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In 1996, two hospitals reported sustained transmission of nosocomial Legionnaires disease (LD). The hot water distribution systems in each hospital were implicated as the sources of infection. This report summarizes investigations in these two hospitals by hospital personnel, state and local health officials, and CDC and efforts to control transmission.
A hospital pharmacy department's implementation of enteral nutrition product distribution and its proposal for an enteral nutrition product admixture service are described. Responsibility for the distribution of enteral nutrition formulations was transferred from the central distribution department to the pharmacy after problems with inventory control, billing procedures, and inappropriate administration of enteral nutrition products were recognized by personnel from the central-distribution area and nutrition services. After additional problems were identified using a multi-disciplinary approach, the pharmacy department implemented an enteral nutrition product distribution system and developed an enteral nutrition product formulary. A proposal was developed for a pharmacy-based enteral nutrition admixture service, but implementation of this service was deferred because data from a cost-effectiveness evaluation and random bacteriologic monitoring did not justify adding the service. Pharmacy-based distribution and formulary control of enteral nutrition products alleviated problems with inaccurate patient charges and accumulation of stock on the nursing units. Pharmacists at this hospital hope to develop an enteral nutrition product admixture program that will result in cost savings for the institution.
Just as computerized information systems are revolutionizing the way hospitals distribute patient information around the healthcare system, interactive video technology now is revolutionizing the way television sets are used in patient rooms. The TV set is becoming a source of hospital and patient information, and helps provide patient education.
As an important drug consumer in Dubrava University Hospital, Department of Cardiac Surgery has been chosen for testing a new model of drug distribution system known as unit dose drug distribution system. During the first 39 weeks in 1996--comparative period, drugs were delivered from the Pharmacy to the Department of Cardiac Surgery in traditional way, known as floor stock system. Next 65 weeks, until the end of 1997--pilot study period, drugs were delivered directly from the Pharmacy to the patients, using unit dose drug distribution system. Consumption of drugs was measured every week by statistical unit DDD/100 hospital days (Defined Daily Dose) according to Anatomic-Therapeutic-Chemistry (ATC) classification of drugs. For statistical measurements, beside common arithmetic means, geometric means were used which are less sensitive to extreme values of drug consumption. During comparative period drug consumption was chaotic with great oscillations around mean value, while in pilot study period that process was without great oscillations around lower mean value and did not exceed the limits of process. Drug consumption was completely under control, so it was a predictable process. In the pilot study period total drug consumption was 39% less, while consumption of drugs from group C was 30% less. During comparative period group C makes 34%, while in the pilot study period it makes 38% of the total drug consumption. This model of drug distribution in hospital leads to a rationalization of drug consumption and great savings. The pharmacist-physician interactive role began to emerge as a direct result of these changes in the drug distribution system. Hospital pharmacist has become a visible member of health care team who is responsible for Quality of all medication-related activities and thus has taken opportunity for clinical pharmacy practice.
Results of the 1999 ASHP national survey of pharmacy practice in acute care settings that pertain to drug dispensing and administration practices are presented. Pharmacy directors at 1050 general and children's medical-surgical hospitals in the United States were surveyed by mail. The response rate was 51%. About three-fourths of respondents described their inpatient pharmacy's distribution system as centralized. Of those with centralized distribution, 77.4% indicated that their system was not automated. Decentralized pharmacists were used in 29.4% of the hospitals surveyed; an average of 58.9% of their time was spent on clinical, as opposed to distributive, activities. About 67% of directors reported pharmacy computer access to hospital laboratory data, 38% reported access to automated medication-dispensing-unit data, and 19% reported computer access to hospital outpatient affiliates. Only 13% of hospitals had an electronic medication order-entry system; another 27% reported they were in the process of developing such a system. Decentralized medication storage and distribution devices were used in 49.2% of hospitals, while 7.3% used bedside information systems for medication management. Machine-readable coding was used for inpatient pharmacy dispensing by 8.2% of hospitals. Ninety percent reported a formal, systemwide committee responsible for data collection, review, and evaluation of medication errors. Virtually all respondents (98.7%) reported that their staff initiated manual reports. Only two thirds tracked these reports and reported trends to the staff. Fewer than 15% reported that staff were penalized for making or contributing to an error. Pharmacists are making a significant contribution to the safety of medication distribution and administration. The increased use of technology to improve efficiency and reduce costs will require that pharmacists continue to focus on the impact of changes on the safety of the medication-use system.
