Leveraging Rules and Alerts to Improve Patient Safety and Clinical Pharmacy Services

Transcription

1 Objectives Leveraging Rules and Alerts to Improve Patient Safety and Clinical Pharmacy Services Sonali Muzumdar Pharm.D., CPHIMS Informatics Pharmacist Mercy Hospital and Medical Center Comprehensive Pharmacy Services Describe a method to assist pharmacist identification of changing renal function over time for patients on renally adjusted medications Identify a method to improve patient safety by preventing medication errors associated with weight changes List pharmacy clinical services that can be improved by use of rules and alerts 1 2 Audience Poll Mercy Hospital & Medical Center Chicago, Illinois How many sites have CPOE? 3 4 Mercy Overview History and Mission MAPS Timeline Applications Healthcare Information Management & Systems Society Stage 6 Hospital Recognition The Leapfrog Group Quick Facts 479 Licensed Beds 286 Staffed Beds 16,353 Annual Inpatients 14 Offsite locations 252,630 Outpatient Visits 56,172 ED Visits 1,503 FTE s 100 Interns and Residents 5 1

2 EHR Applications (Cernerize) PowerChart E-prescribe Power Note PowerPlans PowerOrders CareNet SurgiNet / Anesthesia RadNet ProVision Web I-Net NHIQM Dashboard PharmNet FirstNet APACHE CareAware CareMobile Discern Expert/Explorer BMDI/Open Port CPOE ProFile - HIM Foreign System Interfaces Knowledge Catalog M Pages Pharmacy Team 15 Clinical Pharmacists 6 Clinical Specialists 2 Internal Medicine 2 Emergency Medicine 1 Ambulatory Care 1 Critical Care 2 Pharmacy Practice Residents 1 Informatics Pharmacist (0.6 FTE) DOP, ADOP, Clinical Manager 20 FTE pharmacy technicians 7 8 Pharmacy Clinical Services Renal dosing Automatic IV-PO conversion Anticoagulation management service Pharmacokinetic monitoring Inhaler training Anticoagulant counseling Medication profile review JCAHO Recommendations Safety 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 JCAHO Recommendations After 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. Outline Mercy Hospital and Medical Center Overview Renal Rule Weight Change Anticoagulant Counseling Anticoagulant alerts

3 Renal Dosing Gap Identified History Adjust medications for impaired renal function at order verification Built in stop dates Creatinine clearance changes over time McCoy et al Population: adult inpatients with acute kidney injury Intervention: interruptive alert to modify medication therapy Conclusion: Increased rate and timeliness of modification or discontinuation of targeted orders Medications readjusted at time of renewal verification or medication profile review McCoy et al. Am J Kidney Dis : Renally Adjusted Medications RIFLE Criteria Acyclovir, Valacyclovir Alendronate Allopurinol Amphoteracin Beta-lactams Bivalirudin Ciprofloxacin, Levofloxacin Colchicine Colistin Dabigatran Enoxaparin, Fondaparinux Famciclovir, Ganciclovir Famotidine, Ranitidine Fluconazole, Voriconazole Hydroxyurea Ketorolac Levetiracetam Lithium Memantine Metformin Methylnaltrexone NRTIs Oprelvekin Quinidine Rifabutin Sotalol Spironolactone Tetracycline SMX-TMP Zoledronic acid Bellomo et al. Crit Care :R Pilot Testing Design of Renal Rule Change in Serum Creatinine Time Period (hours) Resulted in a Meaningful Medication Review 50% 24 1/5 (20%) 30% 24 6/15 (40%) 30% (lower limit of 0.8) 24 5/10 (50%) 30% (lower limit of 0.8) 72 10/15 (67%) Age >= 18 yrs Patient has an active order for a renally excreted medication Serum creatinine >= 0.8 mg/dl Change in serum creatinine is at least 30% Subsequent serum creatinine has changed Patient does not have any hemodialysis orders Change has occurred within a 72 hour period Pharmacy Renal Evaluation order is fired Task fires to the pharmacy task list

4 Real time testing Have the alert go to your Review rules prior to turning them on for the department Review alert fatigue Testing/Building Rules Evaluate encounter specificity Evaluate the medication order type Task List Example Interventions RENAL INTERVENTIONS % Increase Q12012 Q12013 Q Quality Improvement Data Reported quarterly to Medication and Nutrition Committee Data for one week s audit Task fired 49 times 17/49 had medications that needed adjustment Ongoing Changes Utilize Cockcroft-Gault Creatinine Clearance (CrCl) Medication specific CrCl cutoffs

