ZpackSux said:
My John Deere is fine and well. I'll change the avatar once someone figures out what it is.
Do you guys restrict some antibiotics to IDs and critical care docs only? Like Zyvox, Tygacil, Cubicin and Cancidas? I proposed it to clinical managers at our division meeting (10 hospitals in the division) and they were too busy trying to tell me why they can't do it.... heck, if they were my managers, I would've fired them. At least give it a try..and if you fail, try it differently.
I'm so thankful your John Deere is fine - I was afraid you'd have to transfer that gun rack to your van which your very fine & dear wife drives your childrent to the dentist, which you don't have the time to do
😉 - just j/k.
No - we do not restrict our antimicrobials, but not because we don't want to. It has to do with the politics of a non-teaching institution. We are a community hospital with physicians in private practice who admit.
Each physician who admits is no more "higher nor lower" on the heirarchy than any other. That is because we do not have house staff, no "attendings" or supervisorial physicians over any others. They each have their own private practice & their own ability to admit & write orders independent of any other physician intervention. That sounds as if we don't have any protocols at all - we do. We only allow one 2nd generation cephalosporin, one proton pump inhibitor, etc...we have automatic P&T therapeutic substitutions in place for that. We also have automatic review of aminoglycoside dosing, tpn monitoring, etc & have the authority to adjust it at will. However, we cannot force a private IM or orthopod or OB-GYN for example to require an ID consult. That is outside of what our P&T can force at this time.
We do, however, have hospitalists, who admit for the large groups. Working with them has worked very well for us to limit & have a more "rational" approach to antimicrobial therapy. We also work very closely with ED who writes many of the admit orders for "off hours" admits.
That does not mean that we do not intervene when we perceive a problem - either overuse, misuse or inappropriate use. We have a mechanism for approaching that which sometimes - very rarely, involves the chair of the medical service the physician is part of.
In every case where a situation has occured which has required us to obtain a very expensive drug - it goes for review with the service which the physician is part of concurrently with us ordering it. This is similar to a morbidity & mortality review of a circumstance which has occured in the past in which there has been a question of drug choice & perhaps lack of rapid intervention of a specialist - it is not restricted to antimicrobials. It is not so much as a hand-slapping situation as an educational opportunity in which the physician is educated on how expensive the intervention was & an evaluation of the committee in question if it should go to the P&T committee for further study & decision.
If it does go for further study.....& it is determined that it is not to be available on the formulary, we don't stock it. It takes time to obtain it & we require the physician to comply with a nonformulary drug request. We or the physician obtains the information, it goes to the chair of the dept & by the time we obtain it, the decision is made to give it or not - it has been running 50-50. We are always able to send it back, but we make it difficult to obtain in the first place by just not stocking it.
We can do this becaue we are within 10 miles of a teaching institution. Our physicians usually have dual admit privilges - they can admit there - the process is faster & they are used to having the extremes of drug therapy on hand. It is part of their educational process & they see the extremes of resistant patients - even moreso than we do & we see many.
So...its a two edged sword - fewer pt admits when considering extreme therapy but also fewer budgetary repercussions. Unfortunately for those of us clinically, we see fewer of these drugs early in practice, so we have to come up to speed fast when they become routine, altho we do rely on conversations with our academic counterparts.
So...I understand your clinical managers - they have to work with the physicians. I also understand your budget restrictions & ideal therapeutic restrictions. However, they also must be given rational & reasonable methods to use to satisfy both sides. They have physicians who are trying to pull out all the stops to save a pt. The use of the drug may not save that ONE patient, but it may increase the experience in which it may save someone later....We certainly found that out years ago with TPA - it was misused early more than it was used effectively. But we finally found when the best "window" of opportunity was for its use.
IMO - the idea of "try it & if it fails" leaves them in an untenable situation - it lessens their credibility. Give them something else...something which is fluid & flexible to work with. Give them something where both sides can win something. They have to work with these folks everyday - if you make a stand on an infrequent use of a drug, you may win that battle, but you may lose the war on having them be your partners in trying to decrease your overall antimicrobial use. Now...if your situation is frequent inappropriate use - then get the lab antibiogram & document, document, document....you'll win that one hands down.
Now....back to that avatar. I really cannot see it! It appears to be a 3-d version, but I can't see what's off the 1 position of the central ring.....can you give a bigger, more detailed version???? Its been a very long time since pharmaceutical chemistry
😱
Good luck with your current project!
