Controlling postoperative use of i.v. acetaminophen at an academic medical center.

PURPOSE: Results of an interprofessional formulary initiative to decrease postoperative prescribing of i.v. acetaminophen are reported. SUMMARY: After a medical center added i.v. acetaminophen to its formulary, increased prescribing of the i.v. formulation and a 3-fold price increase resulted in monthly spending of more than $40,000, prompting an organizationwide effort to curtail that cost while maintaining effective pain management. The surgery, anesthesia, and pharmacy departments applied the Institute for Healthcare Improvement's Model for Improvement to implement (1) pharmacist-led enforcement of prescribing restrictions, (2) retrospective evaluation of i.v. acetaminophen's impact on rates of opioid-related adverse effects, (3) restriction of prescribing of the drug to 1 postoperative dose on select patient care services, and (4) guideline-driven pain management according to an enhanced recovery after surgery (ERAS) protocol. Monitored metrics included the monthly i.v. acetaminophen prescribing rate, the proportion of i.v. acetaminophen orders requiring pharmacist intervention to enforce prescribing restrictions, and prescribing rates for select adjunctive analgesics. Within a year of project implementation, the mean monthly i.v. acetaminophen prescribing rate decreased by 83% from baseline to about 6 doses per 100 patient-days, with a decline in the monthly drug cost to about $4,000. Documented pharmacist interventions increased 2.7-fold, and use of oral acetaminophen, ketorolac, and gabapentin in ERAS areas increased by 18% overall. CONCLUSION: An interprofessional initiative at a large medical center reduced postoperative use of i.v. acetaminophen by more than 80% and yielded over $400,000 in annual cost savings.

Addition of tranexamic acid to a traumatic injury massive transfusion protocol.

PURPOSE: The development of eligibility criteria and use of tranexamic acid in conjunction with a massive transfusion protocol (MTP) are described. SUMMARY: The trauma surgery and pharmacy departments collaborated to operationalize tranexamic acid administration in trauma patients for whom an MTP was activated. The MTP at Boston Medical Center, an urban, tertiary, academic medical center, is activated by the attending physician when the patient is expected to require at least 10 units of packed red blood cells in 24 hours. Tranexamic acid was considered in MTP trauma patients who arrived at the medical center within 8 hours of traumatic injury, were 15 years of age or older, and weighed at least 40 kg. Eligible patients were to receive a loading dose of tranexamic acid 1 g i.v. over 10 minutes followed by a maintenance dose of 1 g infused over 8 hours. To ensure that tranexamic acid use was limited to trauma patients, both its location of use and physician-ordering privileges were restricted by the pharmacy department. A 16-month assessment revealed that 16 patients received tranexamic acid, 13 (81%) of whom met all criteria for use. Tranexamic acid was used in 13 (38%) of 34 eligible MTP patients. Barriers to the use of tranexamic acid include a lack of familiarity with the medication among staff, drug availability, the complexity of administration, and the critical setting of MTP activation. CONCLUSION: Multidisciplinary collaboration and standardization of tranexamic acid use in conjunction with an MTP promoted use of the drug within a trauma population.

Evidence-based diagnosis and thrombolytic treatment of cardiac arrest or periarrest due to suspected pulmonary embolism.

When a previously healthy adult experiences atraumatic cardiac arrest, providers must quickly identify the etiology and implement potentially lifesaving interventions such as advanced cardiac life support. A subset of these patients develop cardiac arrest or periarrest due to pulmonary embolism (PE). For these patients, an early, presumptive diagnosis of PE is critical in this patient population because administration of thrombolytic therapy may significantly improve outcomes. This article reviews thrombolysis as a potential treatment option for patients in cardiac arrest or periarrest due to presumed PE, identifies features associated with a high incidence of PE, evaluates thrombolytic agents, and systemically reviews trials evaluating thrombolytics in cardiac arrest or periarrest. Despite potentially improved outcomes with thrombolytic therapy, this intervention is not without risks. Patients exposed to thrombolytics may experience major bleeding events, with the most devastating complication usually being intracranial hemorrhage. To optimize the risk-benefit ratio of thrombolytics for treatment of cardiac arrest due to PE, the clinician must correctly identify patients with a high likelihood of PE and must also select an appropriate thrombolytic agent and dosing protocol.

Standardized versus custom parenteral nutrition: impact on clinical and cost-related outcomes.

PURPOSE: Results of a study comparing clinical and cost outcomes with the use of standardized versus custom-prepared parenteral nutrition (PN) in an acute care setting are reported. METHODS: In a retrospective pre-post analysis, nutritional target attainment, electrolyte abnormalities, and other outcomes were compared in patients 15 years of age or older who received custom PN (n = 49) or a standardized PN product (n = 57) for at least 72 hours at a large medical center over a 13-month period; overall, 45% of the cases were intensive care unit (ICU) admissions. A time-and-motion assessment was conducted to determine PN preparation times. RESULTS: There were no significant between-group differences in the percentage of patients who achieved estimated caloric requirements or in mean ICU or hospital length of stay. However, patients who received standardized PN were significantly less likely than those who received custom PN to achieve the highest protein intake goal (63% versus 92%, p = 0.003) and more likely to develop hyponatremia (37% versus 14%, p = 0.01). Pharmacy preparation times averaged 20 minutes for standardized PN and 80 minutes for custom PN; unit costs were $61.06 and $57.84, respectively. CONCLUSION: A standardized PN formulation was as effective as custom PN in achieving estimated caloric requirements, but it was relatively less effective in achieving 90% of estimated protein requirements and was associated with a higher frequency of hyponatremia. The standardized PN product may be a cost-effective formulation for institutions preparing an average of five or fewer PN orders per day.

Local antimicrobial administration for prophylaxis of surgical site infections.

Despite a lack of consensus guidelines, local antibiotic administration for prophylaxis of surgical site infections is used during many surgical procedures. The rationale behind this practice is to provide high antibiotic concentrations at the site of surgery while minimizing systemic exposure and adverse effects. Local antibiotic administration for surgical site prophylaxis has inherent limitations in that antibiotics are applied after the incision is made, rather than the current standard for surgical site prophylaxis that recommends providing adequate antibiotic concentrations at the site before the incision. The efficacy and safety of local application of antibiotics for surgical site prophylaxis have been assessed in different types of surgery with a variety of antibiotic agents and methods of application. We identified 22 prospective, randomized, controlled trials that evaluated local application of antibiotics for surgical site prophylaxis. These trials were subsequently divided and analyzed based on the type of surgical procedure: dermatologic, orthopedic, abdominal, colorectal, and cardiothoracic. Methods of local application analyzed included irrigations, powders, ointments, pastes, beads, sponges, and fleeces. Overall, there is a significant lack of level I evidence supporting this practice for any of the surgical genres evaluated. In addition, the literature spans several decades, and changes in surgical procedures, systemic antibiotic prophylaxis, and microbial flora make conclusions difficult to determine. Based on available data, the efficacy of local antibiotic administration for the prophylaxis of surgical site infections remains uncertain, and recommendations supporting this practice for surgical site prophylaxis cannot be made.