Impact of Clinical Pharmacy Surveillance on Pharmacy Services: A Quality Improvement Project.

GOAL: The purpose of this quality improvement project was to retrospectively evaluate pharmacist time to clinical surveillance alert intervention before and after implementing a pharmacy-directed alert priority category across a large for-profit United States health system with well-established clinical pharmacy surveillance software integrated into the clinical pharmacy workflow. The findings contributed to a financial evaluation of pharmacist productivity compared with drug spend for pharmacy-directed interventions that included intravenous (IV)-to-oral-conversion and renal dosing opportunities. METHODS: A retrospective quality improvement pre-/postanalysis of deidentified, prepopulated clinical surveillance alert data for the preimplementation period of January 1, 2021, through September 30, 2021, was compared with that for the postimplementation period of November 1, 2021, to January 31, 2022, for 169 hospitals. Clinical pharmacist workflow was mapped pre- and postimplementation. The average time to alert intervention was calculated using the mean time in minutes between the alert firing within the software and when the pharmacist reviewed the alert, grouped by hospital, alert status, and priority category. Medications converted from IV to oral were assessed using the clinical surveillance software IV-to-oral calculator. Postimplementation renal dose cost savings were modeled using pharmacist-completed alerts by rule name that indicated a possible dose decrease based on the patient's renal function and current medication. PRINCIPAL FINDINGS: Time to alert intervention for all completed pharmacist interventions was reduced for high-priority alerts by 32.6 min (p < .001) and routine-priority alerts by 65.1 min (p = .147). Alerts that moved to the pharmacy-directed alert priority category resulted in a reduced time to alert intervention of 38.7 min (p = .003). Normalized average wholesale price (AWP) cost savings from IV-to-oral conversion within 3 days of conversion eligibility were $1,693,600 in the preimplementation period and $1,867,400 in the postimplementation period, a $173,700 increase in cost savings. A total of 7,972 completed postimplementation renal dose adjustments resulted in a modeled AWP normalized cost savings of $1,076,700. PRACTICAL APPLICATIONS: Results indicated that optimizing clinical surveillance software alerts was effective and increased pharmacist productivity. Specifically, creating a pharmacy-directed alert category that pharmacists were able to complete by hospital policy or protocol improved workflow efficiency and increased IV-to-oral medication conversion cost savings. Further study is needed to validate the renal dose-modeled cost savings and address the financial benefits of quality measures to prevent acute kidney injury.

The Impact of Coronavirus Disease 2019 (COVID-19) on Healthcare-Associated Infections.

BACKGROUND: The profound changes wrought by coronavirus disease 2019 (COVID-19) on routine hospital operations may have influenced performance on hospital measures, including healthcare-associated infections (HAIs). We aimed to evaluate the association between COVID-19 surges and HAI and cluster rates. METHODS: In 148 HCA Healthcare-affiliated hospitals, from 1 March 2020 to 30 September 2020, and a subset of hospitals with microbiology and cluster data through 31 December 2020, we evaluated the association between COVID-19 surges and HAIs, hospital-onset pathogens, and cluster rates using negative binomial mixed models. To account for local variation in COVID-19 pandemic surge timing, we included the number of discharges with a laboratory-confirmed COVID-19 diagnosis per staffed bed per month. RESULTS: Central line-associated blood stream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia increased as COVID-19 burden increased. There were 60% (95% confidence interval [CI]: 23-108%) more CLABSI, 43% (95% CI: 8-90%) more CAUTI, and 44% (95% CI: 10-88%) more cases of MRSA bacteremia than expected over 7 months based on predicted HAIs had there not been COVID-19 cases. Clostridioides difficile infection was not significantly associated with COVID-19 burden. Microbiology data from 81 of the hospitals corroborated the findings. Notably, rates of hospital-onset bloodstream infections and multidrug resistant organisms, including MRSA, vancomycin-resistant enterococcus, and Gram-negative organisms, were each significantly associated with COVID-19 surges. Finally, clusters of hospital-onset pathogens increased as the COVID-19 burden increased. CONCLUSIONS: COVID-19 surges adversely impact HAI rates and clusters of infections within hospitals, emphasizing the need for balancing COVID-related demands with routine hospital infection prevention.

Evaluating the Risk Factors for Hospital-Onset Clostridium difficile Infections in a Large Healthcare System.

In this multicenter retrospective cohort study of over 1 million patients at 150 US hospitals, proton pump inhibitors increased the odds of a patient having hospital-onset Clostridium difficile infection as did third and fourth generation cephalosporins, carbapenems, and piperacillin/tazobactam. These findings support appropriate prescribing of acid-suppression therapy and high-risk antibiotics.

