Quality improvement of intravenous to oral medication conversion using Lean Six Sigma methodologies

Leveling Up: Evaluation of IV v. PO Linezolid Utilization and Cost after an Antimicrobial Stewardship Program Revision of IV to PO Conversion Criteria within a Healthcare System

The CDC’s Core Elements of an Antimicrobial Stewardship Program (ASP) lists intravenous (IV) to oral (PO) conversion as an important pharmacy-based intervention. However, despite the existence of a pharmacist-driven IV to PO conversion protocol, conversion rates within our healthcare system remained low. We aimed to evaluate the impact of a revision to the current conversion protocol on conversion rates, using linezolid as a marker due to its high PO bioavailability and high IV cost. This retrospective, observational study was conducted within a healthcare system composed of five adult acute care facilities. The conversion eligibility criteria were evaluated and revised on 30 November 2021. The pre-intervention period started February 2021 and ended November 2021. The post-intervention period was December 2021 to March 2022. The primary objective of this study was to establish if there was a difference in PO linezolid utilization reported as days of therapy per 1000 days present (DOT/1000 DP) between the pre- and post-intervention periods. IV linezolid utilization and cost savings were investigated as secondary objectives. The average DOT/1000 DP for IV linezolid decreased from 52.1 to 35.4 in the pre- and post-intervention periods, respectively (p < 0.01). Inversely, the average DOT/1000 DP for PO linezolid increased from 38.9 in the pre-intervention to 58.8 for the post-intervention period, p < 0.01. This mirrored an increase in the average percentage of PO use from 42.9 to 62.4% for the pre- and post-intervention periods, respectively (p < 0.01). A system-wide cost savings analysis showed projected total annual cost savings of USD 85,096.09 for the system, with monthly post-intervention savings of USD 7091.34. The pre-intervention average monthly spend on IV linezolid at the academic flagship hospital was USD 17,008.10, which decreased to USD 11,623.57 post-intervention; a 32% reduction. PO linezolid spend pre-intervention was USD 664.97 and increased to USD 965.20 post-intervention. The average monthly spend on IV linezolid for the four non-academic hospitals was USD 946.36 pre-intervention, which decreased to USD 348.99 post-intervention; a 63.1% reduction (p < 0.01). Simultaneously, the average monthly spend for PO linezolid was USD 45.66 pre-intervention and increased to USD 71.19 post-intervention (p = 0.03) This study shows the significant impact that an ASP intervention had on IV to PO conversion rates and subsequent spend. By revising criteria for IV to PO conversion, tracking and reporting results, and educating pharmacists, this led to significantly more PO linezolid use and reduced the overall cost in a large healthcare system.

Lean six-sigma (LSS) applications in hospitals: a decade (2011–2020) bibliometric analysis

Purpose

This study examines the research landscape of Lean Six-Sigma (LSS) applications in hospitals for the period of the last decade (2011–2020) to derive answers to the research questions RQ 1: What are the current publication trends for the application of LSS in hospitals concerning document type, Journal (Source), active authors and country-wise publications and their comparison in the two most reputed scientific databases, i.e. Scopus and Web of Science (WoS), RQ2: What are the clusters based on the authors and keywords? RQ3: What are the research trends and author's productivity in LSS applications in Hospitals? RQ4: What are the future research areas?

Design/methodology/approach

This article compares these two databases (Scopus and WoS) based on publication pattern, document type, active authors and co-citation analysis. This article analyzes the core sources, author's productivity, globally cited articles, word growth analysis, thematic map and world collaboration map on the WoS and Scopus dataset. The software used are Vosviewer, Biblioshiny (R Package for Bibliometric) and M.S. Excel.

Findings

The application of LSS in hospitals is a niche theme. In the WoS database International Journal of Lean Six-Sigma and in Scopus database International Journal of Health Care Quality Assurance are the most relevant sources publishing research articles in this field. The USA has the highest scientific production in this field. Among the authors, Antony J is the most active author in this area, with the highest contribution over the years.

Originality/value

This study fills the literature gap by mapping the field of LSS in hospitals.

Practice-enhancing publications about the medication-use process in 2020

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2020 that can impact health-system pharmacy daily practice.

SUMMARY

The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring. Articles evaluating at least one step of the MUP were assessed for their usefulness in practice improvement. A PubMed search for articles published in calendar year 2020 was conducted in January 2021 using targeted Medical Subject Headings (MeSH) keywords, and the table of contents of selected pharmacy journals was searched, providing a total of 9,433 articles. A thorough review identified 49 potentially practice-enhancing articles: 15 for prescribing/transcribing, 10 for dispensing, 6 for administration, and 18 for monitoring. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of why they are important within health-system pharmacy. The other articles are listed for further review and evaluation.

CONCLUSION

It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article assists in identifying and summarizing the most impactful recently published literature. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of the moist significant published studies can assist in changing practice at the institutional level.

Medication Utilisation Program, Quality Improvement and Research Pharmacist-Implementation Strategies and Preliminary Findings

Judicious use of medicines that considers evidence-based practice, together with cost-effectiveness, is a priority for all health care organisations. We describe an initiative to lead a Medication Utilisation Program, incorporating medication quality improvement and research activities. In August 2020 an advanced pharmacist position was implemented to lead the Program. The purpose was to provide oversight and facilitate initiatives promoting medication optimisation to create sustainable change in practice. A strategic plan was developed with key performance indicators. A governance structure was implemented with relevant reporting mechanisms. Strategic planning and collaboration with medical, nursing and allied health professionals has seen the successful implementation of seven codesigned medication-use evaluations and eight quality improvement projects centred around patient safety, quality and value-based care. Several research studies have been designed with subsequent commencement of pharmacists enrolled in university Research Higher Degree programs. Cost containment initiatives have realised potential savings approximating AUD 250,000. Educational programs included protocol design, ethics approvals and report writing. Key success criteria for a Medication Utilisation Program include dedicated pharmacist resources, structured governance and reporting mechanisms. Alignment of study complexity with staff experience and interdisciplinary collaboration are also critical.

