Read OIP JUL 11 text version

Outcomes In Perspective

Volume 12--Number 10 July 2011

TGH Grant Awards

Jennifer Cooper, Director, Research and Sponsored Projects

A newsletter for the physicians of Tampa General Hospital

In May of 2011, with the support of the TGH administration, the TGH Research Steering Committee and Office of Clinical Research were again able to offer grant awards to support research aimed at improving the treatment and quality of life of patients at Tampa General Hospital. The second round of grant submissions awarded $50,000 among the following award recipients. Siviero Agazzi, MD: "Absolute Cerebral Oximetry with the FORESITE." Thomas Bernasek, MD and John Sinnott, MD: "Physicians Health Screening." Elias Doumit, MD: "Does Hyperlipidemia Mask the Detection of Ethanol and/or Isopropyl Alcohol by Osmometry?" Cynthia Lewis-Younger, MD: "Implementation of the First Center for the Multicenter Study: Emergency Treatment of Coral Snake Envenomation with AnacoralTM Antivenom." Mark Kayton, MD: "Compatibility of Ethanol, Heparin, and Citrate for Prevention of Central Venous Catheter Infections." Devanand Mangar, MD: "Postoperative Knee Surgery Following Total Knee Replacement: a Double-Blinded Randomized Comparison Study." Michel Murr, MD: "Hepatic Gene Expression in Patients with Nonalcoholic Fatty Liver Disease and Obesity."

The Committee would like to thank all of the individuals who submitted proposals, as we greatly appreciate their commitment to research.

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Ramon Docobo, PharmD, Assistant Director, Pharmacy Service

A number of issues have arisen related to prescription writing. In an effort to provide the latest information to our physician staff, the following guidelines are provided.

A written prescription for drugs MUST be legibly written and contain the following information:

· · · · · · Name of the prescribing practitioner Name and strength of medication Quantity of the drug in both textual and numerical format (e.g. #30 thirty) Directions for use Date with the month written in textual letters (e.g. July 1, 2011, not 7/1/11) Signed by the prescribing practitioner on the day when issued

Tips to Reduce Prescription Errors

1. 2. 3. 4. All prescriptions must be legible and written in black ink. Avoid abbreviations and dangerous dose expressions. All prescriptions should include a brief notation of purpose (e.g. nausea, for blood pressure) Always use a leading zero before a number less than one (e.g. 0.5mg) and never use a trailing zero (e.g. 5.0 mg) 5. Do not make any changes or cross-outs.

Prescribing Controlled Substances

Federal law states that a prescription for a controlled substance may be issued only by an individual practitioner who is authorized to prescribe controlled substances by the Drug Enforcement Agency (DEA) in the jurisdiction where they are licensed to practice their profession. The term "individual practitioner" refers to physicians (MD or DO). In the State of Florida, mid-level practitioners such as nurse practitioners, nurse midwives, nurse anesthetists, clinical nurse specialists, and physician assistants are NOT authorized to prescribe controlled substances.

All outpatient prescriptions for controlled substances must be dated and signed on the day written and must bear the following:

1. Full name and address of the patient

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Ramon Docobo, PharmD, Assistant Director, Pharmacy Service

(Continued from page 2)

2. The drug name, strength, dosage form, quantity prescribed (both in numerical and written form, e.g. #30 Thirty), and directions for use. 3. Sign and printed name of the prescriber and DEA number of the prescriber. 4. Prescriptions for controlled substances Schedule II may not be combined with another medication on the same prescription. Schedule II medications must be written on a separate prescription form.

Prescriptions for controlled substances Schedules III ­ V are valid for only 6 months from the date they were written and may be refilled, as prescribed, up to five times during the six month period. Under Florida law, refills for controlled substances Schedule II, are NOT permitted. Medical Residents may prescribe outpatient controlled drug prescriptions if:

They have a valid individual DEA registration number AND medical license number. OR 2. They are appropriately registered with the Board of Medicine as an unlicensed physician in training and MUST use the hospital's DEA number along with their unique suffix. 1.

Discharge Prescriptions Practitioners are encouraged to complete discharge prescriptions as early as possible in the discharge planning process to avoid delays and improve patient satisfaction.

