Freeman Health System Pharmacy Uses VigiLanz to Improve Care, Workflows, and Costs

Background

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Freeman Health System, a 485-bed, three-hospital system in Joplin, Missouri, serves a population of 450,000 people across Missouri, Arkansas, Kansas, and Oklahoma. Ranked one of the top hospitals in Missouri by U.S. News & World Report, Freeman continually seeks out new and innovative ways to improve patient care.

Within Freeman, the pharmacy department is known for its commitment to exploring new tools that improve efficiency as well as patient safety. Since implementing VigiLanz in 2018, Freeman’s pharmacy team has created over 650 VigiLanz rules that aid in pharmacy department interventions. These rules use dashboards and real-time notifications to alert team members whenever information pulled from the electronic health record (EHR) meets rule criteria. 

“This approach has made a significant impact on patient care, pharmacy workflows, and costs,” said Adrienne Carey, PharmD, BCPS, Clinical Pharmacist and Data Mining Program Manager at Freeman Health System. “Because of the improved capabilities within VigiLanz’s rule engine, we’ve been able to identify more opportunities for intervention more quickly than before.”

Here are five examples of how the Freeman team used VigiLanz’s pharmacy workflow solutions to support key initiatives that improved patient care and safety while reducing costs.

Initiative #1: Rule-building to inform discharge counseling

Each year, Freeman Health System residents use VigiLanz to build rules or create data mining searches to identify patient populations and gather data for a 12-month research project. This year, residents used VigiLanz rules to identify cardiology patients who were being discharged with a new medication not listed on their home medication list.

When the rule was triggered, pharmacists received a real-time alert. Pharmacists then educated patients about their new medication(s), documented them in the activation, and followed up with patients to assess the effectiveness of the education and its impact on readmission rates. Since these cardiology patients typically had a short length of stay, the VigiLanz rules were especially helpful in quickly identifying appropriate patients for education.

The patients who received education from pharmacy were 11% more likely to remember their counseling than those who received education through other discharge processes. Patients with the pharmacy education also had a 30-day readmission rate of 5.25% (compared to a rate of 21.25% among those who did not receive the education).

Initiative #2: Validation studies to support antibiotic discontinuation

A negative Methicillin-resistant Staphylococcus aureus (MRSA) nasal screening can help providers determine when to safely discontinue vancomycin, an antibiotic commonly used in patients with MRSA. However, since some providers are reluctant to discontinue the drug based on this test, another Freeman resident used VigiLanz to quantify the probability of disease based on screening results.

The resident created VigiLanz data mining searches to capture MRSA+ screens with positive cultures, MRSA+ screens with negative cultures, MRSA- screens with positive cultures, and MRSA- screens with negative cultures. Results showed a 97.2% correlation that a negative MRSA screen resulted in no MRSA infection. This enhanced providers’ confidence in using the screen to safely discontinue vancomycin, and therefore, reduced the risk of antimicrobial resistance and adverse events.

Initiative #3: Alerts to decolonize patients with positive MRSA screens

Studies indicate that MRSA colonization in the nose could increase the risk of MRSA infection, and that nasal administration of Mupirocin ointment reduces infections in patients with positive MRSA nasal screens. Based on this information, Freeman created a new protocol that authorized pharmacists to order Mupirocin ointment nasally when a patient has a positive MRSA nasal screen.

Freeman then used VigiLanz rules to identify patients with positive MRSA screens and alert pharmacists in real time. Since implementing this rule in January 2022, the facility has ordered Mupirocin decolonization for 162 patients, resulting in $98,000 in estimated cost savings due to less time spent in isolation, lowered risk of infection, and fewer readmissions.

Initiative #4: Tools to monitor drugs and prevent drug shortages 

Freeman’s pharmacy team uses VigiLanz to quickly and efficiently search for pharmacy orders (a functionality not included in their health information system). Examples include:

  • Central staff and buyers use VigiLanz to identify patients on medications in short supply so that pharmacists can alert providers and help prevent drug shortages.
  • Pharmacists use VigiLanz to search for high alert drugs to monitor proactively. Floor pharmacists run a system-wide kinetics search each morning—including vancomycin, heparin, and aminoglycosides—to identify the patients they are expected to manage.
  • Night shift pharmacists use pharmacy orders to identify heparin patients that need to be monitored.

