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The 2010 NHIA Idea Exchange Poster Session Program ABSTRACTS

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BOARD # TITLE AUTHOR(S)

1 Establishing Smart Pump Parameters for Home and Ambulatory Infusion Patients

Anna Nowobilski‐Vasilios PharmD MBA FASHP CNSC BCNSP1; Don Filibeck PharmD MBA2; Ramona Moenter RPh3; Glenn Zenner RPh3 ; Caryn Dellamorte Bing MS RPh FASHP2 ; Bruce Larson RPh4; Kathy Puglise MSN/ED BSN CRNI5; Susan Poole BSN MS CRNI CNSN CIC6; Lisa Hoh BSN CRNI4; Marianne Duda MS RD LD CNSD7; and Mary Ward‐Welisevich BA4. 1Anovation Care Management Innovation; 2Critical Care Systems; 3Coram Healthcare; 4Smiths Medical ASD; 5Home Choice Partners; 6Southwest Horizon Health Care Consulting; 7 CarePoint Partners.

2

Evaluating the safety of intravenous administration of enzyme replacement therapy in the home setting for infantile‐onset Pompe disease.

Jean M. Stumpf, RN, CRNI and Jill C. Leibers, PharmD, Pediatric Home Service

3 Comparison of catheter occlusions between a mechanical valve injection cap and positive displacement injection cap

Debbie Cain RN, CRNI and Glenda Jones, RN, Home Parenteral Services

4 Intravenous eculizumab in the treatment of paroxysmal nocturnal hemoglobinurea: Transition to home treatment

Michael Sweeney, RPH, MBA; Donna Betz RN, CRNI; Martha Michael RN, CRNI; and Elizabeth Roesch RN, CRNI; Thomas Jefferson University Hospital, Home Infusion Department, Philadelphia, PA

5 Implementation of a Viable Air Sampling Program using Volumetric Collection Devices

Steve Kennedy Pharm D, Lisa Linn Siefert, RPh, and Matt Lange, Pharm.D., Walgreens‐OptionCare

6

Meeting Calcium and Phosphate requirements in Pediatric BMT patients receiving PN – A Case Report using a novel approach

Leigh Reiter, RPh1, Justin Gollon Pharm.D, B.C.P.S.2 ; and Carol Rollins, MS, RD, Pharm D, BCNSP2 1University Medical Center Home Infusion, 2University Medical Center

7 Implementation of an Electronic Parenteral Nutrition Order Form and Admixture Assessment

Kevn M. McNamara, PharmD; and Brenda L. Gray, PharmD, Coram Specialty Infusion

8 Continuous Home Infusion Chemotherapy: Creating an Ideal Patient Experience

Debra S. Kovacevich, RN, MPH; Karen Hammelef, MS; Jamie Tharp, PharmD; Kathy Bishop, MHSA; Kelly Wright, PharmD; and Christopher J. Maksym, PharmD. University of Michigan Home Care Services, University of Michigan Comprehensive Cancer Center, University of Michigan College of Pharmacy

9 Development of Workload Benchmarks for Home Infusion Pharmacists

Charles Cooper, RPh, MBA, Manager, and Kyle Skiermont, PharmD, Assistant Director, Fairview Home Infusion Pharmacy

10 Supporting Patient Travel—Case Study Of Patient Traveling Internationally While Receiving Parenteral Nutrition

Brenda L. Gray, PharmD, and Kevn M. McNamara, Pharm.D., Coram Specialty Infusion

11 Evaluating new automated compounding technology in the home infusion pharmacy

Rich Monty, RPh, and Kim Templeton BSN , CRNI, VP Infusion, Preferred Homecare

12

Patient Satisfaction with Subcutaneous Immune Globulin (SCIG) Therapy for Primary Immune Deficiency (PID), and Reasons for Conversion to Intravenous Immune Globulin (IVIG) Therapy

Carol Ernst, RN, OCN, and Peg Gruenemeier, RN, CRNI, BioRx

13 Evaluating the Need for a Pediatric Education Program for Home Infusion Pharmacists

Brenda L. Gray, PharmD, and Kevn M. McNamara, Pharm.D., Coram Specialty Infusion

14 Exploring the Role of the Pharmacist in the Management of Patients in an Ambulatory Infusion Suite

Kevn M. McNamara, PharmD; and Brenda L. Gray, PharmD, Coram Specialty Infusion

15 Successful Management of a Complex Patient by a Home Nutrition Support Team

Pammi J Farren, Branch Infusion Manager, RPh, PhD; Therese Austin MS, RD, LD, CNSD; Yulia Bar, PharmD. Coram Specialty Infusion Columbus, OH


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BOARD # TITLE AUTHOR(S)

ENCORE POSTER PRESENTATIONS‐ PHARMACY RESIDENTS AND STUDENTS

A

Retrospective review and comparison of the clinical and economic outcomes of vancomycin and daptomycin treatment of complicated skin and soft tissue infections in the home infusion setting

Kecia D. Anderson, Pharm.D., Critical Care Systems

B Daptomycin usage trends in a home infusion setting

Mariam Seddiqi, PharmD, Critical Care Systems

C

Economic and safety outcomes of pediatric parenteral lipid infusion: evaluation of a dual chamber versus lipid‐separate infusion in the home care setting

Melisa Tong, PharmD, Critical Care Systems

D

Examining the 30‐day hospital readmission rate of patients receiving parenteral inotropic therapy from a national home infusion provider

Christine Parlatore, PharmD, Critical Care Systems

E Analysis of total parenteral nutrition interventions during point of care transition to the home setting

Carolyn Timm, PharmD, Critical Care Systems

1‐ TITLE: Establishing smart pump parameters for home and ambulatory infusion patients AUTHORS: Anna Nowobilski‐Vasilios PharmD MBA FASHP CNSC BCNSP1; Don Filibeck PharmD MBA2; Ramona Moenter RPh3; Glenn Zenner RPh3 ; Caryn Dellamorte Bing MS RPh FASHP2 ; Bruce Larson RPh4; Kathy Puglise MSN/ED BSN CRNI5; Susan Poole BSN MS CRNI CNSN CIC6; Lisa Hoh BSN CRNI4; Marianne Duda MS RD LD CNSD7; and Mary Ward‐Welisevich BA4. 1Anovation Care Management Innovation; 2Critical Care Systems; 3Coram Healthcare; 4Smiths Medical ASD; 5Home Choice Partners; 6Southwest Horizon Health Care Consulting; 7 CarePoint Partners. BACKGROUND: As the medical device industry transforms its ambulatory infusion pumps into those with smart technology for the hospital setting, these same pumps will soon be available for home and ambulatory care. Smart pumps, equipped with an organization‐specific drug library, are designed to improve the safety of medication administration, thus allowing the pump to assist in recognizing a programming error. PURPOSE: While home and ambulatory infusion providers are confident of the safety measures they have implemented for their current pump fleet, legacy electronic ambulatory infusion pumps will eventually be retired from service and replaced with smart pump counterparts in all patient care settings. This poster provides a methodology for designing a smart pump library appropriate to the outpatient infusion therapy population, addressing this additional preparatory step in smart pump implementation. METHODS: Smart pump libraries are designed to perform a test of reasonableness, defining hard and soft upper and lower infusion limits specific to drugs and therapies administered. While this methodology is very logical, the actual determination of programming parameters can be confusing and difficult to interpret. Each organization will create its own drug library, specific to the patient


