Award winners stress patient care, cost control
Abbott Labs’ national quality awards
A money-saving idea that contributes to patient care and the bottom line: That pretty much sums up the formula for a winning entry to Abbott Laboratories’ National Hospital Pharmacy Quality Awards. This year, 10 hospital pharmacies found that winning combination and picked up checks ranging from $10,000 for the first-place finisher to $1,500 for honorable mentions.
While better patient care is the supposed reason for the competition, each of the winning entrants shared one measurable characteristic: They saved money. In some cases, lots of money. So, if you’re thinking about entering the contest next year, Abbott’s Laureen Cassidy has some advice: "There has to be a concrete outcome to discuss," Cassidy says. In other words, quantify in dollars what you saved, or how much less medicine you used, or how many side effects were prevented.
Several of the winners engaged in creative methods of cost control, perhaps none more so than Gilles L. Fraser, PharmD, of the Maine Medical Center in Portland. Fraser got his staff involved in stopping the wasteful practice of ordering digoxin levels at inappropriate times and for patients who didn’t need them drawn frequently.
"In 1991, we found we were spending $250,000 a year on digoxin assays," Fraser says. "That accounts for 30% of the total assays. There was room for improvement." The problem, Fraser says, was that physicians were ordering digoxin levels in a wanton fashion and inefficiently at that. Some levels were being drawn during the distributive phase of the drug.
But instead of engaging in a labor-intensive review of patient charts, Fraser says the pharmacy did a limited educational effort directed at physicians, followed by a few changes to the computer system that made doctors stop and think before they ordered digoxin levels. "We removed the capability for physicians to order digoxin levels qd, qod, or serially," he says. "It used to be, Serial levels until discharged.’ Now, we force physicians to consider each and every digoxin level."
Other changes included delaying the time of digoxin administration until the afternoon to allow the phlebotomist to draw more meaningful levels. Fraser says utilization has dropped 20% over the past five years, with a cost savings of $50,000 a year.
What’s exciting about Fraser’s effort is its ease of expandability and low cost to implement. Computer reminders — if well-detailed and user-friendly — have proved to be an effective means of guiding physicians to use lower-cost and more appropriate products. For example, orders for vancomycin levels were halved at Maine Medical by inserting a reminder in the computer program that trough levels are the only ones applicable, Fraser says. And for deep vein thrombosis prophylaxis, physicians are guided down a medication pathway toward the most appropriate agent — heparin or a low molecular weight anticoagulant.
Improving patient outcomes is key
Heparin also was the theme for the winning entrant from the Hospital of the University of Pennsylvania. Lily K. Cheung, PharmD, says an increasing number of reports of heparin-associated bleeding spurred the hospital’s drug use effects committee to look at the problem. The committee — made up of representatives from pharmacy, nursing, medicine, and legal and quality affairs — found four major reasons for the side effects: medication errors, some caused by having multidose vials available on the floors; inappropriate use of high-concentration agents for heparin flushes; heparin-induced bleeding after cardiopulmonary bypass surgery; and inappropriate dosing and monitoring of heparin infusion therapy.
Cheung says by controlling floor stock, eliminating some of the concentrations of heparin carried, and using a computer system to calculate post-op heparin doses, the hospital has drastically reduced the number of heparin-associated bleeding incidents over the past two years. "Actually, some of the [side effects] we don’t find anymore," Cheung says.
Patient satisfaction soars
It’s hard for patients to get better if they’re in pain, and better pain relief was the goal at the Valley Medical Center in Renton, WA. Lily S. Hwang-Ho, PharmD, says patient satisfaction with pain relief has risen markedly, according to patient satisfaction surveys.
How can pharmacists help relieve pain? By tailoring doses: Hwang-Ho says postoperative patients are especially prone to developing severe pain. "During recovery, they’re heavily dosed with pain medications, but [later] the pain level builds up." Hwang-Ho says patient-controlled devices need to be set at higher levels to achieve effective pain relief during these periods.