Add-On Non-Emergent, Invasive Procedures/Cases Scheduling (TX-128)

To enhance the environment of safety for our patients, TGH is creating a standardized process to add-on unscheduled procedures/cases in all of its procedural areas: i.e. Operating Rooms, GEC, CVC, Radiology, L&D and the Bronchoscopy Lab. Physicians or Mid-Level Providers (PA and ARNP) will need to complete the following to initiate this process: 1. Complete and document Consult and/or Procedural Plan in the Progress Notes. 2. Write an order for the procedure/case to be performed in the patient's record including the procedural area or unit where the procedure/case will be performed and laterality (if applicable).

In addition, procedures to be added-on to the Operating Room schedule must still be communicated telephonically or in person with the staff attending the Operating Room Control Desk as well as complying with requirement 1 and 2 above prior to the patient being transported to the Operating Room. Life threatening emergencies are exempted from this process

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TGH Pharmacy & Therapeutics (P & T) Committee UPDATE: April & May 2011

Earnest Alexander, PharmD, Manager Pharmacy Services *Please visit "tgh pharmacy" link for more details of the latest formulary decisions and access to the TGH Formulary. "tgh pharmacy" link gives you access to Micromedex and FORMULARY ADVISOR - available on the desktop of any computer in the hospital with an internet browser!


IV acetaminophen (Ofirmev®)

Acetaminophen injectable (Ofirmev) is a newly FDA approved product used in the setting of perioperative pain management in patients unable to take PO or PR acetaminophen. The agent was added to formulary and is best utilized and most well studied in this perioperative setting. Vial sizes are limited to 1000mg, therefore orders written for 650mg acetaminophen IV q4h will be converted to 1gram IV q6h to prevent waste of the product and ensure proper dosing, with the exception of pediatric patients and adult patients less than 50 kg that require weight based dosing. It is important to note that the total amount of acetaminophen from all routes should not exceed 4000mg per day. As the PO form of the drug is equally effective, the agent has been added to the IV to PO conversion protocol. Orders written as "IV or PO" will not be allowed. A medication use evaluation will be conducted in 3 to 6 months time to gauge the settings in which the agent is being used.


Sildenafil (Revatio®) injection

An injectable form of sildenafil is available as Revatio. The agent was added to the formulary for patients unable to take PO sildenafil. The agent is also restricted to pulmonary, cardiology, critical care, neonatology, and pediatric critical care physicians. All new starts of the medication are to be administered on cardiac telemetry or in the ICU. The maximum dose is 10mg IV TID.


Medication reconciliation policy revision

The Joint Commission has revised their National Patient Safety Goal to simplify the Medication Reconciliation process, and TGH has proposed changing its policy and process to reflect this. The major change is that pharmacists will not be required to cosign the Medication Reconciliation forms before discharge. Pharmacists will focus their Medication Reconciliation efforts on high risk patient populations. The education about the new process will take the form of a flyer and target nurses and pharmacists.


Epoprostenol (Valetri®)

Epoprostenol sodium is a naturally occurring prostaglandin and a known metabolite of arachidonic acid. It directly stimulates vasodilation of pulmonary and systemic arterial vascular beds, and inhibits platelet aggregation. Epoprostenol requires the use of a specialty access program and confirmation of outpatient insurance approval prior to initiation. Therapy is usually life-long and will need to be continued when patient is discharged. Epoprostenol is available as 2 brand name medications as well as a generic. · The generic form has been on backorder and has been unavailable for use. There is no plan for release of this product · Flolan® (epoprostenol) and Veletri® (epoprostenol) are the 2 brand name drugs available. Flolan is temperature labile and requires ice pack refrigeration during infusion or changing the IVPB every 8

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hours. Veletri is temperature stable and does not require an ice pack with longer stability for longer infusion time. The P & T approved Veletri as the sole product to be used for continuous intravenous infusion because better temperature stability allows for improved medication dispensing, administration, and minimal waste. Flolan will be limited to inhalation use only.


