Developing and Validating a Novel Tool to Enhance Functional Status Assessment: The Tennessee Functional Status Questionnaire (TFSQ).

PURPOSE: Functional status is a major contributor to overall health and reflects both daily activity level (performance) and maximum attainable activity level (capacity). Existing assessment tools evaluate only 1 domain of function and do not provide insight into contributors to functional decline. We addressed these deficiencies by developing the Tennessee Functional Status Questionnaire (TFSQ), which reports activity levels in metabolic equivalents (METs) and evaluates 5 key areas: performance, capacity, activity, pain, and acute care. We validated the activity levels reported by the TFSQ against the Duke Activity Status Index (DASI). METHODS: In this prospective, observational study, 120 patients completed both the TFSQ and the DASI. TFSQ-reported functional performance and capacity was correlated with DASI-calculated METs. RESULTS: Pearson correlation between TFSQ-reported capacity and DASI-calculated METs was r = 0.69, P < .001. TFSQ capacity was significantly lower in patients who reported recently decreased activity, pain affecting function, or recent acute care exposure. CONCLUSIONS: The TFSQ is a brief and efficient assessment of patient function, standardized to METs and validated against the DASI. Our study suggests that many patients may have the functional reserve to increase daily physical activity and that factors such as changes in activity, pain, and recent acute care interaction may lower functional capacity.

Comparison of traditional anesthesia method and jet injector anesthesia method (MadaJet XL®) for Nexplanon® insertion and removal.

BACKGROUND: This study compared a needle-free anesthesia method with traditional local anesthesia for insertion and removal of Nexplanon® long-acting removable contraceptive device. In our clinic, patients often avoid this highly effective form of contraception due to fear of needles. We sought to determine if patients perceived a difference in pain with the injection, anxiety level or pain with the procedure when local anesthesia was given with a needle v/s a needle-free jet injector device. METHODS: Patients were randomly assigned to one of two groups: jet injector or needle lidocaine delivery. Outcomes were ease of use, patient anxiety level, painfulness, and efficacy of anesthesia method. RESULTS: Patient pain perception with administration of jet injector lidocaine was statistically lower than traditional needle with no difference in anxiety or ease of use, or efficacy of the anesthesia. CONCLUSION: The jet injector device is a reasonable alternative to needle injection delivery of anesthesia prior to insertion/removal of Nexplanon® device. Further studies may determine whether this needle-free alternative for administration of local anesthetic would result in more women choosing Nexplanon® as a contraceptive method.

Development and implementation of a clinical decision support tool for treatment of uncomplicated urinary tract infections in a family medicine resident clinic.

OBJECTIVES: Outpatient antimicrobial stewardship has become increasingly important. While clinical decision support (CDS) tools have been effective in improving guideline-directed antibiotic prescribing, most notably for upper respiratory tract infections, their use for uncomplicated urinary tract infections (UTIs) has been less extensively studied. The objective of this study was to develop and implement a CDS tool to optimize antimicrobial prescribing for uncomplicated UTIs. SETTING: University-affiliated family medicine resident clinic. PRACTICE DESCRIPTION: This outpatient clinic is the practice site for 24 medical residents, 12 full-time faculty physicians, 1 nurse practitioner, and 1 full-time clinical pharmacist. PRACTICE INNOVATION: An interdisciplinary team including physicians, pharmacists, quality coordinator, and a coding and billing specialist collaborated to develop and implement a CDS tool into the clinic electronic health record to guide diagnosis, documentation, and antibiotic prescribing for uncomplicated UTIs. Prescribing practices were characterized, and a clinic-specific antibiogram was developed to identify focus areas for the CDS tool. EVALUATION: A retrospective chart review was conducted to evaluate empiric antibiotic prescribing before and after implementation of the CDS tool and after implementation when the tool was used or not used. RESULTS: Utilization of the tool clinic-wide was 29%. Overall fluoroquinolone use decreased from 42% to 15% after tool implementation (odds ratio [OR] 0.25; 95% CI 0.13-0.5; P < 0.001). Specifically, when the CDS tool was used, no patients received empiric therapy with fluoroquinolones (P = 0.005). With use of the tool following implementation, trimethoprim/sulfamethoxazole use decreased by 20% (OR 0.21; 95% CI 0.45-0.955; P = 0.003), nitrofurantoin for cystitis increased by 31% (OR 3.83; 95% CI 1.32-11.1; P = 0.01), and guideline-directed duration of therapy increased 32% (OR 4.34; 95% CI 1.48-12.73; P = 0.005). CONCLUSION: In an attempt to optimize empiric antimicrobial treatment for uncomplicated UTIs, we developed and implemented a CDS tool into the electronic health record in a family medicine resident clinic. Despite a 29% usage rate, many benefits were seen after tool implementation.

