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Laurence A Goldberg
HPE Editorial Consultant
The translation of scientific and technological advances into genuine improvements in the care of patients remains a major problem in healthcare today, according to Eve Slater (former Assistant Secretary for Health, US Department of Health and Human Services).
Implementing technological advances in healthcare
Dr Slater’s experience as a cardiologist and in the pharmaceutical industry has enabled her to see both sides of the coin. There are three fundamental “translational gaps”: persistent inappropriate prescribing; an epidemic of preventable medical errors; and poor compliance. Inappropriate prescribing exposes patients to unnecessary risks: for example, long-acting benzodiazepines increase the risk of falls in the elderly. More than 16,000 annual road traffic accidents in the USA are attributed to adverse drug events (ADEs). Underprescribing is also a problem: for example, only 25–50% of postmyocardial infarction patients are prescribed cholesterol-lowering treatment, and only 33% of patients with coronary artery disease are prescribed aspirin despite the known benefits of these treatments. Dr Slater said that in 2000 an estimated 50–100,000 deaths in the USA were due to preventable medical errors, 7,000 of which arose from medications. This number had doubled in each of the three years that followed, she continued. In spite of remarkable advances in drug development, surveys show that large numbers of patients do not take their medicines as prescribed.
Turning to solutions, Dr Slater said that three main areas would be important: namely, development of an IT-based infrastructure, enhanced communication between carers and members of the healthcare team, and increasing use of evidence-based interventions. Computerised physician order entry (CPOE) and electronic physician–patient communication would both be critical developments. In the State of Massachusetts, CPOE is projected to eliminate 47,000 preventable ADEs, up to 3,100 life-threatening ADEs, up to 29,000 hospital visits and up to 4,300 ADE-related hospitalisations per annum. These benefits would accrue from improvements in care quality, guiding prescribers towards more cost-effective medications and error reduction. The estimated net annual benefit for inpatients with CPOE alone, after taking into account all implementation costs, would be $966 million for the State of Massachusetts. CPOE systems are not yet perfect; some suffer from poor software design, print that is too small to read and inflexible ordering systems, noted Dr Slater. Another critical issue is healthcare information exchange and interoperability. Electronic standards, dictionaries and connectivity issues will need to be addressed. Other barriers to implementation include cost, user education, legal and regulatory issues, especially those concerning privacy, cultural resistance and inertia. A more subtle problem is that the benefits of improved IT often do not accrue to the purchaser, so there is little incentive to invest. Strong leadership at federal level would be needed to make this happen, and issues such as educational and cultural resistance have to be addressed by professional societies, said Dr Slater.
One place where IT developments in healthcare have been tackled well is the UK, where the National Programme for Information Technology (NPfIT) is being implemented. The key components of this programme are electronic healthcare records, e-booking of appointments and e-transmission of prescriptions. Each individual is given a unique, secure National Health Service (NHS) number. The status of electronic healthcare records in the USA is at present “quite dismal”, said Dr Slater. A recent survey showed that less than 5% of hospitals use CPOE, and less than 10% of primary care physicians use basic systems that could support electronic prescribing. Overall, approximately 3% of healthcare revenues are spent on IT, whereas for other industries, such as banking, 7–10% is normal. In the USA there is a 10-year plan for the implementation of IT in healthcare, but it is “primitive compared with the UK”, said Dr Slater. She concluded her presentation by reminding the audience that we do what is easy and avoid the hard things, but this is one situation where we have to work together to tackle the difficult jobs.
Clinical decisions and economic factors
There should be a common understanding in the hospital that generic (aut idem) and therapeutic (aut simile) substitution of medicines is practised, Irene Krämer (Director of Pharmacy, Johannes Gutenberg University Hospital, Mainz, Germany) told the audience in a session devoted to the links between clinical decisions and economic factors. In future the situation is likely to become more complex, as more bio-similar drugs will be used and the determination of biological similarity will require more rigorous techniques, she predicted.
Drug costs are considered only after safety and efficacy issues have been taken into account. The hospital pharmacy can influence prescribing on three levels: at the hospital level through a hospital formulary; at the diagnosis-related group (DRG) level through therapeutic guidelines; and at the individual patient level through generic substitution and therapeutic interchange. It is important for a hospital to have mechanisms at all three levels and also to have schemes for their implementation. Formularies “need a lot of explanation” because there is a widespread lack of understanding amongst patients and the public about the reasons for having a hospital formulary. In Dr Krämer’s hospital, a form has been developed that shows the type of substitution recommended and the reasons for it. For example, when a combination product containing an angiotensin-converting enzyme (ACE) inhibitor and a diuretic was prescribed three times daily (resulting in an evening diuretic dose), the pharmacist suggested equivalent doses of separate drugs with the diuretic dose in the morning. The reverse side of the recommendation form is a clinical pharmacy intervention monitoring form. In future, CPOE will enable automatic conversion to formulary drugs, and this would be particularly useful for H(2)-receptor antagonists, proton-pump inhibitors, quinolones and low-molecular- weight heparins, said Dr Krämer.
