Health System

A 30-year-old African-American, B.H., is scheduled for hernia repair surgery at your hospital. In his admitting medical history, he acknowledges to your student that he is a heavy drinker and uses marijuana recreationally. Your student is suspicious that his recreational drug use may extend beyond marijuana. Will you recommend any modifications to your standard premedication/ anesthesia/postsurgery protocol?

Nearly two million people a year contract an infection during a hospital stay, according to the Centers for Disease Control & Prevention, often attributable to antimicrobial-resistant organisms. "Health-system pharmacists are instrumental in reducing that rate, through passive and active interventions," said Steve Ebert, Pharm.D., president of the 400-member Society of Infectious Diseases Pharmacists.

A dizzying array of new products was highlighted at the National Association of Chain Drug Stores Marketplace 2005 conference, held in New Orleans last month. At this largest front-end trade show in the industry, the buzzword was natural, with the majority of new products containing natural ingredients to satisfy customer demand for safer solutions to healthcare problems. Here's a look at the new entries in personal care, dietary supplementation, and home health care.

Communications between caregivers and medication use safety dominate the Joint Commission on Accreditation of Healthcare Organizations' 2006 National Patient Safety Goals for hospitals. Among the major additions to the 2006 goals are new requirements that "hand-offs" of patients between caregivers be standardized and that all medication containers, including syringes, medicine cups, basins, and other solutions used in perioperative areas, be labeled.

In a show of solidarity, ASHP persuaded more than 500 of its members to sign a petition urging the Centers for Medicare & Medicaid Services to restore pass-through Medicare funding for specialized pharmacy residency programs. ASHP joins the American College of Clinical Pharmacy (AACP) in asking CMS to revise the proposed rule. The ongoing battle between ASHP and CMS that has been brewing for two years was one of the highlights of the 2005 ASHP Summer Meeting in Boston last month.

Drugs in the winners' circle

A 50-year-old man, C.C., has been hospitalized for acute myocardial infarction (MI) and a stent was placed. C.C. also has end-stage renal disease (ESRD) and is on three-times-weekly hemodialysis. Post-MI, his physician has prescribed metoprolol 50 mg b.i.d., ramipril (Altace, King Pharmaceuticals) 10 mg q.d., atorvastatin (Lipitor, Pfizer) 10 mg q.d., nitroglycerin 0.4 mg sublingual, warfarin 5 mg q.d., and clopidogrel (Plavix, Sanofi-Aventis) 75 mg q.d. C.C.'s predialysis lab values today are parathyroid hormone=405 pg/dl, corrected Ca=10.3 mg, P=5.7 mg, Ca x P 58.71 mg 2 /dl 2. Dialysate calcium concentration is 2.4 mEq/L. C.C.'s nephrologist is evaluating whether to change his preexisting regimen of calcium acetate and calcitriol. What do you suggest?

At the recent annual meeting of the American Society of Clinical Oncology (ASCO), some 25,000 cancer specialists from around the world came to Orlando, Fla., to consider the latest advances in cancer care, treatment, and prevention. Novel targeted therapies for major cancers abounded, as did improvements in quality of life for patients suffering adverse effects from conventional therapy. Here are some highlights

Neuropathic pain (NP) is a condition that is more common than has generally been recognized. Patients often report a pain in their extremities akin to being on pins and needles. It is estimated that in the United States, more than three million people have diabetic peripheral neuropathy (DPN) and as many as one million have postherpetic neuralgia (PHN). Luckily, newer drugs such as duloxetine (Cymbalta, Eli Lilly) and gabapentin (Neurontin, Pfizer) have proven efficacious for providing relief.

Despite all the hype on bar-code technology, less than 5% of the nation's hospitals have installed a bedside bar-code system, even though there is mounting evidence that the technology combined with a comprehensive medication management system can substantially reduce medication errors and improve overall patient safety.

State and federal regulators are beginning to question discounts greater than 90% on drugs used in hospitals. The practice, called nominal pricing, could affect drug prices paid by Medicaid.

Current treatment of dialysis patients with cardiovascular disease (CVD) is suboptimal, according to newly published guidelines by a work group of the National Kidney Foundation (NKF). Lack of evidence of treatment efficacy and exclusion of dialysis patients from major CVD clinical trials may have contributed to the problem.

The hardest part of installing a CPOE (computerized physician order entry) system may be getting the physicians to use it. A hospital can have chosen good software and hardware and may have all the technology in place, but no system will work until physicians start to use it.

In 2002, JCAHO formed the Sentinel Event Alert Advisory Group to help develop the first set of National Patient Safety Goals (NPSGs) that were put into effect on Jan. 1, 2003. NPSGs and their accompanying requirements represent specific actions that JCAHO-accredited organizations are expected to take in order to prevent medical errors such as miscommunication among caregivers, unsafe use of infusion pumps, and medication mix-ups. USP has studied medication error data findings reported to the MEDMARX program in relation to the following 2005 NPSGs

In 2002, with data supplied by the British National Health Service, newspapers in England began publishing the names of hospitals with high infection rates. By 2004, every hospital in Great Britain was required to display its infection rate in a prominent place where patients could see it.