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population it serves. When designing a pump library for the outpatient population, several variables must be considered. These differ from patient to patient, and include age, weight, drug concentration, therapeutic intent, infusion volume, and catheter type. At the most basic, the hard lower infusion limit could be interpreted as that rate under which the catheter might occlude. The hard upper limit might be the rate that would deliver the maximum dose as defined by prescribing information, or over which the parenteral nutrition patient could not maintain glucose homeostasis. To limit confusion when transitioning from legacy to smart pumps, the pump defined therapy mode is translated to those modes currently in use: continuous, intermittent, patient controlled analgesia, taper and step. RESULTS: Samples of drug library protocols from each therapy type are presented, including: pain management, inotropic therapy, immune globulin, parenteral nutrition, chemotherapy, and anti‐infectives. These examples may be used as models for developing an organization’s home infusion pump library. CONCLUSION: For smart pumps to be effective in outpatient infusion care, programming must be efficient. Although pump programming is traditionally the responsibility of the pharmacy department, a multidisciplinary approach is needed to create an effective library for this unique patient care setting. Pharmacists can readily research the maximum doses for therapies administered to determine pump hard upper limits, while infusion nurses bring understanding of catheter dynamics to define the lower hard limit rate for the organization’s pump library. Nutrition support clinicians are needed for their understanding of glucose utilization to define the upper hard limit for parenteral nutrition therapies. With patients increasingly under the simultaneous care of multiple organizations, it may become more important to provide additional safety measures, preventing patient harm from pump programming errors. Home infusion organizations must learn from their hospital colleagues and be prepared for the challenge of managing this new generation of infusion pumps. 2‐ TITLE: Evaluating the safety of intravenous administration of enzyme replacement therapy in the home setting for infantile‐onset Pompe disease AUTHORS: Jean M. Stumpf, RN, CRNI and Jill C. Leibers, PharmD, Pediatric Home Service BACKGROUND: Enzyme replacement therapy (ERT) is the only treatment for Pompe disease, a glycogen storage disease that causes debilitation in skeletal, cardiac, and smooth muscle. Without treatment, the disease progresses rapidly and most children die within the first year of life. ERT, specifically alglucosidase alfa, has demonstrated significant improvement in muscle involvement and improved long‐term survival. Alglucosidase alfa is given over 6 to 8 hours every two weeks, and requires pre‐medication. It carries a black‐box warning due to potentially life‐threatening cardio‐respiratory complications during administration. For these reasons, it has typically been given in a hospital or clinic setting. PURPOSE: The purpose of this evaluation was to determine if alglucosidase alfa could be safely administered in the home setting. Recent studies have shown significant psychosocial benefits to


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families receiving ERT at home, including increased flexibility, fewer interruptions to patient routines, decreased stress on the child, families, and workplace, and decreased expense of transporting patients (who are typically wheelchair and/or ventilator dependent) to the hospital/clinic. METHODS: A multi‐disciplinary approach was utilized in evaluating the safety of alglucosidase alfa infusions in the home. This home infusion organization’s pharmacy worked with the referring clinic to develop criteria to screen patients for appropriateness for home care, including a history of at least 12 months of hospital/clinic based infusions, no cardiac or respiratory compromise, central vascular access, and compliance with treatment by patient/family. In addition, the clinic wrote a protocol for home administration of alglucosidase alfa, including dosing specifics, monitoring parameters, emergency protocols, and a plan for coordination of care. The patients being considered for ERT had tracheotomies, ventilator support, and pulse oximetry which decreased concern for life‐threatening reactions. This home infusion organization’s nurses specialize in pediatric assessment, infusion therapy, and home care – all three skills are essential to safely manage these complex, medically fragile children during alglucosidase alfa infusions. Emergency kits containing epinephrine and other rescue medications are provided for all infusions. We provided additional training on Pompe disease and ERT by inviting the pharmaceutical representative to present inservice education. RESULTS: To date, this home infusion organization has administered a total of 77 doses of alglucosidase alfa to two patients in the home setting with no adverse reactions. These children are able to receive therapy with a minimal disruption to their day‐to‐day activities. In addition to the benefit for the patient, the decision to provide ERT in the home setting has also benefitted this organization. We have experienced an improved relationship with the referring physician/clinic, and have seen an increase in referrals for complex, multiple‐therapy patients over the past two years. CONCLUSIONS: Transition to the home setting for ERT infusions is possible with careful patient selection, reliable vascular access, a detailed management plan for adverse reactions, and education of clinical staff. Ongoing management of these patients requires care coordination through close contact between providers, infusion nurses, in‐home extended hours nursing, and the family. 3‐ TITLE: Comparison of catheter occlusions between a mechanical valve injection cap and positive displacement injection cap AUTHORS: Debbie Cain RN, CRNI and Glenda Jones, RN, Home Parenteral Services BACKGROUND: Based on recommendations published by Infusion Nurses Society (INS), this home infusion organization changed heparin concentration for vascular access device (VAD) flushing from heparin 100 unit/ml to heparin 10 unit/ml for most VAD's. Six months later the organization changed from a mechanical valve (MV) injection cap to a positive displacement mechanical valve (PPMV). Over the next six month period the organization recognized a 47% increase in use of declotting agent for catheter clearance. PURPOSE: To determine whether the increase of clotted VAD's was related to the change in heparin concentration, injection cap change or both.


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METHODS: A retrospective study of all VAD's requring declotting agent over a one year period was performed. The organization also evaluated the number of catheter related blood stream infections (CRBSI) during the time frame of the MV use and after implementation of a PPMV. RESULTS: Data demonstrated that there was no apparent correlation of clotted VAD's after implementation of heparin 10 unit/ml. The increase appeared to be related to the PPMV. However the organization recognized a 61% decrease in CRBSI from 0.18/1000 catheter days to 0.07/1000 catheter days after implementation of the PPMV. CONCLUSIONS: Study results demonstrated a significant increase in VAD clotting after implementation of the PPMV however the organization also recognized a significant decrease in CRBSI with implementation of the PPMV. The organization evaluated risk vs benefit with the MV and PPMV and will continue to utilize the PPMV. After several clinical practice changes are implemented further studies will be conducted to evaluate if the increase in clotted VAD’s is related to the PPMV vs clinical practice. 4‐ TITLE: Intravenous eculizumab in the treatment of paroxysmal nocturnal hemoglobinurea: Transition to home treatment AUTHORS: Michael Sweeney, RPH, MBA; Donna Betz RN, CRNI; Martha Michael RN, CRNI; and Elizabeth Roesch RN, CRNI; Thomas Jefferson University Hospital, Home Infusion Department, Philadelphia, PA BACKGROUND: Chronic conditions require chronic treatment. Paroxysmal nocturnal hemoglobinurea (PNH) is one such chronic condition, an acquired hematopoietic stem cell disorder that causes thrombosis, end organ damage, impaired quality of life, and increased mortality. Chronic hemolysis is the underlying cause of PNH morbidities and mortalities. Eculizumab is a monoclonal antibody specifically indicated to reduce hemolysis and its harmful effects in PNH. Treatment consists of a 4‐week induction phase (600 mg IV infusion once every seven days), followed by 900 mg IV seven days later (week 5), and then a maintenance regimen of 900 mg IV every 14 days. This hospital‐affiliated home infusion service received a consult to provide intravenous eculizumab at home for a patient who completed induction therapy and was receiving maintenance infusions at an ambulatory infusion center. PURPOSE: The purpose of this presentation is to outline a process for initiating eculizumab maintenance therapy in the home setting. METHODS: Using a multidisciplinary approach, clinicians researched eculizumab, considering stability, administration, and reimbursement factors with patient safety and satisfaction as their focus. A thorough patient assessment, including appropriateness of home eculizumab therapy for this patient, was performed between nursing and pharmacy clinicians. Drug administration and monitoring guidelines were developed. The patient had already been vaccinated with meningococcal vaccine (per prescribing information) due to the increased risk of meningococcal infection with eculizumab.


