Health System

A 22-year-old woman, L.N., arrived at your emergency department after a "spell." Based on her symptoms and EEG findings, her physician has diagnosed the spell as a complex partial seizure that generalized to a secondary tonic-clonic seizure. L.N.'s neurological exam, physical exam, complete blood count, serum glucose, electrolytes, drug/alcohol screen, and lumber puncture were normal. However, while in the hospital, she experienced a second seizure, prompting her physician to consider antiepileptic drug (AED) therapy. Because L.N. is two months pregnant, her doctor requests a pharmacist consult. What do you recommend?

The always high-interest Late Breaking Clinical Trials at the Annual Scientific Session of the American College of Cardiology, held in Orlando, Fla., were particularly notable this year. First, they included an unprecedented three individual sessions on the antiplatelet agent Plavix (clopidogrel, Sanofi-Aventis). Second, justifying the plunge to lower and lower LDL-cholesterol (LDL-C) targets, they included strong results for a trial of 80 mg of atorvastatin (Lipitor, Pfizer), and, finally, they featured a session with conflicting messages on the risks of COX-2 inhibitors.

Is there a renal dialysis center in your future? There could be if the Centers for Medicare & Medicaid Services gets its wish.

More and more hospitals are using specialty pharmacies as suppliers of injectable biotech therapies. For the most part, the drugs are shipped directly to the patients, physician offices, or home infusion vendors, but there are times when the drugs are delivered to a hospital to be given at an on-site infusion clinic or in hospital-based physician offices. Pharmacy directors may be wondering exactly where their responsibility for these drugs begins and ends.

Management strategies for nosocomial pneumonia are changing. The American Thoracic Society and the Infectious Diseases Society of America just issued the first new guidelines for the treatment of hospital and healthcare-related pneumonia in nine years. They appeared in the February issue of American Journal of Respiratory and Critical Care Medicine.

Recognizing a need for healthcare systems to be able to evaluate employee attitudes about patient safety and quality improvements, the Medical Errors Workgroup of the Quality Interagency Coordination Task Force (QuIC) sponsored the development of a survey tool. The tool will help hospitals, and their departments, evaluate employees' support-or nonsupport-of safety and quality issues.

Most hospitals are not complying with standard guidelines for antibiotic (ABX) prophylaxis before surgery. Barely more than half of patients in a recent study received antibiotics within one hour of the initial incision. Less than half of patients were taken off ABX prophylaxis within 24 hours following surgery. The result is an unknown number of surgical site infections that could have been prevented with more appropriate treatment.

While not on the New York Times Bestseller List, "USP Chapter 797, Pharmaceutical Compounding: Sterile Preparations"is a must-read for all compounding pharmacists. It took effect on Jan. 1, 2004.

Pharmacy directors looking for the perfect hospital information system are in a bind. There are computer systems that are strong in business management, systems strong in laboratory or imaging or medical practice management, and systems strong in pharmacy. But no system is strong in every area.

Without prompt intervention, as many as 30% of patients with heparin-induced thrombocytopenia (HIT) will die, and an additional 10% to 20% will require limb amputation. HIT is an antibody-mediated reaction to heparin that produces a procoagulant state, during which patients are at increased risk for thromboses.

A 60-year-old woman, A.R., with rheumatoid arthritis for two years, is being discharged from your hospital after acute myocardial infarction (MI). She uses methotrexate (MTX) 30 mg weekly subcutaneously but still experiences joint pain and swelling; she takes naproxen regularly. Dismissal orders are nitroglycerin 0.4 mg sublingual p.r.n., metoprolol 25 mg, atorvastatin 40 mg, aspirin 162 mg, warfarin 2.5 mg (all q.d.); INR level twice weekly; lipid levels in six weeks. Her physician is pondering whether to add etanercept (Enbrel, Immunex) or another disease-modifying antirheumatic drug (DMARD) to MTX to better control RA. What do you recommend?

Is there a renal dialysis center in your future? There could be if the Centers for Medicare & Medicaid Services gets its wish.

The Joint Commission on Accreditation of Healthcare Organizations has backtracked on its prohibition against the use of potentially unsafe abbreviations. Rather than eliminating the use of QD (daily), U (units), and other shortcuts within the organizations it surveys, JCAHO is pushing to restrict abbreviation use in handwritten, preprinted, or in free text entry of patient care and medication records.

The business practices of three large group purchasing organizations were put under the microscope recently after the Office of Inspector General (OIG) released a report based on an audit of GPOs' revenues. The report concluded that GPOs' revenues from vendor fees substantially exceeded operating costs.

