Best Practices for Adopting a Medication Use Policy ... · PDF fileBest Practices for Adopting a ... Medication safety Operating room Pain management Etc., etc., ... • Narcotic Analgesics

© Copyright Visante, Inc. All rights reserved | www.visanteinc.com

Best Practices for Adopting a Medication Use Policy Through a System-Wide P&T Committee Part 2: Medication Use Policy

March 2017

© Copyright Visante, Inc. All rights reserved | www.visanteinc.com 2

Objectives

•  Describe the role of a system Pharmacy and Therapeutics Committee as a foundation for system medication use policy

•  Identify the evolution of medication use policy following implementation/establishment of a system formulary

•  Provide examples of initiatives in medication use policy and within other specialties outside of the pharmacy realm


Rationale for System P&T/Formulary/Medication Use Policy

Standardization

Information Technology

Economic Drivers

Optimizing Medication Use


System Med Use Policy Rationale- Standardization

•  Approach quality measures and safety initiatives from broader perspective

•  Identify best practices to meet regulatory standards and system goals

•  Learn from successes at one institution and apply to the remainder

•  Examples: -  glycemic variability –  VTE risk assessment –  smart pump alert analysis –  emergency department protocols –  antimicrobial surgical prophylaxis

Improved Quality and Safety


System Med Use Policy Rationale - IT

•  Centralized file build, file maintenance, trouble shooting and clinical decision support developed and maintained by centralized IT staff

•  Minimize duplicate builds/work by supporting System P&T-approved initiatives –  Order sets, guidelines, interchanges, protocols, formulary products

•  Report standardization and analysis –  BCMA compliance –  drug-drug interaction alerts –  alert monitoring (actions taken, fatigue, etc.)

Decrease duplicative work


System Med Use Policy Rationale - Economic

•  Standardized formulary and med management initiatives to meet contract requirements to achieve maximum savings

–  IDN contracts –  increased buying power for automation

•  Staff Allocation: centralize multiple processes to reduce duplicative work

•  Facilitates patient transfers and cross coverage

Save Money, Improve Efficiency


Essential Components

•  System P&T Committee and Formulary •  System Subcommittees/Work Groups

•  Challenges: –  Too many groups! –  How to ensure participation from ALL sites?? –  Piloting initiatives at one site

System Medication Use Policy

Example Subcommittees Example Work Groups Anti-microbial Emergency care Anti-coagulation Immunization Glycemic management Radiology Medication safety Operating room Pain management Etc., etc., etc.!!


Multi-Phase Implementation

•  First Phase: Pharmacy-controlled –  Compounding (standard concentrations; BUD; light protection; do not

tube) –  Dosing protocols (anticoagulation, aminoglycosides, IV to PO, renal

dosage adjustment) –  Delivery systems (IV workflow, ADCs)

•  Second Phase: Multi-disciplinary –  Medication use guidelines/treatment algorithms –  Electronic order sets –  Clinical decision support –  Safety guidelines (LASA; REMS support; high alert strategies; fall risk

assessment) –  Delivery systems (smart pumps, ADCs)


Polling Question


Example: Anticoagulation Dosing

•  Anticoagulation subcommittee (or group of pharmacist subject matter experts and physician champions)

•  Find commonalities among existing protocols

•  Develop consensus guideline/treatment algorithms

•  Define approach: pharmacists manage only patients receiving therapeutic anticoagulants versus ALL patients on all anticoagulants

•  Agree on minimal acceptable standard



Example: Anticoagulation Dosing

•  Site departmental/subcommittee approvals

•  System P&T approval

•  Publish guidelines/consensus

•  Education and training (standardized)

•  Identify standardized system competencies

•  Monitor standardized, pre-determined outcomes

•  Wash, rinse, repeat



Example of Site System QI/MUE Report

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

A

B

C

D

E

System

Adherence to System Dosing Guidelines - IV Heparin

3rd qtr 2nd qtr 1st qtr

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

A

C

E

Adherence to System Dosing Guidelines - Enoxaparin

3rd qtr 2nd qtr 1st qtr


Example of Site System QI/MUE Report

0% 20% 40% 60% 80% 100%

A

B

C

D

E

System

Rate of Compliance

Completion of Warfarin Counseling

3rd Qtr. 2nd Qtr. 1st Qtr.