Balancing statistical and ethical considerations in planning clinical trials: recommendations for response-adaptive randomization urn designs.

During a clinical trial, balancing statistical and ethical considerations are important. Response-adaptive randomization methods use the information from past patients to increase the probability of the next patient receiving the better treatment while avoiding the statistical concern of selection bias. We compared three response-adaptive randomization urn designs, Randomized Play-the-Winner, Modified Play-the-Winner, and Birth-and-Death Urn with Immigration, to the traditional equal allocation design with respect to power and allocation of patients to the better treatment. Because these designs have been described separately, our motivation was to systematically compare them and provide recommendations. With simulations, we varied sample size and combinations of treatment and control success probabilities. We also compared the response-adaptive randomization designs using exact distribution algorithms and applied them to past clinical trial data that used an equal allocation design. We conclude that Modified Play-the-Winner tends to be unpredictable and can result in allocation of all of the patients to the better treatment. Randomized Play-the-Winner allocates more patients to the better treatment than Birth-and-Death Urn with Immigration, but Birth-and-Death Urn with Immigration is more consistent in its allocations. Randomized Play-the-Winner and Birth-and-Death Urn with Immigration produce allocations that have comparable powers to equal allocation design.

Health Care-Associated Infections Among Hospitalized Patients With COVID-19, March 2020-March 2022.

Importance: The reported incidence of many health care-associated infections (HAIs) increased during the COVID-19 pandemic; however, it is unclear whether this is due to increased patient risk or to increased pressure on the health care system. Objective: To assess HAI occurrence among patients admitted to hospitals with and without COVID-19. Design, Setting, and Participants: A cross-sectional retrospective analysis of inpatients discharged both with and without laboratory-confirmed COVID-19 infection was conducted. Data were obtained between January 1, 2019, and March 31, 2022, from community hospitals affiliated with a large health care system in the US. Exposure: COVID-19 infection. Main Outcomes and Measures: Occurrence of central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, and Clostridioides difficile infection as reported to the National Healthcare Safety Network. Results: Among nearly 5 million hospitalizations in 182 hospitals between 2020 and 2022, the occurrence of health care-associated infections (HAIs) was high among the 313 200 COVID-19 inpatients (median [SD] age, 57 [27.3] years; 56.0% women). Incidence per 100 000 patient-days showed higher HAIs among those with COVID-19 compared with those without. For CLABSI, the incidence for the full 9 quarters of the study was nearly 4-fold higher among the COVID-19 population than the non-COVID-19 population (25.4 vs 6.9). For CAUTI, the incidence in the COVID-19 population was 2.7-fold higher in the COVID-19 population (16.5 vs 6.1), and for MRSA, 3.0-fold higher (11.2 vs 3.7). Quarterly trends were compared with the same quarter in 2019. The greatest increase in the incidence of HAI in comparison with the same quarter in 2019 for the entire population occurred in quarter 3 of 2020 for CLABSI (11.0 vs 7.3), quarter 4 of 2021 for CAUTI (7.8 vs 6.8), and quarter 3 of 2021 for MRSA (5.2 vs 3.9). When limited to the non-COVID-19 population, the increase in CLABSI incidence vs the 2019 incidence was eliminated, and the quarterly rates of MRSA and CAUTI were lower vs the prepandemic 2019 comparator quarter. Conclusions and Relevance: In this cross-sectional study of hospitals during the pandemic, HAI occurrence among inpatients without COVID-19 was similar to that during 2019 despite additional pressures for infection control and health care professionals. The findings suggest that patients with COVID-19 may be more susceptible to HAIs and may require additional prevention measures.

Impact of Adherence to a Standardized Oxytocin Induction Protocol on Obstetric and Neonatal Outcomes.

