Factors associated with inappropriate inpatient prescribing of acid-suppressive therapy.

OBJECTIVES: Acid-suppressive therapy is used for 54-70% of inpatients, and is frequently prescribed for inappropriate indications. The objective of this study was to identify characteristics associated with inappropriate prescribing of acid-suppressive therapy. METHODS: A random sample of adult internal medicine inpatients admitted between 1 July 2005 and 30 June 2006 was screened for acid-suppressive therapy. Patients receiving such therapy without an accepted indication and those not prescribed acid-suppressive therapy were included in group 1 and group 2, respectively. Significant characteristics from separate univariate regression models were entered into a multivariate logistic regression to determine characteristics associated with inappropriate use. The setting was internal medicine units at a tertiary care academic medical centre. KEY FINDINGS: There were 108 patients in group 1 and 134 patients in group 2. Group 1 patients were older, had a longer median length of stay, a greater number of comorbidities, a greater median number of medications upon admission, and a higher rate of cirrhosis. Factors associated with use of acid-suppressive therapy without an accepted indication were use of a proton-pump inhibitor (odds ratio, 15.3; 95% confidence interval, 4.1-56.3) or histamine2 receptor antagonist (14.5; 2.8-74.8) prior to admission, cirrhosis (6.4; 1.02-39.5), use of inpatient anticoagulants (2.7; 1.4-5.2) and length of stay (1.1; 1.1-1.3). CONCLUSIONS: The strongest factors associated with use of acid-suppressive therapy without an accepted indication were use of a proton-pump inhibitor or histamine2 receptor antagonist prior to admission, a diagnosis of cirrhosis and use of inpatient anticoagulants.

Designing and implementing a hospital-based vaccine standing orders program.

PURPOSE: An inpatient pneumococcal polysaccharide vaccine (PPV) vaccination program was designed and implemented to meet federal and state regulatory requirements and national vaccination goals. SUMMARY: In 2002, the Centers for Medicare and Medicaid Services published a final rule removing the federal requirement for an individual patient physician-signed order for the pneumococcal and influenza vaccines in Medicare- and Medicaid- participating hospitals. This statute authorized implementation of standing orders programs (SOPs) in health care institutions. At the University of Pittsburgh Medical Center-Presbyterian (UPMC-P), institutional vaccination rates and the existing mechanism for providing adult vaccinations were evaluated. At the peak of the program's effectiveness in 2000, in-hospital total vaccination rates were 31%; those rates fell to 15% by the end of 2003. To rectify this poor rate of vaccination, a multidisciplinary team convened to evaluate the existing program and to design the tools and processes for a conversion to a vaccine SOP. A standing order form was designed, and it was determined that the SOP should be pharmacy driven. As a result of the SOP, the PPV vaccination rate increased dramatically; in 2005, the average rate was 69%, with the highest rate occurring in March 2005 (87%). CONCLUSION: The cooperative effort of a multidisciplinary work group including physicians, nursing staff, and pharmacy personnel led to the creation of a successful inpatient PPV SOP. Analysis of the previous vaccination program and careful planning were instrumental in designing the SOP. Defined responsibilities for daily performance and user-friendly tools with clear instructions were also crucial to the success of the program.

Role of student pharmacist interns in hospital-based standing orders pneumococcal vaccination program.