0% 1% 2% 3% 4% 5%

A B C D E

System

Incidence of Major Bleeding with Heparin & Warfarin only

3rd qtr. 2nd qtr. 1st qtr.


VTE Risk Assessment


Action Pane (within INITIAL assessment page)

Display active VTE prophylaxis treatments

Auto-calculation of total score

Display reference text and the RISK level

Actionable Items:

Place VTE Prophylaxis Power Plan

Document that patient currently has VTE Prophylaxis ordered

Document that VTE prophylaxis not appropriate

Documentation of Contraindications

Allows for Free-text entry

If Physician disagrees with score, or wishes to add or modify documentation, they can click on headers for each section, which will take them to the areas in the patient’s chart.

Clicking on Submit button commits all the documentation on form into the EMR


Example: Contrast-Induced Nephropathy

•  Identified as a concern

•  Lack of specific subcommittee

•  Small group of pharmacists + radiologists + system chief for radiology

•  Develop consensus guideline/treatment algorithms

•  P&T approval/Site-System Radiology buy-in

•  Publish standards/education

•  Engage CPOE system/IT technology



All radiology orderables with contrast will be converted to an order set. This set will now contain the radiology orderable as well as the “Contrast Induced Nephropathy Interventional” order set. This order set was added so that it would be more efficient and more likely to have appropriate interventional therapy ordered.


If the prescriber determines that the patient is at risk for a contrast induced nephropathy (CIN) and/or has a history of allergy based on the factors listed, they can choose to open the CIN order set and place additional orders.


Other (Potential) System Programs

•  Quality Improvement –  System quality improvement initiatives –  Medication Use Evaluation

•  Device/Supply Acquisition

•  Nursing-Pharmacy

•  Technology Assessment/Implementation •  Medication Safety

Advantage – Using System P&T as Template


System Medication Safety

•  System-wide medication safety program utilizing identical structure as system P&T (dual reporting relationship to System P&T and System Quality Council)

•  System approach –  Data aggregation/trending –  Safeguards within the electronic health record –  Review/response to medication safety alerts (e.g., FDA, ISMP) and TJC

NPSGs

•  Site approach –  Review of all site MVs/ADRs/implementation of select initiatives –  Identification of site specific issue -> evaluation of other sites –  Specific med safety committee v. site nursing/pharm committee



System Medication Safety

•  Review of monthly medication errors of high severity –  site representative required to know case/follow-up → discussion whether

“one off” versus potential system/process error → applicable to other sites → monitor → decision if system intervention needed

•  Examination of FDA, ISMP alerts –  applicability to system/sites → intervention, if needed

•  Annual review (staggered) of regulatory requirements –  LASA medications; Tallman lettering; high alert medications




Drugs Commonly Associated with Falls

Joint initiative between system medication safety and system patient safety committees with final approval by P&T and nursing leadership


DRUGS YOU MAY EXPECT….. •  Benzodiazepines (alprazolam, lorazepam) •  Antidepressants (fluoxetine, venlafaxine, amitriptyline) •  Anticonvulsants (pregabalin, tiagabine) •  Sleep Aids (zolpidem, diphenhydramine) •  Narcotic Analgesics (morphine, codeine, propoxyphene) •  Muscle Relaxants (baclofen, cyclobenzaprine)

DRUGS YOU MAY NOT EXPECT….. •  Antiarrthymics (procainamide, disopyramide, quinidine) •  Digoxin •  Diuretics (hydrochlorothiazide, furosemide) •  ACE Inhibitors (lisinopril, captopril) •  Nitrates