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The manufacturer provided an in‐service to staff, and clinicians who were scheduled to administer eculizumab at home received individual, just‐in‐time training. RESULTS: The patient has been receiving eculizumab infusions at home every 14 days without incident. CONCLUSIONS: Thorough investigation of the drug and coordination of an educational process for infusion staff resulted in the successful transition of this patient from an ambulatory infusion center to the home. The patient is able to receive his maintenance eculizumab therapy for PNH every other weekend, resulting in an improved quality of life. 5‐ TITLE: Implementation of a viable air sampling program using a volumetric collection device AUTHORS: Steve Kennedy Pharm D, Lisa Linn Siefert, RPh, and Matt Lange, Pharm.D., Walgreens‐OptionCare BACKGROUND: Implementation of the USP <797> Viable Air Sampling process can be done via various methods. This multi‐site infusion pharmacy organization considered several factors in developing a program. This poster will review the factors that need to be considered, challenges of implementation, and results of deciding to conduct in‐house testing. PURPOSE: The large multi‐site organization identified a need to have a cost effective and efficient program to comply with the USP <797> requirement of semi‐annual viable air sampling. METHODS: A team was established consisting of pharmacists, pharmacy technicians and pharmacy students to evaluate development of an air sampling program. The team established a plan that consisted of the following items.

a. Reviewed USP <797> standards regarding Viable Air Sampling b. Developed air sampling device selection criteria c. Researched testing options: Internal verse External testing d. Gathered product information on various Air Samplers e. Reviewed cost and availability data on media f. Stratified products based on selection criteria g. Selected an air sampler based on criteria h. Developed procedures and implemented the process throughout the organization i. Re‐evaluated the process 12 months post‐implementation

RESULTS: The team developed a table to compare selection criteria for the two service options—internal vs. external testing, considering cost, employee involvement, quality of results and flexibility. We determined internal testing was the most cost‐effective and flexible option, whereas external testing was more convenient for employees with a probable higher quality of results (due to externally trained and experienced vendors performing the testing from the outset). This organization decided to do internal testing. Key reasons included:


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• Cost effectiveness of internal testing • Greater involvement from Pharmacy staff was viewed as a plus to increase their knowledge of the

cleanroom environment • With detailed Policies and Procedures and training we developed a process that generates quality

results. • Flexibility to retest and distribute the sampler to where ever it is needed quickly is important

The next step in our process was the comparison of four air sampler products. We created a table to compare features and benefits of each model. Model B was selected due to the following advantages:

• Standard contact plates minimized the number of plates on our formulary • The unit and case appeared to be more durable then the other models‐ an important

consideration since we would need to ship these units between our pharmacy locations. • The customer service from the manufacturer was excellent • The manufacturer was visible at most Pharmacy conventions. This proved their commitment

to servicing the pharmacy community and allowed us to see and try the units a couple times before committing to it.

This organization originally purchased 4 air samplers, to be shared by approximately 20 pharmacies each, requiring a move between sites every 2 weeks. The organization’s asset tracking system was utilized to monitor air sampler activity. Our final step was to conduct a 12 month post‐implementation evaluation, reviewing the cost‐effectiveness of our decision, and the outcome of our implementation plan: • Cost savings has been realized • Keeping the unit moving every 2 weeks was an aggressive goal; 2 additional units were purchased

to improve timeliness of testing and oversight by Regional and Corporate personnel have helped ensure the process continues as planned.

• Routine training is needed to ensure pharmacy staff understand why environmental sampling is important, and how to conduct the testing.

• Scheduling of recalibration with the unit out of service during this short time period is a challenge we did not anticipate.

• Conducting environmental sampling between the certification period gives management a better view of how the engineering and process controls are functioning.

CONCLUSIONS: Purchasing a pool of air samplers proved to be cost and operationally effective for this multi‐site infusion pharmacy organization. Single site organizations need to do an in‐depth analysis to ensure the cost of the device can be overcome with time. Results of air sampling provided us assurance that this organization's cleanroom design and Quality Assurance procedures routinely provide a safe compounding environment.


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6‐ TITLE: Meeting calcium and phosphate requirements in pediatric BMT patients receiving PN – A case report using a novel approach AUTHORS: Leigh Reiter, RPh1, Justin Gollon Pharm.D, B.C.P.S.2 , Carol Rollins, MS, RD, Pharm D, BCNSP2 1University Medical Center Home Infusion, 2University Medical Center BACKGROUND: A large percentage of Pediatric Blood and Marrow Transplant (BMT) patients, especially those who receive unrelated cord blood transplants, require parenteral nutrition (PN) at the time of discharge home. Fluid restriction and high nutrient requirements accompanied by increased electrolyte needs, especially calcium and phosphorous, provide a challenge to the home care practitioner. Medications further complicate management of these patients. Glucocorticoids, foscarnet, and furosemide are typical medications that can increase calcium and phosphate requirements. Over the past three years, several pediatric BMT patients have been discharged with high calcium and phosphate requirements due to these medications. Cysteine hydrochloride, is routinely added to PN for neonates and has the benefit of improved calcium‐phosphate solubility due to decreasing pH of the PN. This principle can be applied to pediatric PN to increase calcium and phosphate provision. PURPOSE: Our challenge as home care practitioners is to provide innovative approaches to managing complex therapeutic issues, while assuring a regimen that can be safely administered by the family. This poster shares the experience of managing a complex pediatric BMT patient with high calcium and phosphate requirements receiving home PN. METHODS: Pediatric BMT discharges were reviewed to obtain a representative case receiving PN that illustrates an innovative approach to managing high calcium and phosphate requirements. RESULTS: PA is a three year old post BMT matched unrelated donor cord blood transplant for acute lymphoblastic leukemia. At discharge home PA was receiving methylprednisolone, cyclosporine, furosemide, foscarnet and PN. The PN volume was restricted to 950 mL/day and she required high amounts of phosphate (2 mmol/kg/day) and magnesium (1.1 mEq/kg/day). Calcium was maximized in the PN; however, supplemental calcium was required outside the PN periodically. PN was formulated as dextrose 264 g/day (31% final concentration) and amino acids 37 g/day (4.4% final concentration). Addition of cysteine (40 mg/g amino acids) allowed nearly an “extra” gram of calcium gluconate to be added to PN daily and avoided separate calcium or phosphate infusions. In turn, this avoided the risk of calcium or phosphate infusions accidentally being administered through the PN line and forming a calcium‐phosphate precipitate in the line. Lipids were run separately due to stability issues from the cysteine and high amount of divalent cations present in the PN. CONCLUSIONS: The addition of cysteine to PN allowed the maximization of calcium and phosphate to meet the patient’s needs and avoided separate infusions of calcium or phosphorus in the home. A drawback to adding cysteine is that the PN becomes a daily mix. However, this is outweighed by the reduced risk of co‐infusing incompatible products and the simpler regimen for the family.