Richard Bertin's optimism is contagious. Bertin, the executive director of the Board of Pharmaceutical Specialties (BPS), expressed enthusiastically and in no uncertain terms that the future of specialized training is not only secure but also in the midst of a growth spurt. Bertin's confidence is bolstered by the fact that 2004 was BPS' strongest year in terms of number of new candidates. A total of 1,004 candidates at 34 sites worldwide were administered specialty certification or recertification exams.

Each year, beginning with 1999, United States Pharmacopeia (USP) has conducted an analysis of aggregate data submitted to the MEDMARX error reporting system database. The most recent report examines error trends over the five-year period 1999-2003. It also includes a special focus on technology-related errors, specifically computer entry, computerized prescriber order entry, and automated dispensing devices.

Hospitals use antibiotics hundreds of times each day. But while they know how much money they are spending on these medications, they do not know how much they are using. So said John G. Gums, Pharm.D., professor of pharmacy and medicine in the departments of pharmacy practice and community health and family medicine at the University of Florida, Gainesville.

Hospice Pharmacia (HP), a division of excelleRx, Philadelphia, recently released its Pediatric Medication Use Guidelines (P-MUGs) to the company's 400 partnering hospices around the country. The new tool will provide medication protocols that will aid healthcare workers in the management of end-of-life symptoms for terminally ill children. Up to now, the firm used guidelines designed to manage pain and palliate symptoms in adults.

The good news in the area of pediatric cancer is that many such conditions have become curable. The bad news is that chemotherapies, radiation, and surgical treatments used to attain the cures have toxicities that can surface years later. And these toxicities are becoming a problem as more pediatric cancer survivors age into adulthood.

Richard Bertin's optimism is contagious. Bertin, the executive director of the Board of Pharmaceutical Specialties (BPS), expressed enthusiastically and in no uncertain terms that the future of specialized training is not only secure but also in the midst of a growth spurt. Bertin's confidence is bolstered by the fact that 2004 was BPS' strongest year in terms of number of new candidates. A total of 1,004 candidates at 34 sites worldwide were administered specialty certification or recertification exams.

An ambitious project to reduce surgical complications by 25% within five years includes a vital role for hospital pharmacists, say members of the Surgical Care Improvement Project (SCIP).

A frail, thin 85-year-old woman, T.C., is brought to your emergency department after a fall in which she broke her arm. T.C.'s blood pressure is 70/60, heart rate = 60. Her temperature is normal, but she appears confused. Lab values were normal except serum sodium = 119 mEq/L, serum osmolality = 235 mOsm/kg. Current medications include ibuprofen 400 mg t.i.d. for arthritis, atenolol 25 mg, and fluoxetine 20 mg q.d. The resident asks whether any medications could be causing T.C.'s symptoms. What do you report?

For many years, tamoxifen therapy has been considered the standard of care for postmen-opausal women with hormone receptor-positive breast cancer. While tamoxifen is effective and generally well-tolerated, cancer still recurs in women taking the drug, and serious adverse effects—including endometrial cancer and thromboembolic disorders—associated with tamoxifen are seen in a small proportion of patients.

Smart infusion pumps have helped reduce medication errors at many facilities. But cultural changes are needed in hospitals to improve results, according to a panel of pharmacy executives who spoke at ASHP's Midyear Clinical Meeting in Orlando, Fla., in early December.

A multidisciplinary antimicrobial management program led by pharmacists at the 473-bed University of Kentucky Chandler Medical Center in Lexington reduced antimicrobial agent expenditures by nearly $500,000 over five years. That cost reduction of 25% led to a 2004 Best Practices Award of $2,000 from ASHP.

An estimated 3,400 cases of pediatric acute leukemia will be diagnosed in the United States in 2005. Acute lymphoblastic leukemia (ALL) is the most common form of pediatric leukemia, and children who do not respond to initial therapy, or who relapse, have a very poor prognosis.

Wouldn't it be great if your automated dispensing systems didn't break down, requiring you to make a service call? Believe it or not, this is not a pipe dream anymore. The Mountain View, Calif.-based technology firm Omnicell claims it has a new product that can anticipate problems with your systems before they manifest themselves.

If there's one word that defines what a state-of-the-art health-system pharmacy needs to operate efficiently and effectively, it's integration. Computerized physician order entry (CPOE) and bar-coding are fast becoming essential technology tools alongside automated dispensing cabinets, robotics, and the ubiquitous pharmacy information system.

Stephen Melvin, Pharm.D., has become a familiar face around the pharmacy department at DCH Regional Medical Center in Tuscaloosa, Ala. Melvin is a pharmacy manager for VHA Inc., and for the past year he's been spending three to five days a month at DCH working on a project designed to standardize drugs and search for new opportunities to reduce the drug budget.