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Program Highlights

2015

Impact of Modified American Academy of Pediatrics Guideline Implementation on Osteopenia of Prematurity Markers

We are excited to announce that Sinai Health System recently won the 2015 ICHP (Illinois Council of Health System Pharmacists) Best Practice Award.  This annual award recognizes the most innovative program or innovative approach to an existing pharmacy practice challenge within the state of Illinois. A multi-disciplinary, team-based approach was utilized to improve the nutrition of premature infants, with the objective of improving overall health of their bones and to ultimately reduce the risk of fractures.  Bone rounds monitoring lab values and risk factors lead by a clinical pharmacist and clinical dietician in collaboration with the neonatologists contributed to positive results, improving the health and outcomes for our smallest (tiniest) patients at Sinai Children’s Hospital for years to come.

Congrats to:

  • Kuntal Patel, PharmD
  • Pavel Prusakov, PharmD
  • Heather Vaule, MS, RD
  • Victoria Geraldo, MD
  • Departments: Pharmacy, Neonatology, Nutritional Services

In addition to the residency project, which was awarded Best Practice, our resident’s projects are vital and compelling.

Current Projects:

       

 

 

Year

Project name  

Resident

Preceptor

Brief Project Description

Impact or Practice Δ  

2018-19

 Effect of Vasopressor Discontinuation on Hemodynamic Stability in Septic Shock

 

Kendall Galarza

Basi Sanuth

 

  • Baseline Evaluation of vasopressor use
  • Action
  • ICU Order Set & Guidelines
  • Comprehensive clinical staff education
    • MD, RNs,  Pharmacists

The results of the study demonstrated that discontinuation of vasopressin prior to norepinephrine led to several suboptimal outcomes:

  • ↑’d incidence hypotension
  • ↑’d  ICU LOS
  • Higher mortality rate
  • No cost benefit

Study results affected a practice change, with update in the Sepsis guidelines

2018-19

 Regadenoson (Lexiscan®) Optimization in Stress Testing

Kasia

Plis-Cyran

Tejal Patel, Zahra Khudeira

 

 

  • Baseline Evaluation:  only 62.5% of regadenoson was appropriately used  in the inpatient setting

ACTION

  • Due to large non-reimbursable drug cost in this setting,  initiatives were implemented to ↓use of lexiscan in patients who were able to tolerate exercise and who did not have contraindications
    • Order set development,
    • Updates to guidelines, and  physician education.
  • Follow-up Evaluation
  • Relative 21.6% improvement in appropriateness of regadenoson use was demonstrated
  • Improvement approximates an  annual savings of   $40,000 for MSH.
  • Further benefit anticipated: expansion of order set to Holy Cross Hospital is planned, yielding additional cost savings

2018-19

 VANCOMYCIN STEWARDSHIP

Vanessa Hutzley

Jason Allegro,

Karen Trenkler 

- Baseline Evaluation of vancomycin use

ACTION:  resident-provided vancomycin

                 stewardship

- For a two week period,  the resident actively evaluated ALL vancomycin orders for appropriateness, excluding surgical prophylaxis

Comparison of Vancomycin Utilization:

                Baseline vs Resident-provided Stewardship

Results

- 18 of 47 orders were D/C’d by resident:  D/C or discontinuance ensures NO more doses administered

  • Savings occurred NOT only in     ↓’d drug Acquisition Cost, but ALSO
    • INDIRECT Savings, including
      • Laboratory reagent
      • Staff Time
        • Pharmacists
        • Lab staff
        • Prescribers
        • Nurses

On a broader level AND going beyond the vancomycin project, resident focused on MSH efforts on two key antibiotic areas 

1. Development of an

     Antibiotic Time Out

    (ATO)   Policy & 

     Procedure (at 72 hrs) and

2.  Implementation of a

     Required Indication

     Field in Meditech for all

     ordered parenteral

     antibiotics  

 

2018-19

OPIOID STEWARDSHIP of Post-Op Analgesic Discharge Prescriptions in a Community Teaching Safety-Net Hospital   

Anne Reda

Dallas Schepers /

Zahra Khudeira

 

  • Baseline Evaluation of discharge opioid prescribing    
  • ACTION : Specific interventions designed and executed by a pharmacy resident:  

    1) elimination of range orders (inpatient

          and outpatient CPOE system) by

          removing 1 – 2 tablet strings;

