Strategies for reducing i.v. drug waste and coping with increased workload.

The amount of i.v. drugs wasted in our centralized i.v. admixture program was initially identified as a problem in 1982. The i.v. drug waste in 1982 was approximately $72,000, which represented 8.8% of the total i.v. drug budget. The i.v. admixture workload had also increased 35% from 1980 to 1982. The pharmacy department decided to approach the i.v. drug waste and increased workload problem by purchasing premixed i.v. solutions. The objective of this study was to evaluate whether premixed i.v. solutions are cost effective by decreasing both drug waste and i.v. preparation time. In addition, pharmacy standardized the doses of various i.v. drugs and instituted an on-call card system for the ordering of selected drug by nursing. By using the above methods, the pharmacy department was able to absorb an additional 37% increase in workload from 196,418 units in 1982 to 269,176 units in 1985. Also, pharmacy was able to reduce the i.v. drug waste from 8.8% of the i.v. budget in 1982, to 2.35% of the 1985 i.v. budget. Both of these goals was achieved without additional staff.     

Pharmacy-nursing report form used to monitor and adjust schedules of large volume parenteral solutions.

The use of an i.v. report form to regularly monitor and adjust the schedules of large volume parenteral solutions and irrigations is discussed. The departments of pharmaceutical services and nursing instituted a program that allowed both departments to compare the schedules of large volume parenterals and irrigations for each shift. This program centers around the use of an i.v. report form, for which clinical nurses record information concerning the progress of i.v. fluids and irrigations. The completed report is forwarded to the pharmacy, where pharmacy personnel use the information to continually update i.v. therapy profiles and adjust the administration schedules of subsequent solutions. Pharmacy's review of the i.v. report form allows the pharmacist to use his/her clinical judgment concerning the appropriateness of therapy and provides an opportunity to prevent and observe medication errors. Although this system has not be formally compared to other systems, it appears that an i.v. report system is an effective means of communication between pharmacy and nursing departments.     

Implementing therapeutic interchange of intravenous famotidine for cimetidine and ranitidine

The steps taken to implement a therapeutic interchange program for i.v. histamine H2-receptor antagonists and to determine the potential cost savings are described. A literature review conducted by pharmacists at a 273-bed nonteaching community hospital showed that i.v. famotidine was as safe and effective as i.v. cimetidine or ranitidine and that it was feasible to add famotidine to total parenteral nutrition (TPN) solutions. Because of famotidine's cost advantage, it was proposed that i.v. famotidine be used in place of specific dosage regimens of i.v. ranitidine or cimetidine and in TPN solutions ordered for patients receiving concurrent H2-antagonist therapy. The approval of the hospital attorney and hospital gastroenterologists was secured, and a formal proposal was submitted. The pharmacy department distributed a memorandum describing the advantages of famotidine, conducted inservice education sessions, and sought the compliance of physicians by placing reminders on order forms and patient charts and by contacting physicians directly. The program was implemented in May 1989. During the first three months, only one physician insisted that patients receive i.v. ranitidine rather than famotidine. It was projected that the interchange of i.v. famotidine for cimetidine or ranitidine would result in a total savings of $37,565 during the first year due to reductions in the cost of drugs, supplies, and nursing labor. The acceptance of a therapeutic interchange program for H2 antagonists was excellent, and the projected savings are substantial.     

Comprehensive pharmaceutical services in the surgical suite and recovery room

The operation of a pharmacy satellite located within the operating suite of a large university hospital is described. The satellite provides comprehensive services 24 hours a day, seven days a week to the staff of the operating room (OR), recovery room, and anesthesia department. Kits of anesthetic agents and other drugs used by the anesthetist and surgeon are prepared for each surgical procedure. The pharmacy staff also prepares i.v. admixtures, cardioplegic solutions, and specialized preparations as needed for surgery and provides drugs and i.v. admixture services to the recovery room for postoperative patients. Controlled substances are signed out to the anesthetist as needed in the particular kits and are issued as single doses upon request to the recovery room. All pharmacy charges to patients in the OR are done directly from the pharmacy satellite using a computer charging system. The decentralized pharmacy satellite has substantially reduced drug loss and waste, improved drug delivery to patients, increased revenue for the institution, reduced drug inventory, improved controlled-drug distribution and accountability, improved clinical services, and eased the nursing workload by reassigning drug-related responsibilities to the pharmacy department. The OR pharmacy satellite is a viable cost-effective operation.     

