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Published on 1 March 2005

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Changing times for US hospital pharmacists

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Laurence A Goldberg
FRPharmS
HPE Editorial Consultant
UK
E:lag@salt.u-net.com

The three things that keep healthcare leaders awake at night are the problems that affect jobs on a daily basis – money, manpower and quality – according to Connie R Curran (Executive Director of C-Change, USA; see Resources).

Problems facing US hospitals
Hospitals in the USA are facing a new phenomenon, in which the beds are occupied but the purse is empty, largely because hospitals have become unprofitable. A number of factors have contributed to the current financial situation, including a change in patient mix and increasing numbers of demanding patients. Patient mix is critical because surgical services are more profitable than medical services, explained Dr Curran. “Baby-boomers” born after the Second World War are now using up to 120% more inpatient days than younger age groups. Another factor is drug prices, which are 81% higher in the USA than in Canada and six Western European countries. Other contributory factors include the increasing price of malpractice insurance, redirection of public funds into the war in Iraq and increased government funding for science at the expense of healthcare. One critical factor is the soaring price of health insurance, said Dr Curran. Insurance premiums have increased by more than 10% per annum since 2001, and now the average family has to spend $10,000 each year. Many small companies no longer provide health insurance for their employees. Currently, about 50 million Americans do not have health insurance, and some hospitals have had to resort to aggressive collection practices to recover their costs. The resulting bad press has further soured people’s views of health services.

Turning to quality, Dr Curran pointed out that the annual number of deaths due to medical error (approximately 100,000) exceeds the total number of deaths from breast cancer, road traffic accidents and AIDS. Two percent of hospital admissions involve a preventable adverse event. There have been 50,000 claims for wrong-site surgery since 1999, and each year 1,800 surgical instruments are left in patients after operations. A report produced by the Leapfrog Group has shown that computerised prescribing can reduce drug errors by 50% (see Resources). A study carried out at Northwestern Memorial Hospital (Chicago) showed that using pharmacists for drug histories resulted in avoidance of harm and considerable cost savings. Another study showed that the level of nurse education had a profound impact on patient outcomes – for every 10% increase in the proportion of nurses with bachelors’ degrees, there was a 5% decrease in the likelihood of death within 30 days of admission.

There are shortages of manpower in every area of patient care. This translates into longer waits, delayed surgery and diversions to other hospitals. Some of the factors that contribute to this situation are raised expectations from better-informed patients, new technologies (including new drugs), the ageing population and the “sicker-quicker” phenomenon. Hospitals responded by increasing the use of contract (agency) staff and by outsourcing ancillary services, although these approaches are often much more expensive. Nurses find the situation demoralising and frequently complain that they cannot do the job they are trained to do. Employees do not quit jobs, they quit managers, said Dr Curran. The usual reasons cited for leaving are bad management, lack of personal development, poor career opportunities, bad cultures, unpleasant coworkers and better rewards elsewhere. Human resources departments should work to achieve “magnet status”: that is, to transform their institutions into attractive places for all professional groups to work. This would involve the adoption of employee-friendly policies and would, in turn, lead to loyal staff and better patient care.

Technology
The implementation of computerised physician order entry (CPOE) represents a significant opportunity for pharmacy, explained James D Carpenter (Regional Information Services, Providence Portland Medical Center, Portland, OR). Pharmacists have a good understanding of drug therapy and monitoring, are familiar with computerised order entry processes and are aware of the potential shortcomings of computerised decision support. For these reasons, they should be involved in the design and development of a CPOE system and also play an active role in user training and implementation support.

Future CPOE systems will be device-independent, offering the possibility of web-based, real-time, wireless access from anywhere in the institution, said Ron Robb (Pharmacy Product Manager, IDX Systems Corporation, Seattle, WA). First-generation CPOE systems were designed to manage clinical information. Improvements in legibility, patient safety, completeness of records, timeliness and formulary guidance were convenient “byproducts”. Key trends in the development of the next generation of CPOE systems will be more sophisticated clinical decision support, embedded best practice guidelines, evidence-based medicine, workflow engines, medical vocabularies and web technologies. Other likely developments will be improved accuracy and efficiency of therapeutic decision-making, population surveillance, antimicrobial management and formulary checking. Systems that cover groups of hospitals or clinics will be developed and security will be improved as a result of advances in authentication, authorisation and auditing. Patient safety will also be improved by integrating e-prescribing with medicines management, barcode charting and hardware such as smart infusion pumps and automatic dispensing robots, said Dr Robb.

The results of a project carried out at the University of Wisconsin Hospitals and Clinics (UWHC) showed that there was an 87% reduction in drug administration errors (from 9.09% to 1.21%) when barcoding of medicines was introduced. Drug dose errors were eliminated in this study, and “wrong drug” errors were reduced by 51%. Brad C Ludwig (Assistant Director, Pharmacy Operations, Madison, NC) described the project and went on to say that point-of-care barcode scanning enhances patient care by reducing medication administration errors, improving the quality of documentation, increasing satisfaction for nurses and patients and capturing costs more accurately.