    2) addition of a  CPOE prescriber alert at

     discharge when an opioid is prescribed,

     with reminder to review patient opioid

     requirement for the 24h period prior to

     discharge; and

     3) prescriber education on

         optimization of opioid use

Verification: follow-up MUE

Result

  • Statistically significant ↓(p=0.039) in patient specific day supply, from 9.3 to 6.5 days, with % of prescriptions exceeding CDC recommendation of 3 day limit trending downwards, from 79% to 60% (p=0.163).  
  • Correspondingly, the mean tablet quantity / Rx prescription ↓’d significantly,  from 35 to 22 (p<0.001)
  • Total oral morphine equivalents (OME) / Rx was ↓’d from 193.2 to 127.0 (p<0.001). 
  • Further, multimodal pain management at discharge ↑’d  from 18 to 38% (p=0.011)   

2017-18

Implementation of Reduced Dose Alteplase for Central Venous Catheter Clearance

Esther Chung

Tejal Patel, Zahra Khudeira

 

  • Baseline: comprehensive literature review, baseline MUE  
  •  Action:  
    • Pharmacy education (including technicians)
    • Automation modification:  CPOE change and change alteplase display
    • Physician education &   Practice change   and
    • Nursing efforts (Enhancement of EMar  documentation, Development of mandatory Nursing Net Learning Module, Issuance of a Nursing Practice Alert).    

- Follow-up MUE

Result:

Based on resident’s small post-implementation study (which, importantly, demonstrated no difference in rate of catheter clearance), a minimum cost-savings of $13 K annually is anticipated for MSH alone    

- Now, as first detailed in the plan, all catheter clearance doses are prepared in the Pharmacy Clean Room.

 

2017-18

Second-Line Vasopressors in Septic Shock Patients

Krista Policchio

Basi Sanuth

 

  • Baseline:  retrospective analysis comparing use of epinephrine vs. vasopressin as second-line vasopressor in septic shock patients. Both epinephrine and vasopressin achieved similar shock outcomes– however, epinephrine resulted in increased incidence of arrhythmias, with a significantly lower cost than vasopressin.
  • ACTION  - Based on the baseline MUE ,   physician/resident education was provided and Sepsis Order Set & Guideline (in late 2017) were optimized by delineating second-line vasopressor selection :  epinephrine in patients without tachyarrhythmias and vasopressin those with tachyarrhythmias.

Follow-up evaluation

Result

Follow-up evaluation demonstrated ↓’d  use of epinephrine in patients with tachyarrhythmias; however, vasopressin use increased overall – even in those patients without tachyarrhythmias. 

  • Further education, reinforcing the data, was then provided.  
  • Sidebar – use of third-line agent, phenylephrine ↓’d --- a drug with virtually no evidence-basis for use and thus quality of care was positively impacted by subsequently ↓ing  use

2017-18

Impact of Incorporating a Pharmacy Resident into a Rapid Diagnosis Protocol for Bloodstream Infections

Daniel Carlsen

Jason Alegro,

Karen Trenkler

 

  • Baseline usage evaluation on appropriateness of hospital use of the Rapid Diagnostic Test.
  • ACTION
  • for a three month period, resident acted   on RDT results, in  the capacity of an Antimicrobial Stewardship pharmacist

Comparison Baseline response to Resident-provided RDT Stewardship

  • Results demonstrated that incorporating an antimicrobial stewardship pharmacist into RDT protocols for blood cultures :  time to optimal therapy ↓’d (trending to significance) as did LOS    
  • Trends were demonstrated, but   statistical significance was not achieved because of prolonged ‘down times’ of evenings & weekends

2017-18

Chronic Care Management Pays Off

Lisa Do

Brooke Griffin, Julio Rebolledo

Chronic Care Management (CCM)  is a topic at the ‘cutting edge’ of Ambulatory Care.  CCM is defined as non-face-to-face services provided to Medicare beneficiaries (> 65 years) who have multiple (>2) chronic conditions. Medicare may pay for a healthcare professional's help to manage those conditions in non-face-to-face interactions.   Centers for Medicare and Medicaid Services (CMS) estimates 2/3 of Medicare beneficiaries, ≈ 35 million individuals, are eligible for CCM services . 

-CCM is overall cost sparing:  in 2016 CMS paid out $52 million in CCM fees, but, realized a net savings $36 million.  CCM is substantially underutilized in the entire Midwest

Baseline:  resident studied the patient population at two Sinai clinics, evaluating patient profiles for CCM opportunities   

  • Estimates for the range of reimbursement potential were provided  – possible revenues ranged from $530,000/year for 980 standard care patients to $556,000 for 472 complex care (e.g., Type 2 DM) patients. 

Based on resident assessments, the resident estimated that it would be a reasonable workload for an ambulatory care pharmacist to conduct 10 x 20 minute phone calls per day, working 260 days per year for a total 0f 2600 standard interventions.  

  • At the time of project completion, there was a continued ongoing study at Sinai Clinics.    
  • Subsequently, pharmacists dedicate set hours to this function weekly.