OBJECTIVE: To describe the role of student pharmacist interns in supporting a standing orders program (SOP) for pneumococcal polysaccharide vaccination in hospitalized patients. SETTING: University of Pittsburgh Medical Center (UPMC) Presbyterian, an academic teaching hospital in Pittsburgh. PRACTICE DESCRIPTION: The hospital-based Drug Use and Disease State Management (DUDSM) program designs, implements, and promotes evidence-based practice guidelines to ensure safe and cost-effective drug therapy. PRACTICE INNOVATION/INTERVENTIONS: Paid student pharmacist interns provide manpower for screening and maintaining the vaccination SOP. Student preparation includes classroom learning about immunization concepts, on-site SOP workflow training, and direct patient care activities. Students participate in the vaccination SOP by (1) screening daily admissions through computerized information systems, (2) reviewing databases for documented prior vaccination, (3) completing preprinted orders for pharmacists, (4) inserting orders into patient charts, (5) checking vaccine administration, (6) educating nurses, and (7) managing the databases. Pharmacists verify and sign vaccine orders. Nurses obtain patient history and consent and administer vaccines. MAIN OUTCOME MEASURES: Hospital vaccination rates as determined monthly for quality improvement reporting, and student time required to complete SOP functions. RESULTS: In 2005, an average monthly vaccination rate of 70% for hospitalized elderly was achieved by this inpatient SOP, with the highest rate (89%) occurring in March. On average, 800 patients were screened each month, with 480 vaccine orders placed into patient charts. CONCLUSION: A vaccination SOP is resource-intensive and requires a diligent effort from qualified personnel. In our institution, trained student interns in the DUDSM program perform the necessary daily functions, such as patient screening, that are instrumental in maintaining the SOP.

Overcoming barriers to establishing an inpatient vaccination program for pneumococcus using standing orders.

OBJECTIVES: To identify and classify barriers to establishing a standing orders program (SOP) for adult pneumococcal vaccination in acute care inpatient facilities and to provide recommendations for overcoming these roadblocks. Vaccination rates in hospitals with SOPs are generally higher than those in hospitals that require individual physician orders. The array of solutions drawn from our experience in different hospital settings should permit many types of facilities to anticipate and overcome barriers, allowing a smoother transition from initiation to successful implementation of an inpatient pneumococcal vaccination SOP. DESIGN: Descriptive study of barriers and solutions encountered during implementation of a pneumococcal vaccination SOP in three hospitals of the University of Pittsburgh Medical Center Health System (UPMC) and in the scientific literature. SETTING: As of 2004, two UPMC tertiary-care hospitals and one UPMC community hospital had incorporated SOPs into existing physician order-driven programs for inpatient vaccination with pneumococcal polysaccharide vaccine. RESULTS: Barriers were identified at each step of implementation and categorized as patient related, provider related, or institutional. Based on a process of continual review and revision of our programs in response to encountered barriers, steps were taken to overcome these impediments. CONCLUSIONS: A strong commitment by key individuals in the facility's administration including a physician champion; ongoing, persistent efforts to educate and train staff; and close monitoring of the vaccination rate were essential for successful implementation of a SOP for pneumococcal vaccination of eligible inpatients. Legal statutes and evaluations of external hospital-rating associations regarding the effectiveness of the vaccination program were major motivating factors in its success.

Pharmacists' role in increasing pneumococcal and influenza vaccination.

PURPOSE: The role of the pharmacist in increasing pneumococcal and influenza vaccination rates and the clinical efficacy of pneumococcal and influenza vaccines are discussed. SUMMARY: Institutional pharmacists often play key roles on multidisciplinary committees and have the opportunity to make preventive therapies, such as vaccination, a priority. Standing-order programs authorize health care professionals to screen for vaccine eligibility and contraindications, administer vaccines, and monitor for adverse effects when following a physician- or institution-approved protocol. Current vaccination levels for the influenza and pneumococcal vaccines are suboptimal and well below the Healthy People 2010 goal of 90% of high-risk patients. Pharmacists should be familiar with the composition, immunogenicity, dosage, administration, efficacy, adverse reactions, contraindications, precautions, and cost-effectiveness of each vaccine, as well as with Advisory Committee on Immunization Practices recommendations and the supporting literature. CONCLUSION: Health-system pharmacists have the opportunity and responsibility to protect those at highest risk of pneumococcal disease and influenza through the use of standing-order vaccination programs.

Aminoglycoside-associated nephrotoxicity in the elderly.

