30-Day Readmission Reduction in a Skilled Facility Population Through Pharmacist-Driven Medication Reconciliation.

BACKGROUND: Transitions of care can be difficult to manage and if not performed properly, can lead to increased readmissions and poor outcomes. Transitions are more complex when patients are discharged to skilled nursing facilities. PURPOSE: We assessed the impact of pharmacist-led initiatives, including medication reconciliation, on readmission rates between an academic medical center and a local skilled nursing facility (SNF). METHODS: We conducted a two-phase quality improvement project focusing on pharmacist-led medication reconciliation at different points in the transition process. All-cause 30-day readmission rates, medication reconciliation completion rates, and total pharmacist interventions were compared between the 2 groups. RESULTS: The combined intervention and baseline cohorts resulted in a 29.8% relative reduction (14.5% vs. 20.6%) in readmission rates. Medication reconciliation was completed on 93.8% of SNF admitted patients in the first phase and 97.7% of patients in the second phase. Pharmacist interventions per reconciliation were 2.39 in the first phase compared with 1.82 in the second phase. CONCLUSION: Pharmacist-led medication reconciliation can contribute to reduction of hospital readmissions from SNFs and is an essential part of the SNF transition process.

Prospective, Controlled Study of Acyclovir Pharmacokinetics in Obese Patients.

The current recommendations for intravenous (i.v.) acyclovir dosing in obese patients suggest using ideal body weight (IBW) rather than total body weight (TBW). To our knowledge, no pharmacokinetic analysis has validated this recommendation. This single-dose pharmacokinetic study was conducted in an inpatient oncology population. Enrollment was conducted by 1:1 matching of obese patients (>190% of IBW) to normal-weight patients (80 to 120% of IBW). All patients received a single dose of i.v. acyclovir, 5 mg/kg, infused over 60 min. Consistent with current recommendations, IBW was used for obese patients and TBW for normal-weight patients. Serial plasma concentrations were obtained and compared. Seven obese and seven normal-weight patients were enrolled, with mean body mass indexes of 45.0 and 22.5 kg/m(2), respectively. Systemic clearance was substantially higher in the obese than normal-weight patients (mean, 19.4 ± 5.3 versus 14.3 ± 5.4 liters/h; P = 0.047). Area under the concentration-time curve was lower in the obese patients (15.2 ± 2.9 versus 24.0 ± 9.4 mg · h/liter; P = 0.011), as was maximum concentration (5.8 ± 0.9 versus 8.2 ± 1.3 mg/liter; P = 0.031). Utilization of IBW for dose calculation of i.v. acyclovir in obese patients leads to lower systemic exposure than dosing by TBW in normal-weight patients. While not directly evaluated in this study, utilization of an adjusted body weight for dose determination appears to more closely approximate the exposure seen in normal-weight patients. (This study has been registered at ClinicalTrials.gov under registration no. NCT01714180.).

Multidisciplinary performance improvement team for reducing health care-associated Clostridium difficile infection.

Clostridium difficile is the most frequent cause of health care-associated diarrhea and is a significant cause of morbidity and mortality. It is also associated with a considerable financial burden. A concerted multidisciplinary approach is required for prevention.

Comparison of immune response to the influenza vaccine in obese and nonobese healthcare workers.

OBJECTIVE: To determine whether there is a difference in antibody titers and functionality after receipt of the influenza vaccine for obese versus nonobese healthcare workers (HCW). DESIGN: Prospective observational study. SETTING: Tertiary medical center. PARTICIPANTS: Healthcare workers. METHODS Baseline influenza antibody titers for obese and nonobese HCW were recorded during the hospital's 2011 annual influenza vaccination day and follow-up antibody titers were measured 4 weeks later. Antibodies were measured using the hemagglutination inhibition assay and functionality was measured using the micro-neutralization method. RESULTS: Of 200 initial HCWs, 190 completed the study (97 obese and 93 nonobese). Seroprotection after immunization was not significantly different for nonobese compared with obese HCW for each strain (influenza A [H1N1], 99% and 99%; influenza A [H3N2], 100% and 99%; and influenza B, 67% and 71%, respectively) All geometric mean titers measured by micro-neutralization showed statistically significant increases in activity. In comparison, there was no difference in the 4-fold increase in H1N1 or B titers. There was a significant difference in the 4-fold increase of H3N2 titers between the nonobese and obese HCWs (82/93 [88%] vs 64/97 [66%], P=.003) In an ad hoc analysis we found that obese HCWs had a statistically greater number of 4-fold decreases in titers with H1N1 and H3N2. CONCLUSIONS: There was no significant difference in protection from influenza between obese and nonobese HCWs after immunization.

