Strategies for success in creating an effective multihospital health-system pharmacy and therapeutics committee.

PURPOSE: Lessons learned from the creation of a multihospital health-system formulary management and pharmacy and therapeutics (P&T) committee are described. SUMMARY: A health system can create and implement a multihospital system formulary and P&T committee to provide evidence-based medications for ideal healthcare. The formulary and P&T process should be multidisciplinary and include adequate representation from system hospitals. The aim of a system formulary and P&T committee is standardization; however, the system should allow flexibility for differences. Key points for a successful multihospital system formulary and P&T committee are patience, collaboration, resilience, and communication. When establishing a multihospital health-system formulary and P&T committee, the needs of individual hospitals are crucial. A designated member of the pharmacy department needs to centrally coordinate and manage formulary requests, medication reviews and monographs, meeting agendas and minutes, and a summary of decisions for implementation. It is imperative to create a timeline for formulary reviews to set expectations, as well as a process for formulary appeals. Collaboration across the various hospitals is critical for successful formulary standardization. When implementing a health-system P&T committee or standardizing a formulary system, it is important to be patient and give local sites time to make practice changes. Evidence-based data and rationale must be provided to all sites to support formulary changes. Finally, there must be multidisciplinary collaboration. CONCLUSION: There are several options for formulary structures and P&T committees in a health system. Potential strengths and barriers should be evaluated before selecting a formulary management process.

Institutional care paths: Development, implementation, and evaluation.

PURPOSE: The Cleveland Clinic experience with care paths, including their creation and implementation, challenges overcome during development and testing, and outcomes of selected care path evaluations, is described. SUMMARY: Care paths are tools to assist healthcare professionals in practicing evidence-based medicine. The Cleveland Clinic health system has implemented or is developing approximately 100 care paths, including care paths designed to optimize management of sepsis and septic shock and to promote timely use of i.v. tissue plasminogen activator and correct dosing of antithrombotics and statins in patients with stroke. Key steps in successful care path initiatives include (1) identifying key stakeholders, (2) achieving stakeholder consensus on a standardized approach to disease or condition management, (3) cultivating provider awareness of care paths, (4) incorporating care path tools into the electronic health record and workflow processes, and (5) securing the resources to develop, implement, and maintain care paths. Electronic health records facilitate the use of and adherence to care paths. After care path implementation, revisions are typically needed due to unexpected issues not initially identified and to optimize care path features and support resources for clinical practice. Ongoing evaluation is required to determine whether an implemented care path is producing the intended patient and quality performance outcomes. CONCLUSION: Care paths provide a standardized approach to treatment or prevention of a disease or condition, reducing unnecessary variability and expense while promoting optimal, cost-effective patient care.

Development of a pharmacy resident rotation to expand decentralized clinical pharmacy services.

PURPOSE: The development of a pharmacy resident rotation to expand decentralized clinical pharmacy services is described. SUMMARY: In an effort to align with the initiatives proposed within the ASHP Practice Advancement Initiative, the department of pharmacy at Cleveland Clinic, a 1,400-bed academic, tertiary acute care medical center in Cleveland, Ohio, established a goal to provide decentralized clinical pharmacy services for 100% of patient care units within the hospital. Patient care units that previously had no decentralized pharmacy services were evaluated to identify opportunities for expansion. Metrics analyzed included number of medication orders verified per hour, number of pharmacy dosing consultations, and number of patient discharge counseling sessions. A pilot study was conducted to assess the feasibility of this service and potential resident learning opportunities. A learning experience description was drafted, and feedback was solicited regarding the development of educational components utilized throughout the rotation. Pharmacists who were providing services to similar patient populations were identified to serve as preceptors. Staff pharmacists were deployed to previously uncovered patient care units, with pharmacy residents providing decentralized services on previously covered areas. A rotating preceptor schedule was developed based on geographic proximity and clinical expertise. An initial postimplementation assessment of this resident-driven service revealed that pharmacy residents provided a comparable level of pharmacy services to that of staff pharmacists. Feedback collected from nurses, physicians, and pharmacy staff also supported residents' ability to operate sufficiently in this role to optimize patient care. CONCLUSION: A learning experience developed for pharmacy residents in a large medical center enabled the expansion of decentralized clinical services without requiring additional pharmacist full-time equivalents.

Liposomal bupivacaine versus continuous infusion bupivacaine via an elastomeric pump for the treatment of postoperative pain.

PURPOSE: The duration of analgesia and comparative efficacy of liposomal bupivacaine and an elastomeric bupivacaine pump in a diverse surgical population were determined. METHODS: A retrospective cohort study was conducted to evaluate patient outcomes following liposomal bupivacaine and elastomeric bupivacaine pump use from January through June 2013. The primary objective of the study was to evaluate 24-hour postoperative opioid use (in morphine equivalents). RESULTS: Sixty-seven liposomal bupivacaine and 262 elastomeric bupivacaine pump patients were included. Significant between-group differences were seen in American Society of Anesthesiologists physical status, patient-controlled analgesia use, postoperative nonopioid use, and surgical procedure. On univariate analysis, liposomal bupivacaine-in comparison with elastomeric bupivacaine pump -was associated with reduced median (interquartile range, IQR) 24-hour postoperative opioid use (33.0 mg morphine equivalents [IQR, 19.0-80.4 mg morphine equivalents] versus 70.4 mg morphine equivalents [IQR, 37.1-115.4 mg morphine equivalents], p < 0.001) and median 72-hour postoperative opioid use (61.3 mg morphine equivalents [IQR, 28.7-142.8 mg morphine equivalents] versus 115.9 mg morphine equivalents [IQR, 69.9-175.4 mg morphine equivalents], p < 0.001). However, after adjustment for potential confounders with linear regression analysis, study medication was not associated with a decrease in 24-hour (ß coefficient for elastomeric bupivacaine pump: 10.26; 95% confidence interval [CI]: -8.42 to 28.95; p = 0.281) or 72-hour postoperative opioid use (ß coefficient for elastomeric bupivacaine pump: 2.23; 95% CI: -29.88 to 34.34; p = 0.891). CONCLUSION: No difference was found between patients who received liposomal bupivacaine compared with elastomeric continuous infusion bupivacaine from a traditional pump in 24- or 72-hour postoperative opioid utilization after adjustment for baseline differences.

