Utilizing Pharmacists to Optimize Medication Management Strategies During the COVID-19 Pandemic.

As the COVID-19 pandemic swept through the United States, our heath-system mobilized clinical pharmacy services to address critical clinical medication management needs. Reinforcing recommended medication management strategies for clinical pharmacists was key to successful implementation. Best practice strategies include converting patients from intravenous (IV) to oral medication, transitioning to IV push medication administration, evaluating standard medication administration timing, reviewing metered dose inhaler (MDI) and nebulizer utilization, using alternatives for medications in short supply, reviewing coronavirus disease COVID-19 treatment recommendations, reviewing COVID-19 patient care on interdisciplinary rounds, de-prescribing and de-escalating to eliminate unnecessary medications, and assessing for appropriate venous thromboembolism prophylaxis. These strategies served to help protect medication supply, reduce number of staff entries into patient rooms to conserve personal protective equipment, limit nursing time in patient rooms to reduce COVID-19 exposure risk, and to conserve compounding supplies. Here we present example medication management guidance as used by a large healthcare system during the COVID-19 pandemic.

Using inpatient electronic medical records to study influenza for pandemic preparedness.

BACKGROUND: We assessed the ability to identify key data relevant to influenza and other respiratory virus surveillance in a large-scale US-based hospital electronic medical record (EMR) dataset using seasonal influenza as a use case. We describe characteristics and outcomes of hospitalized influenza cases across three seasons. METHODS: We identified patients with an influenza diagnosis between March 2017 and March 2020 in 140 US hospitals as part of the US FDA's Sentinel System. We calculated descriptive statistics on the presence of high-risk conditions, influenza antiviral administrations, and severity endpoints. RESULTS: Among 5.1 million hospitalizations, we identified 29,520 hospitalizations with an influenza diagnosis; 64% were treated with an influenza antiviral within 2 days of admission, and 25% were treated >2 days after admission. Patients treated >2 days after admission had more comorbidities than patients treated within 2 days of admission. Patients never treated during hospitalization had more documentation of cardiovascular and other diseases than treated patients. We observed more severe endpoints in patients never treated (death = 3%, mechanical ventilation [MV] = 9%, intensive care unit [ICU] = 26%) or patients treated >2 days after admission (death = 2%, MV = 14%, ICU = 32%) than in patients treated earlier (treated on admission: death = 1%, MV = 5%, ICU = 23%, treated within 2 days of admission: death = 1%, MV = 7%, ICU = 27%). CONCLUSIONS: We identified important trends in influenza severity related to treatment timing in a large inpatient dataset, laying the groundwork for the use of this and other inpatient EMR data for influenza and other respiratory virus surveillance.

Medical chart validation of inpatient diagnosis codes for transfusion-related acute lung injury 2013-2015.

INTRODUCTION: Transfusion-related acute lung injury (TRALI), an adverse event occurring during or within 6 hours of transfusion, is a leading cause of transfusion-associated fatalities reported to the US Food and Drug Administration. There is limited information on the validity of diagnosis codes for TRALI recorded in inpatient electronic medical records (EMRs). STUDY DESIGNS AND METHODS: We conducted a validation study to establish the positive predictive value (PPV) of TRALI International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes recorded within a large hospital system between 2013 and 2015. A physician with critical care expertise confirmed the TRALI diagnosis. As TRALI is likely underdiagnosed, we used the specific code (518.7), and codes for respiratory failure (518.82) in combination with transfusion reaction (999.80, 999.89, E934.7). RESULTS: Among almost four million inpatient stays, we identified 208 potential TRALI cases with ICD-9-CM codes and reviewed 195 medical records; 68 (35%) met clinical definitions for TRALI (26 [38%] definitive, 15 [22%] possible, 27 [40%] delayed). Overall, the PPV for all inpatient TRALI diagnoses was 35% (95% confidence interval (CI), 28-42). The PPV for the TRALI-specific code was 44% (95% CI, 35-54). CONCLUSION: We observed low PPVs (<50%) for TRALI ICD-9-CM diagnosis codes as validated by medical charts, which may relate to inconsistent code use, incomplete medical records, or other factors. Future studies using TRALI diagnosis codes in EMR databases may consider confirming diagnoses with medical records, assessing TRALI ICD, Tenth Revision, Clinical Modification codes, or exploring alternative ways for of accurately identifying TRALI in EMR databases. KEY POINTS: In 169 hospitals, we identified 208 potential TRALI cases, reviewed 195 charts, and confirmed 68 (35%) cases met TRALI clinical definitions. As many potential TRALI cases identified with diagnosis codes did not meet clinical definitions, medical record confirmation may be prudent.