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7‐ TITLE: Implementation of an electronic parenteral nutrition order form and admixture assessment AUTHOR: Kevn M. Mcnamara, PharmD, and Brenda L. Gray, PharmD, Coram Specialty Infusion BACKGROUND: Providing parenteral nutrition (PN) in the home is not the same as providing it in the hospital or long term care facility. Stability and solubility must be evaluated in a different manner as a health care provider is not available to visually inspect each solution immediately prior to infusion. PURPOSE: To ensure the provision of a stable PN solution, an electronic PN order form with an integrated micro and macronutrient assessment program was created and launched. The integrated form and assessment allows the clinician to enter the PN order and the amounts of micro and macronutrients are calculated on a per liter basis for ease of comparison with accepted literature guidelines for extended stability. METHODS: An electronic PN order form with an integrated micro and macronutrient assessment form was developed, prompting entry of the PN formula and comparing each component to acceptable ranges. The form is a spreadsheet that performs calculations to evaluate final solution stability and indicate where adjustments may be needed. All clinicians were provided with access to this electronic form and education was provided regarding the policy and use of the form. The form was trialed and adjustments were made based on ongoing feedback and recommendations received from users. Guidelines were based on published stability data and any variable listed on the assessment guide that was determined to be out of limits was reviewed on a case by case basis for potential solution instability. Recommendations for altering the formula to prevent or minimize solution instability were offered by a team of experienced clinical pharmacists. RESULTS: Clinicians were directed by the policy to contact one of a team of experienced clinical pharmacists for therapeutic options with any out of limit variable. Based on a review of a sampling of the calls received, the most common stability concerns were related to the final lipid concentration of the solution, the amount of sodium, acetate, calcium and magnesium combined per liter and calcium‐phosphate solubility. Alterations in the formulation were recommended such as use of dual chamber bags, alternate day lipid infusions, providing higher amounts of alternating electrolytes or the use of hydration bags to provide sufficient electrolytes in extreme cases. The pharmacist would then contact the prescriber with the recommended formulation change and obtain permission to alter the order. CONCLUSIONS: Providing a stable PN solution in the home offers some unique challenges to the clinician. With proper evaluation of the data and utilization of clinical resources, many complications associated with solution instability may be prevented.


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8‐ TITLE: Continuous Home Infusion Chemotherapy: Creating an Ideal Patient Experience CONTRIBUTING AUTHORS: Debra S. Kovacevich, RN, MPH; Karen Hammelef, MS; Jamie Tharp, PharmD; Kathy Bishop, MHSA; Kelly Wright, PharmD; and Christopher J. Maksym, PharmD. University of Michigan Home Care Services, University of Michigan Comprehensive Cancer Center, University of Michigan College of Pharmacy BACKGROUND: Continuous chemotherapy home infusions have resulted in improved quality of life for patients and cost reductions through eliminating hospitalization. The home infusion process is complex; involving multiple handoffs between departments and caregivers. This complexity increases likelihood of adverse events, patient dissatisfaction and system inefficiency. At our institution, patients receive chemotherapy in a facility‐based infusion area prior to connection of a continuous chemotherapy home infusion. Patient dissatisfaction regarding connection delays and the occurrence of a significant medication error prompted a formal process review and improvement project using the “lean” healthcare philosophy. Lean thinking is part of our continuing effort to improve quality, safety, efficiency and appropriateness within our health system‐based organization. PURPOSE: The purpose of this lean project was to review current outpatient and home continuous infusion (CI) chemotherapy processes to reduce patient wait time through improved care coordination and efficient chemotherapy preparation, create an integrated scheduling process, and improve medication safety and patient satisfaction. METHODS: A multidisciplinary team of clinicians and leaders from various departments utilized lean healthcare principles to create a current state map, analyze root causes, gather activity data, create a future‐state vision and generate implementation recommendations. Steps that did not have value or produced waste were eliminated from the process. A sample of pre‐ and post‐ implementation metrics included number of scheduled visits, number of adverse events (actual or near misses), patient wait time, and patient satisfaction. RESULTS: Following implementation of the project, changes were made to 19 steps in the process that included: the number of tasks that could be accomplished prior to the chemotherapy infusion visit to allow for pre‐planning increased from 1 to 6; the number of patients educated by the education team prior to discharge increased from 0 to 100%, and the number of CI connections by home infusion nurses increased from 86.5% to 100%, the number of standardized order sets increased from 0 to 23, and 100% of the orders are imaged into the electronic medical record; thus accessible to all clinicians. Scheduling the CI pump connection improved from 0 to 187 of 198 (94.4%); scheduling distinct education visits remained unchanged at 19%. The mean amount of time a patient was onsite was 5.42 hours prior and 5.27 hours post‐implementation (NS, p=0.61). Time spent by Cancer Center and Home Infusion clinicians to coordinate care decreased from 3,131 to 580 minutes post‐implementation. Patient safety measured by adverse event reports also improved; 7 near misses during the project that were due to changes in drug dosage were resolved during double checking processes.


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Patient satisfaction scores (5 point Likert scale) ranged from 4.7 to 4.9 for criterion related to equipment training and performance, 4.6 to 5 for medication/supply knowledge and 4.7 to 5 for overall customer satisfaction. CONCLUSIONS: This lean project demonstrated that standardizing chemotherapy orders and coordinating care across multiple departments improved safety, patient satisfaction, and increased clinician productivity by eliminating non‐essential tasks in the initiation of continuous infusion home chemotherapy at a large academic center. The elimination of non‐value added work and managing patient expectations (standard education processes and content) contributes to favorable customer satisfaction. Wait time did not significantly decrease, but this may be due to small sample size. 9‐ TITLE: Development of workload benchmarks for home infusion pharmacists AUTHORS: Charles Cooper, RPh, MBA, Manager, and Kyle Skiermont, PharmD, Assistant Director, Fairview Home Infusion Pharmacy BACKGROUND: This home Infusion pharmacy has four pharmacist teams with diverse patient loads and variable pharmacist hours worked. Establishing staffing patterns for pharmacies is generally done by evaluating workload and providing sufficient hours to meet anticipated need. Home infusion pharmacy does not have widely accepted cognitive time benchmarks for common therapy types. Hospital and community pharmacies have established benchmarks to assist in setting appropriate staffing levels, and to evaluate staffing between pharmacies. PURPOSE: The purpose for this study was to establish a bench mark of pharmacist cognitive time associated with common therapy types in home infusion. Once established, the data can be used to balance workload between pharmacist teams and within teams. The data can also be used to determine when additional staff may need to be added. METHODS: This home infusion pharmacy has developed assessment templates for initial and ongoing care for all common therapy types; including antibiotic, HPN, hydration, pain, chemotherapy, and other. This organization added a free form time box to each assessment to be completed by each pharmacist with each assessment. Time to coordinate, evaluate and process the order and time to coordinate with the patient or caregiver was requested. The recorded time did not include time to compound, check or deliver the product. 3722 time values were collected from January 2009 – June 2009. Time values were averaged for initial or ongoing assessments for each therapy type. Then, from July – December, the calculated averages for each therapy type were applied to daily, weekly and monthly workload. RESULTS: Specific time values for initial and ongoing assessments were developed for each therapy type. Applying the average time to each order processed, by therapy type, accounts for approximately 50% ‐ 60% of the pharmacist’s available time. On average, this organization determined that one HPN patient is equal to two patients of any other therapy type, in the amount of