The day surgery center at NYU Hospitals Center installed an automated medication and supply distribution system as part of its facility renovation. A constricted Manhattan site prohibited physical expansion, so space efficiency became top priority. Goals also included increasing revenue, positioning for managed care contracting, improving access to supplies and medications, use tracking and inventory adjustment, documenting and tracking, accurate charging, and enhancing patient and staff member satisfaction. Space efficiencies achieved via automated distribution enabled planners to save one OR, which generates approximately $1 million in revenue annually. Demonstrated quarterly cost savings total $35,615, for an expected $142,460 in annual savings. The number of full-time employees did not increase from the amount budgeted for the prior system in any department participating in implementing the new system.
The medication error rate in an existing ward stock drug distribution system and in an alternative system developed after failure-mode and effects analysis (FMEA) was applied to the ward stock system was studied. In the ward stock system of a large teaching hospital in Western Australia, bulk drug packs were stored in cupboards on the wards, and drug products were transferred to drug trolleys before dose administration by nurses. A pharmacist used the disguised-observer technique to determine the error rate in the ward stock system for a medical ward and a surgical ward. The errors and each step in the system were studied by FMEA. A unit supply individual-patient dispensing (USIPD) system was formulated to respond to the failure modes identified. In this system, a five-day supply of medication was dispensed for each patient from a satellite pharmacy close to the ward. Medication charts were reviewed by a pharmacist, and drugs were dispensed in labeled vials that were placed in a locked drawer at the patient's bedside. The error rate under the USIPD system was determined. Problem areas in the ward stock system identified by FMEA included drug availability, review of orders, drug selection, patient-related issues, and use of nurses' time. The percentage of opportunities during which any error occurred was significantly lower under the USIPD system on both wards. FMEA was used to identify deficiencies in the ward stock system that led to medication errors in an Australian hospital. An alternative drug distribution system designed to address the problems identified was associated with fewer errors.
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The hospital's department of pharmacy plays an important role in lessening the risk of bloodborne disease transmission through its influences in the coordination and control of the hospital's drug distribution system, intravenous (IV) admixture service and purchasing decisions with regard to injectable drug products. A review of drug distribution systems has shown that the unit-dose system is the most advantageous in terms of accuracy, safety, time savings and overall costs to the institution. Needlestick injuries are an occupational hazard for healthcare workers. Today, the need for safety in medication administration is a priority in injectable medication systems. Pre-filled cartridges offer a number of advantages, one of which is their safety in preventing needlesticks, through facilitating administration of medication quickly and easily and disposal of the needle immediately thereafter.
Legionellas are present in water distribution systems and cooling towers of many hospitals. No firm data are available regarding the need for prophylactic disinfection of these contaminated systems. Disinfection of water systems and cooling towers is an accepted and effective means of ending nosocomial Legionnaires' disease, but it should be performed in conjunction with good epidemiological and microbiological studies to pinpoint environmental reservoirs and disseminators. Chlorination, pasteurization, or both, are the only means of disinfection found to be effective in disease outbreaks. Prospective surveillance of immuno compromised patients with pneumonia is probably the most effective means to determine if a hospital is a source of Legionnaires' disease and, therefore, requires further investigations and disinfection.
Nosocomial aspergillosis, a life-threatening infection in immunocompromised patients, is thought to be caused primarily by Aspergillus organisms in the air. A 3-year prospective study of the air, environmental surfaces, and water distribution system of a hospital in which there were known cases of aspergillosis was conducted to determine other possible sources of infection. Aspergillus species were found in the hospital water system. Significantly higher concentrations of airborne aspergillus propagules were found in bathrooms, where water use was highest (2.95 colony-forming units [cfu]/m(3)) than in patient rooms (0.78 cfu/m(3); P=.05) and in hallways (0.61 cfu/m(3); P=.03). A correlation was found between the rank orders of Aspergillus species recovered from hospital water and air. Water from tanks yielded higher counts of colony-forming units than did municipal water. An isolate of Aspergillus fumigatus recovered from a patient with aspergillosis was genotypically identical to an isolate recovered from the shower wall in the patient's room. In addition to the air, hospital water systems may be a source of nosocomial aspergillosis.