Initiative #5: Rules to guide and decrease antibiotic use

A Freeman pharmacy resident used VigiLanz to conduct a research project comparing Freeman providers’ antibiotic orders (including Zithromax, Aztreonam, Cefepime, Ceftriaxone, Ciprofloxacin, Levofloxacin, Meropenem, Zosyn, and vancomycin) for treating pneumonia according to professional guidelines. The study found that, for each type of pneumonia, some antibiotics were prescribed for longer than recommended. As a result, Freeman created order sets to guide providers about the appropriate number of days to prescribe each antibiotic.

Freeman also created a “Pneumonia Pathway Hard Stop” rule in VigiLanz to ensure the hard stop stays with the antibiotic order, regardless of any dosage changes made that could inadvertently remove the initial hard stop.

As a result, floor pharmacists can more easily determine when patients complete their therapies, and Freeman can reduce its usage of antibiotics consistent with professional guidelines.

 

To learn more about how VigiLanz helps hospitals improve their patient safety and clinical surveillance, visit https://vigilanzcorp.com/ today.

Holmes Regional Medical Center Pharmacists Use VigiLanz to Improve Care

Innovative projects improve glycemic control and decrease thrombosis risk

This success story was written in 2021.

Pharmacists across the country face numerous competing demands and priorities—from preventing adverse events to supporting cost-saving objectives to partnering with physicians to ensure high quality care. With so many critical tasks, it can be difficult to implement and pursue new initiatives.

That’s why the achievements of the pharmacy team at Holmes Regional Medical Center (HRMC), part of the four-hospital Health First network in Central Florida, are so impressive. The team continually pursues new and innovative projects, using technology to support their efforts.

“Our department thrives when novel patient care initiatives enable pharmacists to practice at the top of their license,” said Michael Sanchez, PharmD, BCCCP, Pharmacy Residency Coordinator. “We’re always looking for ways to optimize medication therapies, prevent adverse events, and contribute to antimicrobial stewardship.”

Three recent initiatives spearheaded by HRMC’s pharmacy team and supported by VigiLanz have significantly improved patient care while reducing costs.

Initiative #1: Medication optimization protocol reduces hyperglycemia in patients with acute COPD

In September 2019, HRMC pharmacists began collaborating with pulmonologists across the Health First network to identify opportunities to improve care for patients with acute exacerbation of COPD (AECOPD).

“We had seen some small studies describing the benefits of having pharmacists transition IV corticosteroids to PO, and we wanted to see how that could impact our hospital,” said Sanchez. “Oral and IV corticosteroid therapy have comparable outcomes, but oral therapy is associated with fewer adverse events and is less expensive.”

To test and evaluate the impact, HRMC implemented a protocol enabling pharmacists to independently change IV corticosteroids to oral prednisone, when appropriate. VigiLanz supports the initiative by sending an alert to pharmacists whenever a patient with AECOPD meets HRMC’s eligibility criteria.

“The VigiLanz alert is highly accurate in detecting patients who would benefit from streamlining to oral corticosteroids,” said Sanchez. “We wouldn’t have been able to implement this new protocol without it, due to the complexities of the eligibility criteria.” The criteria include current use of IV corticosteroids, respiratory rate, blood gas results, allergies, and history of asthma.

The workflow:

  • VigiLanz alerts pharmacists of eligible patients, based on eligibility criteria
  • Pharmacists review patients’ medical records to confirm eligibility
  • Pharmacists switch eligible patients from IV corticosteroids to 40 mg of oral prednisone per day for five days

To assess the impact of the new protocol, HRMC pharmacists compared outcomes for 128 AECOPD patients admitted pre-protocol (November 1, 2018 to February 9, 2019), with outcomes for 134 AECOPD patients admitted post-protocol (November 1, 2019 to February 9, 2020).

“To our knowledge, this is the largest study examining the impact of a pharmacist-led IV to PO corticosteroid conversion protocol for AECOPD, and it’s the only study to examine safety endpoints, such as hyperglycemia,” said Sanchez.