Pharmacists are gaining new support in the organ transplantation world. UNOS, the United Network for Organ Sharing, is encouraging all transplant centers to include at least one clinical R.Ph. on each transplant team. UNOS coordinates organ donation and transplantation specialists nationwide.

A 40-year-old HIV-positive man, V.L., is hospitalized with Pneumocystis carinii pneumonia (PCP). His current viral RNA load > 50,000 copies/ ml, CD4 = 40 cells/mcl.

Scios Inc., a Johnson & Johnson company, has changed its package labeling to add data about deaths associated with its heart failure drug nesiritide (Natrecor) after studies in prominent medical journals raised questions about an increased risk of fatal renal problems. The Food & Drug Administration-approved label change, which stops short of an outright warning, indicated that in clinical trials 5.3% of the patients treated with nesiritide died, compared with 4.3% who took other agents, including diuretics and intravenous nitroglycerin. However, the new label states that the data might not be statistically significant because of the small number of patients involved.

Are hospitalized heart failure patients getting adequate discharge instructions, such as counseling on diet, exercise, medication management, and smoking cessation? Not according to the results of a new study released by the world's largest heart failure registry-ADHERE (Acute Decompensated Heart Failure National Registry).

Does your state require the reporting of medication errors? If the answer is No, get ready for a change. Twenty-three states, including California, Florida, New York, and other major hospital population centers, already mandate med-error reports. Another six states are actively considering legislation, according to on-line publisher NETSCAN, based in Falls Church, Va.

A: Findings from the Womens Health Initiative (WHD) and other studies offered important information about the risks and benefits of long-term menopausal therapy. As a result, it is currently recommended that HRT be used only for the treatment of moderate to severe menopausal symptoms (vasomotor symptoms, symptoms of vulvar and vaginal atrophy) at the lowest effective dose and for the shortest duration of time consistent with a woman's individual treatment goals and risks. Results from these trials have prompted many women to seek alternatives to conventional HRT. One such alternative is bioidentical hormone replacement therapy (BHRT).

A study of 928 breast cancer patients showed that those receiving first and subsequent cycle administration of pegfilgrastim (Neulasta, Amgen) had a whopping 94% decline in the incidence of febrile neutropenia, a 93% decline in hospitalizations, and an 80% drop in intravenous anti-infective use. The patients had been considered at moderate risk for neutropenic complications.

A California hospital recently lost its accreditation from the Joint Commission on Accreditation of Healthcare Organizations, and another one is at risk of losing it. In both cases, medication-related problems accounted for part of the reason for their predicament. Their experience could signal a tougher approach by JCAHO.

Health-system pharmacists are taking a wait-and-see attitude about proposed rule changes for hospitals' conditions of participation (CoPs) in Medicare that were announced recently by the Centers for Medicare & Medicaid Services. When the feds first proposed these rules eight years ago, it provoked a firestorm of protest from R.Ph.s.

The next time patients pick up a prescription at a Target pharmacy, they will receive their pills in a newly designed bottle, thanks to Deborah Adler, a graphic designer for Milton Glaser in New York City. Called ClearRx, the new system features a flat Rx bottle with colored rubber band rings that come in six colors and fit around the neck of the bottle.

Lately, the term pharmacogenomics has been discussed with increasing frequency in the context of individualized medicine. However, many pharmacists lack an appreciation for the potential impact of this emerging field on professional practice. To fully understand pharmacogenomics, let's explore the foundation of this science from its molecular underpinnings and therapeutic applications to the challenges and opportunities for the pharmacy profession.

Perhaps nothing is as professionally frustrating to today's health-system pharmacists as the gap between the promise and reality of computerized physician order entry (CPOE). Concern may have risen to a new level in March with publication of a report in the Journal of the American Medical Association that said CPOE could cause as many medication errors as it prevents. Add that to a growing awareness among R.Ph.s that many physicians hate the systems and the fact that most hospitals can't afford them, and CPOE's promise of improved patient safety seems a dream.

The improper programming of an intravenous pump is among the most common mistakes made at the patient's bedside. A decimal point in the wrong place could be catastrophic. But what if a physician's order were electronically transmitted from a point-of-care medication management system directly to the infusion device at the bedside, with a safety check feature that ensures the pump is programmed properly and consistent with the physician's order?

A growing move by states and health plans nationwide to post hospital charges for public scrutiny is eliciting yawns from pharmacists. "We don't expect any impact on pharmacy," said Pharmacy Society of Wisconsin spokesman Tom Engels. State law requires disclosure of hospital charges through a program called Wisconsin Pricepoint, run by the Wisconsin Hospital Association.

The Centers for Disease Control & Prevention recently released detailed recommendations to state health departments that are considering mandatory public reporting of healthcare-associated infections (HAIs). "HAIs are a major public health problem in the United States," said Patrick Brennan, M.D., chairman of the CDC's Healthcare Infection Control Practices Advisory Committee (HICPAC), which wrote the document.