Hospital Pharmacy - October 2017 - 629
629
Dubrovskaya et al
Antimicrobial Stewardship Programs" outlining specific
pharmacy-driven interventions, such as dosing adjustments,
intravenous (IV) to oral antimicrobial switches, and managing antibiotic-related drug interactions.8 Recently, Bessesen
et al described a novel approach integrating ward pharmacists to perform core ASP interventions at the time of multidisciplinary patient care rounds with their assigned medical
teams.9 In addition, Chahine et al proposed specific ASP
activities to engage pharmacy residents such as extended
hours for pharmacist-led prior authorization for restricted
antimicrobials.10 And yet, leveraging pharmacy personnel
resources for the purpose of ASP operations presents a challenging task. In this report, we describe our experience establishing a multilayer model of pharmacy participation in ASP
to extend comprehensive coverage provided by dedicated
full-time ASP clinical pharmacotherapy specialists (CPS).
and clusters was introduced. A corresponding workflow
where ASP CPS receive electronic real-time notifications 3
times daily to facilitate optimal therapy based on the PCR
results was implemented. At the same time, ASP PAF was
extended to include medication reconciliation of patients on
antiretroviral therapy (ART).
All ASP interventions are directly communicated to the
primary team verbally or as a phone call by a member of ASP
team as no system for automatic pharmacy interventions is
currently established. Prior to July 2014, weekends, holidays, evenings, and nights ("WHEN hours") constituted a
gap in providing comprehensive full-spectrum ASP coverage, because ASP CPS were available only 8 am to 4 pm during weekdays. Of note, ID fellows were solely responsible
for providing approvals for restricted antimicrobials during
the weekday hours of 4 pm to 10 pm and on weekends and
holidays during the hours of 8 am to 10 pm.
Methods
Setting
Establishing Pharmacy Participation in ASP
NYU Langone Health Tisch Hospital is a 730-bed tertiary
care, academic hospital in New York City. Our pharmacy
department provides 24-hour services from a combination of
centralized pharmacy and satellite pharmacies. Pharmaceutical
services are supported by automated dispensing technology
and Epic computerized physician order entry (CPOE) system
(Epic Systems Corporation, Verona, Wisconsin), and provided in conjunction with collaborative patient care rounds by
CPS in critical care (CC), emergency medicine, infectious
diseases (ID), internal medicine, pediatrics, and hematology/
oncology. The Department of Pharmacy offers a postgraduate
year 1 (PGY1) general pharmacy residency program (4 positions) and PGY2 specialty residency programs in ID (1 position) and CC (1 position).
In December 2008, we initiated a formal ASP for adult
patients led by a board-certified ID physician. Our ASP utilizes a combination of preauthorization and prospective
audit and feedback (PAF) as core strategies. The ASP developed and implemented facility-specific guidelines to
improve antibiotic use for common infections including
pneumonia (PNA), sepsis, skin and soft tissue infections,
intra-abdominal infections, and urinary tract infections
(UTIs). In addition, dosing and monitoring guidelines for
aminoglycosides, vancomycin, and β-lactams were established to guide licensed independent providers (LIPs) at the
time of ordering, and to assist hospital pharmacists at the
point of verification. Although our institution lacks a formal
protocol for a pharmacokinetic dosing service, all hospital
pharmacists are trained and available to make recommendations for vancomycin and aminoglycoside dosing. Also,
both ASP CPS and non-ASP CPS assist with dosing, adjustments, and therapeutic drug monitoring for vancomycin and
aminoglycosides. In 2014, rapid microbiologic diagnostic
testing (RDT) with polymerase chain reaction (PCR) of
blood cultures growing gram-positive cocci (GPC) in pairs
Preimplementation phase. A stepwise plan outlining a multilayer model to extend pharmacy participation in ASP and
provide evening and weekends comprehensive coverage
(Figure 1) was developed by the ASP/ID pharmacy clinical
manager in collaboration with pharmacy leadership. Based
on the proposed model, ASP CPS would continue to perform ASP activities during weekdays; non-ASP CPS would
be integrated into ASP to provide high-level activities such
as antimicrobial recommendations, approval of restricted
antimicrobials, and de-escalation during weekday multidisciplinary bedside patient care rounds; and PGY2 pharmacy
residents (ID and CC) would be utilized to extend full onsite ASP coverage to weekends (8 am-4 pm).11 Hospital
pharmacists would be empowered to perform ASP-related
interventions at the point of verification of anti-infective
orders.
System changes to the CPOE system included customization of Epic iVents (Clinical Interventions) to allow for documentation, tracking, and reporting of ASP interventions
based on the level of pharmacist participation in patient care.
In addition, ASP CPS developed educational activities for all
pharmacists. ASP education consisted of sessions with nonASP CPS to review ASP guidelines, and sessions with hospital pharmacists to review ASP goals including pharmacy
participation, vancomycin and aminoglycosides dosing protocols, allergy documentation, and major anti-infective
related drug interactions accompanied by an ID/ASP competency exam at the end of their training. These ID/ASP sessions were integrated into the onboarding process for newly
hired hospital pharmacists. For the first 3 months, newly
hired non-ASP CPS were required to discuss requests for
restricted antibiotics with an ASP CPS before official
approval could be provided. An internal pharmacy website
was utilized to post all the ASP guidelines, dosing protocols,
summaries, and checklists.
