inadequate and/or ineffective for reviewing the data collected and improving the outcomes in patient safety.

OBJECTIVE

To describe the Web-application Duke Surgery Patient Safety, designed for the anonymous reporting of adverse and near-miss events as well as scheduled reporting to surgeons and hospital administration. SOFTWARE ARCHITECTURE: DSPS was developed primarily using Java language running on a Tomcat server and with MySQL database as its backend.

RESULTS

Formal and field usability tests were used to aid in development of DSPS. Extensive experience with DSPS at our institution indicate that DSPS is easy to learn and use, has good speed, provides needed functionality, and is well received by both adverse-event reporters and administrators.

DISCUSSION

This is the first description of an open-source application for reporting patient safety, which allows the distribution of the application to other institutions in addition for its ability to adapt to the needs of different departments. DSPS provides a mechanism for anonymous reporting of adverse events and helps to administer Patient Safety initiatives.

CONCLUSION

The modifiable framework of DSPS allows adherence to evolving national data standards. The open-source design of DSPS permits surgical departments with existing reporting mechanisms to integrate them with DSPS. The DSPS application is distributed under the GNU General Public License.

Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for 2010

Medication errors in hospital settings are considered both widespread and costly to the American healthcare system; yet, it is tractable to available solutions. This article offers a novel prescription for the problem that could be implemented by 2010. It consists of a systems approach--failure mode effects analysis (FMEA)--in combination with emerging technologies, such as a decision support system (DDS) with integrated real-time medical informatics, electronic medical records (EMR), computer physician order entry (CPOE), bar coding, automated dispensing machines (ADM), and robotics. Cost and benefit analysis reveals that this proposed integrated solution will radically reduce medication errors in hospitals and save the lives of thousands of Americans who frequent such facilities on an annual basis, as well as reduce healthcare costs.