OBJECTIVE: To determine whether there was an increased incidence of nephrotoxicity in elderly patients (> or =65 y) prescribed single-dose (SD) versus multiple-dose (MD) aminoglycosides and whether aminoglycoside-induced nephrotoxicity was associated with length of therapy and other risk factors. METHODS: A prospective, observational audit at a university teaching hospital was conducted. Physician prescribing was used to stratify subjects according to dosing regimen: MD (n = 60) or SD (n = 26). Nephrotoxicity was defined as an increase in the serum creatinine level of 0.5 mg/dL sustained over 2 days. RESULTS: Eighty-six patients were included; 9.3% developed nephrotoxicity, of whom 62.5% received SD therapy. The incidence of nephrotoxicity did not differ between regimens (p = 0.051). There was an increased length of therapy in those who developed nephrotoxicity (mean +/- SD 6.1 +/- 6.2 vs. 3.7 +/- 2.8 d; p = 0.044). Additionally, patients who developed nephrotoxicity had an increased length of hospitalization (20.3 +/- 16.1 vs. 8.4 +/- 5.4 d; p < 0.001). Nephrotoxicity correlated with a diagnosis of diabetes mellitus (OR 15.1; 95% CI 1.11 to 205), concomitant angiotensin-converting enzyme (ACE) inhibitor therapy (OR 28.0; 95% CI 2.15 to 365), and SD therapy (OR 20.7; 95% CI 1.45 to 297). CONCLUSIONS: Our overall incidence of nephrotoxicity is consistent with that reported in the literature. A diagnosis of diabetes mellitus, concomitant use of ACE inhibitors, and SD regimens were risk factors for the development of nephrotoxicity. An adequately powered, randomized trial is needed to assess whether a difference in the incidence of nephrotoxicity exists between SD and MD therapy in the elderly.

Intravenous immunoglobulin: appropriate indications and uses in hematopoietic stem cell transplantation.

Intravenous immune globulin (IVIG) therapy has been prescribed in many different disease states. Hyperimmune products are also available. Recently, routine use for many indications has come under scrutiny secondary to high cost, limited supply, and unclear benefit. IVIG is U.S. Food and Drug Administration-approved for application in hematopoietic stem cell transplantation (HSCT), a very common indication for its use. In an attempt to clarify the most appropriate indications and doses in HSCT recipients, we conducted a MEDLINE search in which we reviewed all relevant articles from 1966 to the present. Search terms included bone marrow transplantation, intravenous immune globulin, hyperimmune globulin, GVHD, and cytomegalovirus (CMV). Also, the references of all pertinent studies and review articles were scanned for studies missed via MEDLINE. CMV prophylaxis/treatment and GVHD prophylaxis are the 2 indications with the most significant clinical support, but there are very few prospective, randomized, controlled trials reported. Furthermore, sample size usually was small, included heterogeneous patient populations, and employed different primary end points. Several reports support IVIG therapy in combination with ganciclovir for prevention and treatment of CMV infection, whereas others have shown ganciclovir monotherapy to be effective, blurring the benefit of IVIG administration. CMV IgG data are also imprecise and difficult to interpret. The role of IVIG therapy in prevention and treatment of GVHD also is vague. Only 1 randomized investigation showed a benefit in the prevention of acute GVHD, and no studies showed efficacy in chronic GVHD prophylaxis and therapy. Reports examining the utility of IVIG or CMV IgG in HSCT are hampered by marked variation in trial design and dosing and diverse patient characteristics. Although IVIG may be useful as a component of preemptive therapy and treatment of CMV disease, its contribution to the prevention of reactivation of CMV infection is dubious. Extended IVIG therapy during GVHD prevention may impair recovery of humoral immunity, and its role in prophylaxis and therapy of GVHD has not been clearly defined. Hospital monitoring programs may be a valuable way to detect areas of high use and allow for streamlining of prescribing.