Hospital Pharmacy

A Medical Board-approved pharmacy-based inpatient STanding Orders Protocol (STOP) for influenza and pneumococcal vaccination was designed and implemented at Montefiore Medical Center in response to federal and state regulations put in place in 2006. This vaccination program aims to improve historically poor vaccination rates in a complex, urban patient population. Developing this initiative in a large health care system with high turnover and a diverse (many non-English speaking) population represented a formidable challenge.

In 2006 the institution initiated a program to improve patient care. The program involved a clinical pharmacist rounding on patient care units specifically to encourage the acceptance of the pneumococcal and influenza vaccine in patients at least 65 years of age at 1 of the 2 campus sites in the Bronx, New York. Medical residents were also employed to facilitate the pharmacist and achieve national standards. Registered nurses and licensed practical nurses are authorized to administer standing orders for vaccines and anaphylaxis treatment agents as needed under this protocol without direct physician examination. Vaccine information sheets (VIS) and gender- and ethnicity-specific patient teaching aids provide statistical information regarding disease and mortality rates. Language barriers are reduced by providing VIS in both Spanish and English, and telephone translation in most languages are utilized when necessary. Documentation of refusal of, previously received, or a newly ordered vaccination is placed in the patient's chart and in the central database.

Prior to the STOP program, the total in-hospital vaccination encounter rates according to various Center for Medicare and Medicaid Services (CMS) audits was approximately 18% for pneumococcal and 27% for influenza vaccinations, respectively. The institution's current encounter rates have dramatically increased to more than 85% for pneumococcal and 55% for influenza vaccine.

The cooperative efforts of physicians, pharmacists, and nursing staff have led to the creation of a successful inpatient-based vaccine standing orders protocol. As a result, in 2007 the institution approved a second clinical pharmacist to allow for coverage at both of Montefiore's hospital sites. The hospital's goal is to ultimately decrease pneumococcal disease and its severity, increase and maintain the highest vaccination rates in New York City, and comply with national standards. The implication for decreasing morbidity and readmission of patients is promising. Future plans include the development of an ambulatory-based program with a similar design model.

The purpose of this pilot study was to review the implementation of symptom-triggered benzodiazepine therapy and evaluate the feasibility and outcomes as compared with a previous hospital standard of fixed-dose phenobarbital protocol for alcohol withdrawal on a family medicine service.

This retrospective chart review of 46 patients' medical records was performed on admissions to the family medicine service occurring between February and October of 2005 compared with February and October of 2006. Included in the study were adults who were suffering from alcohol withdrawal symptoms (AWS), who admitted to heavy daily alcohol intake, who were intoxicated on admission, and who had a history of AWS and/or history of AWS-related seizures. The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) was used to evaluate the impact of individualized symptom-triggered therapy on outcome measurements utilizing symptom-triggered benzodiazepine therapy compared with the previous hospital standard using a fixed-dose phenobarbital protocol.

One hundred percent of the patients in the phenobarbital group required drug compared with 38% in the benzodiazepine group (P < 0.001). Fewer patients (9.5%) in the benzodiazepine group left the hospital against medical advice (AMA), while 36% of patients in the phenobarbital group left AMA (P = 0.045). There was no significant difference in length of stay or the number of days on the protocol.

The results of the pilot study demonstrated that symptom-triggered therapy using benzodiazepines resulted in better outcomes than fixed-dosing phenobarbital. Importantly, most patients in the benzodiazepine group required no drug administration.

Stress-related mucosal disease (SRMD) can adversely affect patient morbidity and mortality. The use of stress ulcer prophylaxis (SUP) in patients with no risk factors for clinically important bleeding, however, is contributing to health care-related adverse events, drug interactions, and costs. The objective was to determine the percentage of hospitalized patients who receive SUP without an approved indication and to evaluate the financial impact of inappropriate prescribing as well as the risk for significant drug-drug interactions.

A retrospective chart review was performed of hospitalized adult cardiology, family medicine, and internal medicine patients between July 1, 2006 and June 30, 2007. Prescribing of acid suppressive therapy (AST) during hospital admission and indications for SUP were evaluated. Concomitant medications, cost of therapy, and discharge medications were assessed as secondary outcomes.

Of the 4,603 patients admitted during the study period, 418 were randomly selected for study inclusion. Approximately 53% (221/418) of the selected patients received SUP during hospital admission, 93% (206/221) of whom had no indication for prophylaxis. Of those who continued AST at discharge (14%; 31/221), 84% (26/31) had no approved indication. Overuse of SUP resulted in 77 potential drug-drug interactions and an estimated 30-day outpatient cost of $37,950 for patients receiving these medications at discharge.

SUP is frequently prescribed to non–critically ill patients when the risk of SRMD is low. Use of SUP for patients who do not meet evidence-based criteria appears to contribute to increased health care expenditures, potential adverse events, and drug interactions.