Implementation of a prioritized scoring tool to improve time to pharmacist intervention

PURPOSE

The implementation of a prioritized scoring tool to improve time to pharmacist intervention is described.

SUMMARY

At the Ohio State University Wexner Medical Center, pharmacists are accepted providers of therapeutic drug monitoring of vancomycin and aminoglycosides. At the onset of this initiative and despite the implementation of an integrated electronic medical record (EMR), management of pharmacokinetically monitored medications was conducted using a paper monitoring form. The potential for transcription errors during this process provided an opportunity for improvement. For these reasons, the department of pharmacy focused its initial efforts for a patient scoring system on the pharmacokinetics scoring module. Adjustment of associated medications based on pharmacokinetic values was a core function of pharmacists of the institution and was expected to be conducted without fail. Vancomycin was used as the index surrogate pharmacokinetically monitored medication within the module for testing and validation because of the clear expectations and standardized resources available to pharmacists to complete the task. The pharmacokinetics scoring module was designed specifically for the function of dosing management, searching throughout the EMR and concisely displaying the information a pharmacist needs to make a clinical decision. Importantly, integration of the scoring module reduced the time to intervention from hours to minutes. The median time to intervention was reduced to within a clinical working shift (8 hours) with the scoring module versus 24 hours or longer with the paper monitoring system.

CONCLUSION

The implementation of an internally developed pharmacokinetics scoring module built into the EMR substantially reduced the time to clinical intervention for pharmacokinetic monitoring of vancomycin drug levels.

National survey of comprehensive pharmacy services provided in cancer clinical trials

PURPOSE

Pharmacy services provided in clinical trials at National Cancer Institute (NCI)-designated centers were assessed.

METHODS

This was a cross-sectional survey of 61 NCI-designated cancer centers. Directors of pharmacy were contacted and data were collected electronically via Qualtrics over 2 months. Trial participants were asked to estimate the frequency that their sites performed 26 services and the perceived importance of these services. Services were examined with respect to the difference between their reported performance and their reported importance. Eight of the 26 services showed a difference of at least 40% between the proportion of respondents performing the activities "often" or "almost always" and the proportion considering them "important" or "very important." Demographic information was collected, as well as perceived barriers.

RESULTS

Survey response rate was 59% (36 out of 61). The majority of services for clinical trials (19 out of 26) were viewed as important for pharmacists to perform; however, less than half (10 out of 26) were performed more than 50% of the time. Eight services had a gap of more than 40% when comparing the importance versus extent of implementation. Some of the largest gaps were reported in investigator-initiated trials development, medication reconciliation, therapeutic drug monitoring, and oral chemotherapy adherence assessment. Future studies can assist with cost justification by demonstrating the regulatory, safety, and financial benefits of pharmacist involvement in cancer trials.

CONCLUSION

A survey of pharmacy directors at cancer centers revealed gaps between what respondents considered important pharmacist services in the provision of cancer clinical trials and the actual performance of those services in their institution.

A.S.P.E.N. Statement on Parenteral Nutrition Standardization

In response to questions regarding use of standardized parenteral nutrition (PN) formulations, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) developed a Task Force to address some of these issues. A.S.P.E.N. envisions standardized PN as a broader issue rather than simply using a standardized, commercially available PN product. A standardized process for PN must be explored in order to improve patient safety and clinical appropriateness, and to maximize resource efficiency. A standardized process may include use of standardized PN formulations (including standardized, commercial PN products) but also includes aspects of ordering, labeling, screening, compounding, and administration of PN. A safe PN system must exist which minimizes procedural incidents and maximizes the ability to meet individual patient requirements. Using clinicians with nutrition support therapy expertise will contribute to that safe PN system. The purpose of this statement is to present the published literature associated with standardized PN formulations, to provide recommendations, and to identify areas in need of future research.

Assessment of Barriers to Providing Introductory Pharmacy Practice Experiences (IPPEs) in the Hospital Setting

Objectives: The primary objective of the study is to identify the barriers to providing Introductory Pharmacy Practice Experiences (IPPEs) in the hospital setting. Methods: Potential barriers to IPPEs were identified via literature review and interviews with current IPPE preceptors from various institutions. Based on this information, an electronic survey was developed and distributed to IPPE preceptors in order to assess student, preceptor, logistical and college or school of pharmacy related barriers that potentially exist for providing IPPE in the hospital setting. Results: Sixty-eight of the 287 eligible survey respondents (24%) completed the electronic survey. Seventy-six percent of respondents agreed or strongly agreed that available time was a barrier to precepting IPPE students even though a majority of respondents reported spending a third or more of their day with an IPPE student when on rotation. Seventy-three percent of respondents disagreed or strongly disagreed that all preceptors have consistent performance expectations for students, while just 46% agreed or strongly agreed that they had adequate training to precept IPPEs. Sixty-five percent of respondents agreed that IPPE students have the ability to be a participant in patient care and 70% of preceptors believe that IPPE students should be involved in patient care. Conclusions: Conducting IPPEs in the institutional setting comes with challenges. Based on the results of this study, experiential directors and colleges/schools of pharmacy could make a positive impact on the quality and consistency of IPPEs by setting student expectations and training preceptors on appropriate and consistent expectations for students.   Type: Original Research