Curcumin for inflammatory bowel disease: a review of human studies.

OBJECTIVE: To evaluate the use of curcumin in inflammatory bowel disease. DATA SOURCES: ALTMEDEX, Comprehensive Database of Natural Medicines, MEDLINE/PubMed were searched from January 1980 through May 2009 using the terms curcumin, turmeric, ulcerative colitis, Crohn's disease, Curcuma longa, Curcuma domestica, Indian saffron, inflammatory bowel disease. Data was limited to human trials. References of identified articles were reviewed. DATA SYNTHESIS: Data evaluating the use of curcumin in inflammatory bowel disease (including ulcerative colitis and Crohn's disease) is limited to two studies comprising data for only 99 patients. Curcumin in conjunction with mainstream therapy, consisting of sulfasalazine (SZ) or mesalamine (5-aminosalicylic acid [5-ASA] derivatives) or corticosteroids was shown to improve patient symptoms and allow for a decrease in the dosage of corticosteroids or 5-ASA derivatives. In one small study of 10 patients, some patients even stopped taking corticosteroids or 5-ASA. CONCLUSIONS: Although two small studies have shown promising results, all authors conclude that larger-scale, double-blind trials need to be conducted to establish a role for curcumin in the treatment of ulcerative colitis. In addition to improving results when used in conjunction with conventional medications for UC, curcumin may pose a less-expensive alternative.

Acute stroke with high-dose intravenous immune globulin.

PURPOSE: A case of acute stroke in a patient who was receiving high-dose intravenous immune globulin (IVIG) for dermatomyositis is reported. SUMMARY: A 43-year-old woman presented with overwhelming proximal weakness and myalgias, swelling in her hands, facial and knee rash, generalized fatigue, numbness in her left arm, and lower-back pain. Physical examination revealed that she had symptoms consistent with dermatomyositis. The patient was initially treated with prednisone but developed a severe adverse drug reaction to the medication. The prednisone was discontinued, and the patient was admitted to the hospital for a first-time dose of IVIG therapy. During the infusion, the patient was found to have a facial droop, left-sided hemiplegia, and an increase in restlessness. A large, significant right internal carotid artery occlusion was discovered and initially treated mechanically and then with drugs in an attempt to establish revascularization. A subsequent computed tomography scan of the brain demonstrated a large right-middle cerebral distribution infarct with slight hemorrhage into the basal ganglia. IVIG is increasingly being used for many approved and non-approved indications. Although rare, stroke associated with thrombosis caused by the administration of IVIG has been reported in the literature. On the basis of the Naranjo probability scale, this adverse drug event was calculated as a probable reaction due to the administration of IVIG. CONCLUSION: A patient had an acute stroke after receiving a high dose of IVIG for dermatomyositis. Patients should be given a slower rate of infusion and smaller dosages of IVIG, and they should be closely monitored for potential stroke associated with thrombosis during IVIG therapy.

Clinical and economic outcomes in thrombolytic treatment of peripheral arterial occlusive disease and deep venous thrombosis.

PURPOSE: Over the past 2 decades the use of thrombolytic therapy in the management of peripheral occlusive diseases, most notably peripheral arterial occlusion (PAO) and deep venous thrombosis (DVT), has become an accepted and potentially preferable alternative to surgery. We examined the period when urokinase was in short supply and subsequently unavailable, to explore potential differences in clinical outcome and economic effect between urokinase and recombinant tissue plasminogen activator (rt-PA). MATERIAL AND METHODS: Data were obtained from the Premier Perspective Database, a broad clinical database that contains information on inpatient medical practices and resource use. The study population included all patients hospitalized in 1999 and 2000 with a primary or secondary diagnosis of PAO or DVT. Incidence was calculated for common adverse events, including bleeding complications, intracranial hemorrhage, amputation, and death. Cost data were also abstracted from the database, and are expressed as mean +/- SD. RESULTS: Demographic variables were similar in the urokinase and rt-PA groups. The rate of bleeding complications was similar in the urokinase and rt-PA groups. There were no intracranial hemorrhages in the urokinase group, compared with a rate of 1.5% in the rt-PA PAO group (P = .087) and 1.9% in the rt-PA DVT group (P = .175). The in-hospital mortality rate was lower in the urokinase-treated PAO subgroup (3.6% vs 8.5%; P = .026), but a similar finding in the DVT subgroup did not achieve statistical significance (4% vs 9.8%; P = .069). While pharmacy costs were greater in the urokinase-treated group (US 5472 dollars +/- US 5579 dollars vs US 3644 dollars +/- US 6009 dollars, P < .001; PAO subgroup, US 11,070 dollars +/- US 15,409 dollars vs US 6150 dollars +/- US 12,398 dollars, P = .003), overall hospital costs did not differ significantly between the 2 groups. This finding appears to be explained by a shorter hospital stay and reduced room and board costs in the urokinase-treated group. CONCLUSION: There were significant differences in outcome in patients with PAO and DVT who received treatment with urokinase and rt-PA. While pharmacy costs were significantly greater when urokinase was used, reduction in length of stay accounted for similar total hospital costs compared with rt-PA. These findings must be considered in the context of the retrospective nature of the analysis and the potential to use dosing regimens that differ from those in this study.