Disclosure. Objectives. Roles and Responsibilities. Medication Reconciliation

Transcription

1 47 th Annual Meeting August 2-4, 2013 Orlando, FL The Evolving Role of the Pharmacy Technician: The Clinical Pharmacy Technician Roma Merrick RPhT., CPhT Pharmacy Technician Coordinator St. Vincent s Medical Center Southside Jacksonville, FL Disclosure I do not have a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation 2 Objectives Upon completion of this activity, the participant should be able to: Define the role of a Clinical Pharmacy Technician Identify daily activities and responsibilities of a Clinical Pharmacy Technician Discuss the career path of a Clinical Pharmacy Technician Discuss available education and/or training opportunities for Clinical Pharmacy Technicians What is a Clinical Pharmacy Technician? Pharmacy Technician job description help licensed pharmacists dispense prescription medication (Department of Labor and Statistics, 2010). Clinical Pharmacy Technician job description there are no hard definitions for this job, due to the position being new to the field. 3 4 Roles and Responsibilities Medication Reconciliation/Histories Allergy Information Intravenous to Oral Therapy Conversions Antimicrobial Stewardship Lab Value Assessment Dialysis Patient Monitoring Medication Reconciliation Medication Reconciliation is, the process of comparing a patient s medication orders to all of the medications that the patient has been taking (The Joint Commission, 2006)

2 1. Develop a list of current medications 2. Develop a list of medications to be prescribed 3. Compare the medications on the two lists 4. Make clinical decisions based on the comparison 5. Communicate the new list to appropriate caregivers and to the patient (The Joint Commission, 2006) 7 What is the purpose of medication reconciliation? To avoid errors like omissions, duplications, dosing errors, and drug interactions. Causes for Errors Performance deficits Inaccurate transcription Omissions Improper documentation Communication problems Workflow disruptions 8 Error Rates and Statistics More than half of patients have at least one unintended medication discrepancy at hospital admission (Agency for Healthcare Research & Quality, 2012). 6% of discrepancies have severe harm potential 33% of discrepancies have moderate harm potential 61% of discrepancies have no harm potential Background Poor communication of medical information at transition points are responsible for as many as 50% of all medication errors and up to 20% of adverse drug events in the hospital (Resar, Midelfort, Claire, 2004). A discrepency is viewed as any missing or incorrect medication information and is a marker for potential adverse drug events (The Joint Commission, 2006) What have a pharmacy technician perform medication review with patients? Clinical knowledge Patients tend to forget Nurses overwhelmed Patients overwhelmed Patients not telling the nurse or physician how or what they REALLY take Overlooking nutraceuticals and OTC meds When looking at pharmacy orders, what components do we look for? Drug Name Dose Formulation Route Frequency PRN indication

3 Examples of Common Findings on Medication Histories The next set of slides will exemplify the different problems that are being encountered when reviewing the Medication History Profiles. Find the Problem Insulin detemir (Levemir) SQ Insulin detemir (Levemir) SQ Aspirin (Bayer Aspirin) Esomeprazole (Nexium) Ranolazine (Ranexa) Losartan (Cozaar) Carvedilol (Coreg) Carvedilol (Coreg) Carvedilol (Coreg) Find the Problem Cont. Metoprolol 25mg Lisinopril 10mg PO qid Alendronate 70mg Hydrochlorthiazide 25mg PO qid Find the Problem Cont. Acetaminophen 325mg Polyethylene Glycolol 3350 with electrolytes Bisacodyl Tab 5mg daily Docusate Cap 100mg bid Potassium Chloride 40mEq/15mL TID Ipratropium qid Multivitamin daily Magnesium Oxide 400mg daily Find the Problem Cont. Examples of Clarifications Simvastatin 40mg PO bedtime Atorvastatin 80mg PO bedtime Enalapril 40mg PO daily Lisinopril 10mg PO daily Listed on the Profile Lisinopril 2.5mg PO daily Oxycodone ER 10mg PO bid prn headaches Warfarin 7.5mg PO daily Atorvastatin 40mg PO qhs Diclofenac 75mg PO tid What it Should Have Been Losartan 25mg PO daily Oxycodone 10mg PO q6hr prn severe pain Warfarin 7.5mg PO every other day Simvastatin 40mg PO qhs Patient was taken off of Diclofenac 3 years ago