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time to coordinate, evaluate and process an order. This organization also determined that the time for an initial set up of any therapy type was longer than ongoing assessments. On average, each pharmacist is managing a minimum of 50 patients with an active drug therapy. Patients receiving catheter maintenance or enteral supplies only were not included in this calculation. CONCLUSIONS: Applying the time data to orders processed has allowed this home infusion pharmacy to balance workload and adjust staffing patterns between the four pharmacist teams. Pharmacist hours have been redistributed between the teams, and patients have been redistributed between the teams during short term fluctuations in workload. Redistribution of patient load between teams has been viewed favorably by the pharmacist staff, and has allowed for more time to work on projects and tasks outside of direct patient care. Further study will need to be done to determine the maximum number of patients a pharmacist can safely handle. 10‐ TITLE: Supporting patient travel – case study of patient traveling internationally while receiving parenteral nutrition CONTRIBUTING AUTHORS: Brenda L. Gray, PharmD, and Kevn M. McNamara, Pharm.D., Coram Specialty Infusion BACKGROUND: The ability to maintain a “normal lifestyle”, including traveling, while receiving infusion therapy may positively impact quality of life for long‐term patients. Some of the barriers a patient may experience when traveling include governmental or carrier regulations, duration of the travel (including duration of transit and time away from home), dose scheduling, medication stability and beyond use dating and patient support if a problem arises with the medication or condition while in transit. A successful travel experience begins prior to embarking with an awareness of potential barriers, identification of options and a plan of action for any issues which may arise including appropriate documentation necessary for each step. PURPOSE: The purpose of this case study was to identify barriers which may be experienced by a patient traveling internationally while receiving parenteral nutrition and to develop a plan of action to ensure successful completion of the trip. METHODS: A prospective planning conference was held prior to departure to review potential barriers for an extended trip to Brazil by an American patient receiving parenteral nutrition (PN). A review of the trip was conducted upon return to the United States to identify any problems that developed during the travel and determine any changes that could assist other patients. Prior to the trip, discussions were held with the patient, carepartner, prescriber, airline personnel, Transportation Security Administration, a liaison from the United States Department of State and a representative from the Consulate General office for the Embassy of Brazil. Concerns reviewed were storage and shipping of medications and supplies, infusion of PN via pump in flight, documentation for security and customs regulations, adjustment of infusion schedule, patient communication and care of the patient abroad. The case review evaluated the success of the preparation and identification of deficiencies and additional barriers to improve continuity of care for other traveling patients.


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RESULTS: The primary objective of a successful trip to Brazil without interruption of PN therapy was achieved. Prior to departing, some products were changed to extend stability and reduce complications during travel as well as meet Brazilian regulations. Based on the guidance provided by of the State Department and the Brazilian Embassy, this organization determined what documentation was required to utilize and transport products and supplies into Brazil and the United States. The PN solution was transported at the appropriate temperatures and infused during both air travel and the visit. Communication was maintained with the patient via email and internet telephone services. CONCLUSIONS: Careful planning prior to departure can allow a medically stable patient to travel without interrupting infusion therapy. The lessons learned from preparing for and supporting this patient’s travel experience will be instrumental in the creation of a more extensive travel support program for all patients desiring to travel while receiving infusion therapy. 11‐ TITLE: Evaluating new automated compounding technology in the home infusion pharmacy. AUTHORS: Rich Monty, RPh, and Kim Templeton BSN , CRNI, VP Infusion, Preferred Homecare BACKGROUND: Choosing the right automated compounding device (ACD) requires careful consideration of numerous factors including product design, safety features, speed, ease of use, compounding documentation, and software and hardware platform. This homecare organization had utilized an existing ACD for 7 years and was interested in determining if new compounding technology was warranted. PURPOSE: The purpose of this evaluation was to determine if a new ACD technology offered any improvements in compounding efficiency and safety when compared to the existing ACD. METHODS: An ACD study protocol was developed with consistent methodology for measuring and reporting each ACD feature, safety benefit, and compounding time study. Time data collection performance measures were: time taken to fill a bag, volume of each bag, and number of bags filled. The current ACD was already in use with a rich history of validated use and an evaluation period of one month was recorded. The second new ACD* was first implemented with appropriate staff training and a two week trial use before the evaluation period of one month was recorded. Time data analysis was sent to a third party statistician for statistical analysis to determine compounding times per ACD (taking various bag volumes into account) and if the two ACDs differ. RESULTS: No compounding errors were reported but the new ACD technology eliminated any potential manual errors associated with mis‐programming compounding volumes through an interface as the existing ACD required manual order programming. However, compounding benefits were still recorded even though new ACD required an extra step of positive solution barcode confirmation as compared to the existing ACD passive solution check. Additionally, the new ACD software platform enabled numerous advantages, such as compounding history reports, user security and tracking, compounding inventory reports, live context sensitive help screens, and remote


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pharmacist software access in comparison to the existing ACD which is non‐computer based and requires manual input. Statistical analysis results from the time data reported the following conclusions:

- The new ACD is estimated to reduce the compound time by 0.86 minutes per bag compared to the existing ACD. This reduction is regardless of the bag size.

- With 95% confidence the reduction in time is between 0.51 minutes and 1.21 minutes. CONCLUSIONS: The new ACD technology provided numerous user benefits, safety enhancements, and significantly reduced compounding time as compared to our existing ACD. With an average of 50 total parenteral nutrition (TPN) patients per day, our organization realized a reduction in compounding time by approximately 43 minutes per day that can be saved in labor, allocating resources to other compounding activities. * B. Braun PINNACLE® TPN Management System 12‐ TITLE: Patient satisfaction with subcutaneous immune globulin (SCIG) therapy for primary immune deficiency (PID), and reasons for conversion to intravenous immune globulin (IVIG) therapy AUTHORS: Carol Ernst, RN, OCN, and Peg Gruenemeier, RN, CRNI, BioRx BACKGROUND: Healthcare providers and patients increasingly have begun using an immune globulin, human, 16% for subcutaneous administration as an alternative to IVIG for the prophylactic treatment of various PID diseases. Because SCIG is a weekly self‐administered subcutaneous infusion, providers and patients encounter a different set of educational and side‐effect management considerations as compared to monthly IVIG. These considerations can contribute to a patient’s decision to stop receiving their immunoglobulin treatment via the subcutaneous route. PURPOSE: This organization was interested in understanding the rate at which SCIG patients convert (or switch back) to IVIG therapy, and the patient’s rationale for making this change, in order to develop best practices that would reduce the SCIG to IVIG conversion rate. METHODS: This organization conducted a retrospective review of a population of SCIG patients, identifying those patients who stopped receiving SCIG and left service entirely, as well as those patients who requested a return to IVIG after trying SCIG. Chart reviews, customer service note reviews, clinician interviews, patient interviews, and reimbursement file reviews were conducted to identify SCIG patients who were on service with this organization between 11/07 and 4/09 and discharged from service, or experienced a prescription change from SCIG to IVIG, and why the change occurred. RESULTS: The majority of patients (n= 80, or 87%) were retained on SCIG therapy with 13% (n=12) discontinuing SCIG treatment. Of the 12 who discontinued treatment, 7 (58.3%) chose to return to IVIG treatment, and 5 (41.7%) elected to stop home infusion altogether.