A Health Technology Assessment in Maxillofacial Cancer Surgery by Using the Six Sigma Methodology

Squamous cell carcinoma represents the most common cancer affecting the oral cavity. At the University of Naples "Federico II", two different antibiotic protocols were used in patients undergoing oral mucosa cancer surgery from 2006 to 2018. From 2011, there was a shift; the combination of Cefazolin plus Clindamycin as a postoperative prophylactic protocol was chosen. In this paper, a health technology assessment (HTA) is performed by using the Six Sigma and DMAIC (Define, Measure, Analyse, Improve, Control) cycle in order to compare the performance of the antibiotic protocols according to the length of hospital stay (LOS). The data (13 variables) of two groups were collected and analysed; overall, 136 patients were involved. The American Society of Anaesthesiologist score, use of lymphadenectomy or tracheotomy and the presence of infections influenced LOS significantly (p-value < 0.05) in both groups. Then, the groups were compared: the overall difference between LOS of the groups was not statistically significant, but some insights were provided by comparing the LOS of the groups according to each variable. In conclusion, in light of the insights provided by this study regarding the comparison of two antibiotic protocols, the utilization of DMAIC cycle and Six Sigma tools to perform HTA studies could be considered in future research.

Antibiotic utilization, sensitivity, and cost in the medical intensive care unit of a tertiary care teaching hospital in Nepal

Background:

High utilization and irrational use of antibiotics in an intensive care unit increases microbial resistance, morbidity, mortality, and costs.

Objective:

This study aimed to evaluate the utilization, sensitivity and cost analysis of antibiotics used in the medical intensive care unit of a tertiary care teaching hospital of Nepal.

Methods:

A prospective cohort study was conducted on patients admitted to the medical intensive care unit at a tertiary care teaching hospital in central Nepal from July to September 2016. Antibiotic utilization, defined daily dose per 100 bed-days and the cost of antibiotics per patient were calculated. Descriptive statistics were performed using IBM-SPSS 20.0.

Results:

A total of 365 antibiotics were prescribed in 157 patients during the study period, with an average of 2.34 prescriptions per patient. Total antibiotic utilization in terms of defined daily dose per 100 bed-days was 49.5. Piperacillin/tazobactam (45.2%) was the most commonly prescribed antibiotic, and meropenem was the most expensive antibiotics (US$4440.70). The median (interquartile range) cost of antibiotics used per patient was US$47.67 (US$63.73). Escherichia coli, Acinetobacter, and Pseudomonas sp. were the common organisms isolated and were found to be resistant to some of the commonly used antibiotics.

Conclusion:

This study suggests that the utilization and cost of antibiotics are high in medical intensive care unit of the hospital and E. coli was resistant to multiple antibiotics. The findings highlight an urgent need for the implementation of antibiotic stewardship program in order to improve antibiotic utilization in such hospital settings.

Impact of Antimicrobial Stewardship Bundle on Inpatient Use of Highly Bioavailable Antibacterials

OBJECTIVES

Intravenous (IV) to enteral transition of highly bioavailable antibacterial drugs is associated with improved safety and lower cost. We evaluated the impact of a bundle of stewardship-driven interventions (including in-person stewardship rounding, clinical pathways, and clinical pharmacist-driven enteral transition workflows) on IV versus enteral administration of highly bioavailable antibacterials at a freestanding children's hospital.

METHODS

We collected 2010-2018 inpatient usage data for clindamycin, levofloxacin, ciprofloxacin, metronidazole, rifampin, linezolid, and trimethoprim-sulfamethoxazole. We analyzed total use (in days of therapy [DOTs] per 1000 patient-days [PDs]) and the percentage of total use administered enterally, both hospital wide and stratified by unit subgrouping, specifically comparing use 1-year prestewardship implementation with year-5 postimplementation.

RESULTS

Across the 8-year study window, clindamycin, fluoroquinolones, and metronidazole, together, accounted for 96% of IV DOTs for highly bioavailable antibacterials. Overall, clindamycin use decreased from 44.4 to 20.2 DOTs per 1000 PDs (P < .001), with the enteral percentage of total use increasing from 23% to 43% (P < .001) hospital wide. Overall, fluoroquinolone use decreased from 33.7 to 19.3 DOTs per 1000 PDs (P < .001), with the enteral percentage increasing from 40.7% to 55.9% (P < .001). Overall, metronidazole use increased, and the enteral percentage decreased (42.0% to 33.7%; P = .007). Low-IV-use antibacterials (rifampin, linezolid, and trimethoprim-sulfamethoxazole) showed no significant changes in total use or the enteral percentage of total use.

CONCLUSIONS

Stewardship interventions were associated with decreased overall use and an increased enteral percentage of total use for both clindamycin and fluoroquinolones, although not metronidazole. These data provide an easy-to-collect benchmark for pediatric hospitals to compare IV with enteral use of highly bioavailable antibacterials within the context of overall antibacterial use.