Epoprostenol (Flolan®) continuous inhalation/nebulization therapy ­ Attachment III

Maresa Glass, PharmD and Cherri Klacsan, RT presented a proposal for epoprostenol continuous inhalation therapy to be used for acute pulmonary hypertension in post cardiothoracic surgery patients, refractory hypoxemia in Acute Respiratory Distress Syndrome, and acute pulmonary hypertension therapies prior to initiation of chronic therapies. Our current use of inhaled epoprostenol is limited to therapy administered intermittently, every 4 hours, to treat pulmonary hypertension until we have approval to move patient to chronic therapy. Epoprostenol has a very short half-life (6 minutes), so the effectiveness of this therapy is questionable. The initiative to implement continuous epoprostenol therapy is in response to escalating costs of nitric oxide therapy, on track to be $1,200,000 over budget this year. Literature review and discussion with similar academic medical centers through University Health Systems Consortium led to the development of the epoprostenol continuous inhalation protocol as an alternative to nitric oxide. An order set and policy were reviewed by the Committee. Pharmacy and respiratory therapy are currently working on obtaining the appropriate equipment to allow us to administer drug by continuous nebulization. The respirator to be used will attach to the Alaris pump. Special precautions will be put in place to isolate the epoprostenol inhalation from IV therapies. Respiratory therapy will manage the epoprostenol inhalation using a dedicated Alaris pump that will be placed on the opposite side of the bed from the IV pump. The Alaris pump used for continuous inhalation will have a different face plate to visually distinguish the pump. The initial protocol excludes the neonatal use of nitric oxide. Attending level approval will be required on order sets. The continuous inhalation epoprostenol protocol and order sets were approved. The committee requests to have follow-up and efficacy data after appropriate period of time.


Clozapine protocol

· The P & T Committee reviewed processes to assure compliance with clozapine REMS (Risk Evaluation Mitigation Strategy) as mandated by FDA. Protocol presented and has components to assure patient, prescribing physician and dispensing pharmacy are registered with the clozapine registry program. Because of potential serious adverse effects of clozapine, the program requires that CBC with differentials is documented at predefined intervals and does not permit the patient to receive additional therapy until the evaluation is completed. The protocol would permit Tampa General Hospital pharmacists to order CBC with differential if the test has not already been ordered by the physician. The protocol clearly outlines the process for interpreting the results. The process has been reviewed and approved by psychiatry.


Pharmaceutical Shortage Update

· New shortages were discussed during the April and May P & T Committee meetings related to suspension of drug distribution from American Regent who is a single source supplier for the following products: IV acetylcysteine (Acetadote®), acetylcysteine 10%, 20% (Mucomyst®), iron sucrose injection(Venofer®), trace minerals, and potassium phosphate. These shortages have been communicated via PreCise update, Outcomes in Perspective articles, Physician Lounge updates, Micromedex Formulary Advisor updates, and direct communication with medical teams as soon as they it is deemed appropriate/necessary. The P & T recommended reserving currently available Mucomyst® for treatment of acetaminophen overdose as there is no alternative agent for this indication.


Critical Shortages are highlighted on the initial screen in PreCise!


The physicians below were added to TGH staff: 5/31/2011

Duane M. Belongie, MD Mekeshia S. Fitzgerald, DO Timothy J. Floreth, MD Maureen C. Holasek, MD Nyirgi M. Kemmer, MD Jerome Yankowitz, MD Orthopaedic Surgery Hospital Medicine Pulmonary Disease & Critical Care Radiological Services Internal Medicine Obstetrics/Gynecology

This newsletter is produced by Tampa General Hospital's Quality Improvement Department. All comments, responses or suggestions are welcome and should be directed to: Sally H. Houston, M.D. Sr. V.P. & Chief Medical Officer Tampa General Hospital, P.O. Box 1289, Tampa, Florida 33601 ~~~~~~~~~~

Editorial Review Board

KUDOS TO OUR PHYSICIANS! Congratulations to the following physicians who were recognized by their patients in the form of personal letters to TGH leadership.


Dr. Tarik Haddad, Dr. Mark Rolfe, Dr. Cedric Sheffield, Dr. Rajendra Kedar, and Dr. Frank Garcia.

LAYOUT & DESIGN Paul DeLand BOARD MEMBERS Deana Nelson, RN, MHA Thomas Bernasek, M.D.



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