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Of the 7 patients who elected to stop SCIG and resume IVIG treatments, we noted that infusion frequency was the most commonly cited reason (n=5) with other factors such as change in caregiver support and interruption of parenting responsibilities contributing to the “inconvenience” weekly treatments seemed to create. CONCLUSION: Patient convenience is the most commonly cited reason for discontinuing SCIG and returning to IVIG. These 7 patients did not report unmanageable side effects from IVIG infusions and were maintaining good health status prior to switching to SCIG. Opportunity to change practice to minimize SCIG treatment conversion to IVIG was not immediately evident on the basis of the data we collected. Further study is needed to understand if there is opportunity for this organization to approach the care of and education of SCIG patients differently to further reduce this already low rate of SCIG to IVIG conversion. The patients in this overall population were stratified evenly among age groups; however, a disproportionate number of patients in the 31‐40 age group voluntarily terminated subcutaneous infusion therapy as compared to the population as a whole. No concrete conclusion can be drawn from this information, and more study is needed; but it may suggest that people in this age group are more likely to be parents or have significant career obligations that may drive them toward a therapy with fewer infusions per month (eg. IVIG at 1 time per month vs. SCIG at 4 or more times per month). The number of nursing visits (training visits) performed on the patients did not differ significantly between the two populations and likely did not contribute to patients’ decisions to stay on or discontinue therapy. Of note, this organization utilizes a unique nursing model in which a small group of highly trained nurses travel within a multi‐state territory to teach self‐administration of SCIG to new patients. While we believe that nursing visits conducted by specially trained and therapy‐experienced nurses contribute to the high success and retention rates experienced in our SCIG patient population, we need to validate this assumption by comparing our SCIG patient retention data to similar data gathered by other home infusion or specialty pharmacy organizations, particularly those who utilize a more traditional local‐nursing blend of employees and contracted home health agency nurses. 13‐ TITLE: Evaluating the need for a pediatric education program for home infusion pharmacists CONTRIBUTING AUTHORS: Brenda L. Gray, PharmD, and Kevn M. McNamara, Pharm.D., Coram Specialty Infusion BACKGROUND: Home infusion therapy is centered on the ability of a patient to receive infusions safely in the home. Extended product stability and patient friendly medication delivery systems are essential to successful cost‐effective home infusion therapy. Traditional methods of infusions such as gravity or ambulatory pumps commonly used in the adult population are not always ideal for children. Volume restriction is one of the primary rate limiting factors when providing medications to a pediatric patient. The concentration of the medication may limit stability while the volume of medication may influence the method of administration. These factors are essential components of the medication delivery plan. When providing home infusion therapy to pediatric patients the


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pharmacist must be prepared to evaluate orders and make safe decisions about medication administration. PURPOSE: The purpose of this study was to review pediatric orders for clinical appropriateness, drug stability and safe medication administration by the caregiver. The concerns identified are critical for developing an education program to prepare the pharmacist to successfully manage pediatric patients in the home. METHODS: A retrospective chart review was conducted to evaluate a sample of orders received for pediatric patients. Pharmacists were interviewed to provide further information on how a medication was prepared and the infusion method used for delivery. Important considerations evaluated include volume of infusions, stability of the medication, administration method and patient/caregiver teaching. RESULTS: Orders reviewed demonstrated some knowledge deficits in the pharmacist’s understanding of certain pediatric specific variables. Weight based dosage calculations were validated and double checked. The compounding steps were double checked by two clinicians to ensure the ordered dose was provided. In some cases, documentation indicated the ordered dose was also validated with the literature for accuracy. Educational opportunities based on the review of these orders include volume of fluid provided and the method of medication administration. Elastomeric devices were the primary administration method utilized. In over 40% of the cases for children under 4 years of age, volumes used exceeded 30% of the patient’s daily fluid allowance. Most commonly, the medication was delivered over an hour per dose. In the majority of cases (74%), a syringe pump would have reduced the volume and infusion time required. When appropriate, intravenous “push” administration was only used in approximately 25% of the cases reviewed. Based on these opportunities, a training program will be developed and implemented to optimize pediatric infusion therapy. CONCLUSIONS: Additional training should be provided to home infusion pharmacists who may not have pediatric experience to appropriately provide infusion medications in the home. Pharmacists should evaluate every order received to ensure the dose, fluid volume and method of infusion are optimized for each child and family. 14‐ TITLE: Exploring the role of the pharmacist in the management of patients in an ambulatory infusion suite CONTRIBUTING AUTHORS: Kevn M. McNamara, PharmD; and Brenda L. Gray, PharmD, Coram Specialty Infusion BACKGROUND: Ambulatory Infusion Suites (AIS), also referred to as Ambulatory Infusion Centers, are facilities where a patient may receive an infusion medication on an acute or chronic basis in a controlled health care environment other than a physician’s office or hospital. AIS offer unique opportunities for both the patient and the pharmacy clinician.


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PURPOSE: The purpose of this review was to evaluate the current role and expand the future role for a pharmacist in the clinical care of a patient receiving therapy at the AIS. METHODS: A review of the literature and discussion groups with pharmacists and nurses was completed. The data gathered was then used to create a survey which was sent to the twenty five selected pharmacy managers in branches with highly active AIS. Data collected from the surveys was reviewed by corporate clinical pharmacists to evaluate the current activities conducted by the pharmacist, their satisfaction with their role and determine potential areas for expansion of pharmacist based services. RESULTS: The current roles for the pharmacist in the preadmission, initial visit and ongoing care of the patient were evaluated. The primary role of the pharmacist in the AIS was to counsel patients about there medication (94%), obtaining orders for acute infusion reactions (94%), entering the medication orders (94%) and obtaining the medication profile (88%). One key area the pharmacist was not involved in was checking the expiration dates for the medications in the emergency drug kit, signing it out when a patient is receiving therapy in the AIS and securing the kit in the pharmacy when all patients have been seen for the day (44%). The ongoing role of the pharmacist was limited to the areas required by law (entering orders, maintaining medication profile and offering to counsel). Based on the survey results the pharmacists felt satisfied (69%) with their involvement with patients in the AIS and 25% would like a larger role in patient management in the AIS patient. One area that must be addressed is the role of the pharmacist and the acute infusion reaction box that should be available for every patient receiving therapy. Potential areas for future expansion in the role of the pharmacist include increased patient education, disease state management and monitoring, provider consultations and medication administration guidance. CONCLUSIONS: Currently in the AIS the pharmacist plays a strong distributive role. For optimal patient care and improved job satisfaction, the expansion of the clinical role of the pharmacist into patient medication and disease state management and optimizing medication administration. To achieve these goals, process development and staff education would need to be addressed. 15‐ TITLE: Successful management of a complex patient by a home nutrition support team CONTRIBUTING AUTHORS: Pammi J Farren, Branch Infusion Manager, RPh, PhD; Therese Austin MS, RD, LD, CNSD; Yulia Bar, PharmD. Coram Specialty Infusion Columbus, OH BACKGROUND: There are several benefits of a home nutrition support team (HNST) managing complex parenteral nutrition (PN) patients including: preventing complications at home to avoid a hospital admission, reduced exposure to infectious agents and improved patient quality of life. A multi disciplinary team of skilled clinicians is necessary to achieve fluid and electrolyte balance, glycemic control, prevent over and underfeeding, reduce hepatic complications and resolve catheter complications. PURPOSE: To demonstrate the benefits of the HNST model of care for a medically complex patient


