Consultant Pharmacist Report

Transcription

1 Consultant Pharmacist Report Reported in compliance with F-tag 429. Action requested per F-tag 430 **THIS REPORT IS TO BE USED FOR QUALITY IMPROVEMENT PURPOSES ONLY** Patient Name: BOWEN, T Room: A008A Wing: A **CMS-F329: IRON SUPPLEMENTS- DURATION Appropriate Duration RE: CMS-F329: IRON SUPPLEMENTS- DURATION The recommended duration for Iron therapy is 2 mos (per CMS guidelines). The last CBC charted is from 4/6/2009. Please consider checking a CBC and evaluating the need for the supplement based on the results. Patient Name: CHILDRESS, M Room: A016A Wing: A Lab Reminder General RE: LAB REMINDER Please consider checking a Dilantin/ Phenytoin level. (Last done 1/23/2009) Patient Name: KENNEDY, MARY Room: A001B Wing: A **CMS-F329: DUPLICATE ANTIDEPRESSANT DRUGS- SEPARATE INDICATIONS Drug Duplication Ms. Kennedy has trazodone 50mg qhs prescribed for insomnia and mirtazapine 15mg qhs for anorexia. Since mirtazapine is used for both conditions, could the trazodone be discontinued or changed to qhs prn insomnia? Patient Name: SINGER, IMA Room: A008B Wing: A **CMS-F329: ANTIPSYCHOTIC GRADUAL DOSE REDUCTION RE: CMS-F329: ANTIPSYCHOTIC GRADUAL DOSE REDUCTION Ms. Singer is due for an antipsychotic evaluation. Please consider the following trial dose reduction if felt possible: Risperdal 0.25mg qd prn agitation Antipsychotic Drug Evaluation Saturday, May 10, 2014 Page 1 of 10

2 Patient Name: STEWART, BJ Room: A003B Wing: A **CMS-F329: ANTIPSYCHOTIC GRADUAL DOSE REDUCTION RE: CMS-F329: ANTIPSYCHOTIC GRADUAL DOSE REDUCTION- (SEROQUEL 37.5MG QHS) Mr. Stewart is due for an antipsychotic evaluation. Please consider the following trial dose reduction: SEROQUEL 25MG QHS Antipsychotic Drug Evaluation Patient Name: WOODWARD, BOBBIE Room: A001A Wing: A No Indication/ Diagnosis Supporting Drug Use Appropriate Diagnosis RE: ARICEPT 10MG QHS Please add the supporting indication. If this medication is no longer needed, please consider discontinuation to reduce poly-pharmacy. (Assumed use is Vascular Dementia (?)) Patient Name: BURDETTE, M Room: B016B Wing: B **CMS-F329: ANTIDEPRESSANT (TCA) USE IN THE ELDERLY (EXCEPTIONS)- 1. Mr. Burdette is currently receiving Doxepin 10mg qhs. (Also receiving Citalopram for depression) He has a history of constipation and cardiac arrythmia that may affected by the tricyclic antidepressant. If used for insomnia, please consider trazodone or mirtazapine. If used for neuropathic pain, please consider Cymbalta (and d/c citalopram), which is indicated for PN and depression. 2. Please consider checking a baseline BMP. Indication or Diagnosis Saturday, May 10, 2014 Page 2 of 10

3 Patient Name: CULLIFER, E Room: B007A Wing: B **CMS-F329: DUPLICATE ANTIDEPRESSANT DRUGS Drug Duplication RE: CMS-F329: DUPLICATE ANTIDEPRESSANT DRUGS (BUPROPRION 150 BID, EFFEXOR XR 150 QD) Use of two or more antidepressants simultaneously may increase the risk of side effects, and require additional documentation concerning the rationale under CMS F-329. Please address the following: (Please check the appropriate response) [ ] Duplicate agents are being used due to differing mechanisms of action that result in augmentation in managing symptoms of depression. Usage is based on clinical experience or medical literature and the risk vs benefit has been considered [ ] Duplicate agents with similar mechanisms are being used in an attempt to use lower dosages of each individual agent. Usage is based on clinical experience or medical literature and the risk vs benefit has been considered [ ] Duplicate agents are being used for different indications. (please specify below) [ ] Other rationale (Please describe below) Patient Name: ERVIN, J Room: B006A Wing: B General Lab Recommendation Drug Monitoring Please consider checking the following lab(s): BMP (Potassium was 3.4 on 6/1/09) Patient Name: HALL, Q Room: B017B Wing: B Neurontin (Gabapentin) Indication Appropriate Diagnosis RE: NEURONTIN (GABAPENTIN) 300 MG QHS Ms. Hall has diabetes and chronic pain, so I assume the indication for this med is diabetic neuropathy. Just as a clarification, please check below. FDA Approved Uses Partial Seizures, [ ] Post-herptic neuralgia, [ ] Non-FDA-Approved Uses [ ] ALS, [ ] Bipolar,[ ] Diabetic Neuropathy, [ ] Multiple Sclerosis, [ ] Neuropathic Pain, [ ] spascity, [ ] tremor, [ ] mood disorders, and [ ] attenuation of disruptive behaviors in dementia. (If this medication is felt to be unnecessary at this time, please consider discontinuation) Saturday, May 10, 2014 Page 3 of 10

