1 Sonali Muzumdar Pharm.D., CPHIMS Informatics Pharmacist Mercy Hospital and Medical Center...
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1 Sonali Muzumdar Pharm.D., CPHIMS Informatics Pharmacist Mercy Hospital and Medical Center Comprehensive Pharmacy Services Leveraging Rules and Alerts
1 Sonali Muzumdar Pharm.D., CPHIMS Informatics Pharmacist Mercy
Hospital and Medical Center Comprehensive Pharmacy Services
Leveraging Rules and Alerts to Improve Patient Safety and Clinical
Pharmacy Services
Slide 2
2 Describe a method to assist pharmacist identification of
changing renal function over time for patients on renally adjusted
medications Identify a method to improve patient safety by
preventing medication errors associated with documented weight
changes List pharmacy clinical services that can be improved by use
of rules and alerts Objectives
Slide 3
Audience Poll How many sites have CPOE? 3
Slide 4
4 Mercy Hospital & Medical Center Chicago, Illinois
Slide 5
5 Mercy Overview History and Mission MAPS Timeline Applications
Healthcare Information Management & Systems Society Stage 6
Hospital Recognition The Leapfrog Group
10 JCAHO Recommendations Safety alerts should help clinicians
determine urgency and relevancy. Review skipped or rejected alerts
as important insight into clinical practice. Review appopriate
documentation to determine which which alerts need to be a hard
stop. http://www.jointcommission.org/assets/1/18/SEA_42.PDF
Slide 11
11 JCAHO Recommendations After implementation, continually
reassess and enhance safety effectiveness and error-detection
capability, including the use of error tracking tools and the
evaluation of near-miss events. Maximize the potential of the
technology in order to maximize the safety benefits.
http://www.jointcommission.org/assets/1/18/SEA_42.PDF
Slide 12
12 Outline Mercy Hospital and Medical Center Overview Renal
Rule Weight Change Anticoagulant Counseling Anticoagulant
alerts
Slide 13
13 Renal Dosing Gap Identified Adjust medications for impaired
renal function at order verification Built in stop datesCreatinine
clearance changes over time Medications readjusted at time of
renewal verification or medication profile review
Slide 14
14 History McCoy et al Population: adult inpatients with acute
kidney injury Intervention: interruptive alert to modify medication
therapy Conclusion: Increased rate and timeliness of modification
or discontinuation of targeted orders McCoy et al. Am J Kidney Dis
2010. 56:832-41
16 RIFLE Criteria Bellomo et al. Crit Care 2004.
8:R204-212
Slide 17
17 Pilot Testing Change in Serum Creatinine Time Period (hours)
Resulted in a Meaningful Medication Review 50%241/5 (20%) 30%246/15
(40%) 30% (lower limit of 0.8)245/10 (50%) 30% (lower limit of
0.8)7210/15 (67%)
Slide 18
18 Design of Renal Rule Age >= 18 yrs Patient has an active
order for a renally excreted medication Serum creatinine >= 0.8
mg/dL Patient does not have any hemodialysis orders Subsequent
serum creatinine has changed Change in serum creatinine is at least
30% Change has occurred within a 72 hour period Pharmacy Renal
Evaluation order is fired Task fires to the pharmacy task list
Slide 19
Real time testing Have the alert go to your email Review rules
prior to turning them on for the department Review alert fatigue
19
Slide 20
20 Testing/Building Rules Evaluate encounter specificity
Evaluate the medication order type
Slide 21
21 Task List Example
Slide 22
22 Interventions
Slide 23
23 Quality Improvement Data Reported quarterly to Medication
and Nutrition Committee Data for one weeks audit Task fired 49
times 17/49 had medications that needed adjustment
25 Outline Mercy Hospital and Medical Center Overview Renal
Rule Task Weight Change Task Warfarin Counseling Task Senior ED
Task
Slide 26
26 Audience Poll Who has a weight problem?
Slide 27
27 ISMP Best Practice for 2014 Measure and express patient
weights in metric units only. Ensure that scales used for weighing
patients are set and measure only in metric units. Numerous
medication errors have been reported
http://www.ismp.org/tools/bestpractices/TMSBP-for-Hospitals.pdf
Slide 28
28 Importance of a Correct Weight Affects drug dosing Drugs
dosed in mg/kg, mcg/kg/min Drugs dosed based on BMI & BSA
Cockcroft-Gault formula Dietary requirements Monitoring heart
failure patients
Slide 29
29 Documentation Errors Pounds instead of kilograms
Typographical errors (105 cm vs 150 cm) Height & Weight numbers
are transposed Estimated weight is never updated Another patients
weight entered in the system ISMP newsletter. August 2010.