Premixed intravenous admixtures: a critical challenge for hospital pharmacy

The advantages and disadvantages of premixed intravenous admixtures are discussed in the context of their effects on hospital pharmacy practice. Premixed i.v. admixtures offer the advantages of preparation-time savings, assurance of properly reconstituted drugs, lengthy expiration dating, and appropriate labeling. However, because not all drugs will be available from all three i.v. solution manufacturers, hospitals may be forced to use several types of i.v. containers and administration sets. Storage-space requirements will be increased, as the pharmacy will need to stock both premixed and unmixed products. Health-care personnel may be confused about whom to call (the drug manufacturer or the i.v. manufacturer) for drug information on premixed admixtures. Quantity discounts will likely decrease as fewer base i.v. solutions and unmixed drug products are purchased. Plans should be made now to shift personnel from admixture preparation to clinically oriented programs and to develop new workload indicators for pharmacy departments.     

Patient-teaching program for home intravenous antimicrobial therapy

The development of a home i.v. antimicrobial therapy program and associated procedures for patient teaching are described. The pharmacy department at a 940-bed, acute-care, general medical-surgical teaching hospital participated with four other departments in the development of standardized teaching methods for a home i.v. antimicrobial therapy program. The pharmacy and nursing departments each developed sections of a home antimicrobial therapy manual. Over a 16-month period, i.v. antimicrobial therapy was prescribed for 37 patients who were discharged from the hospital. Most patients or their care-givers were able to prepare and administer the medications. After the patient was discharged, the pharmacy department offered services such as supplying medications, coordinating pharmacokinetic dosing, providing drug information, and acting as a patient contact. Hospitals that provide home i.v. antimicrobial therapy should coordinate the resources of the various departments involved to develop standardized patient-teaching methods.     

Comprehensive pharmaceutical services in the outpatient surgery center of a health maintenance organization

The pharmaceutical services provided to the outpatient surgery center of a health maintenance organization (HMO) are described. The satellite pharmacy is managed by the nearby central pharmacy. The satellite pharmacist prepares and dispenses all needed medications and i.v. admixtures, maintains the inventory of all drugs and i.v. supplies, and supplies clinical and drug information. The pharmacist ensures that i.v. admixtures are made according to guidelines, that drug interactions and drug allergies are guarded against, and that each patient has access to oral pain medications and medication counseling while still in the recovery room. The tighter inventory control created by this arrangement helps to reduce costs, and the surgical nursing staff has been relieved of many medication-related activities. The presence of the pharmacist in the surgery center also allows for more accurate documentation of controlled-drug dispensing. The presence of a pharmacist in the surgery center has ensured strict control of drug use and enabled nurses to spend more time on direct patient care.     

Monitoring waste in an intravenous admixture program

A method for collecting and analyzing data on i.v. admixture waste is described, and examples of the use of these data to reduce waste are presented. In 1984, a pharmacy department serving 580 hospital beds projected annual expense for waste of i.v. products to be nearly $30,000. Five major changes were implemented to reduce waste. Modification of expiration dating policies for cefoxitin and tobramycin substantially reduced waste. After an operating room pharmacy satellite was opened, decreased waste of dobutamine, dopamine, nitroglycerin, and nitroprusside was estimated to save $1000 per year. Changing times of batch processing of i.v. admixtures resulted in cost savings that were not significantly different for three-month periods before and after the change. The method of identifying small-volume injections (SVIs) to be manufactured was improved, and SVIs of expensive drugs were prepared every 12, instead of 24, hours; these changes resulted in reduction of one technician full-time equivalent but little change in the percentage or cost of SVIs wasted. Decentralized pharmacists were asked to order certain items on an as-needed basis; this did not affect costs or waste. From 1984 to 1985, total costs associated with waste decreased an estimated $11,000, or 27.5%. This department's attempt to change i.v. admixture procedures based on timely data has resulted in substantial reductions in the cost of waste.     