4 Patient Name: HANSARD, K Room: B011A Wing: B **CMS-F329: ANTIDEPRESSANT USED FOR BEHAVIOR Gradual Dose Reduction (Other) RE: TRAZODONE 50MG QHS Ms. Hansard also receives Mirtazapine 15mg qhs for sleep and appetite. Would it be possible to attempt a trial reduction with the Trazodone to 25mg qhs? Patient Name: HANSARD, P Room: B011B Wing: B **CMS-F329: GI MEDICATIONS- METOCLOPRAMIDE USE CLARIFICATION Indication or Diagnosis RE: CMS-F329: GASTROINTESTINAL MEDICATIONS- METOCLOPRAMIDE This medication is Not recommended for first-line treatment of certain GI disorders in older individuals given the potential for EPS. He is also receiving Nexium 40mg qd. Is this medicaiton needed long-term? Note: When used for gastroparesis the relative benefits and risks should be assessed and documented. Patient Name: LAZENBY, H Room: B013A Wing: B CBC needed with Iron (Fe++) Therapy Drug Monitoring The regulations now require that Iron use be assessed every two months (CMS recommended duration for iron preparations). In general, I look at Hgb values every 3 months. The last CBC was 4/7/09. Please check a CBC if possible to justify continued use. Patient Name: MARTIN, IMOGENE Room: B014A Wing: B General Lab Recommendation Drug Monitoring Please consider checking the following lab(s): Lipid Profile (Lipitor) CMP (LFTS- Lipitor, Furosemide) HBA1c Saturday, May 10, 2014 Page 4 of 10

5 Patient Name: SPECHT, D Room: B009B Wing: B Diagnosis (Dx)/ Indication Clarification Appropriate Diagnosis RE: SUPPORTING INDICATION CLARIFICATION Please clarify the reason for use of the following: ALLOPURINOL 100MG QD (Assumed h/o gout/ increased uric acid) Thanks Patient Name: CROWN, H Room: C013B Wing: C Antipsychotic use in dementia-behavior identification/ monitoring As part of the CMS regulations associated with antipsychotic use in Dementing Illness with behavioral problems, behavioral specific behavioral patterns should be identified. Please check all that apply for use of Zyprexa 5mg q evening: [ ] Delusional behavior, [ ] Audio/ Visual Hallucinations, [ ] Paranoia OR Agitated Behavior (check types below) Antipsychotic Behavior Monitoring [ ] Biting, [ ] Making faces, [ ] Complaining, [ ] Making physical sexual advances, [ ] Constant requests for attention or help, [ ] Making verbal sexual advances, [ ] Cursing or verbal aggression, [ ] Negativism, Eating/ drinking inappropriate substances, [ ] Pacing or aimless wandering, [ ] General [ ] restlessness, [ ] Repetitive mannerisms, [ ] Grabbing on to people, [ ] Pushing, [ ] Handling things inapprorpriately, [ ] Repetitive sentences/ questions, [ ] Hiding things, [ ] Scratching, [ ] Hitting (including self), [ ] Screaming, [ ] Hoarding, [ ] Spitting (including meals), [ ] Hurting self or others, [ ] Strange movements, [ ] Inappropriate disrobing, [ ] Weird laughter or crying, [ ] Intentional falling, [ ] Destroying property, [ ] Kicking, or [ ] Constantly trying to get to a different place. Patient Name: HARRISON, K Room: C014A Wing: C Lab Reminder General RE: LAB REMINDER Please consider checking a BMP following the increased lasix dose on and return to 60mg qd. Saturday, May 10, 2014 Page 5 of 10

6 Patient Name: KING, N Room: C006A Wing: C Lab Reminder General RE: LAB REMINDER Please consider checking a CBC to monitor for potential GI blood loss. (receiving prednisone and warfarin) Patient Name: PAONESSA, SYLVIA Room: C009A Wing: C **CMS-F329: ANTIDEPRESSANT INDICATION CLARIFICATION Indication or Diagnosis RE: CMS-F329: ANTIDEPRESSANT INDICATION CLARIFICATION Sertraline 25mg qd- Trazodone 50mg qhs- (has history of somnolence) Patient Name: REED, M Room: C004B Wing: C Diagnosis (Dx)/ Indication Clarification Appropriate Diagnosis RE: SUPPORTING INDICATION CLARIFICATION Please clarify the reason for use of the following: PATANOL 0.1% SOLN- 1 GTT OU BID. (Ordered ) Thanks Patient Name: ROCKEY, B Room: C012B Wing: C LMWH Duration- Condensed Appropriate Duration RE: LOVENOX 40MG SC QD It appears that this med was started per the hospital records. The package insert recommends 12 days for DVT/PE prophylaxis (14 days is commonly ordered) Please consider adding an anticipated stop date or bridge to warfarin if needed. Saturday, May 10, 2014 Page 6 of 10