“ “

Evaluation of ibuprofen and indomethacin use in neonates with patent ductus arteriosus

 

Lisa Do

Kelli Covington, Karen

Trenkler

  • Baseline Evaluation:  resident studied the two agents used in MSH NICU for closure of patent ductus arteriosus (PDA) – ibuprofen IV and indomethacin IV.  In line with literature, Lisa found that IV ibuprofen and IV indomethacin are comparable in terms of rate of ductal closure.  (Although not shown in Lisa’s study (due to sample size), ibuprofen has with a more favorable intestinal and renal safety profile, per literature); further it is less costly.  Acetaminophen was demonstrated effective in 2011 and has since been incorporated into multiple major US NICUs treatment algorithms.  Acetaminophen is associated with improved safety and lower cost that the historic standards, indomethacin and ibuprofen

Actions

  • Guidelines
  • Administration Criteria

Improvement were targeted, based on lit review

 1) Using ibuprofen, when appropriate, to the extent possible – based on improved safety  AND lower cost

  2) Using ibuprofen orally

      in appropriate patients

  3) Using acetaminophen

      in appropriate  patients  

 

 

 

2016-17

Efficacy and safety of inhaled nitric oxide compared to inhaled epoprostenol in patients with acute respiratory distress syndrome

MinHa Kim

Basi Sanuth

  • Baseline Evaluation

ACTION

  • P&T Formulary review
  • ICU Order Set & Guidelines
  • Comprehensive clinical staff education
    • MD, RNs, Respiratory Therapists, Pharmacists, Pharmacy Techs
  • Enactment of major critical care practice change, then ensuring integration into actual practice

Follow-up assessment

Critical Care Practice Change:  resident affected a change from Nitric Oxide to Epoprostenol in management of adult ARDS, with comprehensive clinician education.

  • Spared hospital > $ 250K in first year

2016-17

Impact of ambulatory care pharmacy services on human immunodeficiency virus (HIV) patients with concomitant diabetes, hypertension, or both in a safety-net clinic

Diebh Faraj

Sharon Sam, Thomas Yu

  • Baseline Evaluation, with evaluation post  

Incorporation of a pharmacist in HIV clinic

Action

  • Resident conducted both arms of the evaluation
  • Outcomes
    • A1c and BP in HIV patients with DM and/or Hypertension
    • Comparison with and without pharmacist presence in HIV clinic

Demonstration of benefit of clinical pharmacist in an ambulatory care HIV ID clinic

2016-17

Medication administration through enteral feeding tubes: a quality improvement project

Katherine Wang

Karen Trenkler, Dallas Schepers

Baseline evaluation of Medication administration through enteral feeding tubes

ACTION

  • P&P and Guideline development
  • Meditech (EMR) enhancement
  • Comprehensive clinical staff education
    • Nurses, pharmacists

 

Development of updated P&P, Guideline on Medication Administration through Feeding Tubes.   Meditech messages and alerts.

2016-17

Gentamicin Utilization as Infection Prophylaxis in Open Fractures

Tanya Abi-Mansour

Kuntal Patel,

 Marc McDowell

  • Baseline evaluation of Open Fracture Anti-infective Prophylaxis

ACTION

  • Development of MSH Guideline on Prophylaxis in Open Fracture Anti-infective

Study of identified potential for quality improvement in documentation of bone fracture scores

2015-16

Implementation of a behavioral pain score in a community teaching hospital

Darah Preston

Basi Sanuth

  • Baseline Evaluation, with follow-up  

ACTION

  • Comprehensive clinical staff education
  • MD, RNs, Resp Therapist, Pharmacists, Pharm Techs
  • Enactment of major crit care practice change, then ensuring integration into actual practice   
  • Meditech Enhancement

Follow-up, ongoing assessment

Critical Care Practice Change:   Change in pain assessment from FLACC to BPS, with demonstration of improved criteria and outcomes

2015 - 16

Evaluation of transition from patient controlled analgesia to oral analgesia in post surgical patients

Alok Salgia

  Dallas Schepers, Tejal Patel

  • Baseline MUE :  Study of opportunities for improvement in the “post-PCA” period post-op

ACTION

  • Development / Implementation of Order Set to  facilitate the transition off PCA to oral analgesia
  • Comprehensive Clinical Education
  • Surgeons, Nurses, Pharmacists

Follow-up MUE

  •  Demonstration of improved process

2015-16

Patient characteristics impacting understanding, retention, and demonstration of inhaler technique in an underserved population

Alika Moitra

Karen Trenkler

  • Baseline evaluation, with follow-up: study of patient literacy, inhaler knowledge and skill

ACTION

  • Optimization of patient education materials
  • Development of enhanced educational  material for pharmacy students:  “train the trainer” method

Follow-up MUE

 

- Demonstration of improvement in patient knowledge and skill  

  • -      

2014-15

Evaluation of opportunities for pharmacist integration into the discharge process 

