Monthly Archives: March 2017

Impact of an antimicrobial stewardship initiative on time to administration of empirical antibiotic therapy in hospitalized patients with bacteremia [Notes]

Purpose

The impact of an antimicrobial stewardship initiative on time to first antibiotic dose and clinical outcomes in bacteremic patients was evaluated.

Methods

A single-center, retrospective study was conducted for adult inpatients who received antibiotics before and after implementation of a rapid administration of antimicrobials by an infectious diseases specialist (RAIDS) protocol. Patients admitted to an inpatient service from June to October 2011 (pre-RAIDS protocol) and from December 2011 to February 2012 (post-RAIDS protocol) were eligible for inclusion if (1) they were age 18 years or older, (2) their infection occurred two or more days after hospital admission, and (3) they had a blood culture growing an organism other than common skin contaminants (i.e., coagulase-negative staphylococci, Bacillus species). The primary outcome was the time to the first antibiotic dose (TFAD), defined as the time that elapsed from a positive blood culture result to administration of the first empirical antimicrobial dose.

Results

A total of 111 bacteremic patients were included in the analysis. Implementation of the RAIDS protocol led to significantly faster antibiotic order entry, verification, and administration of empirical antibiotics in patients with bacteremia. The median TFAD was approximately 8 hours faster in the post-RAIDS group than in the pre-RAIDS group (9:09 hr:min versus 1:23 hr:min, p < 0.001). Patients in the post-RAIDS group had a significant reduction in infection-related mortality (p = 0.047), though all-cause 30-day mortality was similar.

Conclusion

Early notification of an infectious diseases pharmacist about positive blood cultures using the RAIDS protocol led to increased appropriateness of empirical drug selection and a dramatic reduction in the administration of antibiotics and was associated with decreased infection-related mortality.

Evaluation of a pharmacist-led outpatient direct oral anticoagulant service [Practice Research Report]

Purpose

The impact of a pharmacist-led direct oral anticoagulant (DOAC) service on prescription appropriateness and patient adherence was simultaneously evaluated.

Methods

In this retrospective analysis, patients age 18 years or older for whom a DOAC was prescribed from September 20, 2013, through December 31, 2014, were identified through electronic medical record review of all DOAC prescriptions within the University of Michigan Health System. Patients had their DOAC therapy managed by a pharmacist-led DOAC service or by their physician (usual care). Primary endpoints included the percentage of patients who had appropriate DOAC therapy prescribed at baseline and at follow-up appointments at 3–6 months. Secondary endpoints included mean medication possession ratios (MPRs).

Results

A total of 258 patients were included in the study, with 129 in each group. Patients in the pharmacist-led DOAC service were significantly more likely to have an appropriate combination of DOAC and dosage prescribed for their indication at baseline compared with the usual care group (p = 0.009), a finding that persisted at follow up (p = 0.016). There was no significant difference between groups in the number of patients determined to have an appropriate DOAC prescribed for an approved indication (independent of dose) in the pharmacist-led service (95.3%) versus usual care (93.0%) at baseline. Patients in the pharmacist-led service had a greater mean adjusted MPR compared with the usual care group (p = 0.0014) over a median follow-up period of 248 days.

Conclusion

A pharmacist-led DOAC service increased appropriate dosing of DOACs at baseline and follow up as well as patient adherence to therapy.

Development of a bedside scoring system for predicting a first recurrence of Clostridium difficile-associated diarrhea [Clinical Research Reports]

Purpose

A scoring system for identifying patients at high or low risk for recurrent Clostridium difficile–associated diarrhea (CDAD) is described.

Methods

A retrospective cohort study was performed using data on adults with CDAD admitted to a 3-hospital system from 2009 to 2014. The primary endpoint was the rate of recurrent CDAD within 60 days of clinical cure of CDAD. Risk factors for CDAD recurrence were identified, and a risk prediction tool was developed using multivariate logistic regression.

Results

The CDAD cure rate in the study cohort (n = 340) was 92.3%; the 60-day recurrence rate was 16.9%. Five factors were significantly associated with high recurrence risk: presence of CDAD at admission, body temperature of >37.8 °C at admission, leukocytosis, nosocomial CDAD, and abdominal distention on CDAD presentation. From that information a risk prediction tool, the CDAD "recurrence score," was developed (1 point is assigned for each factor present, for a maximum score of 5). Validation testing of the recurrence score indicated an area under the receiver operating characteristic curve of 0.72 (95% confidence interval, 0.65–0.80). A score of ≥2 had a negative predictive value of 91%, while a score of ≥4 had a positive predictive value of 70%.

Conclusion

If externally validated in future studies, a tool for predicting the risk of recurrent CDAD using data readily available at the time of presentation could allow clinicians to identify patients at high risk for recurrence, address modifiable risk factors, and select tailored treatments to improve patient outcomes.

Analysis of variations in the display of drug names in computerized prescriber-order-entry systems [Descriptive Reports]

Purpose

The variations in how drug names are displayed in computerized prescriber-order-entry (CPOE) systems were analyzed to determine their contribution to potential medication errors.