7 Patient Name: BERRY, P Room: D010 Wing: D **CMS-F329: ANTIPSYCHOTIC GRADUAL DOSE REDUCTION RE: CMS-F329: ANTIPSYCHOTIC GRADUAL DOSE REDUCTION- SEROQUEL 37.5MG AT 10A, 2PM AND 200MG QHS. Ms. Berry is due for an antipsychotic evaluation. Please consider the following trial dose reduction: SEROQUEL 37.5MG AT 10A, 2PM AND 100MG QHS Antipsychotic Drug Evaluation Patient Name: BRAND, NAME Room: D005 Wing: D **CMS-F329: ANXIOLYTICS- GRADUAL DOSE REDUCTION RE: CMS-F329: ANXIOLYTICS- GRADUAL DOSE REDUCTION - Clonazepam 0.5mg qhs Ms. Brand is due for an anxiolytic drug evaluation per CMS guidelines pertaining to use in elderly Please consider a trial reduction to Clonazepam 0.5mg tabs- 1/2t (0.25mg) qhs Anxiolytic Intervention Patient Name: BRODNAX, MILDRED Room: D019 Wing: D LMWH Duration- Condensed Appropriate Duration RE: FRAGMIN 2500MG Q8PM Fragmin is usually used short-term (post surgery) and is very expensive. Please add the supporting indication if it is continued. If possible, and continued anticoagulation is needed, please bridge to warfarin. Saturday, May 10, 2014 Page 7 of 10

8 Patient Name: EDWARDS, ROBERT Room: D015 Wing: D MISC. DUPLICATION IN THERAPY Drug Duplication There is currently an order for Nexium 40mg capsules qd and Nexium 40mg packet qd. Which is the active order. Also, please add the supporting indication. Patient Name: GOLD, NORMA Room: D009 Wing: D Diagnosis Needed- PPI Appropriate Diagnosis RE: PRILOSEC 40MG QD Please circle the indication supporting continued proton pump inhibitor use. Thanks. [ ] Duodenal ulcer [ ] Esophagitis [ ] Gastric ulcer [ ] GERD [ ] Helicobacter pylori [ ] NSAID-induced ulcer prophylaxis [ ] Pyrosis/ heartburn [ ] Zollinger-Ellison syndrome If the therapy is no longer indicated, please consider discontinuation to reduce polypharmacy. Patient Name: LEACH, IMA Room: D004 Wing: D General Information General Ms. Leach has an order for Ferrous Sulfate Elixir 220/5cc- 6.8cc (299.2mg) qd. Could this be changed to 7.5cc (330mg) qd for easier administration? Saturday, May 10, 2014 Page 8 of 10

9 Patient Name: MCREYNOLDS, A Room: D016 Wing: D **CMS-F329: ANXIOLYTICS- GRADUAL DOSE REDUCTION RE: CMS-F329: ANXIOLYTICS- GRADUAL DOSE REDUCTION - CLONAZEPAM 0.5MG QHS Ms. McReynolds is due for an anxiolytic drug evaluation per CMS guidelines pertaining to use in elderly Please consider a trial reduction to Clonazepam 0.25mg qhs Anxiolytic Intervention Patient Name: TORO, J Room: D002 Wing: D **CMS-F329: ANTIPSYCHOTIC GRADUAL DOSE REDUCTION RE: CMS-F329: ANTIPSYCHOTIC GRADUAL DOSE REDUCTION Ms. Sorozak is due for an antipsychotic evaluation. Please consider the following trial dose reduction if felt possible: Risperidone 0.25mg BID (25% reduction) Antipsychotic Drug Evaluation Saturday, May 10, 2014 Page 9 of 10

10 Patient Name: WAGNON, P Room: D017 Wing: D **CMS-F329: ANTIPSYCHOTIC GRADUAL DOSE REDUCTION RE: CMS-F329: ANTIPSYCHOTIC GRADUAL DOSE REDUCTION- RISPERDAL 0.5MG BID Ms. Wagner is due for an antipsychotic evaluation. Please consider the following trial dose reduction: RISPERDAL 0.125MG QAM, 0.25MG QHS (25% reduction) Antipsychotic Drug Evaluation Saturday, May 10, 2014 Page 10 of 10