Plasma and tissue cefazolin concentrations in obese patients undergoing cesarean delivery and receiving differing pre-operative doses of drug.

BACKGROUND: Patients undergoing cesarean delivery typically receive a 1-g to 2-g dose of cefazolin as pre-operative antibacterial prophylaxis. This traditional dosage may not provide an adequate tissue concentration of cefazolin in obese patients during the peri-operative period. This study compared the tissue concentrations of prophylactic cefazolin administered as a either a 2-g or a 4-g dose prior to cesarean delivery in obese patients. METHODS: Twenty obese patients (first trimester body mass index [BMI] >35) who underwent cesarean delivery completed this randomized study. Eleven patients received 2 g of cefazolin, and nine received 4 g. Blood and subcutaneous tissues were collected at the times of the incision and closure. Myometrial biopsies were collected at uterine closure. A cefazolin concentration threshold of 4 mcg/g for tissue samples was used as a surrogate adequate concentration. Plasma and tissue cefazolin concentrations were compared for the two doses. RESULTS: Mean plasma, umbilical cord, and myometrial cefazolin concentrations were significantly higher in the 4-g treatment group (p<0.05). Subcutaneous incision site tissue obtained at time of incision creation also was significantly higher in the 4-g group than in the 2-g group (40.11±24.10 mcg/g vs. 18.36±6.68 mcg/g; p=0.0005). Subcutaneous tissue concentrations at closure were significantly different in the two dosage groups (34.89±17.42 mcg/g vs. 21.73±16.02 mcg/g; p=0.044). All tissue samples were above the target of 4 mcg/g. Body morphometry did not correlate with the variability in cefazolin tissue concentration. No surgical site infections, endometritis, or other adverse effects were observed. CONCLUSIONS: Administering a prophylactic dose of 4 g of cefazolin produced blood and tissue cefazolin concentrations that were significantly higher than concentrations obtained from a 2-g dose in patients with BMIs between 35 and 60 kg/m(2) undergoing cesarean delivery. It is unclear if the larger cefazolin dose produces a more protective anti-infective effect than that obtained with the more traditional 2-g dose for cesarean delivery in obese patients.

Impact of alcohol-impregnated port protectors and needleless neutral pressure connectors on central line-associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit.

BACKGROUND: A major risk factor for the development of bloodstream infection is the presence of a central venous catheter (CVC), especially in immunocompromised patients. CVC hub contamination is a risk factor for central line-associated bloodstream infection (CLABSI). METHODS: This observational before-after trial in a tertiary care hospital's oncology unit included adult patients with a CVC. During the intervention period, the practice of central line hub care was changed from cleaning with alcohol wipes to using alcohol-impregnated port protectors. To accommodate the protectors, the needless hubs were changed to a neutral pressure connector. The intervention period (January-July 2010) was compared with a historical control (January-December 2009). RESULTS: A total of 3,005 central line-days and 1 CLABSI (a rate of 0.3 infections/1,000 central line-days) were documented during the intervention period, compared with 6,851 central line-days and 16 CLABSIs (2.3 infections/1,000 central line-days) during the control period (relative risk, 0.14; 95% confidence interval [CI], 0.02-1.07; P = .03). The rate of contaminated blood cultures (CBCs) from central lines was 2.5% (17 of 692) during the control period, but only 0.2% (1 of 470) during the intervention period (relative risk, 0.09; 95% CI, 0.01-0.65; P = .002). CONCLUSIONS: The implementation of alcohol-impregnated port protectors and needleless neutral pressure connectors significantly reduced the rates of CLABSIs and CBCs in our oncology patient population.

Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients.