While the study found no significant differences in average length of stay, 30-day readmissions, average blood glucose, or mean cost of corticosteroids per patient, it did find that the post-protocol group had a significantly lower rate of hyperglycemia (62% vs 37%).

“The odds were really stacked against that outcome because the intervention group had

more diabetic patients,” said Sanchez. “In the next few years, I hope we can gather more data to evaluate if there’s also a reduction in glucose related complications.”

The Health First network is considering incorporating the protocol into an AECOPD order set to guide physicians toward oral corticosteroid treatment. Based on feedback from providers, the new protocol would recommend moving from a single 40 mg daily dose of prednisone to two 20 mg doses to further reduce hyperglycemia.

Initiative #2: Kcentra initiative reduces thrombosis risks and cuts

In early 2020, Ted Heierman, PharmD, Clinical Pharmacy Specialist at HRMC, and Brianna Glenn, Pharmacy Resident at HRMC, noticed an increase in prescriptions for Kcentra, the only FDA-approved alternative to plasma for urgent warfarin reversal.

“We suspected that some of the increase in Kcentra utilization was inappropriate, and we confirmed that suspicion with a medication use evaluation,” said Heierman. “We began exploring how VigiLanz could help us address this problem.”

Heierman and Glenn worked with VigiLanz to create a Kcentra alert that is sent to the pharmacy team whenever the medication is prescribed.

The workflow:

  • VigiLanz alerts pharmacists of Kcentra orders in real-time
  • Pharmacists screen patients to ensure they meet Kcentra use criteria
  • If patients don’t meet use criteria, pharmacists discuss medication alternatives with prescribers

“With this new approach, we found that Kcentra was being inappropriately prescribed about 15 percent of the time,” said Heierman, noting that the alert has been in place since September 2020. “This new approach has reduced inappropriate use to nearly zero.”

HRMC’s Kcentra use criteria:

  • Life-threatening bleed
  • Documented warfarin or direct-acting oral anticoagulant (DOAC) use
  • For DOAC use, anti-factor Xa (AntiXa) above 0.5.
  • For intracerebral hemorrhage-Glasgow coma scale(ICH-GCS) above 8 and neurosurgical evaluation and planned surgical intervention

“The initiative has significantly improved patient care and reduced costs,” said Heierman, noting that Kcentra comes with thrombotic risks, so ensuring appropriate use decreases the risk of thrombosis. “With a 15 percent reduction in use and 100 percent appropriate use, our HRMC can potentially save around $105,000 each year.”

Initiative #3: Pharmacist interventions reduce hypoglycemia and cut costs

In 2019, Health First identified that one of the top risk factors for severe hospital-acquired hypoglycemia in its health system was providers not adjusting insulin regimens after patients had episodes of hypoglycemia. HRMC pharmacists immediately began exploring how they could help prevent this problem.

The result was a new protocol, implemented in March 2019, that enables pharmacists to independently decrease rapid and long-acting insulin regimens if a hospitalized patient has had a severe hypoglycemic event after receiving insulin.

When the protocol was first implemented, nurses were tasked with notifying pharmacists of severe hypoglycemic events. However, the pharmacy team quickly recognized that real-time clinical surveillance could improve efficiency and reduce the risk of an error. “VigiLanz ensures we receive timely notifications and can adjust the patients’ insulin therapy sooner,” said Sanchez.

The workflow:

  • VigiLanz alerts pharmacist when patients with hypoglycemic events have received insulin in the past 24 hours
  • Pharmacists review patients’ information, and decrease insulin based on glucose value, as follows:
    • 61 – 69 mg/dL = Reduce all meal insulin by 1 unit
    • 51 – 69 mg/dL = Reduce basal insulin by 20 percent daily
    • Less than or equal to 60 mg/dL = Reduce all meal insulin by 2 units
    • Less than or equal to 50 mg/dL = Reduce basal insulin by 40 percent daily

    HRMC had completed VigiLanz activations for 235 patients as of November 2020, and the protocol had decreased severe hypoglycemic events in patients with insulin from 7.14 percent to 5.45 percent.