Pharmacists have become such experts at pain relief at Valley Medical, that the Drug Enforcement Administration recently granted DEA numbers to some on the staff. That will enable continuity of pain medication once the patient leaves the hospital, in case, for example, the patient needs a narcotic but can’t get in touch with the doctor.
Finding other categories of patients who can be helped by a pharmacist is relatively easy. Just look for those taking large numbers of medications — oncology patients, for example. They were part of the winning formula for St. Mary’s Health Center in Jefferson City, MO. Alice E. Taku, PharmD, quality assurance coordinator, says this growing area of the hospital has benefitted enormously by having a dedicated pharmacist review medication orders. "The oncology program has been going for 18 months, and it has proven very successful," she says. Taku estimates about $30,000 has been saved since the program’s inception, mostly by pharmacists picking out therapeutic duplications and enforcing stop orders on antibiotics.
For pharmacy departments, formulary manipulations remain a cornerstone of cost control, but how many hospitals make partners out of the pharmaceutical industry? That’s the strategy at the Alexandria (VA) Hospital, where Shannon Goldwater, PharmD, clinical coordinator, says industry cooperation is essential to make formulary changes stick.
There are always winners and losers when a formulary change is made, but Goldwater says hospitals can eliminate much drug company retaliation — for example, a loser trying to undermine a formulary decision by lobbying doctors to use a "nonpreferred" agent — by considering the drug company’s input during the decision.
And while Alexandria’s formulary policies aren’t that much different from other hospitals, Goldwater says there is something unique about it: "We document outcomes, but not just financial outcomes. Clinical outcomes," she says. Documenting clinical outcomes is critical for physician buy-in to the formulary program, Goldwater says, because it lets the medical staff know that cost is not the overriding concern. "If we see a problem [with a formulary medication], we’re ready to jump," Goldwater says. (See chart, next page.)
That attitude has kept physician compliance with formulary rules in the 76% to 99% range, Goldwater says. Thus far, the pharmacy has made more than 11,000 switches to preferred agents over the past two years, and most important, clinical outcomes fell in the acceptable range nearly 90% of the time.
Intervention pharmacist saves $300,000
Alexandria has even hired an intervention pharmacist whose task when hired was to save the department $200,000 over a two-year period. That pharmacist, Anissia Neal Janifer, PharmD, has more than met that goal, with a $300,000 savings realized. Janifer picks up nonpreferred drug orders via a computer printout of all therapeutically interchangeable items and then investigates why the aberrant agent was ordered.
Other winners of Abbott awards include Bassett Healthcare in Cooperstown, NY, for tightening up on antibiotic use and in the process saving $55,000 a year. The Medical Center in Columbus, GA, was recognized for handing over order-entry duties to pharmacy technicians, freeing pharmacists to spend time on clinical activities.
The University Hospital in Denver also found a way to use pharmacy technicians to cut costs. As Nancy Stolpman, PharmD, clinical coordinator explains, the pharmacy was concerned about the extreme unreliability of reported aminoglycoside levels. One reason for the unreliability: lack of communication. Stolpman says a phlebotomist might draw a scheduled aminoglycoside level, not realizing the patient had just returned from a procedure and the antibiotic bag was just hung. Such a high level might prompt the physician to drop the dose to a sub-therapeutic level.
Stolpman says the pharmacy was fortunate to have on staff a technician who also was a licensed phlebotomist. The results: good levels, good kinetics, increased patient care, and less waste on repeat blood levels. (See chart, above.) Stolpman says any technician can be trained to draw levels, but check with your state to see if licensure is required.
And finally, Mission St. Joseph’s Health System in Asheville, NC, implemented a systems review for potential medication errors — good enough for an honorable mention.
Hospitals interested in entering Abbott’s fifth Quality Awards contest next year should look for registration forms in the mail and in various pharmacy journals during the year.
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