BACKGROUND: Medication history taking is important because clinicians rely on the information that is collected; however, medication histories are often inaccurate and incomplete. The use of a medication at home without a corresponding disease or condition in the patient's records (ie, "unspecified" medication) warrants investigation of the need for that medication. The process of reconciling medications with current diseases or conditions on hospital admission has not been officially advocated by The Joint Commission, but it could help clinicians better assess the continued need for home medications and possibly decrease the use of polypharmacy. OBJECTIVES: The objectives of this study were to expand on a previous study conducted at our institution by estimating the prevalence of discrepancies between medication histories and reported diseases or conditions in a larger and more diverse patient population, and to determine whether a pharmacist could clarify the reasons for the unspecified medications, thereby enhancing the medication reconciliation process. METHODS: Patients >or=50 years of age who were taking >or=4 home medications were randomly selected within 24 hours of hospital admission. Medical chart information and home medication lists, obtained shortly after admission, were reviewed retrospectively for the selected patients. Patients were excluded if they were admitted directly to an intensive care unit. Only home medications that the patient continued to take after admission were included in the analysis. Therapeutic hospital formulary substitutes (eg, atorvastatin given instead of pravastatin) were considered to be the same medication. Nonprescription medications, "as needed" medications, and vitamins/supplements taken at home were excluded from analysis. If an unspecified medication was found, a pharmacist proceeded through an algorithm designed to clarify the reason for the unspecified medication. In the event of a common off-label (unapproved) use of a drug, the drug was not considered unspecified. RESULTS: Home medication lists were available for 300 patients (154 women, 146 men; mean [SD] age, 69 [10.6] years; >98% white) admitted to a 541-bed university hospital between December 2007 and June 2008; a total of 114 patients (38%) had >or=1 unspecified medication. Of the 200 unspecified medications reported in patient charts, the 2 most frequently reported drug classes were proton pump inhibitors and selective serotonin reuptake inhibitors, used by 21% and 11% of patients, respectively. Patients with unspecified medications received a higher mean number of home medications (9.7 vs 7.6 per patient; odds ratio = 1.18; 95% CI, 1.11-1.28; P < 0.001). Rates of discordance were independent of age, sex, and pathway to admission to the emergency department. Ultimately, the study pharmacist was able to clarify 96% of the unspecified medications by applying the study algorithm. Answers were provided by patients (80%), old clinic or hospital chart notes (12%), or physicians (4%); 4% could not be clarified. CONCLUSIONS: Many of the unspecified medications that were identified in this study have been associated with polypharmacy in the literature. The results of this study suggest that matching home medications with indications for those medications on admission to the hospital enhanced the medication reconciliation process. Direct patient questioning by the pharmacist clarified medication use and contributed to more accurate and complete medication history taking.

Crystal-storing histiocytosis due to massive accumulation of charcot-leyden crystals: a unique association producing colonic polyposis in a 78-year-old woman with eosinophilic colitis.

Crystal-storing histiocytosis is a rare diagnosis that to date has only been associated with 2 conditions: intracytoplasmic accumulation of crystallized immunoglobulins in patients with lymphoproliferative disorders or plasma cell dyscrasias, and histiocytic accumulations of phagocytosed clofazimine, a drug used to treat lepromatous leprosy. We describe a 78-year-old woman with a past medical history of dermatologic mastocytosis and peripheral eosinophilia who presented with diarrhea and weight loss, and was found at colonoscopy to have polyposis limited to the right and transverse colon. She eventually underwent subtotal colectomy to remove the segment of polyposis. At gross examination, the colonic mucosa contained numerous polyps ranging from 1 to 7 mm which on histologic evaluation proved to represent mucosal and submucosal collections of histiocytes whose cytoplasm was distended by numerous brightly eosinophilic crystals. An intense eosinophilic infiltrate surrounded the histiocyte collections and also mildly involved the intervening colonic mucosa and superficial submucosa. Electron microscopy confirmed the presence of intracytoplasmic material identical to Charcot-Leyden crystals within histiocytes, representing the breakdown products of degranulated eosinophils. This is the first reported case of crystal-storing histiocytosis produced by massive accumulation of Charcot-Leyden crystals in eosinophilic colitis.