Effect of barcode-assisted medication administration on emergency department medication errors

OBJECTIVES

Barcode-assisted medication administration (BCMA) is technology with demonstrated benefit in reducing medication administration errors in hospitalized patients; however, it is not routinely used in emergency departments (EDs). EDs may benefit from BCMA, because ED medication administration is complex and error-prone.

METHODS

A naïve observational study was conducted at an academic medical center implementing BCMA in the ED. The rate of medication administration errors was measured before and after implementing an integrated electronic medical record (EMR) with BCMA capacity. Errors were classified as wrong drug, wrong dose, wrong route of administration, or a medication administration with no physician order. The error type, severity of error, and medications associated with errors were also quantified.

RESULTS

A total of 1,978 medication administrations were observed (996 pre-BCMA and 982 post-BCMA). The baseline medication administration error rate was 6.3%, with wrong dose errors representing 66.7% of observed errors. BCMA was associated with a reduction in the medication administration error rate to 1.2%, a relative rate reduction of 80.7% (p < 0.0001). Wrong dose errors decreased by 90.4% (p < 0.0001), and medication administrations with no physician order decreased by 72.4% (p = 0.057). Most errors discovered were of minor severity. Antihistamine medications were associated with the highest error rate.

CONCLUSIONS

Implementing BCMA in the ED was associated with significant reductions in the medication administration error rate and specifically wrong dose errors. The results of this study suggest a benefit of BCMA on reducing medication administration errors in the ED.

Adult starvation and disease-related malnutrition: a proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus Guideline Committee

BACKGROUND & AIMS

Multiple definitions for malnutrition syndromes are found in the literature resulting in confusion. Recent evidence suggests that varying degrees of acute or chronic inflammation are key contributing factors in the pathophysiology of malnutrition that is associated with disease or injury.

METHODS

An International Guideline Committee was constituted to develop a consensus approach to defining malnutrition syndromes for adults in the clinical setting. Consensus was achieved through a series of meetings held at the A.S.P.E.N. and ESPEN Congresses.

RESULTS

It was agreed that an etiology-based approach that incorporates a current understanding of inflammatory response would be most appropriate. The Committee proposes the following nomenclature for nutrition diagnosis in adults in the clinical practice setting. "Starvation-related malnutrition", when there is chronic starvation without inflammation, "chronic disease-related malnutrition", when inflammation is chronic and of mild to moderate degree, and "acute disease or injury-related malnutrition", when inflammation is acute and of severe degree.

CONCLUSIONS

This commentary is intended to present a simple etiology-based construct for the diagnosis of adult malnutrition in the clinical setting. Development of associated laboratory, functional, food intake, and body weight criteria and their application to routine clinical practice will require validation.

Parenteral Nutrition Safe Practices: Results of the 2003 American Society for Parenteral and Enteral Nutrition Survey*

BACKGROUND

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recently published a revision of its "Safe Practices for Parenteral Nutrition" guidelines. Because there is a paucity of published scientific evidence to support good practices related to ordering, compounding, and administering parenteral nutrition (PN), a survey was performed in the process of the revision to gain insight into the discrepancies between reported practices and previous guidelines.

METHODS

A web-based survey consisting of 45 questions was conducted (n = 651) June 1-30, 2003. Respondents were queried about primary practice setting, professional background, processes for writing PN orders, computer order entry of PN orders, problems with PN orders, and adverse events related to PN.

RESULTS

There were 651 survey responses, 90% of which were from hospital-based practitioners. Almost 75% of responders processed between 0 and 20 PN orders per day. Overall, physicians (78%) were responsible for writing PN orders, but dietitians and pharmacists had significant involvement. PN base components were most often ordered as percentage final concentration after admixture (eg, 20% dextrose), which is inconsistent with safe practice guidelines of ordering by total amount per day (eg, 200 g/day). There was no consistent method for ordering PN electrolytes. Approximately 45% of responders reported adverse events directly related to PN that required intervention. Of these events, 25% caused temporary or permanent harm, and 4.8% resulted in a near-death event or death.

CONCLUSIONS

Although the survey found consistency in PN practices for many areas queried, significant variation exists in the manner by which PN is ordered and labeled.

