Attitudes of Ohio hospital pharmacists toward pharmacy technicians.

A survey was conducted to determine the attitudes of Ohio pharmacists toward pharmacy technicians. A questionnaire was developed with questions about the current and future scope of technician responsibilities; training, certification and licensure; and possible displacement of pharmacist positions. The questionnaire was mailed in January 1990 to a random sample of 357 hospital pharmacists registered with the Ohio State Board of Pharmacy. There were 182 usable questionnaires returned, for a response rate of 51%. Nearly all the respondents (98.4%) employed pharmacy technicians. Of 32 functions listed in the questionnaire, 16 were performed by technicians at more than half of the responding hospitals. The functions performed by technicians varied depending on the size and location of the hospital; and the education, experience, and current position of respondents influenced their opinions on the appropriateness of having technicians perform several functions now and in the future. Most respondents agreed that all technicians should receive standardized training and education, and more than a third believed that technicians should be certified. The respondents did not believe that increased use of technicians would eliminate present pharmacist positions in their department but were neutral toward a statement that technicians would eliminate pharmacist positions in general. Ohio pharmacists' attitudes toward the expanding role of pharmacy technicians seemed in concert with the recommendations that have emerged in the profession.

ABC analysis of the relationship between pharmacy charges and DRGs.

DRGs and pharmacy charges were analyzed using the ABC analysis for a cross section of hospitals represented in the Blue Cross of Central Ohio (BCCO) region and for Riverside Methodist Hospital (RMH). A total of 43,969 patients were discharged from the 43 BCCO hospitals and 6,121 patients from RMH in the one-year study period. They were retrospectively assigned to 465 and 371 DRG categories, respectively. The ABC analysis of pharmacy charges and DRGs showed that 10 major diagnostic categories (MDCs) accounted for 80.4% and 80.1% of all pharmacy and i.v. charges for the BCCO hospitals and RMH, respectively. Hospital charges were found to be strongly related to pharmacy charges, and length of stay was found to be moderately related to pharmacy charges. In the absence of pharmacy cost data per DRG, the ABC analysis can be used to categorize DRGs on the basis of pharmacy charges. Before using pharmacy or hospital charges data per DRG for resource monitoring, hospital pharmacy directors should investigate the causes of high pharmacy charges for the high-cost DRGs and MDCs.

Therapeutic risk-assessment model for identifying patients with adverse drug reactions.

The association between factors that place patients at risk for adverse drug reactions (ADRs) and the occurrence of ADRs was examined, and a therapeutic risk-assessment model was developed. Theoretical risk factors for ADRs to digoxin and theophylline were identified through the literature by researchers at a private tertiary-care hospital. Data were then collected from two groups of 67 patient charts each during a 15-month period. One group of charts represented patients who had experienced an ADR to digoxin or theophylline. The other group represented matched control patients who had not experienced an ADR to either drug. ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modifications) ADR codes were assigned by medical records department personnel, and the ADRs were verified by using the Naranjo algorithm. Seven risk factors for each drug were found to be significantly associated with ADRs. A serum digoxin concentration greater than 2.5 ng/mL and elevated blood urea nitrogen were the two best predictors of an ADR to digoxin. The probability of experiencing an ADR to digoxin was 94.1% for a patient with both of these risk factors. A serum theophylline concentration greater than 25 micrograms/mL was the greatest predictor of an ADR to theophylline; the probability of experiencing an ADR to theophylline was 85.2% if a patient had that risk factor. The sensitivity and specificity of the therapeutic risk-assessment model were 92.9% and 61.8%, respectively, for digoxin and 95.8% and 84.0%, respectively, for theophylline. Several laboratory-based screening criteria demonstrated an ability to predict ADRs to digoxin and theophylline.

Sensitivity and specificity of three methods of detecting adverse drug reactions.

The sensitivity and specificity of three methods of detecting adverse drug reactions (ADRs) were determined. Minimal use of a voluntary ADR reporting program prompted this investigation of three ADR detection methods, as follows: screening of laboratory reports, pharmacist screening of medication orders, and voluntary reporting. A total of 98 patients who were receiving oral or i.v. digoxin therapy, oral or i.v. theophylline therapy, or i.v. gentamicin therapy were randomly selected and monitored for possible ADRs. A physician reviewed the charts of patients with suspected ADRs using the Naranjo algorithm to assess causality. The chart review served as the reference method to which the other three methods were compared. Thirteen "true" (i.e., confirmed by the Naranjo algorithm) ADRs were identified in 11 different patient charts, resulting in a 13.3% ADR incidence rate for the 98 sampled patients. For the three ADR detection methods, the decreasing order for level of sensitivity was screening of laboratory reports, pharmacist screening of medication orders, and voluntary reports; however, only the difference between laboratory reports and voluntary reports was significant. For level of specificity, the decreasing order for the three methods was voluntary reports, pharmacist screening of medication orders, and pharmacist screening of laboratory reports; the differences among all three methods were significant. Screening of laboratory reports and pharmacist screening of medication orders are two detection methods that appear to exhibit an appropriate combination of sensitivity and specificity for identifying ADRs; trials with larger sample sizes are needed to confirm the results of this study.

