Project Kickoff

Sonali Muzumdar Pharm.D., CPHIMSInformatics PharmacistMercy Hospital and Medical CenterComprehensive Pharmacy ServicesLeveraging Rules and Alerts to Improve Patient Safety and Clinical Pharmacy Services#1Describe a method to assist pharmacist identification of changing renal function over time for patients on renally adjusted medicationsIdentify a method to improve patient safety by preventing medication errors associated with documented weight changesList pharmacy clinical services that can be improved by use of rules and alerts

Objectives#2Audience PollHow many sites have CPOE?33Mercy Hospital & Medical CenterChicago, Illinois

#4Mercy OverviewHistory and MissionMAPS TimelineApplicationsHealthcare Information Management & Systems SocietyStage 6 Hospital RecognitionThe Leapfrog Group #479 Licensed Beds286 Staffed Beds16,353 Annual Inpatients14 Offsite locations252,630 Outpatient Visits56,172 ED Visits1,503 FTEs100 Interns and ResidentsQuick FactsEHR Applications (Cernerize)PowerChartE-prescribePower NotePowerPlansPowerOrdersCareNetSurgiNet / AnesthesiaRadNetProVision WebI-NetNHIQM Dashboard

PharmNetFirstNetAPACHECareAwareCareMobileDiscern Expert/ExplorerBMDI/Open PortCPOEProFile - HIMForeign System InterfacesKnowledge CatalogM Pages

#Pharmacy Team15 Clinical Pharmacists6 Clinical Specialists2 Internal Medicine2 Emergency Medicine1 Ambulatory Care1 Critical Care2 Pharmacy Practice Residents1 Informatics Pharmacist (0.6 FTE)DOP, ADOP, Clinical Manager20 FTE pharmacy technicians#8Pharmacy Clinical ServicesRenal dosingAutomatic IV-PO conversionAnticoagulation management servicePharmacokinetic monitoringInhaler trainingAnticoagulant counselingMedication profile review#9JCAHO RecommendationsSafety 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#10JCAHO RecommendationsAfter 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

#11OutlineMercy Hospital and Medical Center OverviewRenal Rule Weight Change Anticoagulant Counseling Anticoagulant alerts#12Renal Dosing Gap Identified#13HistoryMcCoy et al Population: adult inpatients with acute kidney injuryIntervention: interruptive alert to modify medication therapyConclusion: Increased rate and timeliness of modification or discontinuation of targeted orders

McCoy et al. Am J Kidney Dis 2010. 56:832-41#14Renally Adjusted MedicationsAcyclovir, ValacyclovirAlendronateAllopurinolAmphoteracinBeta-lactamsBivalirudinCiprofloxacin, LevofloxacinColchicineColistinDabigatranEnoxaparin, FondaparinuxFamciclovir, GanciclovirFamotidine, RanitidineFluconazole, VoriconazoleHydroxyurea

KetorolacLevetiracetamLithiumMemantineMetforminMethylnaltrexoneNRTIsOprelvekinQuinidineRifabutinSotalolSpironolactoneTetracyclineSMX-TMPZoledronic acid

#15RIFLE CriteriaBellomo et al. Crit Care 2004. 8:R204-212

#.16Pilot TestingChange in Serum CreatinineTime Period (hours)Resulted in a Meaningful Medication Review50%24 1/5 (20%)30%246/15 (40%)30% (lower limit of 0.8)245/10 (50%)30% (lower limit of 0.8)7210/15 (67%)#17Design of Renal Rule#18Real time testingHave the alert go to your email Review rules prior to turning them on for the departmentReview alert fatigue1919Testing/Building RulesEvaluate encounter specificityEvaluate the medication order type

#20Task List Example

#21Interventions#22Quality Improvement DataReported quarterly to Medication and Nutrition CommitteeData for one weeks auditTask fired 49 times17/49 had medications that needed adjustment

#23Ongoing Changes Utilize Cockcroft-Gault Creatinine Clearance (CrCl) Medication specific CrCl cutoffs#24OutlineMercy Hospital and Medical Center OverviewRenal Rule TaskWeight Change TaskWarfarin Counseling TaskSenior ED Task

#25Audience PollWho has a weight problem? #26ISMP Best Practice for 2014Measure 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#27Importance of a Correct WeightAffects drug dosingDrugs dosed in mg/kg, mcg/kg/min Drugs dosed based on BMI & BSACockcroft-Gault formula Dietary requirementsMonitoring heart failure patients#28Documentation ErrorsPounds instead of kilogramsTypographical errors (105 cm vs 150 cm)Height & Weight numbers are transposedEstimated weight is never updatedAnother patients weight entered in the system