4 Examples of Clarifications Cont. Allergy Information Listed on the Profile Glipizide ER 4mg PO daily Aspirin 81mg PO daily Fluticasone Oral Inhaler 2 puff each nostril daily Metoprolol Succinate 25mg PO bid Hydroxyzine 25mg PO qid Amlodipine 5mg PO daily What it Should Have Been Glimepiride 4mg PO daily Aspirin 325mg PO daily Fluticasone Nasal Spray 2 sprays each nostril daily Metorpolol Tartrate 25mg PO bid Hydralazine 25mg PO qid Amiloride 5mg PO daily What is an allergy? An abnormal reaction of the immune system to otherwise harmless substances (Allergy, 2012) What is a side effect? A peripheral or secondary effect, especially an undesirable secondary effect of a drug or therapy (Side effect, 2012) Allergy Information Cont. Why is this important? Many patients do not understand the difference between an allergy and a side effect Allergy name is listed but no reaction is given Allergies have not been updated recently Incorrect allergies/side effects are listed Patients stating they are allergic to something because a parent or sibling is allergic to something Allergy Information Cont. What does reviewing allergy information do? Having a more in depth clarification of reported allergies will allow the provider to make a more accurate assessment on whether or not it is a true allergy, side effect, or other reaction, leading to improved patient outcomes. Reduces the use of medications with more side effects and/or less efficacy due to incorrect allergy information Allergy Information Cont. What to ask when a patient states he has an allergy. Can you recall your reaction to the medication? Do you know how long ago that occurred? Do you know if you have taken any medications similar to this drug? Intravenous to Oral Therapy Conversions (IV to PO) What is IV to PO? When a medication is changed from the intravenous formulation to the oral formulation Why is this done? Ease of administration Decreasing the risk of infusion related adverse events Decreased of line infections Phlebitis Reduces hidden expenses IV sets IV pumps May allow for earlier discharge from the hospital

5 Types of IV to PO Conversions Sequential therapy Replacing the IV version of a medication with its oral counterpart Switch therapy A conversion from an IV medication to the PO equivalent that may be within the same class and potency, but a different compound Step down therapy Converting an injectable medication to an oral medication in another class or to a different medication within the same class where frequency and dose may not be exactly the same Pantoprazole Famotidine Ranitidine Ciprofloxacin Levofloxacin Common Sequential IV to PO Conversions Metronidazole Levetiracetam Linezolid Fluconazole Moxifloxacin (Kuper, 2008) Selection of Patients for IV to PO Therapy Conversion Intact and functioning gastrointestinal (GI) tract Improving clinical status Diet restrictions Reason for medication use Use of antiemetic medications Duration of therapy 57 year old male, is being administered Pantoprazole 40mg IV push daily. He has no GI issues and is on the medication for prophylaxis, no use of antiemetic medications, and is eating a regular diet. Do you think this patient is a good candidate for conversion to the oral formulation of Pantoprazole? year old female is being administered Pantoprazole 40mg IV push q12hrs. She has an active GI bleed, on a clear liquid diet, has been administered Promethazine 12.5mg slow IVpush every four hours for the past day. Do you think this patient is a good candidate for conversion to the oral formulation of Pantoprazole? Antimicrobial Stewardship What is an Antimicrobial? Antibiotics, antivirals, antifungals, antiparasitics What is Antimicrobial Stewardship? Coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration (Infectious Disease Societies of America, 2013)