The distribution and control systems for controlled substances were evaluated. A mail survey of other hospitals was conducted to obtain samples of control substance systems and the associated procedures. From these samples of existing programs and previous experiences with the current program, a system was designed to meet the needs of an 800-bed hospital with a decentralized pharmacy distribution system. The new distribution and control system completely replaced the prior system. Therefore, new forms and procedures were generated. The total system was implemented in a stepwise procedure in two-week increments over approximately 14 weeks until the entire hospital was converted. The new system has increased control as well as identified workload, inventory utilization, and problem areas.
An experimental hospital pharmacy management information system (HPMIS) was evaluated in a national pilot test. Approximately 250 information and materials packets were distributed to hospitals that had inquired about the project. Monthly data on pharmacy expenses, personnel use, and productivity were collected for a six-month period by participating hospitals. This information was processed quarterly and converted into the HPMIS indicators; results were categorized according to hospital characteristics and locations. A questionnaire soliciting opinions about the system was sent to participants at the end of the data-collection period. One hundred six hospitals agreed to participate; 84 hospitals submitted data for at least one quarterly period. The range of values for most indicators varied 100-fold; this was attributed to misinterpretation of data item definitions. Based on indicator values, drug and personnel expenses and supportive-personnel use were greater in unit dose hospitals than in hospitals without total unit dose drug distribution systems. Both drug and fluid costs and the extent of supportive-personnel use increased with increasing hospital size. Data-collection time was less in hospitals with computerized pharmacy operations. Responses to the questionnaire indicated that the clinical services indicators were favored the least; however, only a few changes in the data-collection format of the system were suggested. HPMIS appears to be a useful work-measurement tool but needs to be simplified if it to serve as the standard for these systems.
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Contamination of tap water by Mycobacterium kansasii in an hospital is described. This contamination was responsible for an increased frequency of M. kansasii isolates from gastric washings. The hygiene measures taken to eliminate the mycobacteria from the water distribution system in the hospital are reported.
A project is described for the interim renovation of a labor intensive existing foodservice facility. The renovated area will provide effective food management during the hospital's redevelopment period, including a new foodservice. Objectives of the interim project were to conserve labor while emphasizing control and centralization, provide economic foodservices with improved quality, and incorporate one tray distribution system throughout the hospital complex. Immediate measures were necessary in order to generate funds to proceed. Renovations had to occur without disrupting food-service to patients. The project was planned over a three year period and included an ingredient control area, two patient tray service centres, a renewed production kitchen and test kitchen facility. Each phase has been financed on the understanding that the costs of construction and equipment will be repaid within one fiscal year of operating the renovated facility. Positive results are being achieved, attributable to the support and encouragement received from staff during the change process.
The Veterans Health Administration (VHA) is at the forefront of designing and managing health care information systems that accommodate the needs of clinicians, researchers, and administrators at all levels. Rather than using one single-site, centralized corporate database VHA has constructed several large databases with different configurations to meet the needs of users with different perspectives. The largest VHA database is the Decentralized Hospital Computer Program (DHCP), a multisite, distributed data system that uses decoupled hospital databases. The centralization of DHCP policy has promoted data coherence, whereas the decentralization of DHCP management has permitted system development to be done with maximum relevance to the users'local practices. A more recently developed VHA data system, the Event Driven Reporting system (EDR), uses multiple, highly coupled databases to provide workload data at facility, regional, and national levels. The EDR automatically posts a subset of DHCP data to local and national VHA management. The development of the EDR illustrates how adoption of a corporate perspective can offer significant database improvements at reasonable cost and with modest impact on the legacy system.
Thirty-four samples of warm waters from 12 psychiatric centres in Victoria and New South Wales were examined for legionellae by guinea-pig inoculation. Legionella pneumophila was isolated from 20 of the samples collected from ten of the establishments investigated. The detected prevalence proportion of L. pneumophila in waters of temperatures 36 to 43 degrees C was 0.9 (18/20), whereas the prevalence in waters of temperatures 45 to 54.2 degrees C was 0.14 (2/14). The two 'positive' waters within the latter range showed evidence of low numbers of L. pneumophila. No significant antibody titres to relevant serogroups were detected in the 112 exposed residents tested from seven psychiatric hospitals in New South Wales. The findings show that the temperature range with the greatest prevalence of L. pneumophila in warm waters is 36 to 43 degrees C. The presence of legionellae in these warm water-distribution systems contrasts with their absence from the water-distribution systems of Victorian hospitals in an earlier survey and underlines the value and simplicity of the usual Australian practice of maintaining hospital hot water temperatures at about 70 degrees C in the control of L. pneumophila.