Use of an automated medication storage and distribution system.

The effects of an automated medication storage and distribution system in a hospital setting were evaluated. The Pyxis Medstation system was implemented on two nursing units at a 1000-bed tertiary-care referral hospital. The system, which is designed like an automated bank teller, dispenses items to authorized users and records all transactions. Floor-stock controlled substances and noncontrolled medications, large-volume i.v. solutions, and i.v. administration sets were stocked in the system. The system was evaluated (1) by comparing the mean patient charge capture rates for six months before and for three months after implementation, (2) by measuring nurse and pharmacy technician time required for various tasks before and after implementation, and (3) through questionnaires filled out by nurses and technicians. After the system was installed, nursing personnel spent less time on medication-related activities, charting, and documentation and more time interacting with patients. Pharmacy technicians spent more time on floor-stock activities and less time on billing activities. Nurses indicated positive attitudes toward the system features. Both nurses and pharmacy technicians indicated that the system should remain in use. After implementation, the charge capture rate for noncontrolled medications, i.v. solutions, and i.v. sets increased from 63% to 97%. This increase, extrapolated to the entire hospital, reflects $35,000 in additional revenue over the total costs of implementation of the system. Implementation of an automated medication storage and dispensing system is expected to increase hospital revenue and enable nurses to spend more time interacting with patients at this institution.

Compounding times and contamination rates associated with the preparation of intravenous admixtures in three types of plastic containers.

The compounding times and contamination rates associated with the preparation of admixtures in three different plastic i.v. containers of dextrose 5% in water were compared. The time required for a technician to prepare, in a laminar air flow hood by the needle and syringe technique, 120 admixtures in each of three different plastic i.v. containers was measured and recorded by two investigators. The 360 admixtures were tested within one hour of preparation for sterility using an enriched brain heart infusion broth. The total time required to compound the i.v. admixtures varied significantly with container design (p less than 0.01), preparation being fastest with the Accumed container, followed by the LifeCare then the Viaflex containers. The major contributing factors to increased compounding time were (1) removal of outer wrap, (2) swabbing of LifeCare and Viaflex medication ports with isopropyl alcohol pads and (3) freeing of the hangar flap from the Viaflex container. Sterility tests revealed no detectable contamination of any of the admixtures. Container design of plastic i.v. containers did influence the preparation time for admixtures but did not influence admixture sterility.

A novel comprehensive DUE program--five years of experience.

A comprehensive program has been developed to evaluate prescribing practices in diverse drug therapy categories and in all areas of the institution. Input for topic selection comes not only from the pharmacy department, but also from QA, medical staff, and nursing. The development of monitoring criteria and review of the results by the P&T Committee, Medical Executive Committee, and other key medical staff members, promotes ownership of the program by the medical staff. The benefit of this ownership is active support for the program and participation in peer review. Overall, the results of this cost-effective program include limited use of broad spectrum antibiotics, select prescribing of high-risk drugs, and focused educational efforts to improve quality of patient care. The primary goal for the future of the program is to develop criteria and documentation mechanisms for reporting measurable clinical outcomes. In making the transition, it is important to use the success and impact of the current program as the foundation. This is particularly true for the concurrent monitoring program and its immediate feedback mechanism. The major challenge will be evaluating negative clinical outcomes and developing corrective actions as well as documenting the positive outcomes and the avoidance of negative outcomes of the current program. To meet this challenge, the DUE program must be integrated with all other institutional QA programs. Although a difficult task, this is a significant yet necessary step in the right direction for assuring optimal patient care.

Change in prescribing patterns of intravenous histamine2-receptor antagonists results in significant cost savings without adversely affecting patient care.

OBJECTIVE: The cooperative efforts and educational activities associated with a major histamine2-receptor antagonist (H2RA) formulary change and the clinical and financial results are described. EVALUATION PROCESS: An extensive financial and clinical evaluation was conducted. Sources included primary literature, reference texts, institution-specific financial data, and reports of other hospitals' experiences. INTERVENTIONS: Through cooperative efforts with key members of the medical staff, several interventions were adopted: maintain only one parenteral H2RA on the formulary; develop guidelines for H2RA use and stress ulcer prophylaxis; investigate a target drug-reminder system to promote oral H2RA use. RESULTS: Within a month after implementing the formulary change and educational process, prescribing of parenteral H2RAs changed from 80 percent ranitidine to 99 percent cimetidine. Monitoring of nonformulary ranitidine use revealed only three cases of possible or probable association of adverse central nervous system effects with cimetidine in an eight-month period. Elevations of theophylline, lidocaine, or phenytoin serum concentrations; or prothrombin time above the therapeutic range during warfarin therapy occurred in only 5 of 142 monitored patients who received concomitant therapy with an H2RA. No change in serum theophylline concentrations above the therapeutic range was noted to the hospital before and after the conversion. Savings have been estimated at $250,000 in the first year and $775,000 over four years, mostly from the conversion from intravenous ranitidine to intravenous cimetidine therapy. CONCLUSIONS: Successful intervention can be accomplished by cooperation between the pharmacy and the medical staff to achieve cost savings without sacrificing the quality of care.