Outsourcing inpatient i.v. compounding: expense and medication error implications

A quasi-experiment was conducted to evaluate differences in intravenous (i.v.) drug compounding costs and frequency of medication administration errors of omission before and after outsourcing the hospital's i.v. admixture refill program to an alternate site home i.v. infusion pharmacy. As part of the outsourcing changes, the pharmacy redeployed an i.v. admixture technician to do i.v. recycling on the nursing units. The study was a single subject, pretest, posttest (within subjects) design using an observer. The independent variables were outsourcing and having an i.v. recycling technician. The dependent variables were medication errors of omission and costs directly associated with the two i.v. programs. A statistically significant reduction in the frequency of medication administration errors of omission was associated with implementation of the outsourcing program. In addition, first year expenses were reduced by an estimated $86,356.     

Bar-code technology for documenting administration of large-volume intravenous solutions

The failure to properly document dispensing, administration, charging, and crediting of large-volume plain i.v. solutions in a hospital, along with the potential for using bar-code technology to reduce documentation discrepancies, was investigated. Portable bar-code scanners and preprinted bar-code labels were employed to identify large-volume plain i.v. solutions administered on two selected nursing units of a 1000-bed, private, not-for-profit hospital. Inservice training sessions were conducted to instruct hospital personnel in the use of the scanning equipment. Comparisons of patient statements and medication administration records for large-volume plain i.v. solutions established the level of documentation errors in the study hospital. The causes of these errors were traced to three primary sources: (1) failure to document administration of a solution to a patient (38%), (2) failure to credit patients for i.v. solutions returned to the pharmacy (37%), and (3) administration of a solution to a patient other than the patient for whom the solution was dispensed (25%). Accountability for large-volume plain i.v. solution charges to patients was improved by 19% using bar-code technology. The pharmacy manager desiring to employ bar-code technology should determine convenient methods for applying bar-code labels to solutions and for scanning the bar codes, as well as provide programming that can compensate for erroneous scans.     

Temperature of refrigerated i.v. fluids and admixtures during infusion

The effects of infusion rate, drop size, and solution composition on the infusion temperature of i.v. fluids and admixtures that had been stored at refrigerated temperatures were determined. Polyvinyl chloride bags containing 5% dextrose injection, 0.9% sodium chloride injection, cefazolin 20 mg/mL in 5% dextrose injection, or total parenteral nutrient (TPN) solution were removed from the refrigerator after 12 hours and hung from i.v. poles. An administration set was attached to each bag, and the distal end of the administration tubing was placed in a beaker-funnel-flask apparatus that served as a collection vessel for effluent during simulated i.v. infusions. Thermo-couples were inserted into each i.v. bag and positioned under the distal end of each administration set to monitor the temperatures of the solution in the bag and of the effluent. 5% Dextrose injection and 0.9% sodium chloride injection were studied at two flow rates (125 and 60 mL/hr) using two different administration sets (60-drops/mL microdrip set and 15-drops/mL primary set); the cefazolin admixture and the TPN solution were studied at both flow rates using the primary set only. The temperatures at each probe were measured in triplicate at the start of each infusion and at 3, 6, 9, 12, 15, and 25 minutes during the infusion; each infusion was repeated three times. All of the solutions warmed significantly as they passed through the administration sets. Throughout all time intervals, the cefazolin admixtures had the smallest proximal-distal temperature increase, and the TPN solutions had the greatest increase.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cost of wastage in a hospital intravenous admixture program

The wastage in a hospital centralized pharmacy intravenous admixture program was assessed. The loss rate was similar during two separate 36-day study intervals, averaging 6.2% of intravenous admixture preparations, accounting for an estimated loss of $26,077 for the year. Discontinuation of intravenous therapy accounted for half of the returned intravenous admixtures. Patient unavailability, drug changes, and malfunction of intravenous equipment were also causes for returns. Improved communication between hospital ward units and pharmacy personnel as well as increased flexibility in admixture preparation scheduling may reduce wastage. Ultimately, pharmacists assigned to individual ward units as part of the unit-dose pharmacy dispensing system may resolve the problem.     