Diane Cluxton

Karen Trenkler

  • Baseline Medication Reconciliation MUE- demonstrating suboptimal results

ACTION

  • Project:  resident functioned as TOC  pharmacist  for a period of 2 months
    • Adm & Dischg Med Hx, Pt Counseling
  • Comparison of readmission rates prior to resident project to those patients with admissions during resident project (those patients benefiting from resident service)

 

Demonstration of an expanded role for pharmacists at discharge – based on resident effort.  Highlighted significance of accurate ADM Med History.  Ultimately, resulted in eventual hire of 2 TOC pharmacists

***One of TOP 4 RESIDENCY PROJECTs of 2015, ICHP ***

2014-15

Clinical and economic outcomes of diabetes management at an outpatient clinic within an urban community hospital system 

Irvin Lau

Anupa Patel

  • Baseline evaluation vs.   FOLLOWING addition of pharmacist to Chronic Disease Amb Care Clinic, focus on DM
  • Outcome:  A1c

Study of the impact of clinical pharmacist on DM outcomes (A1c) in the Ambulatory Care setting

  • Resulted in doubling of FTE allocation to Ambulatory Care, from 0.5 to 1.0

2014-15

Impact of modified American Academy of Pediatrics guideline implementation on osteopenia of prematurity markers

Kuntal Patel

Pavel Prusakov

  • Baseline evaluation   vs. subsequent to Bone Round Implementation 

Improvement in Bone Care & Outcomes for NICU preemies

***AWARDED ICHP Best Practice for 2015***.

2013-14

Management of alcohol withdrawal syndromes (AWS) at an urban teaching hospital

Jacqui Aroworade

Adrienne Perotti, Jillian Szseziul

  • Baseline MUE

ACTION

  • Revision of AWS Order Set

Follow-up MUE

Optimization of AWS Order Set

2013-14

A retrospective analysis of vancomycin dosing and monitoring in patients on hemodialysis 

Tyler A Bickel

Karen Trenkler, Basi Sanuth

  • Baseline MUE demonstrating opportunities for improvement
  •  
  • Development / Implementation of Guideline, then Protocol, for Vancomycin Dosing in HD

Development of Guidelines for dosing & monitoring of Vancomycin in hemodialysis patients

2013-14

Utilization of  a patient monitoring program to improve patient safety  

Maureen Ebo

Zahra Khudeira

  • Baseline assessment of medication surveillance

Action

  • Customization of MedMined (surveillance software) for MSH
  • Implementation of MedMined
  • Comprehensive Pharmacist Educatioon

Implementation of surveillance software system (Medmined)

2013-14

Management of sickle cell crisis in an urban teaching hospital 

Uzoma Okeagu

Karen Trenkler

  • Baseline MUE

Action

  • Education of Pharmacists
  • Meditech enhancement

 

Analysis of Efficacy of Analgesia – Design of Guidelines for Sickle

   Cell patients

2012-13

Pharmacist initiative to optimize  medication therapy at transitions of care: a focus on human immunodeficiency virus (HIV) patients in an underserved population   

Andrea Bidlencik

Karen Trenkler

  • Baseline MUE

ACTION

  • Development and Implementation of MSH’s initial inpatient HIV  medication guidelines
  • Education – pharmacists and physicians
  • Meditech EMR automated alerts enhancements

Follow-up MUE

  •  Demonstrated improvement in pharmacotherapy of hospitalized HIV patients
  • Represented the initial action of MSH  HIV Stewardship Program

2012-13

Evaluation of the potential use of Hydroxyethyl starch 130/0.4 

Andrew Volk

Karen Trenkler

Pharmacoeconomic Analysis

  •  

Formulary evaluation & analysis for P&T

  • Medication Usage Evaluation

Cost – Efficacy review of Plasma Volume Expanders

2011-12

Optimization of Empiric Treatment of Obstetrics and Gynecologic (Ob-Gyn) Infections

Jonathan Murray

Karen Trenkler

  • Baseline MUE

Action

  • Development/Implementation of OB-Gyne Anti-infective Guidelines (new)
  • Comprehensive clinical staff education
    • Physicians, pharmacists

Implementation of Empiric Antibiotic Treatment Guidelines for Obstetrics and Gynecologic (Ob-Gyn) Infections

2011-12

Adherence of Patient-Controlled Analgesia Order Form on an Oncology Unit 

Tejal Patel

Zahra Khudeira

  • Baseline MUE

Action

  • Development/Implementation of PCA Orderset
  • EMR (Meditech) Enhancements
  • Comprehensive clinical staff education
    • Physicians, pharmacists
  • PCA Order Set, PCA Dosing Card, Automated Nursing Assessments
  • EMR (Meditech) Enhancements