Development of a Pharmacy Technician-Driven Program to Improve Vaccination Rates at an Academic Medical Center.

Background: Influenza and pneumococcal disease contribute substantially to the burden of preventable disease in the United States. Despite quality measures tied to immunization rates, health systems have struggled to achieve these targets in the inpatient setting. Pharmacy departments have had success through implementation of pharmacist standing order programs (SOP); however, these initiatives are labor-intensive and have not resulted in 100% immunization rates. Objective: The objective of this study was to evaluate a pilot utilizing pharmacy technician interventions, in combination with a nursing SOP, to improve vaccination rates of hospitalized patients for influenza and pneumococcal disease. Methods: A process was developed for pharmacy technicians to identify patients who were not previously screened or immunized during the weekend days on the Cardiovascular Progressive Care unit at the University of Kansas Health-System. Targeted pharmacy technician interventions consisted of phone call reminders and face-to-face discussions with nursing staff. The primary study outcome was the change in immunization compliance rates between the control and intervention groups. Results: Influenza vaccine rates showed a statistically significant increase from 72.2% (52 of 72) of patients during the control group to 92.9% (65 of 70, P = .001) of patients during the intervention group. A pneumococcal vaccination rate of 81.3% (61 of 75) was observed in the control group, compared with 84.3% (59 of 70) of patients in the intervention group (P = .638). Conclusion: An improvement in inpatient influenza immunization rates can be achieved through targeted follow-up performed by pharmacy technicians, in combination with a nursing-driven SOP.

Preceptor development: providing effective feedback.

Feedback plays a significant role in precepting and is indispensable in residency training. As described by the Accreditation Council for Graduate Medical Education, the goal of any postgraduate residency program is to prepare individual trainees to function as qualified practitioners. Although feedback and evaluations have traditionally been synonymous, our goal is to differentiate the two and describe the role of each within resident performance. The goal of this article is to provide preceptors with the tools to provide timely, effective, and quality feedback to residents on a regular basis. Although the focus of this article is on residency training, these concepts can be utilized in student rotations as well.

I.V. admixture contamination rates: traditional practice site versus a class 1000 cleanroom.

PURPOSE: The contamination rates associated with the preparation of medium-risk i.v. admixtures in a traditional practice site and in a class 1000 cleanroom were compared. METHODS: Simulated product media fills served as the samples. Each investigator, a pharmacist and a pharmacy technician, prepared 500 vials and 500 small-volume parenteral (SVP) bags in five separate runs at a traditional practice site and in a cleanroom. United States Pharmacopeia chapter 797 medium-risk compounding procedures were followed, and strict adherence to aseptic technique was employed. Single-strength tryptic soy broth was substituted for the drug and diluent in the admixtures. Positive and negative controls were also prepared and stored for the duration of the study. The pharmacist and technician prepared a total of 4057 samples: 2027 samples (1014 vials and 1013 SVP bags) were prepared in a class 1000 cleanroom, and 2030 (1014 vials and 1016 SVP bags) were prepared at a traditional practice site. RESULTS: Contamination rates did not significantly differ between the traditional practice site (0.296%) and the cleanroom environment (0.344%) (p = 1.0). A significant difference in the number of contaminated samples was found between the two investigators (2 of 2057 were contaminated by the pharmacist and 11 of 2000 were contaminated by the technician) (p = 0.012). Contamination rates by the pharmacist (p = 1.0) and technician (p = 1.0) did not significantly differ between sites. CONCLUSION: The most important variable affecting microbial contamination of admixtures was the aseptic technique of personnel, not the environment in which the drugs were compounded.

Implementation of standardized dosing units for i.v. medications.