ISMP newsletter. August 2010.#29Medication Error ExampleOrder: panitumumab IV every 3 weeksUsual dose: 6 mg/kg every 2 weeksClinical trial dose: 9 mg/kg every 3 weeksHeight (cm) was entered as the weight and the weight (kg) was entered as the heightResult: the patient received about 650 mg more panitumumab than intended for the first dose of therapyISMP newsletter. August 2010.#30Height & Weight Documentation

#31Documenting Weight Based Drips

Clinical Weight automatically defaults for weight based dosing#32Height & Weight Documentation#33Medication Safety Committee ReviewCurrent Height/Weight form does not alert the user if there is a weight change from previous documentationPotential for error exists during documentationPharmacy should be notified if there is a significant weight change

#34Design of Weight Task Rule#35Future Height & Weight Documentation#36Pharmacist Clinical ProcessTask firesPharmacist communicates with the RN to reweigh the patientUpdate clinical weightReview patient profileCorrect dose and/or interval#37Outcomes of the Weight TaskOld incorrect weight: 120 kgNew correct and verified weight: 100 kgHeparin infusion and boluses80 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)Enoxaparin120 mg Q12H to 100 mg Q12HCefepime2 gram Q8H to 2 gram Q12H

#38Monthly Pharmacy Weight Tasks#39Weight Task ChangesAveraging 15 tasks per weekSignificant pharmacist timeCorrection did not occur quicklyAlert for RN/CNA built#40Alert for nurse and cna

#41OutlineMercy Hospital and Medical Center OverviewRenal Rule TaskWeight Change TaskAnticoagulation Counseling TaskAnticoagulant Alerts

#42Warfarin Counseling GoalsDepartment goal50% of inpatients receive warfarin counselingAssist in documentationNational Hospital Inpatient Quality measuresVTE-5: Venous thromboembolism warfarin therapy discharge instructionsComplianceDietary adviceFollow-up monitoringPotential for adverse drug reactions and interactions#43Warfarin Counseling Task Process#44

Quality Measure Documentation

#45Improvement in Patient Counseling% Patients counseled from Jan 2012-Dec 2013#46Limitations of the task listTask list is not front & center for the pharmacistsKeeping up with the task listDuplicate tasks

#47OutlineMercy Hospital and Medical Center OverviewRenal Rule TaskWeight Change TaskWarfarin Counseling TaskAnticoagulation safety

#48Audience PollDoes your EHR alert you when your patient has received an epidural morphine injection and enoxaparin is ordered?#49Black Box WarningWARNING: SPINAL/EPIDURAL HEMATOMAEpidural 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

#50Anticoagulants and Spinal AnesthesiaIncreased 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.

51Anticoagulants and EpiduralsDrugAnticoagulant on profileEpidural on profileHeparin IVMay remove catheter 2-4 hrs after last heparin dose

May heparinize 1 hr after neuraxial techniqueClopidogrel/Ticagrelordiscontinue 7 days prior to neuraxial blockade N/ADirect 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 5252Vanderbilt Clinical Decision SupportAlert 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]5353Anticoagulant-Epidural AlertNeed due to lack of notification in our EHRImprove our generic epidural alertDiscussed with anesthesiologistsGuidelines developedReferenced ASRA, GSAICM, ACCP2 Alerts built per anticoagulantPrior to catheter administrationAfter catheter removal

54.54Anticoagulant-Epidural Warning55

afterafter55

#.56VTE-1: Venous ThromboprophylaxisAssesses 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#57VTE ProphylaxisIncrease in VTE prophylaxis ordersOrder setsCore measures

Patients with a therapeutic INR5858Elevated INR Alert59

59Quality Improvement DataAlert fires from 3-11/monthReported quarterly to Medication & Nutrition Committee15/19 (79%) appropriate interventionsModify alert so an over-ride reason is required

60 Alertsfired Non-med induced INR elevationMedication induced INR elevationPharmacistinterventions Bypassed alerts/ missed interventionOct31221Nov1101183Dec5145060ConclusionsAn interruputive renal task is beneficial to clinical pharmacy servicesCorrection of weight documentation errors can prevent dosing errorsAnticoagulation safety can be improved with specific drug-drug and drug-lab alerts

6161Review QuestionsA combination of rules and a task list can help improve a pharmacys renal dosing program.

True or False

TRUE6262Review QuestionsWhich 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 ABOVE6363Review QuestionsThere is an increased risk of spinal bleeding when some anticoagulants are administered to patients that have received an epidural/intrathecal medication.TRUE OR FALSE

TRUE6464