    The new protocol has also reduced costs, because the Centers for Medicare and Medicaid characterizes certain complications due to hypoglycemia as never events, said Sanchez. As a result, it does not reimburse hospitals for the extra costs associated with these events.

    “On a personal level, my passion for supporting this initiative arose from helping the code response team identify severe hypoglycemia in a coding patient,” said Sanchez. “I’m confident this protocol has, and will continue to, prevent devastating outcomes for many patients.”

    To learn more about how VigiLanz helps hospitals improve their patient safety and clinical surveillance, visit https://vigilanzcorp.com/ today.

Northern Arizona Healthcare Uses VigiLanz to Fight COVID-19 and Mitigate Drug Shortages

Customer Profile 

Northern Arizona Healthcare, the largest healthcare system in a region that encompasses more than 50,000 square miles, provides comprehensive healthcare services through clinics, surgical centers, and two hospitals: Flagstaff Medical Center and Verde Valley Medical Center.  The health system serves more than 700,000 people in communities across the region, and is committed to continually improving and enhancing patient safety.

Challenge

Northern Arizona Healthcare’s Flagstaff Medical Center (FMC) is the biggest major medical center in Northern Arizona. The Navajo Nation, the largest Native American Reservation in the country, resides in FMC’s service area. This community was hit hard and early with a significant COVID-19 outbreak. At its peak, the Navajo Nation had a higher per capita COVID-19 rate than all major cities in the U.S. including New York (3.4 percent vs 1.9 percent).

FMC initially bore the brunt of this outbreak, well before the Arizona State COVID-19 Healthcare Surge Hotline was created in mid-May to help balance the load of cases across the state. FMC treated their first COVID-19 patient in mid-March of 2020, and quickly ramped up to more than 30 critically ill COVID-19 patients by the end of the month. They experienced a peak of 51 positive cases (a full third of their census) followed by a second surge in mid-June.

Kristen Bamberg, PharmD, MS, BCPS, BCCCP, Lead Critical Care Pharmacist at FMC, and Andrea Boyce, PharmD, BCIDP, Lead Antimicrobial Stewardship Pharmacist at FMC, were immediately thrust into a fast-paced and highly challenging environment due the influx of COVID-19 patients. They faced constantly evolving therapeutic recommendations, and a continual fight to mitigate critical shortages of medications like sedatives, neuromuscular blockers, and antibiotics.

Solution

Bamberg and Boyce had an excellent team behind them working to overcome the challenges presented by COVID-19, but they also recognized that they needed to fully utilize all of their resources in order to continue to provide optimal care to patients.

“We knew how useful VigiLanz’s alerts and reports already were in helping us care for patients on a day-to-day basis,” said Bamberg. “So we turned to them to help us quickly determine how their alerts and reports could be tailored to help us specifically address the needs and demands of the pandemic.”

Ultimately, Bamberg and Boyce worked with the clinical surveillance provider to implement dozens of new rules and alerts. These rules resulted in three key benefits:

Benefit #1: Real-time alerts that led to a more proactive response to COVID-19 patients and helped conserve PPE

At the beginning of the pandemic, FMC immediately recognized that the earlier healthcare providers could be informed of a patient’s COVID-19 status, the better. If a patient tested positive, that patient could continue to be isolated and contact tracing could begin; if a patient tested negative, staff members no longer needed to use PPE when interacting with that patient (which could help combat the PPE shortage).

As a result, Bamberg and Boyce worked with VigiLanz to implement real-time alerts to inform relevant healthcare providers and staff as soon as a COVID-19 test result was available. They also implemented alerts to inform them if a re-admitted patient had a history of COVID-19.

Examples of alerts:

  • COVID-19 results: Alerted pharmacists of a new COVID-19 RNA or PCR test result
  • Patients with a history of COVID-19: Alerted pharmacists if a patient was re-admitted and had a positive result on a previous encounter in the last 90 days

“The support and responsiveness of VigiLanz to our abundance of requests was incredible,” said Bamberg. “It helped us work through countless therapeutic and workflow issues in real time.”