PURPOSE: The implementation of standardized dosing units for six i.v. medications at an academic medical center is described. SUMMARY: During the implementation of an electronic health record system at an academic medical center, it was noticed that providers could order some i.v. medications in multiple dosing units, including epinephrine, isoproterenol, midazolam, nitroglycerin, norepinephrine, and phenylephrine. Possible options to standardize i.v. medications along with their pros and cons were presented for discussion to key providers in all of the intensive care units. Once the providers agreed on a solution, the information was presented to the pharmacy and therapeutics committee for final approval. A nursing education plan was created and administered before the standardization of dosing units was implemented. A nursing survey was conducted before and after implementation of dosing-unit standardization to determine the effectiveness of nursing education on compliance with the standardization of the dosing units for the listed medications. The survey was designed to evaluate, when given a choice, what dosing units nurses would use to administer epinephrine, isoproterenol, midazolam, nitroglycerin, norepinephrine, and phenylephrine. The decision was made by the key providers to use weight-based dosing-micrograms per kilograms per minute-to allow for consistency of use of these medications for pediatric and adult patients. Nursing education was completed to ensure that nurses were aware of how to safely administer these medications using the new dosing units. CONCLUSION: Dosing-unit standardization for dose-adjustable i.v. infusions can provide improved consistency and decrease the potential for dosing errors when administering epinephrine, isoproterenol, midazolam, nitroglycerin, norepinephrine, and phenylephrine.

Effects of a hospitalwide pharmacy practice model change on readmission and return to emergency department rates.

PURPOSE: The impact of an innovative medication reconciliation and discharge education program on 30-day readmissions and emergency department (ED) visits was evaluated. METHODS: An observational pre-post analysis was conducted at an academic medical center to compare rates of hospital readmissions and return to ED visits during three-month periods before and after implementation of a restructured pharmacy practice model including (1) medication reconciliation at transitions of care for every patient and discharge education for a high-risk subgroup, (2) new or expanded services in the preanesthesia testing clinic and ED, (3) a medication reconciliation technician team, and (4) pharmacist-to-patient ratios of 1:30 on acute care floors and 1:18 on critical care units. The primary outcome was the composite of rates of readmissions and return to ED visits within 30 days of discharge. RESULTS: A total of 3,316 patients were included in the study. Pharmacy teams completed medication reconciliation in 95.8% of cases at admission and 69.7% of cases at discharge. Discharge education was provided to 73.5% of high-risk patients (defined as those receiving anticoagulation therapy or treatment for acute myocardial infarction, chronic obstructive pulmonary disease, congestive heart failure, or pneumonia). No significant difference was observed between the preimplementation and postimplementation groups with regard to the primary outcome. In the high-risk subgroup, there was a significant reduction in the 30-day rate of hospital readmissions, which declined from 17.8% to 12.3% (p=0.042); cost projections indicated that this reduction in readmissions could yield annual direct cost savings of more than $780,000. CONCLUSION: Implementation of a team-based pharmacy practice model resulted in a significant decrease in the rate of 30-day readmissions for high-risk patients.

Leveraging drug-utilization and external benchmarking data to drive change in prescribing behaviors.

PURPOSE: Improved outcomes and cost savings achieved at a large hospital through a drug utilization benchmarking and reporting initiative are described. SUMMARY: Using the University HealthSystem Consortium (UHC) Clinical Resource Manager (CRM) database, the University of Kansas Hospital identified nine target areas (based on Medicare Severity Diagnosis-Related Group) in which the hospital's drug-utilization practices were deemed suboptimal relative to those of other UHC member facilities with similar caseloads. The pharmacy department developed a CRM template for generating customized reports comparing the hospital's performance on various drug-utilization metrics with that of top-performing peers (i.e., institutions achieving the best patient care outcomes in terms of mortality and length of stay) in the nine target areas. A pre-post comparison of drug-utilization data collected before and after implementation of the reporting initiative indicated improved outcomes in all nine initially selected target areas, with estimated cumulative annualized cost savings of about $900,000. The CRM-generated reports are now distributed semiannually to attending physicians and other hospital leaders via electronic and hard-copy means, focusing on variances from UHC top-performer and overall UHC averages in the use of higher-cost drugs. The reporting initiative has generally fostered enhanced physician-pharmacist collaboration in the investigation of identified drug-utilization variances and implementation of practice changes. CONCLUSION: By evaluating service-specific trends of internal drug utilization against external benchmarks and emulating prescribing practices at top-performing institutions, an academic medical center has achieved improved patient care outcomes and cost savings.

Compliance with recommendations for prevention and detection of controlled-substance diversion in hospitals.