Table of Contents for the Digital Edition of Hospital Pharmacy - October 2017
Pharmacists and Medical Missions
Current FDA-Related Drug Information
Summaries of Safety Labeling Changes Approved By FDA- Boxed Warnings Highlights April-June 2017
Pharmaceutical Pipeline Update
Cholesterol Ester Transfer Protein Inhibitor Review
Formulary Drug Review
Ocrelizumab
Patient Outcomes Associated With Phenobarbital Use With or Without Benzodiazepines for Alcohol Withdrawal Syndrome: A Systematic Review
Development of a Pharmacy Technician–Driven Program to Improve Vaccination Rates at an Academic Medical Center
Safety and Efficacy of Enoxaparin Compared With Unfractionated Heparin for Venous Thromboembolism Prophylaxis in Hemodialysis Patients
Multilayer Model of Pharmacy Participation in the Antimicrobial Stewardship Program at a Large Academic Medical Center
Impact of Inpatient Automatic Therapeutic Substitutions on Postdischarge Medication Prescribing
Impact of Respiratory Viral Panel Polymerase Chain Reaction Assay Turnaround Time on Length of Stay and Antibiotic Use in Patients With Respiratory Viral Illnesses
Administration of Injectable Vitamin K Orally
Hospital Pharmacy - October 2017 - 577
Hospital Pharmacy - October 2017 - 578
Hospital Pharmacy - October 2017 - 579
Hospital Pharmacy - October 2017 - 580
Hospital Pharmacy - October 2017 - 581
Hospital Pharmacy - October 2017 - 582
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Hospital Pharmacy - October 2017 - 585
Hospital Pharmacy - October 2017 - 586
Hospital Pharmacy - October 2017 - 587
Hospital Pharmacy - October 2017 - 588
Hospital Pharmacy - October 2017 - Pharmacists and Medical Missions
Hospital Pharmacy - October 2017 - Current FDA-Related Drug Information
Hospital Pharmacy - October 2017 - Summaries of Safety Labeling Changes Approved By FDA- Boxed Warnings Highlights April-June 2017
Hospital Pharmacy - October 2017 - 592
Hospital Pharmacy - October 2017 - Pharmaceutical Pipeline Update
Hospital Pharmacy - October 2017 - Cholesterol Ester Transfer Protein Inhibitor Review
Hospital Pharmacy - October 2017 - 595
Hospital Pharmacy - October 2017 - Formulary Drug Review
Hospital Pharmacy - October 2017 - Ocrelizumab
Hospital Pharmacy - October 2017 - 598
Hospital Pharmacy - October 2017 - 599
Hospital Pharmacy - October 2017 - 600
Hospital Pharmacy - October 2017 - 601
Hospital Pharmacy - October 2017 - 602
Hospital Pharmacy - October 2017 - 603
Hospital Pharmacy - October 2017 - 604
Hospital Pharmacy - October 2017 - Patient Outcomes Associated With Phenobarbital Use With or Without Benzodiazepines for Alcohol Withdrawal Syndrome: A Systematic Review
Hospital Pharmacy - October 2017 - 606
Hospital Pharmacy - October 2017 - 607
Hospital Pharmacy - October 2017 - 608
Hospital Pharmacy - October 2017 - 609
Hospital Pharmacy - October 2017 - 610
Hospital Pharmacy - October 2017 - 611
Hospital Pharmacy - October 2017 - 612
Hospital Pharmacy - October 2017 - 613
Hospital Pharmacy - October 2017 - 614
Hospital Pharmacy - October 2017 - Development of a Pharmacy Technician–Driven Program to Improve Vaccination Rates at an Academic Medical Center
Hospital Pharmacy - October 2017 - 616
Hospital Pharmacy - October 2017 - 617
Hospital Pharmacy - October 2017 - 618
Hospital Pharmacy - October 2017 - 619
Hospital Pharmacy - October 2017 - 620
Hospital Pharmacy - October 2017 - Safety and Efficacy of Enoxaparin Compared With Unfractionated Heparin for Venous Thromboembolism Prophylaxis in Hemodialysis Patients
Hospital Pharmacy - October 2017 - 622
Hospital Pharmacy - October 2017 - 623
Hospital Pharmacy - October 2017 - 624
Hospital Pharmacy - October 2017 - 625
Hospital Pharmacy - October 2017 - Multilayer Model of Pharmacy Participation in the Antimicrobial Stewardship Program at a Large Academic Medical Center
Hospital Pharmacy - October 2017 - 627
Hospital Pharmacy - October 2017 - 628
Hospital Pharmacy - October 2017 - 629
Hospital Pharmacy - October 2017 - 630
Hospital Pharmacy - October 2017 - 631
Hospital Pharmacy - October 2017 - 632
Hospital Pharmacy - October 2017 - Impact of Inpatient Automatic Therapeutic Substitutions on Postdischarge Medication Prescribing
Hospital Pharmacy - October 2017 - 634
Hospital Pharmacy - October 2017 - 635
Hospital Pharmacy - October 2017 - 636
Hospital Pharmacy - October 2017 - 637
Hospital Pharmacy - October 2017 - Impact of Respiratory Viral Panel Polymerase Chain Reaction Assay Turnaround Time on Length of Stay and Antibiotic Use in Patients With Respiratory Viral Illnesses
Hospital Pharmacy - October 2017 - 639
Hospital Pharmacy - October 2017 - 640
Hospital Pharmacy - October 2017 - 641
Hospital Pharmacy - October 2017 - 642
Hospital Pharmacy - October 2017 - Administration of Injectable Vitamin K Orally
Hospital Pharmacy - October 2017 - 644
Hospital Pharmacy - October 2017 - 645
Hospital Pharmacy - October 2017 - 646
Hospital Pharmacy - October 2017 - 647
Hospital Pharmacy - October 2017 - 648
Hospital Pharmacy - October 2017 - 649
Hospital Pharmacy - October 2017 - 650
Hospital Pharmacy - October 2017 - 651
Hospital Pharmacy - October 2017 - 652
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