Methods

A diverse set of 10 inpatient and outpatient CPOE system vendors and self-developed CPOE systems in 6 U.S. healthcare institutions was evaluated. A team of pharmacists, physicians, patient-safety experts, and informatics experts created a CPOE assessment tool to standardize the assessment of CPOE features across the systems studied. Hypothetical scenarios were conducted with test patients to study the medication ordering workflow and ways in which medications were displayed in each system. Brand versus generic drug name ordering was studied at 1 large outpatient system to understand why prescribers ordered both brand and generic forms of the same drug.

Results

Widespread variations in the display of drug names were observed both within and across the 6 study sites and 10 systems, including the inconsistent display of brand and generic names. Some displayed drugs differently even on the same screen. Combination products were often displayed inconsistently, and some systems required prescribers to know the first drug listed in the combination in order for the correct product to appear in a search. It also appeared that prescribers may have prescribed both brand and generic forms of the same medication, creating the potential for drug duplication errors.

Conclusion

A review of 10 CPOE systems revealed that medication names were displayed inconsistently, which can result in confusion or errors in reviewing, selecting, and ordering medications.

Automated detection of look-alike/sound-alike medication errors [Notes]

Purpose

The development and evaluation of an algorithm for detecting potential medication errors due to look-alike/sound-alike (LASA) drug names are described.

Summary

A computer algorithm that detects potential LASA errors by analyzing medication orders and diagnostic claims data was developed. The algorithm flags a potential error when (1) a medication order is not justified by a diagnosis documented in the patient’s record, (2) another medication whose orthographic similarity to the index drug exceeds a specified threshold exists, and (3) the latter drug has an indication that matches an active documented diagnosis. A review of medication orders and diagnostic claims at a large health system identified cases in which cycloserine was ordered but cyclosporine was the intended treatment. Subsequent review of all cycloserine orders over a 7-year period indicated that 11 of 16 orders were erroneous, prompting placement of an alert regarding the potential for LASA errors involving cycloserine and cyclosporine in the electronic order-entry system. Automated detection and confirmation of LASA errors via chart review can be used retrospectively to identify problematic pairs of drug names and to assess associated error rates within a healthcare system. The same techniques can be used to prevent errors in real time through indication alerts if accurate diagnostic information is available at the time of order entry.

Conclusion

Automated methods involving the use of medication orders, diagnostic claims, and indications can be used to detect and prevent LASA errors.

Standardizing concentrations of adult drug infusions in Indiana [Descriptive Reports]

Purpose

A multidisciplinary, consensus-driven initiative to promote the use of standardized medication concentrations for adult drug infusions across the state of Indiana is described.

Methods

To accomplish development of the Indiana Standard Concentrations of Adult Drug Infusions List ("the Indiana List"), several available lists of i.v. concentrations were compiled, consolidated, and compared. Lists of adult standardized i.v. concentrations were primarily drawn from Indiana regional patient safety coalitions, published literature, and publicly available lists of recommended i.v. concentrations. The standardization project, which expanded initial work completed by the Indianapolis Coalition for Patient Safety, was conducted in conjunction with Purdue University’s Center for Medication Safety Advancement, the Indiana Hospital Association, and the 11 regional patient safety coalitions across the state.

Results

After a review of 9 existing lists of standard i.v. concentrations, an initial list of 69 concentrations representing a total of 37 medications was derived; 34 of those concentrations were represented on at least 1 of the 3 evaluated Indiana regional patient safety coalition lists. A statewide interdisciplinary work group of representatives of regional patient safety coalitions and 9 health systems representing a total of 81 hospitals ranging from academic medical centers to critical access hospitals assembled to develop consensus on a final list of standard medication concentrations for adult i.v. infusions.

Conclusion

A final list of 28 concentrations of 26 medications was identified for the recommended Indiana List by an interdisciplinary work group. A checklist of considerations for implementation was also developed.

Empirical gentamicin dosing based on serum creatinine levels in premature and term neonates [Clinical Research Reports]

Purpose

Empirical gentamicin dosing based on serum creatinine (SCr) levels in premature and term neonates was evaluated.

Methods

This single-center, retrospective cohort study was conducted in a standalone children’s hospital with a level IIIB, 44-bed neonatal intensive care unit (NICU). Data were abstracted and collected for all neonates admitted to the NICU from March 5, 2012, through March 5, 2014. Patients were included in the study if gentamicin was administered within the first 7 days of life, a trough gentamicin level was measured, and the neonate had a baseline SCr level measured within the first 24 hours of life. A series of logistic regressions was conducted to determine if gentamicin trough levels were influenced by gestational age (≤29 weeks [group 1], 30 weeks to 34 weeks and 6 days [group 2], and ≥35 weeks [group 3]) and SCr level (0.81–0.99 mg/dL [mildly elevated] and ≥1 mg/dL [elevated]).

Results

Of the 577 neonates reviewed during the study period, 507 met the inclusion criteria. Mildly elevated and elevated SCr levels were significantly associated with the presence of an elevated gentamicin trough (p < 0.001). When the effect of gestational age was evaluated, the data suggested that SCr is a strong predictor of elevated gentamicin troughs.

Conclusion

Neonates with a gestational age of ≥30 weeks who had an SCr level of ≥1 mg/dL within the first 12–24 hours of life were more likely to have an elevated gentamicin trough level than their counterparts with normal SCr levels.