***LOOK FOR THE YELLOW WRIST BAND***


List of medications and dates here


System Infection Prevention

•  System-wide infection prevention team utilizing same structure as P&T

•  System approach –  Data aggregation/epidemiological trending –  Safeguards within the electronic health record –  Review/response to infection prevention national initiatives –  Regulatory readiness

•  Site approach –  Site infection prevention teams responsible for implementation of

select system initiatives and site-determined needs –  Identification of site specific issue -> evaluation of other sites



Intended Use Patient Age Product

INPATIENT USE

Flu vaccine Protocol Product >36 months Fluzone QIV 0.5 ml vial, syringe, MDV

6 – 35 months Fluzone QIV 0.25 ml syringe

High dose - per MD or employee request

>65 years Fluzone TIV High Dose 0.5 ml syringe

OUTPATIENT USE (EMPLOYEE HEALTH, OP CLINICS)

Intradermal – per pt request 18 – 64 years Fluzone QIV 0.1 ml intradermal

Patient with egg allergy >4 years Flucelvax QIV 0.5 ml syringe

TIV – site requested option >4 years Fluvirin TIV MDV

Example: Influenza Vaccination Protocol

•  Standardized flu vaccine formulary products and prescribing for inpatients, OP clinics and employees −  Collaboration with pharmacy, infection control, employee health and supply

chain

•  Implemented flu vaccine nursing protocol for inpatient use •  Flu vaccine product formulary:




Patient Location

Medical Record #

Patient Name

Task Status

Date/Time Mnemonic Order Details

XSS42 12345689 Test, One Complete Completed 3/1/2017 09:00 EST

Influenza Vaccination Risk Assessment

3/1/2017 04:49:29 EST Order entered secondary to patient admission

XSS18 12457888 Test, Two Pending Scheduled 3/1/2017 11:40 EST

Influenza Vaccination Risk Assessment

3/1/2017 11:40:14 EST Order entered secondary to patient admission



Example: System Pharmacy Policies

•  Facilities will adopt system policy and delete hospital-specific policy

•  Implementation questions: –  System policy cover page

!  IU Health logo and facility logo !  Site specific signatures !  Site specific approval dates

–  System policy signature page !  Chair of SPTC !  System Pharmacy Vice President/Chief Pharmacy Officer !  System committee approval dates



System Medication Management Initiatives

•  Purpose: This policy outlines the types of system medication management initiatives that may be developed

•  System initiatives types: –  Guidelines –  Interchanges –  Medication protocols –  Pharmacy protocols –  Restrictions

•  Outlines procedures for each initiative type: –  Purpose –  Approval –  Notification to prescriber –  Prescriber responsibilities –  Pharmacist responsibilities

System Pharmacy Policy


Lessons Learned System Medication Use Policy

•  Standardizing practice across system

•  Long turnaround time for review/implementation − Site → Subcommittee→System→Implementation

•  Complexity of implementation at multiple facilities –  FTE mix / varying processes / equipment –  Electronic health record/CPOE system

•  Order set review and build processes (rogue hospitals “bootlegging” order sets)

•  Lack of support for system by hospital leadership


Challenges / Barriers System Medication Use Policy

•  Trust/Engagement •  Time/compensation for prescriber involvement •  “Who” is the expert??? •  Sense (real or perceived) that certain sites dominate •  How do you balance efficiency at getting the work done

with making sure that everyone has a voice and is involved in the decisions?

•  Once you establish the system P&T, what is the role of the site P&T Committees? –  Are quality and safety issues (error reports, ADRs, quality

improvement initiatives) addressed at a system level, the site level, or both?

•  “Town vs Gown”

© Copyright Visante, Inc. All rights reserved | www.visanteinc.com

Questions/Discussion

Visante

Documents

Best Practices for Adopting a Medication Use Policy ... · PDF fileBest Practices for Adopting a ... Medication safety Operating room Pain management Etc., etc., ... • Narcotic Analgesics