Ideally, the barcode should be attached to the smallest unit of use by the pharmaceutical industry, but the hospital system must be sufficiently flexible to enable the pharmacy to generate barcode labels to attach to extemporaneously prepared medicines. Three types of barcode are available, but the one-dimensional linear barcode was chosen as the standard at UWHC, as most commercial barcode readers could read it with a high degree of accuracy. However, it holds a limited amount of data, and as the amount of data increases, so does the size of the label.

The two-dimensional linear barcode can store up to 100 times more data, can be printed with a standard printer and is no more expensive, but the barcode can easily be damaged or stained and it has to be read with a more expensive two-dimensional (2D) scanner. Data matrix barcodes can be up to 30 times smaller and can be read even if 60% is damaged. They are extremely accurate but can be read only by expensive, specially programmed scanners. If barcodes are incorporated in patient ID bracelets and employee ID badges, these items need to be durable and cheap. It is essential to establish secure procedures for the issue and recovery of badges for starters and leavers, and to deal with lost or stolen badges.

As with any new technology, new sources of error have been identified. On some occasions, nurses did not scan barcodes but used the override function to save time. Other “shortcuts” included not scanning patients at the bedside but using duplicate wristbands, giving doses without scanning and completing the process later.

Radiofrequency identification devices (RFIDs) enable products to be identified and tracked throughout the supply chain, explained Mitch Javidi (CEO and President, Digiton Corporation, Holly Springs/ Director of Pharma Forum, College of Management, North Carolina State University). They are tiny microchip and antenna units that can store and transmit information. This ensures inventory tracking and prevents counterfeiting and diversion (theft). The main advantage over barcoding is that there is no need for staff to stop and scan each item individually. A further advantage is that each unit is unique, as it is associated with a unique electronic code. Hence, different packs from the same batch can be distinguished from each other.

So far, RFID has been slow to take off. Two factors that may be holding hospitals and suppliers back are the additional investment required and the lack of agreement over a standard operating frequency. Some hospitals are also concerned about the possibility of interference with hospital equipment.

Chemical and biological terrorism
Chemical terrorism could involve attacks using any of the agents originally developed for unconventional warfare, such as nerve gases, vesicants, chlorine or cyanide, and the 12-hour emergency response time developed for other threats would be inadequate for such an attack, Susan E Gorman (Associate Director for Science, Centers for Disease Control and Prevention, Atlanta, GA) told the audience. For this reason, a programme was designed to place repositories of chemical agent antidotes for nerve agent attacks, known as Chempacks, in locations throughout the USA. The reasons for a national programme are that some products have variable shelf-lives, that hospitals hold only small stocks (very large amounts of atropine might be required) and that some state governments hold no stocks at all.

The Chempacks and the Sensaphone(®) monitoring device, which allow remote temperature monitoring, are provided by the Strategic National Stockpile (SNS) programme. Each state has to provide a secure, environmentally controlled storage area and take responsibility for custody of the packs. One major benefit of the stringent monitoring is that, as storage history is fully documented, the products are eligible for the FDA Stockpile Life Extension Program (SLEP) that was originally devised for military items. The estimated cost saving associated with this is nearly $500m over 10 years.

Two types of storage container are available: one designed for emergency responders, mostly containing autoinjectors, and one designed for hospital dispensing. Each Chempack contains sufficient doses to treat 1,000 patients. The drugs in the packs are atropine (to block the effects of acetylcholine), pralidoxime (to reactivate acetylcholinesterase) and diazepam (to treat acetylcholine- induced convulsions). Participation in the programme is voluntary and, when a state enrols in the programme, it is allocated a budget. It is then up to local planners to choose the number of each type of pack, up to the allocated value. So far, 371 Chempacks have been put into place, and delivery will continue at a rate of 150 per month until December 2005, said Dr Gorman.

In a mass-dispensing exercise in response to a simulated anthrax attack, the pharmacy team at the University of Arizona (Tucson) “treated” more than 2,000 people in six hours. “We are confident that we could have treated four to six thousand,” said Theodore G Tong (Executive Director, Arizona Poison and Information Center, Tucson). The pharmacy process was designed to identify three categories of patients: healthy patients, patients with multiple medication problems and patients with symptoms (eg, fever or rash). Treatment was prescribed according to a protocol, and complex cases were referred to a clinical pharmacist or physician. Critical issues included determining who should receive doxycycline (the standard therapy) or ciprofloxacin, emphasising the importance of completing the full course of treatment and providing instruction in Spanish where appropriate (20% of patients).

Resources
C-Change comprises the nation’s key cancer leaders from government, business and nonprofit sectors. These cancer
leaders share the vision of a future where cancer is prevented, detected early, and cured or is managed
successfully as a chronic illness
W:www.ndoc.org
The Leapfrog Group
W:www.leapfroggroup.org



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