Patient characteristics and admitting vital signs associated with coronavirus disease 2019 (COVID-19)-related mortality among patients admitted with noncritical illness.

OBJECTIVE: To determine risk factors for mortality among COVID-19 patients admitted to a system of community hospitals in the United States. DESIGN: Retrospective analysis of patient data collected from the routine care of COVID-19 patients. SETTING: System of >180 acute-care facilities in the United States. PARTICIPANTS: All admitted patients with positive identification of COVID-19 and a documented discharge as of May 12, 2020. METHODS: Determination of demographic characteristics, vital signs at admission, patient comorbidities and recorded discharge disposition in this population to construct a logistic regression estimating the odds of mortality, particular for those patients characterized as not being critically ill at admission. RESULTS: In total, 6,180 COVID-19+ patients were identified as of May 12, 2020. Most COVID-19+ patients (4,808, 77.8%) were admitted directly to a medical-surgical unit with no documented critical care or mechanical ventilation within 8 hours of admission. After adjusting for demographic characteristics, comorbidities, and vital signs at admission in this subgroup, the largest driver of the odds of mortality was patient age (OR, 1.07; 95% CI, 1.06-1.08; P < .001). Decreased oxygen saturation at admission was associated with increased odds of mortality (OR, 1.09; 95% CI, 1.06-1.12; P < .001) as was diabetes (OR, 1.57; 95% CI, 1.21-2.03; P < .001). CONCLUSIONS: The identification of factors observable at admission that are associated with mortality in COVID-19 patients who are initially admitted to non-critical care units may help care providers, hospital epidemiologists, and hospital safety experts better plan for the care of these patients.

Changes in hospitalized coronavirus disease 2019 (COVID-19) patient characteristics and resource use in a system of community hospitals in the United States.

Coronavirus disease 2019 (COVID-19) has migrated to regions that were initially spared, and it is likely that different populations are currently at risk for illness. Herein, we present our observations of the change in characteristics and resource use of COVID-19 patients over time in a national system of community hospitals to help inform those managing surge planning, operational management, and future policy decisions.

Pharmacy Services Reboot Roadmap: Resiliency During the COVID-19 Pandemic.

Description Planning for resumption of patient care services during and following the impact of novel coronavirus disease-2019 (COVID-19) while controlling costs are essential for pharmacy services resiliency. Implementation of a pharmacy services reboot roadmap across a 179 hospital health-system is described. The roadmap encompassed eight key areas: pharmacy leadership, staffing and scheduling, clinical pharmacy services, medication safety, medication supply, regulatory and compliance, team support opportunities, and financial stewardship. A supporting checklist and volume-based staffing plan are included as examples to assist pharmacy leaders in planning optimal pharmacy services support as patient volumes increase, particularly in the emergency department, surgical services and critical care areas. Resiliency strategies are provided as tangible planning considerations to assess the current status of, and prepare for, future operational and clinical pharmacy practice needs to support optimal patient care.

Implementation of standardized pediatric i.v. medication concentrations.

PURPOSE: The development and implementation of a comprehensive and standardized list of pediatric i.v. medication concentrations across a large healthcare system are described. SUMMARY: In accordance with National Patient Safety Goals, facilities affiliated with the Hospital Corporation of America system had independently standardized and limited the number of drug concentrations in use. This resulted in variation among facilities, which prevented the systemwide standardization of drug dictionaries within the computerized pharmacy and prescriber-order-entry systems, complicated the movement of providers among facilities, and contributed to inconsistency in medication prescribing. A team of experts collaborated to create a comprehensive standard list that included 119 medications and 372 concentrations for pediatric i.v. medications. Implementation of this standard list was driven through a financial incentive from the malpractice insurance provider; facilities that completed the required activities for this optional program could apply for a credit of a portion of their malpractice insurance cost. For the standardization of pediatric i.v. medications, required activities included approval of the standard medication list, incorporation of this list into facility pharmacy dictionaries, and update of all smart pump software to include only the new standard medications and concentrations. Of the 145 facilities that were eligible for the implementation of standard pediatric i.v. medication concentrations, 141 (97%) completed all requirements and received the 2% malpractice insurance cost credit. CONCLUSION: The use of a financial incentive strategy, in the form of a malpractice insurance credit, successfully motivated the implementation of standardized pediatric medication concentrations across a large healthcare system.