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METHODS: Case study from one large national home infusion provider that demonstrates the role of the dietitian, pharmacist and nurse in assuring the successful outcome of a medically complex patient with multiple co morbidities who thrived at home on PN. The HNST model of care included home initiation of PN to avoid a hospital admission, weekly lab monitoring and adjustment of PN, weekly pharmacist consultation with the nephrologist to discuss labs and maintain homeostasis with dialysis and PN, weekly pharmacist or dietitian phone contact with patient to ensure tolerance to therapy, multi disciplinary monthly rounds to review progress toward meeting therapeutic goals, and strict catheter care protocol to prevent catheter infection. RESULTS: 41 year old male with chronic renal failure on dialysis and congenital absence of his colon with an ileostomy developed an enterocutaneous fistula of unknown etiology. Plan of treatment was bowel rest and PN with hopes that the fistula would heal. Multiple nutrition risk factors were present including weight loss below his dialysis dry weight, electrolyte abnormalities due to renal failure, high volume fistula losses and bone disease. The patient was transitioned from a skilled nursing facility to home on PN. The Rph, RD and RN worked with the dialysis physician to refine the PN prescription to facilitate weight gain without overfeeding, stabilize serum electrolytes and provide adequate vitamins and trace elements in PN. He was weaned from his PN when his fistula healed. Two weeks later the fistula reopened and the patient experienced a 10% weight loss necessitating gradual re‐initiation of PN at home. The RPh and RD customized the macronutrient and electrolyte content of the PN and gradually cycled the infusion to 12 hours. While on PN the patient was able to regain his functional status and resume his normal work schedule. The patient regained to his dialysis dry weight and serum albumin normalized. Trace element levels were measured, manganese was removed and other trace elements were dosed individually in the PN. A low vitamin D level was treated with calcitriol. CONCLUSION: This case demonstrates the multi disciplinary approach including collaboration with the nephrologist and patient to achieve nutrition goals. The HNST allowed positive outcomes including stabilization of serum electrolytes in a dialysis patient with high fistula losses, prevention of a hospitalization with home initiation of PN, trace element monitoring to customize in PN, appropriate treatment with oral Vitamin D and calcium in PN to minimize bone loss, and improved functional status and quality of life for the patient.


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ENCORE POSTER ABSTRACTS

A‐ TITLE: Retrospective review and comparison of the clinical and economic outcomes of vancomycin and daptomycin treatment of complicated skin and soft tissue infections in the home infusion setting TYPE: Research in progress PRIMARY AUTHOR: Kecia D. Anderson, Pharm.D. PURPOSE: Complicated skin and soft tissue (CSST) infections are among the most common types of human bacterial infections in both the community and hospital. In 2004, Centers for Disease Control and Prevention (CDC) reported that CSST infections accounted for the primary diagnosis in approximately 562,000 hospital discharges. The typical CSST infection involves gram positive pathogens, with Staphylococcus aureus and Streptococci as the most predominant organisms. CSST infections are usually more severe, progress rapidly, involve deeper tissues, and possess a greater risk of limb loss than uncomplicated skin and soft tissue infections. Common examples of CSST infections include cellulitis, abscesses, surgical site infections, as well as diabetic and non‐diabetic foot infections. The increasing prevalence of drug resistant strains such as methicillin‐resistant S. aureus (MRSA) and vancomycin‐resistant enterococci (VRE) further complicates the ability to find simple, safe, and effective treatments to treat patients with complicated skin and soft tissue infections. Several antibiotic classes are effective as single agents, or in combination for treatment of CSST infections due to MRSA and VRE. Vancomycin and daptomycin are the most commonly used parenteral agents for CSST infections in home infusion therapy. Although, vancomycin has a long clinical track record for treating CSST infections, it can be associated with higher overall treatment costs due to the therapeutic drug monitoring involved. Whereas, daptomycin based on several studies conducted in the hospital setting, has been reported to be more cost and clinically‐ effective, due to the convenient once a day dosing and reduced amount of therapeutic drug monitoring. In many cases, CSST infections require initial hospitalization and a prolonged duration of parenteral therapy. For many patients, prolonged hospitalization for the sole purpose of parenteral antiinfective therapy is unnecessary. The economic benefits of home infusion therapy over prolonged hospitalization are well documented and outside the scope of this study. In addition to cost efficiencies, home infusion therapy has a very high patient satisfaction rate, and provides the patient with the benefit of staying at home, returning to work, or attending school while completing parenteral therapy. The purpose of this study is to evaluate the clinical and economic outcomes of vancomycin and daptomycin for complicated skin and soft tissue infections in a home infusion environment. METHODS: The study design is a retrospective review of the electronic medical records for a home infusion pharmacy servicing greater metropolitan Houston. The researcher will apply patient inclusion criteria to identify up to 50 patients treated with vancomycin and up to 50 patients treated with daptomycin from September 2008 through September 2009. Cost of each therapy (to the home infusion organization) will be extracted from the pharmacy purchasing data. Patient inclusion criteria: A home infusion admission diagnosis of a complicated skin and soft tissue infection, adult men and women age 18‐86 and daptomycin or vancomycin as a primary home infusion anti‐infective treatment regimen. Patient exclusion criteria: serious comorbidity infections including osteomyelitis,