Benefit #2: Real-time alerts for medication optimization and prevention of adverse drug events

Bamberg and Boyce also worked with VigiLanz to implement several new alerts that helped optimize medication safety for COVID-19 patients.

“These alerts were particularly useful since we were dealing with a new disease and treatments that were continually changing,” said Boyce. “Many of the alerts resulted in the discontinuation of certain medications and helped us flag potential problems.”

Examples of alerts:

  • Hydroxychloroquine (HCQ) ordered: Alerted pharmacists to check for drug interactions and assess and follow the risk of corrected QT(QTc) prolongation
  • HCQ and weight > 50 kg: Alerted pharmacists to review based on the hospital’s protocol at the time
  • HCQ patients at high risk for QTc prolongation with higher than normal doses used for treatment of COVID-19: Alerted pharmacists when patients had HCQ + azithromycin + K < 4, HCQ + azithromycin + Mag < 2, HCQ + azithromycin + scheduled ondansetron.
  • Metoclopramide longer than three days: Alerted pharmacists to assess efficacy and potential discontinuation of metoclopramide (which many COVID-19 patients were prescribed due to ileus or significantly reduced bowel motility) in an effort to minimize adverse drug events.
  • D-dimer > 1,000: Alerted ICU pharmacists to assess patients (this rule was implemented after a hospital literature review of COVID-19 and thrombosis indicated that patients were experiencing micro thromboemboli and likely required higher than usual doses of chemical deep vein thrombosis prophylaxis). While the hospital eventually abandoned D-dimer as a sole marker of a need for these higher doses, it initially helped the pharmacists make recommendations to intensivists regarding anti-thrombotic therapy.
  • Enoxaparin 0.5 mg/kg SQ Q12H ordered and no Xa level: Alerted pharmacists to monitor patients’ response to treatment, as COVID-19 patients had a higher propensity to clot, a potentially larger clot burden in the form of microthrombosis, and potentially acquired ATIII deficiencies as a result.
  • Remdesivir ordered: Alerted pharmacists to monitor patients to adhere to new protocols (the hospital had a specific Remdesivir protocol in place due to emergency use authorization requirements).

Benefit #3: Real-time alerts to mitigate drug shortages

In addition to ensuring optimal medication usage for COVID-19 patients, Bamberg and Boyce also used VigiLanz to help FMC manage medications in short supply.

“We always need to make sure that we have the right medications on hand for each patient, but this process became even more challenging when COVID-19 hit,” said Boyce. “VigiLanz helped us manage many of the unprecedented shortages we faced, especially when it came to necessary medications like sedatives and antibiotics.”

Examples of alerts:

  • Ketamine ordered: Alerted pharmacists to determine if a more concentrated bag could be used, or if alternative medications were appropriate
  • IV famotidine ordered: Alerted pharmacists so that, if appropriate, they could recommend an IV alternative or switch the patient to oral
  • Doxycycline more than five days: Alerted pharmacists to assess patients’ antibiotic therapy and recommend possible discontinuation as appropriate
  • Albuterol inhaler PRN, not on isolation: Alerted pharmacists to assess whether a non-COVID-19 patient with an active order for an albuterol inhaler could be switched to nebulization

Outcomes

FMC’s ability to quickly respond to the COVID-19 pandemic is a testament to the dedication and innovative ideas of all of its frontline staff—with Bamberg and Boyce playing a critical supporting role. During a significantly challenging time, they were able to think outside the box and use the information they received from VigiLanz to enhance patient care.

Overall, this led to:

  • Earlier identification of positive and negative COVID-19 tests, which helped conserve PPE and enhance patient treatment
  • Earlier identification of readmitted patients who previously tested positive for COVID-19, which helped the health system protect non-COVID-19 patients and staff
  • Optimal medication usage for COVID-19 patients, which enhanced patient treatment
  • Enhanced monitoring of medications in short supply, which led to more targeted and judicious use of medications

“We were among the first and hardest hit hospitals by COVID-19,” said Bamberg.We worked  with VigiLanz to be proactive in tackling this challenge, and it made a significant difference to our patients and community.”

To learn more about how VigiLanz helps hospitals improve their patient safety and clinical surveillance, visit https://vigilanzcorp.com/ today.