Controlling financial variables--changing prescribing patterns

Techniques of formulary management, pharmacy and therapeutics committee intervention, and the use of clinical pharmacy services to change prescribing patterns and contain costs in hospital pharmacy departments are reviewed. Methods of using the formulary to contain costs include deletion of generic and therapeutic equivalents, inclusion of therapeutic categories and cost codes, and regular reviews and updates of its contents. Drug monographs for formulary evaluation prepared for the P & T committee should include a comparative review of other drugs in the therapeutic category and a cost impact statement. The P & T committee can help contain costs by developing policies for automatic stop orders and restricted drug use. Clinical pharmacy activities that can result in cost savings include physician education (focused on prescribing), target drug programs, target disease programs, pharmacist participation on TPN and i.v. therapy teams, and patient training programs for home care. A matrix for evaluating cost-containment activities is presented. By tailoring the described methods to departmental personnel resources and hospital needs, the pharmacy can be effective in controlling costs.     

Charging for hospital pharmaceutical services: combined product-service per diem fees.

The development of a per diem hospital pharmacy charge is reviewed after five years of use. The itemized pharmacy charges for every tenth patient (total of 250 patients) admitted to the hospital during a three-month period were studied to determine the average daily charges for drugs and pharmaceutical services. Six categories of rates were designated, based on the type of hospital service. A comparison of the actual charges and the projected per diem rate indicated that the per diem rate would produce the same revenue as the itemized charging method. A procedure for periodically monitoring the per diem rate was also established. The per diem pharmacy charges range from $3.50 (for patients admitted to the psychiatric service) to $12 (surgical patients). Intravenous solutions, i.v. admixtures, normal human serum albumin, drugs administered in the intensive care and cardiac care units, and drug with an acquistion cost of more than $10 are not included in the per diem charging system. The per diem system enabled the hospital to reduce administrative and accounting costs while continuing to provide quality pharmaceutical services.     

Use of an automated medication storage and distribution system.

The effects of an automated medication storage and distribution system in a hospital setting were evaluated. The Pyxis Medstation system was implemented on two nursing units at a 1000-bed tertiary-care referral hospital. The system, which is designed like an automated bank teller, dispenses items to authorized users and records all transactions. Floor-stock controlled substances and noncontrolled medications, large-volume i.v. solutions, and i.v. administration sets were stocked in the system. The system was evaluated (1) by comparing the mean patient charge capture rates for six months before and for three months after implementation, (2) by measuring nurse and pharmacy technician time required for various tasks before and after implementation, and (3) through questionnaires filled out by nurses and technicians. After the system was installed, nursing personnel spent less time on medication-related activities, charting, and documentation and more time interacting with patients. Pharmacy technicians spent more time on floor-stock activities and less time on billing activities. Nurses indicated positive attitudes toward the system features. Both nurses and pharmacy technicians indicated that the system should remain in use. After implementation, the charge capture rate for noncontrolled medications, i.v. solutions, and i.v. sets increased from 63% to 97%. This increase, extrapolated to the entire hospital, reflects $35,000 in additional revenue over the total costs of implementation of the system. Implementation of an automated medication storage and dispensing system is expected to increase hospital revenue and enable nurses to spend more time interacting with patients at this institution.     

Effect of the Intravenous Lipid Emulsions on the Availability of Calcium when using Organic Phosphate in TPN Admixtures

Purpose  The addition of high amounts of calcium remains a pharmaceutical concern due to its precipitation with phosphate in total parenteral nutrient (TPN) admixtures, compromising also the stability of the lipid emulsion. Materials and Methods  Calcium-phosphate solubility was compared when using binary PN solutions versus all-in-one TPN (admixtures with lipid emulsions) in three formulas using organic calcium gluconate and gulcose-1-phosphate. Results  It was found that variation of Ca–P solubility exists between formulation with or without lipid emulsions. Concentrations of Ca decreased after filtrations of all admixtures (from 5% to 30%) and it was more significant in binary solutions. Precipitation has been observed by microscopy at high concentrations of both organic Ca–P after critical conditions of storage (24 h at 37°C plus one day at ambient temperature) for admixtures containing 1% amino acids and 8% glucose with or without lipids compared to admixtures containing 2% or 3.5% amino acids and 14% glucose. Conclusions  These data demonstrated that availability of Ca using organic glucose-1-phosphate increased when lipids were present in TPN admixtures, without alteration of the lipid emulsion. Thus, high amounts of Ca (up to 30 mmol/l) and phosphates (up to 40 mmol/l) might be provided safely in parenteral nutrition admixtures.     