Hyperglycemia associated with high, continuous infusion rates of total parenteral nutrition dextrose

A retrospective study was performed to determine whether there is an increased incidence of hyperglycemia in patients not predisposed to hyperglycemia (n = 102) who receive total parenteral nutrition (TPN) dextrose in excess of 4 to 5 mg/kg/min. Of the 37 subjects administered dextrose at > 5 mg/kg/min, 18 exhibited hyperglycemia. None did so who received dextrose at < or = 4 mg/kg/min (n = 19). TPN dextrose infusion rate was positively correlated with blood glucose concentration, over and above other variables considered in a multiple regression, including kcal/kg administered, furosemide or dopamine use, gender, age, or diagnosis. Thus, TPN dextrose infusion rates > 4 to 5 mg/kg/min increase risk of hyperglycemia.

Femoral catheters increase risk of infection in total parenteral nutrition patients

Central venous access for the administration of total parenteral nutrition is usually achieved via the subclavian or internal jugular veins. Although a high incidence of complications has been reported with the use of femoral catheters for central venous access, this route has been used when traditional central venous access is contraindicated. We retrospectively reviewed 171 patients who received total parenteral nutrition via a central venous triple-lumen catheter and compared the rates of infections in femoral vs nonfemoral access. A literature review was performed to identify associated complications of and appropriate indications for femoral catheter use. In the 171 patients studied, 355 triple-lumen catheters were placed; these included 331 nonfemoral catheters and 24 femoral catheters. Femoral catheters were placed in nine patients. Femoral catheters had a greater incidence of positive tips (42% vs 6.9%, p < .001) and related bacteremia (16.7% vs 1.8%, p = .002) than did nonfemoral catheters. The organisms most commonly isolated from the blood and catheter tips of both catheter access sites were methicillin-resistant Staphylococcus epidermidis and Candida. The use of femoral catheters for central venous access for total parenteral nutrition administration results in an increased risk of infectious complications.

Nutrition care given new importance in JCAHO standards

The 1995 standards developed by the Joint Commission on Accreditation of Healthcare Organizations are now in effect. In an unprecedented shift, the manual focuses on performance rather than structure and process. It emphasizes the interdisciplinary delivery of care, including nutrition care. This article describes the new standards as they relate to nutrition support professionals.

The effect of catheter type and site on infection rates in total parenteral nutrition patients

Infections pose a major problem in patients receiving total parenteral nutrition. Controversy continues concerning the effect of catheter type (triple-, double-, single-lumen, or pulmonary artery), insertion site (subclavian, internal jugular, or femoral vein), and the incidence of catheter-related infections. We retrospectively studied multi-lumen catheter use for total parenteral nutrition over a 6-month period in 192 patients, a total of 3334 catheter days. Nonintensive care unit catheters were inserted by the Nutrition Support Service, and intensive care unit catheters were inserted by the intensive care unit staff. All catheters were cared for using Nutrition Support Service protocols, with multi-lumen catheters changed every 7 to 10 days and pulmonary artery catheters changed every 4 days. Infections were determined by semiquantitative cultures (> 15 colonies/plate). The incidence of infections for triple-lumen catheters was 5 (subclavian), 17 (internal jugular), and 36% (femoral) respectively; total infection rate for triple-lumen catheters was 10%. Infection rates for pulmonary artery catheters were 4 (subclavian), and 6% internal (jugular site), respectively, the overall infection rate was 5%. There were no differences in infection rates at any site based on catheter type; however, when triple-lumen catheter sites were compared, the differences were significant (p < .001 vs subclavian, chi 2). Catheter duration was 7.8 days (subclavian),, 7.3 days (internal jugular), and 4.6 (femoral) days. These data suggest that the use of multi-lumen catheters for total parenteral nutrition is safe, that there is a benefit associated with the subclavian route, and that the femoral site should be avoided.

A standardized system for assessment and delivery of nutrition support in a large teaching hospital

The nutrition support service (NSS) is consulted to evaluate and provide nutrition support to 500 patients per year. To facilitate this process, three forms--a consultation request form and preprinted parenteral and enteral nutrition order forms are used. The NSS Consult Request form was developed to provide consistency in medical, dietetic, nursing, and pharmacy patient assessments. This form is organized so that it includes clinical information necessary for nutrition assessment. Specifically, the NSS completes a nutrition assessment that includes a diet history; indirect calorimetry, only when indicated; a laboratory (metabolic) assessment; a clinical impression used to put the above-mentioned information into a nutrition perspective; and recommendations for either enteral or parenteral therapy. The recommendation for implementing nutrition support as either total enteral nutrition or total parenteral nutrition is made by using the respective order forms for enteral or parenteral nutrition. These include orders for specific formulas and additives and orders for laboratory monitors, nursing care, and criteria for notification of the physician. These forms facilitate the accurate transcription, preparation, and delivery of NSS orders by pharmacy, dietetics, and nursing departments. This approach provides an excellent framework in which to teach dietitians, pharmacists, nurses, and physicians a method for the delivery of appropriate nutrition support and provides a database for the performance of quality assurance analysis and clinical research.