NR 534 Week 8 System Strategy Paper Example

System Strategy Paper: Every High-Alert Infusion in Nine Buildings Arrives Ready at One Concentration, Priced Campus by Campus at About $123,000 a Year, and the Three Things the System Stops Doing to Get There

Student Name

College of Nursing, Chamberlain University

NR 534: Healthcare Systems Management

Instructor Name

Month Day, Year

System Strategy Paper: Every High-Alert Infusion in Nine Buildings Arrives Ready at One Concentration, Priced Campus by Campus at About $123,000 a Year, and the Three Things the System Stops Doing to Get There

The Recommendation

I recommend that the system board adopt one strategy for high-alert intravenous infusions: every building in the system will give the eight most common high-alert continuous infusions only in ready-to-use form at a single system concentration, either compounded by the tertiary center's pharmacy or purchased as commercial premixed bags. No building will prepare these infusions from vials on the unit, and no building will use a concentration other than the system standard. The eight are norepinephrine, epinephrine, phenylephrine, vasopressin, insulin, heparin, dexmedetomidine and propofol, which account for about nine in ten high-alert continuous infusions given in the system.

The strategy completes work begun this year. The vasopressor standard, SYS-PHM-214, showed that standard concentrations can be adopted across nine buildings, but also that the smaller sites cannot meet a standard their resources do not support. This paper proposes to extend the standard to the other high-alert infusions and to fund the resources that make it achievable everywhere.

Why This, and Why Now

The national pharmacy association has published standard concentrations for adult continuous infusions and argued that adopting them nationally would reduce errors and improve continuity of care across transitions (American Society of Health-System Pharmacists [ASHP], n.d.). A system of nine buildings that share nurses, patients and pump libraries has more to gain than a single hospital, because every local variation travels with the people who move between buildings. Our site comparison found that most variation in vasopressor practice was local habit, and that the rest came from one gap: the smaller sites could not prepare infusions safely at night.

Consolidation was justified to our communities partly by the promise of better care through shared standards. Analysts have cautioned that integration of clinical practice across merged hospitals has been slower than promised (Burns & Pauly, 2018), and that size alone does not bring quality unless systems use their scale deliberately (Tsai & Jha, 2014). This strategy is a deliberate use of scale that nurses at every bedside would notice.

Price by Campus

Table 1 prices the strategy for each building. Added cost is the difference between the current preparation cost and the ready-to-use cost for each building's annual volume of the eight infusions. Offsets are reduced waste from the longer usable life of premixed bags. Pharmacy technician time freed at the community hospitals is shown separately because it will be redeployed, not cut.

Table 1

Annual Cost of the Strategy by Campus

Reading the Prices

The strategy costs about $123,000 a year, almost all of it at the three community hospitals, where premixed bags cost about $13 more per bag than compounding on site. At the small sites the cost is small in dollars and large in effect: for about $10,600 a year across four buildings, nurses at the critical access hospitals and freestanding departments will never again prepare a high-alert infusion from vials at night. The tertiary center adds no cost, because it already compounds at the standard concentrations with round-the-clock pharmacy staff.

The board should also see what the price buys at the community hospitals. About 2.1 full-time pharmacy technician positions spent on compounding these infusions will be redeployed to admission medication histories, work the community hospitals have asked for and could not staff. That benefit is real but not counted in Table 1, because it does not reduce spending.

What the System Stops Doing

A strategy that only adds is not a strategy. This one stops three things.

1. Unit-level preparation of high-alert infusions. Nurses at the critical access hospitals and freestanding emergency departments will stop mixing these infusions from vials. Recipe cards will be withdrawn.

2. Community hospital compounding of the eight infusions. The three community hospitals will stop compounding them and buy premixed bags. Their sterile compounding areas will continue to serve other preparations.

3. Site-specific concentration lists. The system will stop maintaining separate concentration lists by site. There will be one list, and exceptions will go through the existing waiver process with a six-month expiry.

Risks

Premixed supply can be disrupted by manufacturer shortages. The tertiary center's pharmacy will hold the capacity to compound the eight infusions for any site during a shortage and deliver them by the system's existing daily courier. The cost of that contingency is not in Table 1; a shortage would add cost for its duration. Premixed prices may rise; a 10% increase would add about $39,000 a year. Some clinicians will object to losing locally preferred concentrations, particularly anesthesia and intensive care physicians at the community hospitals who are used to titrating from a familiar strength. The system pharmacy and therapeutics committee will meet with each group before the rollout reaches their site, and the pump library will display each drug's dosing in the same units everywhere, which is what clinicians actually program. The waiver process allows a site to argue a clinical case, but not a preference.

What the Board Is Asked to Decide

The board is asked to approve the strategy and its annual cost of about $123,000, to be funded in the system pharmacy budget rather than in site budgets, so that the smallest sites are not asked to pay for a standard they could not previously meet. If approved, the system pharmacy and therapeutics committee will extend SYS-PHM-214 to the other seven infusions, the rollout will follow the same site order used for vasopressors, and the system chief nursing officer will report adoption and medication event data to the board quality committee every six months. The strategy's promise is simple enough for any nurse in any building to check: the bag in a nurse's hand looks the same as the bag in every other building, and nobody on the unit had to make it.

References

American Society of Health-System Pharmacists. (n.d.). Standardize 4 Safety: Adult continuous infusion standards. https://www.ashp.org/-/media/assets/pharmacy-practice/s4s/docs/Adult-Infusion-Standards.ashx

Burns, L. R., & Pauly, M. V. (2018). Transformation of the health care industry: Curb your enthusiasm? The Milbank Quarterly, 96(1), 57-109. https://doi.org/10.1111/1468-0009.12312

Tsai, T. C., & Jha, A. K. (2014). Hospital consolidation, competition, and quality: Is bigger necessarily better? JAMA, 312(1), 29-30. https://doi.org/10.1001/jama.2014.4692