Monetary incentive for pharmacists to control drug costs

An incentive program that paid hospital pharmacists at United Hospitals Incorporated (UHI) and Children's Hospital Incorporated (CHI) a percentage of the money saved by the pharmacy on drug and i.v. expenses in 1984 is described. Hospital administration, as part of a hospitalwide incentive program, approved the pharmacy department's proposal for a monetary incentive program. Pharmacy managers hoped that, by rewarding all pharmacists for their efforts to control costs, they could potentiate other cost-containment programs (stronger formulary control and improved purchasing and inventory control) and improve clinical services while maintaining quality of care. The incentive calculation was derived from the percentage of expenses saved on drugs and i.v. solutions and sets relative to budget. The payout, to be applied to 1984 salaries of pharmacists, could not exceed 10% of salary or more than 35% of the total savings to the hospital. A screening mechanism was established to protect the hospital from paying an incentive if the total pharmacy expenses exceeded budget. In fiscal 1984, drug and i.v. expenses per adjusted case decreased 1.55%, which led to each full-time pharmacist receiving an average payout of $500. This payout was less than had been anticipated because of a nursing strike at other hospitals, which resulted in an influx of intensive-care patients. The monetary incentive program for pharmacists is a useful tool for controlling drug and i.v. expenses and for rewarding pharmacists for successful cost-saving approaches.     

Evaluation of a 2-liter plastic container for parenteral nutrient solutions

Cost effectiveness and clinical applicability of 2-liter flexible polyvinyl chloride containers for administration of total parenteral nutrient (TPN) solutions were studied. Times were measured for single and batch compounding of 50 2-liter and 50 1-liter TPN solutions and for nursing time associated with administration of 20 1-liter and 20 2-liter TPN solutions. Costs were calculated for personnel time and supplies for 100 1-liter and 50 2-liter TPN solutions using single and batch compounding. Rates of return, reuse, and waste were compared during a two-month period. Questionnaires were administered to nurses and physicians to measure acceptance of 2-liter containers. Time savings for 2-liter versus 1-liter containers were 7.33 and 3.06 minutes per 2-liter container for individual and batch processing, respectively. Nursing time saved with use of 2-liter containers was 2.79 minutes per 2-liter container. Total personnel and supply costs for 2-liter containers were $ 1.60 and $ 0.70 less per liter for individual and batch processing, respectively. For 2-liter TPN solutions prepared for 11 patients (129 patient days), waste was not significantly different than for the 1-liter control group. Questionnaire responses indicated overall acceptance of administration of 2-liter solutions as safe and efficient. For centrally administered TPN therapy in the inpatient setting, use of 2-liter flexible polyvinyl chloride containers is efficient and cost effective.     

1200例全肠外营养液使用情况分析

目的了解医院全肠外营养液（TPN）使用情况,规范临床合理用药。方法采用回顾性分析方法,对医院静脉药物配置中心2011年4月、5月静脉用药医嘱进行审核,分析1 200例全肠外营养液医嘱。结果存在不合理医嘱,主要集中于普外科、肝胆外科、重症监护室和胸外科。结论临床使用TPN基本合理规范,存在部分问题,有待改进。     

Increasing pharmacy productivity by expanding the role of pharmacy technicians.

Efforts to meet growing clinical and distributive demands without increasing pharmacy staff are described. Real and expected increases in demands for services led pharmacists at a cancer center to seek ways of accommodating those demands within budgetary limits. Growth in the distributive workload was interfering with clinical consultation work. Research studies by the medical staff were resulting in complex dosage calculations and time-consuming compounding. Increasing requests for clinical services had to be met without compromising distributive services and teaching responsibilities and without raising costs. A plan of action was approved that included the use of a written test and a training manual to allow the hiring and retaining of skilled pharmacy technicians qualified to assume greater responsibilities. Technicians were assigned to enter drug orders into the computer, check other technicians, and dispense certain drugs. Greater use was made of commercially prepared i.v. solutions, and the floor stock was expanded. A comprehensive quality control program was concurrently put in place. The larger role for technicians not only enabled the pharmacy department to increase its distributive workload dramatically but reduced pharmacy medication errors and provided more time for clinical pharmacy practice. The number of pharmacist and technician full-time equivalents increased by only 1.5 in each category between 1985 and 1990. By making more use of pharmacy technicians, a pharmacy department was able to meet escalating demands for services with only a minor increase in personnel.