rishp showcase 2015 c. maxwell m. kelley minimizing polypharmacy: addressing therapeutic...
DESCRIPTION
Objectives Pharmacist Objectives: Describe the process of guideline/order set development for PRN indications of anxiety, agitation, psychoses, nausea/vomiting and constipation in a specialized psychiatric hospital and community hospitals. Explain how use of PRN reasons defined by a guideline/order set facilitates compliance with Joint Commission standards and regulations. Choose the appropriate PRN reason for psychiatric symptoms utilizing the provided guideline.TRANSCRIPT
RISHP SHOWCASE 2015C. MAXWELLM. KELLEY
Minimizing Polypharmacy: Addressing Therapeutic
Duplications
Objectives
Technician Objectives: Understand when therapeutic duplications occur in
the ordering of PRN medications. Provide an example of a therapeutic duplication. Understand how guidelines can be developed to
categorize severity of common psychiatric PRN indications for medications to avoid therapeutic duplications.
Objectives
Pharmacist Objectives: Describe the process of guideline/order set
development for PRN indications of anxiety, agitation, psychoses, nausea/vomiting and constipation in a specialized psychiatric hospital and community hospitals.
Explain how use of PRN reasons defined by a guideline/order set facilitates compliance with Joint Commission standards and regulations.
Choose the appropriate PRN reason for psychiatric symptoms utilizing the provided guideline.
Therapeutic Duplication occurs when:
More than 1 med is ordered for a single indication
The level, degree, or the severity for the indication is not specified
There is not hospital policy or guideline to guide nursing staff on when a med is to be administered
Corrective Action Steps
Clarify some definitions of specific PRN Reasons in Power Plans
Revise the default PRN Reasons for some PRN orders in Power Plans
Create Hospital Guidelines that define the Degree of Severity of some common psychiatric symptoms
Guidelines for Psychiatric PRN Reasons
Guidelines are developed to categorize some common symptoms for which PRN meds are indicated
Anxiety and Severe AnxietyAgitation and Severe AgitationPsychosis and Severe Psychosis
ANXIETY SEVERE ANXIETY
Anxious, apprehensive, movements not aggressive
Physical distress, or feelings of panic
Nausea or abdominal distress
Mild trembling or shakingFeeling tense or “wound
up”Restlessness
Physical distress leading to impairment of ADL Inability to sit still or sleep Marked trembling or shaking Fear of losing control Fear of dying Feelings of panic with somatic complaints
(sweating, shortness of breath, hyperventilation, chest pain, palpitations, tachycardia,)
Paresthesia (numbness or tingling sensations) Feeling dizzy, unsteady, light-headed or faint Physical distress leading to impairment of ADL Inability to sit still or sleep Marked trembling or shaking Fear of losing control Fear of dying Feelings of panic with somatic complaints
(sweating, shortness of breath, hyperventilation, chest pain, palpitations, tachycardia,)
PRN Guideline: Anxiety
AGITATION SEVERE AGITATION
Impulsive, impatient, low tolerance for pain or frustration
Uncooperative, resistant to care, demanding
Rocking, rubbing, moaning or other self- stimulating behavior
Restlessness, pacing, excessive movement
Rapid, loud or excessive talking
Sudden changes of mood
Violent, combative and/ or threatening violence toward people or property
Explosive and/ or unpredictable anger Self- abusiveness, physical and/or verbal
Immediate danger to self or others
PRN Guideline: Agitation
PSYCHOSIS SEVERE PSYCHOSIS
Auditory or Visual Hallucinations
Delusions Paranoid Thoughts
Auditory or Visual Hallucinations with threats of harm to self or others
Delusions with threats of harm to self or others
Paranoid Thoughts with threats of harm to self or others
PRN Guideline: Psychosis
Oral IM
Anxiety – Benzodiazepines, Antihistamines
Agitation - Antipsychotics
Severe Anxiety – Benzodiazepines, Antihistamines
Severe Agitation - Antipsychotics
Default PRN Reasons in Power Plans
PRN Guidelines: Nausea/Vomiting
Order of use defined in the PowerPlans Ondansetron: Use first for N/V Promethazine: Use for N/V refractory to ondansetron Metoclopramide: Use for N/V refractory to
ondansetron and promethazine
PRN Guidelines: Constipation
Order of use defined in the PowerPlans Colace: PRN reason for stool softening
All laxatives below given with colace Senna: Use first for constipation MOM: Use if patient still constipated 24 hours after
Senna Bisacodyl PO/PR: Use if patient still constipated 12
hours after MOM If both PO/PR ordered, use least invasive route first
Miralax: Use if patient is still constipated after 48hours from initial laxative dose
Therapeutic Duplications: Next Steps
Therapeutic Duplication Policy Define order of preference for medications by indication Set criteria for IV or PO options Allow pharmacists to clarify orders per “policy/protocol”
Pharmacist responsibility at time of verification
Continual monitoring Regular audits of duplicates and corrective steps
Summary
TJC and DOH are focused on Therapeutic Duplications
Most commonly found duplicate orders: Pain Agitation/anxiety Nausea/vomiting Constipation
Creation of PowerOrders and a policy Minimize prescribing of duplications Provide clarification when duplications exist
Goal is to minimize patient harm, adverse drug events and unclear orders