PURPOSE: The use of recommended practices for preventing and detecting diversion of prescription controlled substances at U.S. acute-care institutions, as reported by a sample of pharmacy service providers, were characterized. METHODS: A 41-item questionnaire was developed for an online survey of directors of pharmacy regarding strategies to combat controlled-substance diversion at their institutions. The survey questions were based on recommendations presented in a 2007 series of articles in the professional literature focusing on diversion control in three areas (the pharmacy, the operating room, and nursing units). Only institutions that had an accredited pharmacy residency program or were members of the University HealthSystem Consortium (UHC), an alliance of U.S. academic medical centers and affiliated hospitals, were targeted for the survey. Four hundred ninety-nine pharmacists were invited to participate in the survey, and 140 survey responses were received; all respondents did not answer all questions. RESULTS: The survey responses indicated considerable variation among the institutions in the use of 37 specific recommended practices, as reported by the pharmacy providers. Statistical analysis of comparative data suggested that larger institutions (400 or more licensed beds) were more likely to be using more of the recommended practices. CONCLUSION: The results of a survey of directors of pharmacy at a sample of U.S. institutions (hospitals that had pharmacy residency programs or were UHC members) suggest wide variation in facilities' use of recommended practices for the prevention and detection of controlled-substance diversion.

Telepharmacy and bar-code technology in an i.v. chemotherapy admixture area.

PURPOSE: A program using telepharmacy and bar-code technology to increase the presence of the pharmacist at a critical risk point during chemotherapy preparation is described. SUMMARY: Telepharmacy hardware and software were acquired, and an inspection camera was placed in a biological safety cabinet to allow the pharmacy technician to take digital photographs at various stages of the chemotherapy preparation process. Once the pharmacist checks the medication vials' agreement with the work label, the technician takes the product into the biological safety cabinet, where the appropriate patient is selected from the pending work list, a queue of patient orders sent from the pharmacy information system. The technician then scans the bar code on the vial. Assuming the bar code matches, the technician photographs the work label, vials, diluents and fluids to be used, and the syringe (before injecting the contents into the bag) along with the vial. The pharmacist views all images as a part of the final product-checking process. This process allows the pharmacist to verify that the correct quantity of medication was transferred from the primary source to a secondary container without being physically present at the time of transfer. CONCLUSION: Telepharmacy and bar coding provide a means to improve the accuracy of chemotherapy preparation by decreasing the likelihood of using the incorrect product or quantity of drug. The system facilitates the reading of small product labels and removes the need for a pharmacist to handle contaminated syringes and vials when checking the final product.

Nationwide antibiogram analysis using NCCLS M39-A guidelines.

Lack of standardization in antibiogram (ABGM) preparation (the overall profile of antimicrobial susceptibility results of a microbial species to a battery of antimicrobial agents) has not been addressed until recently. The objective of this study was to analyze current antibiograms using the recently published NCCLS M39-A guidelines for preparation of antibiograms to identify areas for improvement in the reporting of antibiogram susceptibility data. Antibiograms from across the United States were obtained by various methods, including direct mailings, Internet searches, and professional contacts. Each ABGM collected was analyzed using prospectively defined elements from the M39-A guidelines. Additionally, seven quality indicators were also evaluated to look for the reporting of any atypical or inappropriate susceptibility data. The 209 antibiograms collected from 149 institutions showed at least 85% compliance to 5 of the 10 M39-A elements analyzed. Clinically relevant elements not met included annual analysis, duplicate isolate notation, and the exclusion of organisms with fewer than 10 isolates. As for the quality indicators evaluated, unexpected results included the 7% of antibiograms that reported <100% vancomycin susceptibility for Staphylococcus aureus, 24% that had inconsistent beta-lactam susceptibility for Staphylococcus aureus, 20% that reported <100% imipenem susceptibility for Escherichia coli, and 37% that reported >0% ampicillin susceptibility for Klebsiella pneumoniae. These findings suggest that antibiograms should be reviewed thoroughly by infectious disease specialists (physicians and pharmacists), clinical microbiologists, and infection control personnel for identification of abnormal findings prior to distribution.