New wound management products
An evidence-based approach to formulary management resulted in major savings on wound management products, according to Herbert Jenzer (Head of Pharmacy, Fribourg Canton Hospital, Fribourg, Switzerland). A survey of 471 wounds had shown that 86% could be assigned to three categories: simple, complex or terminal. In each group, the use of modern wound dressings that do not require daily changes resulted in faster wound healing and overall cost reductions.(1) Dr Jenzer calculated that the switch to modern dressings had saved his hospital more than one million Swiss Francs during 2004. He concluded that traditional wound care procedures that rely on frequent dressing changes and the use of ointments, enzymes and disinfectants are now largely obsolete.
Efficient response to a terrorist attack: lessons from the Madrid bombings
Goodwill and everyone’s determination to help were the key factors that enabled the Madrid hospitals to respond effectively to the terrorist bombing on 11 March 2004, according to Pilar Gomis (Pharmacist, 12 de Octubre Hospital, Madrid, Spain).
At 7:40am, 10 bombs exploded without warning. The bombs had been targeted at trains in the height of the morning rush hour. In total, 191 people were killed and more than 1,600 were injured. The initial blasts killed 177 people; a further 976 were treated in hospital, 250 in temporary hospitals and 204 in primary care. An early decision was made that two hospitals in the south of Madrid, 12 de Octubre Hospital and Gregorio Marañón Hospital, would deal with most of the casualties. Hospitals in the north of Madrid were held in reserve in case of further explosions.
At 7:45am, the 12 de Octubre Hospital received a call from the police, and staff immediately started to move patients out of the trauma receiving area. In addition, staff from otolaryngology, ophthalmology radiology and trauma were mobilised in anticipation of blast injuries. As casualties started to arrive, staff were hampered by not knowing what types of injuries to expect. For example, two patients with burns had to be moved to a hospital with a burns unit. In total, the hospital treated 245 people in the first three hours. One physician took charge, and medical students who were at the hospital were drafted in to help. They identified patients and recorded everything that the physicians did. Two secretaries logged all admissions in the central database. All elective surgery was cancelled, and as many patients as possible were evacuated. A lecture room was set aside for receiving and briefing relatives. By 11:20am the emergency room was empty. During the critical time patients stayed away from the hospital – only one patient came to the emergency room, and he was unconscious with a brain haemorrhage.
The main problems that staff experienced were lack of familiarity with emergency response protocols and inability to communicate information quickly. There was no difficulty in locating healthcare professionals because most were already in the hospital.
At the Gregorio Marañón Hospital, 312 patients were received in the space of three hours. Elective surgery was postponed, and 438 patients were discharged in less than two hours. Medical students again played a key role in helping the professionals to cope with the heavy workload. There was no emergency response protocol in place for the pharmacy, noted Ms Gomis.
Turning to the pharmacist’s role in the response, Ms Gomis said that, in addition to large quantities of intravenous fluids, albumin and plasma expanders, significant amounts of analgesics and sedatives were issued. It became necessary to operate a simplified ad-hoc distribution system to keep up with needs, but all issues were still recorded so that the pharmacy knew where the stock was at all times. Treatment for relatives included paracetamol and bromazepam.
Ms Gomis paid tribute to the pharmaceutical industry, which offered support immediately. They quickly switched their operation to an emergency footing by keeping the order phone of the nearest warehouse free, arranging police escorts for deliveries, communicating by email and even arranging an emergency shipment of goods from Barcelona.
The final tally of injuries showed that 56% of casualties had blast injuries, 50% penetrating injuries, 53% blunt trauma and 31% burns.
Every hospital should have an emergency response plan, according to Ana Herranz (Pharmacist, Gregorio Marañón Hospital, Madrid, Spain). “When an event occurs, everything happens so quickly that there is no time to improvise,” she said. Staff need to be able to respond according to the plan.
Within the pharmacy there should be a predefined team comprising an administrator, an information pharmacist and a logistics coordinator. The pharmacy department should hold an agreed range of medicines, such as analgesics, antidotes and plasma expanders for emergency use. It is important to ensure that the emergency room, intensive care units and surgical areas have trained pharmacy staff present so that they can monitor the products being used and requisition further supplies from the pharmacy before stocks run out. At an early stage, links should be established with local suppliers to ensure that backup stocks are made available.