BACKGROUND: Oxytocin protocols are employed to induce uterine contractions and progressive cervical changes, but they are associated with adverse maternal and neonatal outcomes. The aim of this study was to determine whether compliance with a checklist-based protocol for oxytocin administration was associated with changes in neonatal and maternal outcomes. METHODS: A retrospective cohort study of 86,786 pregnant women undergoing term (> 37 weeks) induction of labor between January 2015 and December 2017 was performed. Systemwide training in the use of an oxytocin administration protocol was provided to obstetricians and nurses. Pre-use and in-use oxytocin checklists were incorporated into each unit's policies and procedures. Subsequently, charts were reviewed and individually audited by an obstetric nurse who scored each record based on the documentation of variables in an oxytocin administration protocol and ranked adherence as complete or absent. Primary outcomes were postpartum hemorrhage, neonatal ICU (NICU) admission, and delivery by cesarean section. Bivariate analyses (t-tests) were performed on adherent and nonadherent groups for comparison of selected demographic variables and the primary outcome variables. Logistic regression was completed on the primary outcome variable with eight covariates. RESULTS: Among patients with complete adherence to the oxytocin administration protocol, the rate of cesarean section in the unadjusted analysis was 16.20%, compared to 18.54% for those with incomplete adherence; the rates of postpartum hemorrhage were 2.64% vs. 3.14%, respectively, and the rates of NICU admission were 3.03% vs. 3.86%, respectively. In the multivariable logistic regression, complete protocol adherence was associated with significantly lower odds of postpartum hemorrhage (adjusted odds ratio [OR] 0.85, 95% confidence interval [CI] 0.76-0.94) but higher odds of Cesarean section (adjusted OR 1.07, 95% CI 1.01-1.13); the adjusted OR for NICU admission was 0.90, which did not reach statistical significance (95% CI 0.81-1.00). Among the covariates, nulliparity and elective induction were the strongest predictors of the primary outcomes of cesarean section, postpartum hemorrhage, and NICU admission. CONCLUSION: Adherence to the oxytocin administration protocol was associated with a decrease in postpartum hemorrhage but an increased risk of delivery by cesarean section.

Pharmacy-Led Medication Reconciliation Program Reduces Adverse Drug Events and Improves Satisfaction in a Community Hospital.

Background: Pharmacy-led medication reconciliation identifies and corrects medication errors that can potentially cause moderate to severe harm. This research sought to identify the impact of pharmacy-led medication reconciliation on patient outcomes and describe the changes in healthcare workers' perceptions of the program. Methods: A pharmacy-led admission medication reconciliation program pilot started in July 2019, and a discharge medication reconciliation proof of concept was tested in September 2020 at a 432-bed hospital. The following periods were compared: August 2018 to February 2019 (pre-program implementation) and August 2019 to February 2020 (post-program implementation). Endpoints included patient outcomes, workforce productivity and interdisciplinary healthcare team satisfaction through program surveys. Patient outcomes were assessed with chisquared tests. Survey responses were assessed using the Likert scale. Descriptive statistics were used for productivity outcomes and the number of discharge medication reconciliations completed. Results: Approximately 18,000 admissions were recorded for each period. The adverse drug event (ADE) rate decreased 49% (p < 0.001), and the complication rate decreased 29.7% (p = 0.001). During post-pilot implementation, 6,530 medication histories were completed, and 70,050 medications were reviewed. Of medication histories completed, 22.6% of patient allergies/adverse drug reactions were updated, 52.3% of medications were clarified, and 54.7% of preferred outpatient pharmacies were updated. Pharmacy services completed medication histories in 38.8% of inpatients. In the proof of concept, 168 discharge medication lists were drafted. Survey results showed statistically significant improvement in healthcare team satisfaction. Conclusion: A pharmacy-led medication reconciliation program involving designated pharmacists and pharmacy technicians has shown to decrease ADEs and complications while improving interdisciplinary healthcare team satisfaction.

Association of obstetric intervention with temporal patterns of childbirth.

OBJECTIVE: To examine the gestational age at and day and time of delivery in current U.S. obstetric practice. METHODS: We examined electronic records from 72 hospitals in 16 states during a 4-month period during 2013. Day of week of delivery, time of day of delivery, and route of delivery were examined in various subpopulations delivering both with and without obstetric intervention. RESULTS: Records of 21,381 women were examined. The distribution curve for gestational age at delivery peaked at 39 weeks both for the entire group and for the subgroup entering labor spontaneously and delivering vaginally without augmentation. Statistical modeling suggests that medical intervention accounts for only a fraction of the shift in distribution peak from 40 to 39 weeks of gestation. Three temporal peaks of total and primary cesarean delivery were seen on weekdays, corresponding to immediate preclinic, lunch time, and immediate postclinic timeframes. These peaks were not seen on weekend days. The risk of nonelective primary cesarean delivery during a weekday was approximately one third higher than on a weekend (relative rate 1.36, confidence interval 1.24-1.49). CONCLUSION: The recently described shift in peak distribution of U.S. gestational age at delivery from 40 to 39 weeks of gestation may reflect an underlying physiologic change in the U.S. population and is not exclusively related to obstetric intervention. During the work week, factors other than medical necessity appear to have a marked association with both timing of delivery and rate of cesarean delivery and may affect up to one third of primary cesarean deliveries.