6 Antimicrobial Stewardship Cont. What is the Clinical Technician s role in the process? Review the culture and sensitivity reports to match drug with the organism. Antimicrobial Stewardship Cont. What to look for on the infection control report Culture Source Blood Urine Bronch wash Abscess Other forms of body fluid Tissue Organism found E. coli Staphylococcus aureus Staphlyococcus aureus Oxacillin resistant (MRSA) Antimicrobial Panel Patient s Therapy Minimum Inhibitory Concentration (MIC) Dilutions The lowest concentration of an antimicrobial that will inhibit the visible growth of a micoorganism after overnight incubation (Andrews, 2001). MIC Interpretation Resistance Sensitivity Antimicrobial Stewardship Cont. Antimicrobial Stewardship Cont. This is a urine culture of a patient on ampicillin, is this appropriate therapy? Escherichia coli MIC Dilution MIC Interpretation Ertapenem <=0.5 S Amikacin 4 S Ampicillin >=32 R Aztreonam >=64 R Cefazolin >=64 R Cefepime >=64 R Ceftiaxone >=64 R Ciprofloxacin >=4 R Gentamicin >=16 R Tobramycin >=16 R 33 What is the goals of this service? Achieve optimal clinical outcomes related to antimicrobial use Minimize toxicity and other adverse drug events Reduce costs of health care for infections Limit the selection for antimicrobial resistant strains (Infectious Disease Societies of America, 2013) 34 Lab Value Assessment Dialysis Patient Monitoring Labs reviewed White blood counts Absolute Neutrophils Counts International normalized ratio (INR) Hemoglobin Multiple Comorbidities Hypotension Sleep problems Anemia Bone diseases Hypertension Fluid overload Hyperkalemia Access site complications Amyloidosis Depression Why monitor this population? Patient compliance Medications Dialysis schedule High Risk for Healthcare Associated Infections Frequent use of catheters and insertion of needles Weakened immune systems High readmission rates High cost of care In 2007 Medicare spent $8.6 billion on hemodialysis patients (Rubin, 2009)

7 Dialysis Patient Monitoring Dialysis Patient Monitoring Cont. Point of contact Patient s dialysis schedule Dialysis center medications Epoetin dosages Iron dosages Paricalcitol Last date of medication administration (*Centers for Disease Control and Prevention, 2013) Iron Panel Serum Ferritin Amount of ferritin (iron) in the bloodstream* Transferrin Saturation Measures for iron overloading* Total Iron Binding Capacity Checks for iron in the bloodstream and how well it moves in the bloodstream* 37 Why is this done? Most dialysis centers do not know their patient is hospitalized until days later Continuation of therapy Make sure patients are placed on the correct dose of recombinant human erythropoietin (epoetin or darbepoetin) 38 Career Path of a Clinical Pharmacy Technician Education and Training Needs of the department Needs of the hospital Changes in the health care field Changes in the pharmacy industry Challenging the current job description of a pharmacy technician The desire to learn Understanding limitations of the role Knowing the brand and generic names of medications as well as pronunciations Staying up to date with new medications on the market Doing your own research Questions

8 References Agency for Healthcare Research & Quality. (2012). Medication Reconciliation. Retrieved from Allergy. (2012). Allergies. The medical dictionary. Retrieved from medicaldictionary.org/definitions a/allergy.html Andrews, J. (2001). Determination of Minimum Inhibitory Concentrations. Journal of Antimicrobial Chemotherapy, 48 (1) Centers for Disease Control and Prevention. (2013). Hemochromatosis (Iron Storage Disease). Retrieved from Department of Labor and Statistics. (2010). Pharmacy Technician. Retrieved from The Joint Commission. (2006). Using medication reconciliation to prevent errors. Sentinel Event Alert. Retrieved from Infectious Disease Societies of America. (2013). Promoting Antimicrobial Stewardship in Human Medicine. Retrieved from Kuper, K. (2008). Intravenous to Oral Therapy Conversion. Competence Assessment Tools for Health System Pharmacies Fourth ed Retrieved from Resar, R., Midelfort, L., Claire, E. (2004). Medication Reconciliation Review. Institute for Healthcare Improvement. Retrieved from ihi.org Rubin, R. (2009). Dialysis treatment in USA: high costs, high death rates. Retrieved from dialysis_n.htm?loc=interstitialskip Side Effect. (2012). The American heritage dictionary of the English language, 4 th ed. Retrieved from