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bacteremia, or endocarditis, documented hypersensitivity to either vancomycin or daptomycin, and pregnant or lactating women. To prevent inclusion or exclusion bias, patient identification will start in September 2009 and work back until the maximum number of 50 patients in each group have been identified. The following data will be collected and summarized: diagnosis, length of therapy, changes of therapy, method of administration (e.g. elastomeric, pump) documented adverse drug reactions, and laboratory monitoring parameters. All data collection will be reported without disclosing patients’ identity and confidentiality will be maintained. B‐ TITLE: Daptomycin usage trends in a home infusion setting TYPE: Research‐in‐Progress PRIMARY AUTHOR: Mariam Seddiqi PURPOSE: Daptomycin, approved by the Food and Drug Administration in 2003, is among the newer parenteral antibiotic agents used to treat gram positive infections. Use of daptomycin is increasing in the home infusion setting secondary to vancomycin treatment failure and/or poor response, ease of daptomycin monitoring, and daptomycin’s safety profile. The objective of this study is to identify daptomycin usage trends in the home infusion setting. METHODS: The study design is a retrospective chart review of patients that received daptomycin from January 2009 to September 2009 and a concurrent review for patients receiving this therapy from October 2009 to February 2010. Patient charts from the Chicago branch of a national home infusion company will be examined. Data collection includes patient demographics, infection site, pathogen, prescriber specialty, prior antibiotic exposure, renal function, creatine phosphokinase levels, daptomycin dosage, method of administration, length of therapy, clinical response, rehospitalization, and discharge status. Statistical tests will be utilized to assess if statistically significant trends exists between collected data. C‐ TITLE: Economic and safety outcomes of pediatric parenteral lipid infusion: evaluation of a dual chamber versus lipid‐separate infusion in the home care setting AUTHOR: Melisa Tong TYPE: Research in Progress PURPOSE: Home infusion pharmacy providers typically dispense a weekly supply of parenteral nutrition and other medications for infusion at home. The complexity of total nutritional admixture (TNA) preparations for a total parenteral nutrition (TPN) infusion can present a challenge when establishing extended stability of these formulations in home infusion. This is particularly problematic with pediatric home TPN patients, since the relatively low dosage of parenteral lipids can compromise the stability of most TNA preparations. The pharmacist has several alternatives for


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separating the lipid emulsion from the other components of a TPN before and/or during administration. The fat emulsion may be dispensed and administered from a separate container with a separate infusion device, or dispensed in a dual‐chamber container which separates the lipid from the rest of the TPN formulation until time of administration. These two delivery systems and administration methods achieve the same therapeutic purpose; however, the supplies, devices, and safety outcomes may differ resulting in one preparation being more favorable than the other. The objective of this study is to compare the economics and safety outcomes of a dual chamber TPN versus a lipid‐separate TPN infusion in a home care setting for pediatric patients. METHODS: Patients on TPN therapy, between the ages of 0‐18, will be identified through the medical record system of the nationwide home infusion organization and further categorized by their treatment delivery container. Patients that lack lipids in their therapy or contain lipids within a TNA will be excluded from this study. Data will be collected over a period of a year, including the following: patient age; gender; diagnosis; access line and lumen number; ancillary supplies used; medical devices used; compounding supplies used; frequency of teaching visits; reported adverse medical events; and reported unusual occurrences. Retrospective data will be gathered to obtain baseline data on each preparation method. Due to the complexity of the patient and payor payment process, this analysis will only review this national home infusion provider cost differences. Average of actual provider organization costs of medical devices and ancillary supplies will be used to calculate cost differences between delivery mechanisms. This national home infusion provider currently tracks a number of safety‐related outcomes as part of the performance improvement program. This study will look at the specific safety data for this patient population, including line infection rates and other patient safety reports. The study will also review the number and duration of patient teaching home visits required for the caregiver to feel comfortable administering the TPN therapy independently. Data is limited by nursing agency through the ability in acquiring line infection rates and nursing visit information. Safety and cost effectiveness will be averaged per therapy day in order to account for any days with a lipid‐free therapy. Data collected from patients will be recorded without patient identifiers and maintained confidentially.

D‐TITLE: Examining the 30‐day hospital readmission rate of patients receiving parenteral inotropic therapy from a national home infusion provider

TYPE: Research‐in‐Progress

PRIMARY AUTHOR: Christine Parlatore

PURPOSE: Heart failure patients historically have a high rate of hospital readmissions. An article recently published in the New England Journal of Medicine discovered that Medicare beneficiaries with heart failure had the highest 30‐day hospital readmission rates. This data has prompted the Centers for Medicare and Medicaid Services to adopt measures that may modify or deny hospital reimbursement for heart failure readmission within 30 days. There are many reasons for rehospitalization of patients due to exacerbation of heart failure. Patients with intractable chronic heart failure or those awaiting transplant may not be sufficiently controlled on oral medications.


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When patients can be stabilized on parenteral inotropic medications (e.g. dobutamine, milrinone,) they are ideal candidates for home intravenous inotropic therapy. Home infusion provides the patient with therapy management and close monitoring through an interdisciplinary team as well as the comfort of the home environment. These exclusive characteristics of home infusion may reduce the rate of rehospitalization and improve the quality of life in this specific patient population. The objective of this study is to evaluate the 30‐day post discharge hospital readmission rates of heart failure patients receiving intravenous inotropic therapy in a home care setting.

METHODS: The study design is a retrospective review of electronic medical records. Customized reports will identify patients started on home intravenous inotropic therapy in a national home infusion pharmacy organization between January 1, 2009 and June 30, 2009. The report will also identify the date of any patient rehospitalizations during this time period. The following data will be collected and summarized: patient age, gender, payor, home parenteral inotropic medication, therapy goal (palliative, bridge to transplant), total home inotropic therapy days excluding rehospitalization period(s), hospital readmission date(s), and, as derived from electronic rehospitalization progress note, reason for each rehospitalization. Data will be recorded without specific patient identifiers and will remain confidential.

E‐ TITLE: Analysis of total parenteral nutrition interventions during point of care transition to the home setting AUTHOR: Carolyn Timm, PharmD TYPE: Research‐in‐Progress PURPOSE: The objective of this study is to examine the qualitative nature of electronic progress notes and categorize the type and number of clinical interventions documented by home infusion pharmacists and registered dieticians providing care for home nutrition support (HNS) patients.

STUDY BACKGROUND: The American Society of Parenteral and Enteral Nutrition (ASPEN) developed guidelines for management of total parenteral nutrition (TPN) for acute/critical care as well as for home care. Most acute care hospitals maintain standardized TPN support protocols for inpatient care. Upon discharge, patient home intravenous nutrition formulations require adjustment to accommodate the practice setting and longer term patient specific needs. The assessment and formulation changes constitute active clinical interventions by the home infusion clinicians. METHODS:

• Retrospective, clinical documentation review of electronic medical records. • Data collection tailored to identify patients initiating HNS and those resuming HNS upon

hospital discharge. • Interventions identified as all clinical progress notes relating to HNS dosage changes.


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• Clinical progress notes include interventions resulting in TPN reformulation required for HNS patients transitioning from hospital settings

• Progress notes will be individually reviewed and categorized by type: Nutritional elements Electrolyte elements

Other pharmacy additives Other patient additives Other therapy interventions Inclusion criteria & data analysis: All adult and pediatric HNS patients who received TPN from this provider in the greater Boston service area between January 1, 2009 and August 31, 2009. Customized data extraction report will gather key demographics and therapy per patient:

Age Sex Disease state(s) ICD9 code(s) TPN formulation suggestions Status of recommendation(s) Number of therapy days

Type and text of electronic progress notes RESULTS: This study is currently in progress. Results will be presented at the Eastern States Conference in late April 2010. Preliminary data, single branch location: Initial review of HNS interventions at one Boston area branch home infusion pharmacy (January‐August 2009):

• 57 average monthly HNS electronic progress notes per 1000 patient days involving clinical interventions and assessments

• Monthly average of 674 HNS patient therapy days • Clinical intervention dose change recommendations represent a higher percentage of HNS

intervention notes than of overall intervention notes

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