Slide 30
30 Medication Error Example Order: panitumumab IV every 3 weeks
Usual dose: 6 mg/kg every 2 weeks Clinical trial dose: 9 mg/kg
every 3 weeks Height (cm) was entered as the weight and the weight
(kg) was entered as the height Result: the patient received about
650 mg more panitumumab than intended for the first dose of therapy
ISMP newsletter. August 2010.
Slide 31
31 Height & Weight Documentation
Slide 32
32 Documenting Weight Based Drips Clinical Weight automatically
defaults for weight based dosing
Slide 33
33 Height & Weight Documentation The Clinical Weight is
updated by the floor nurse/CNA to match the Measured Weight On the
floor Measured Weight is performed and documented In the ED
Estimated Weight & Clinical Weight documented
Slide 34
34 Medication Safety Committee Review Current Height/Weight
form does not alert the user if there is a weight change from
previous documentation Potential for error exists during
documentation Pharmacy should be notified if there is a significant
weight change
Slide 35
35 Design of Weight Task Rule Clinical Weight documented
Subsequent Measured Weight documented Task fires if there is more
than a 15% change
Slide 36
36 Future Height & Weight Documentation Clinical Weight can
only be updated by pharmacy On the floor Measured Weight is
performed and documented In the ED Estimated Weight & Clinical
Weight documented
Slide 37
37 Pharmacist Clinical Process Task fires Pharmacist
communicates with the RN to reweigh the patient Update clinical
weight Review patient profile Correct dose and/or interval
Slide 38
38 Outcomes of the Weight Task Old incorrect weight: 120 kg New
correct and verified weight: 100 kg Heparin infusion and boluses 80
units/kg bolus (9600 8000 units) 40 units/kg bolus (4800 4000
units) Rate 18 units/kg/hr to 21.6 units/kg/hr (mL/hr remains
unchanged) Enoxaparin 120 mg Q12H to 100 mg Q12H Cefepime 2 gram
Q8H to 2 gram Q12H
Slide 39
39 Monthly Pharmacy Weight Tasks
Slide 40
40 Weight Task Changes Averaging 15 tasks per week Significant
pharmacist time Correction did not occur quickly Alert for RN/CNA
built
Slide 41
41 Alert for nurse and cna
Slide 42
42 Outline Mercy Hospital and Medical Center Overview Renal
Rule Task Weight Change Task Anticoagulation Counseling Task
Anticoagulant Alerts
Slide 43
43 Warfarin Counseling Goals Department goal 50% of inpatients
receive warfarin counseling Assist in documentation National
Hospital Inpatient Quality measures VTE-5: Venous thromboembolism
warfarin therapy discharge instructions Compliance Dietary advice
Follow-up monitoring Potential for adverse drug reactions and
interactions
Slide 44
44 Warfarin Counseling Task Process Warfarin ordered Rule fires
a placeholder pharmacy order Patient on Warfarin Patient on
Warfarin orderable fires a Pharmacy Warfarin Counseling task
Pharmacist charts on the task, the quality measure form is
attached.
Slide 45
45 Quality Measure Documentation
Slide 46
46 Improvement in Patient Counseling % Patients counseled from
Jan 2012-Dec 2013
Slide 47
47 Limitations of the task list Task list is not front &
center for the pharmacis t s Keeping up with the task list
Duplicate tasks
Slide 48
48 Outline Mercy Hospital and Medical Center Overview Renal
Rule Task Weight Change Task Warfarin Counseling Task
Anticoagulation safety
Slide 49
49 Audience Poll Does your EHR alert you when your patient has
received an epidural morphine injection and enoxaparin is
ordered?