Assessment of Clinical Pharmacy Interventions to Reduce Outpatient Use of High-Risk Medications in the Elderly.

BACKGROUND: Use of high-risk medications in the elderly (HRME) and drug-disease (Rx-DIS) interactions in the elderly, as defined by the Healthcare Effectiveness Data and Information Set (HEDIS) Measures, are significantly associated with mortality, hospital admission, and need for emergency care. No published studies to date evaluate interventions to reduce the use of HEDIS-defined HRME, although many studies have postulated a beneficial effect of such interventions. OBJECTIVE: To evaluate the effect of pharmacist interventions on use of HRME and Rx-DIS interactions in the outpatient elderly population. METHODS: This retrospective cohort study was conducted in a resident-based family medicine clinic. Patients aged ≥ 65 years were prospectively screened for the use of HRME and Rx-DIS interactions before their visits with their primary care providers. If HRME or Rx-DIS interactions were noted, the clinical pharmacist sent messages to the physicians through the electronic medical record, alerting them of the findings with suggestions of safer alternative agents, if applicable. The recommendation acceptance rate was assessed and then compared with a historical control from a similar time frame. The primary outcome was assessed with a chi square analysis. Secondary outcomes were assessed with descriptive statistics, chi square test, and Fisher's exact test. RESULTS: HRME and/or Rx-DIS interactions were changed 25.9% of the time in the pharmacist intervention group compared with only 2.0% of the time in the historical control group (P = 0.001). The most frequently changed medication classes included skeletal muscle relaxants, benzodiazepines, and nonsteroidal anti-inflammatory drugs. Over 85% of the medication changes were preserved at the end of the study period. There was no difference between groups in the number of patients with HRME or Rx-DIS interactions. CONCLUSIONS: Clinical pharmacy interventions result in significant reductions in use of HRME and Rx-DIS interactions in the outpatient elderly population. Using electronic communication allows pharmacists to provide meaningful interventions for numerous patients receiving care in a high-volume family medicine clinic setting. DISCLOSURES: There was no funding or sponsorship for this study. Rowe reports personal fees from The Medicines Company, outside the submitted work. The other authors have nothing to disclose. Study concept and design were contributed by Jeter, Chamberlin, and Weddle, with assistance from Rowe and Franks. Weddle and Renwick collected the data, and data interpretation was performed by Weddle and Rowe, with assistance from Franks. The manuscript was written by Weddle and Rowe and revised by Weddle and Franks, assisted by Chamberlin. The abstract for the completed study was presented at the American College of Clinical Pharmacy Global Conference, San Francisco, California, October 2015, and the Southeastern Residency Conference, Athens, Georgia, April 2015 (platform presentation). The research-in-progress abstract was presented at the Tennessee Society of Health System Pharmacists, Nashville, Tennessee, February 2015; the American Society of Health System Pharmacists Midyear Clinical Meeting, Anaheim, California, December 2014; and the University HealthSystem Consortium Pharmacy Council, Anaheim, California, December 2014.

Assessing the impact of mobile technology on order verification during pharmacist participation in patient rounds.

PURPOSE: Pharmacists' use of mobile technology (MT) to verify medication orders placed during their participation in medical rounds is investigated. METHODS: A retrospective observational study was conducted at a large academic medical center to assess the impact of MT on the average time to pharmacist verification of medication orders written by general medicine staff during pharmacist participation in patient rounds. A total of 260 medication orders for 129 patients were evaluated: 146 orders processed over a one-month period during which rounding pharmacists verified orders using stationary computer terminals on patient care units and 114 orders processed using an MT device. The primary endpoint was the average time to pharmacist verification for all medication orders; average verification times for orders for specific medication classes (analgesics, antibiotics, antidiabetes drugs, and antihypertensives) were also evaluated. RESULTS: Overall, the average time to order verification was significantly lower with the use of the MT device compared with non-MT-assisted order verification (7.5 minutes versus 38.9 minutes, p < 0.001), with significant (p < 0.001) time benefits favoring MT-assisted verification for all order subsets within the evaluated medication classes. Challenges posed by the use of MT-assisted order verification included the selected device's relatively small keyboard and the frequent loss of network connections as the pharmacist moved from floor to floor within the hospital. CONCLUSION: Clinical pharmacists' use of an MT device to verify medication orders written during patient care rounds can significantly decrease the average time required for order verification relative to the use of stationary computer terminals.