Improve both costs and safety by changing habits
Subcommittee makes effective changes
Hospital pharmacists can help health care systems significantly reduce costs by focusing on the areas where changes can have a big impact on both cost and safety.
The Hospital of Saint Raphael in New Haven, CT, decentralized its pharmacy and therapeutics committee eight years ago with a focus on improving compliance, safety, and costs.
The hospital has benefited from both improved safety and cost savings.
"We looked at the major cost centers and those high on the Joint Commission's compliance areas of interest, and we created subcommittees to the pharmacy and therapeutics committee," says Janet M. Kozakiewicz, MS, PharmD, director of pharmacy services at the Hospital of Saint Raphael.
Pharmacists are leaders on the subcommittees, which focus on infectious disease, cardiology, anesthesia, oncology, nephrology, radiology, and adverse drug events.
An example of how hospital pharmacists can reduce costs is in the antimicrobial program in which a hospital that spends about $2.7 million per year on antimicrobials could save $370,000 by eliminating inappropriate use of broad spectrum antimicrobial agents, according to Saint Raphael's antimicrobial stewardship review in May 2008.
Here are the ways some of the subcommittees have improved the high-cost areas:
• Infectious diseases: "We looked at evidence with regard to surgical antimicrobial prophylaxis," Kozakiewicz says. "We looked at different types of surgeries, and based on IDSA guidelines and what antibiotics were shown to be effective, that's how we determined what changes to make."
Surgery departments might have 400-500 different surgeons who use a wide variety of antibiotics for surgical prophylaxis, she notes.
"So we did a medication use evaluation on surgical patients to look at exactly what we were using, and we mapped this to guidelines of whether it was appropriate or not," Kozakiewicz says. "We looked at which drug was used, the drug's dose, the time the drug was administered, and duration of therapy."
The subcommittee reviewed a month of data, looking at 80% of all surgeries, she adds.
"We have an infectious diseases pharmacist specialist and a pharmacy resident, who did this as a residency project," she says. "They found all different kinds of prescribing practices and brought that information back to the infectious diseases subcommittee and identified those physicians we need to educate more."
For example, they found that physicians were giving antibiotics for longer than 24 hours post-operatively in the bone and joint center.
"Patients were receiving antibiotics for 72 hours and sometimes for a week, and the physicians thought it was necessary," Kozakiewicz says.
• Radiology: "We thought that the radiology department might not have maximized its contracting," Kozakiewicz says. "So we started purchasing the contrast media for them."
Hospital pharmacy departments often have contracts with the same suppliers, and so they can obtain better prices based on their volume of business.
Also, hospital pharmacists and the radiology group could come up with strategies to make the use of contrast media more efficient and safer. (See table on resource utilization review .)
"We added the radiology subcommittee two years ago because the Joint Commission was starting to classify contrast media that we use in radiology for procedures as a drug," Kozakiewicz says. "So pharmacy screens those patients for interactions with contrast media, and we had to have a subcommittee to integrate pharmacy and radiology."
• Cardiology: This group reviews drugs used in cardiology, including the glycoprotein 2b3a inhibitors, a class of antiplatelet medications. The drugs are used in treating acute coronary syndromes and in patients undergoing percutaneous coronary intervention.
"They're very, very expensive, so we have put together protocols for their use," Kozakiewicz says.
The cardiology group also looks at safety and outcomes associated with medications used in this area, she adds.
For example, if a cardiology patient has an adverse drug event associated with antibiotics, then it's reported to the subcommittee, which also has the adverse events group follow-up the report, she explains.
"The adverse event group evaluates it," Kozakiewicz adds.
In another example, hospital pharmacists noticed early data indicating problems with aprotinin injection (Trasylol®), a drug used in cardiac thoracic surgery, she says. "We brought it to the subcommittee for evaluation of use and educated physicians about how it might cause excessive bleeding."
Surgeons reduced their use of the drug, and then the FDA eventually suspended marketing of the drug, she adds.
• Adverse events: The hospital system uses a computer software program to help monitor recalls of drugs, devices, and other items, Kozakiewicz says.
"If the recalled drug is something we have on our formulary, then I ask our purchasing coordinator to make sure he checks our stock, and we address this at the subcommittee," Kozakiewicz says.
The adverse events group also works with other groups when problems occur with drugs used in radiology, cardiology, oncology, etc.
• Oncology: The oncology group has been very successful, Kozakiewicz says.
"We developed disease-specific standing orders (DSSOs), and there's an order for each modality," she says.
For instance, the hospital handles a large number of lung cancer cases, so there is a DSSO for lung cancer, she adds.
The DSSO lists the recommended drugs and dosages, and physicians can follow the recommendations or not, depending on their patients' clinical conditions and needs.
There are close to 30 order sets available to oncology physicians. These were developed by the oncologists themselves along with the oncology subcommittee, Kozakiewicz says.
"The subcommittee and physicians read them and approved them, and then they were sent to the pharmacy and therapeutics committee for final approval," she adds.
After the P&T committee approved the order sets, they were put on the web site, and an oncology pharmacist helped educate physicians about their use, she says.
"We'd propose them at oncology section meetings, and they were rolled out there," she says.
Another change they made was to segregate oncology drugs in the computerized provider entry system, Kozakiewicz says.
"We took oncology drugs out and have a separate system for them," she explains. "The doctor prints out an order set, depending on the cancer they're treating, and it's given to the oncology pharmacist who enters it into the computer system."
Oncologists like the new system because it's easy to use, and it has reduced the number of calls they receive with questions about orders, she notes.
"Historically, they'd write an order, and it'd be incomplete," Kozakiewicz says. "The prior blood work wouldn't be available or something, and now the order sets say that if you do this and this, your order is complete and you won't get a phone call."
For example, a two-page chemotherapy order form includes check-off boxes and fill-in-the-blank lines for the oncologist to complete, including the following:
- Chemotherapy agent
- Dose/m2
- Total dose
- Route
- Diluent, frequency, and administration information
- Days
Another section addresses the medications needed to treat nausea and vomiting and includes the following:
- Ancillary medications
- Anti-emetics for acute nausea/vomiting (DAY of Cisplatin) — Premedication
- Aprepitant 125 mg po
- Ondansetron 8 mg IVP
- Dexamethasone 10 mg IVPB
- Other
The order forms have helped improve care and save money, Kozakiewicz says.
"We have an outpatient oncology provider, as well, so we've been able to have a considerable savings on both sides — inpatient and outpatient," she adds. "As a result of this change, we were able to open a pharmacy satellite — two years ago — in the outpatient oncology area, so we do all of our mixing there."
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