Slide 50
50 Black Box Warning WARNING: SPINAL/EPIDURAL HEMATOMA Epidural
or spinal hematomas may occur in patients who are anticoagulated
with low molecular weight heparins (LMWH) or heparinoids and are
receiving neuraxial anesthesia or undergoing spinal puncture. These
hematomas may result in long-term or permanent paralysis. Consider
these risks when scheduling patients for spinal procedures. Factors
that can increase the risk of developing epidural or spinal
hematomas in these patients include: Use of indwelling epidural
catheters Concomitant use of other drugs that affect hemostasis,
such as non- steroidal anti-inflammatory drugs (NSAIDs), platelet
inhibitors, other anticoagulants A history of traumatic or repeated
epidural or spinal punctures A history of spinal deformity or
spinal surgery
Slide 51
Anticoagulants and Spinal Anesthesia Increased risk of spinal
hematoma when used in conjunction with epidural/spinal procedures
Each drug has its own recommendation for timing Timing for when to
administer the anticoagulant and when to administer the medication
with epidural/intrathecal route.
Slide 52
Anticoagulants and Epidurals DrugAnticoagulant on profile
Epidural on profile Heparin IVMay remove catheter 2-4 hrs after
last heparin dose May heparinize 1 hr after neuraxial technique
Clopidogrel/Ticagrelordiscontinue 7 days prior to neuraxial
blockade N/A Direct thrombin inhibitors -Insufficient information:
recommend against the performance of neuraxial techniques (Grade
2C) -Needle placement 8-10 hrs after dose (GSAICM) Delay subsequent
doses 2-4 hrs after needle placement 52
Slide 53
Vanderbilt Clinical Decision Support Alert at procedural time
if there is an existing anticoagulant Warning when initiating an
anticoagulant and patient has an existing epidural Events decreased
from 26 to 11 for a 3 month time frame. Gupta RK et al. Using An
Electronic Clinical Decision Support System to Reduce the Risk of
Epidural Hematoma. Am J Ther. 2012 Oct 19. [Epub ahead of print]Am
J Ther. 53
Slide 54
Anticoagulant-Epidural Alert Need due to lack of notification
in our EHR Improve our generic epidural alert Discussed with
anesthesiologists Guidelines developed Referenced ASRA, GSAICM,
ACCP 2 Alerts built per anticoagulant Prior to catheter
administration After catheter removal 54
Slide 55
Anticoagulant-Epidural Warning 55 after
Slide 56
56
Slide 57
57 VTE-1: Venous Thromboprophylaxis Assesses the number of
patients who received VTE prophylaxis or have documentation why no
VTE prophylaxis was given Patients should receive prophylaxis
within first 2 days of hospital admission
http://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/Downloads/2014_CQM_EH_FinalRule.pdf
Slide 58
VTE Prophylaxis Increase in VTE prophylaxis orders Order sets
Core measures Patients with a therapeutic INR 58
Slide 59
Elevated INR Alert 59
Slide 60
Quality Improvement Data Alert fires from 3-11/month Reported
quarterly to Medication & Nutrition Committee 15/19 (79%)
appropriate interventions Modify alert so an over-ride reason is
required 60 Alerts fired Non-med induced INR elevation Medication
induced INR elevation Pharmacist interventions Bypassed alerts/
missed intervention Oct 31221 Nov 110 83 Dec 51450
Slide 61
Conclusions An interruputive renal task is beneficial to
clinical pharmacy services Correction of weight documentation
errors can prevent dosing errors Anticoagulation safety can be
improved with specific drug- drug and drug-lab alerts 61
Slide 62
Review Questions A combination of rules and a task list can
help improve a pharmacys renal dosing program. True or False TRUE
62
Slide 63
Review Questions Which of the following can cause weight
documentation errors? a. Documenting in pounds vs kg b.
Typographical errors c. Another patients weight documented d.
Height and Weight transposed e. Estimated weight is never updated
f. All of the above ALL OF THE ABOVE 63
Slide 64
Review Questions There is an increased risk of spinal bleeding
when some anticoagulants are administered to patients that have
received an epidural/intrathecal medication. TRUE OR FALSE TRUE
64