5 Outline Mercy Hospital and Medical Center Overview Renal Rule Task Weight Change Task Warfarin Counseling Task Senior ED Task Audience Poll Who has a weight problem? ISMP Best Practice for 2014 Measure 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 Importance of a Correct Weight Affects drug dosing Drugs dosed in mg/kg, mcg/kg/min Drugs dosed based on BMI & BSA Cockcroft-Gault formula Dietary requirements Monitoring heart failure patients Documentation Errors Pounds instead of kilograms Typographical errors (105 cm vs 150 cm) Height & Weight numbers are transposed Estimated weight is never updated Another patient s weight entered in the system Medication Error Example Order: panitumumab IV every 3 weeks Usual dose: 6 mg/kg every 2 weeks Clinical trial dose: 9 mg/kg every 3 weeks Height (cm) was entered as the weight and the weight (kg) was entered as the height Result: the patient received about 650 mg more panitumumab than intended for the first dose of therapy ISMP newsletter. August ISMP newsletter. August

6 Height & Weight Documentation Documenting Weight Based Drips Clinical Weight automatically defaults for weight based dosing Height & Weight Documentation Medication Safety Committee Review In the ED Estimated Weight & Clinical Weight On the floor Measured Weight is performed and The Clinical Weight is updated by the floor nurse/cna to match the Measured Weight Current Height/Weight form does not alert the user if there is a weight change from previous documentation Potential for error exists during documentation Pharmacy should be notified if there is a significant weight change Design of Weight Task Rule Future Height & Weight Documentation Clinical Weight Subsequent Measured Weight Task fires if there is more than a 15% change In the ED Estimated Weight & Clinical Weight On the floor Measured Weight is performed and Clinical Weight can only be updated by pharmacy

7 Pharmacist Clinical Process Task fires Pharmacist communicates with the RN to reweigh the patient Update clinical weight Review patient profile Correct dose and/or interval Outcomes of the Weight Task Old incorrect weight: 120 kg New correct and verified weight: 100 kg Heparin infusion and boluses 80 units/kg bolus ( units) 40 units/kg bolus ( units) Rate 18 units/kg/hr to 21.6 units/kg/hr (ml/hr remains unchanged) Enoxaparin 120 mg Q12H to 100 mg Q12H Cefepime 2 gram Q8H to 2 gram Q12H Monthly Pharmacy Weight Tasks Weight Task Changes February 2013 to March 2014 Pharmacy Weight Tasks Changed task to look at a 15% weight change from 5kg weight change Averaging 15 tasks per week Significant pharmacist time Correction did not occur quickly Alert for RN/CNA built Alert for nurse and cna Outline Mercy Hospital and Medical Center Overview Renal Rule Task Weight Change Task Anticoagulation Counseling Task Anticoagulant Alerts

8 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 5/2/2014 Warfarin Counseling Goals Department goal 50% of inpatients receive warfarin counseling Assist in documentation National Hospital Inpatient Quality measures VTE-5: Venous thromboembolism warfarin therapy discharge instructions Compliance Dietary advice Follow-up monitoring Potential for adverse drug reactions and interactions Warfarin Counseling Task Process Warfarin ordered Rule fires a placeholder pharmacy order Patient on Warfarin Patient on Warfarin orderable fires a Pharmacy Warfarin Counseling task Pharmacist charts on the task, the quality measure form is attached Quality Measure Documentation Improvement in Patient Counseling Counseling task fired 9/2012 % Patients counseled from Jan 2012-Dec 2013 Goal = 50% Limitations of the task list Task list is not front & center for the pharmacists Keeping up with the task list Duplicate tasks Outline Mercy Hospital and Medical Center Overview Renal Rule Task Weight Change Task Warfarin Counseling Task Anticoagulation safety

9 Audience Poll Black Box Warning Does your EHR alert you when your patient has received an epidural morphine injection and enoxaparin is ordered? WARNING: SPINAL/EPIDURAL HEMATOMA Epidural 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 nonsteroidal 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 Anticoagulants and Spinal Anesthesia Increased risk of spinal hematoma when used in conjunction with epidural/spinal procedures Anticoagulants and Epidurals Drug Anticoagulant on profile Heparin IV May remove catheter 2-4 hrs after last heparin dose Epidural on profile May heparinize 1 hr after neuraxial technique Each drug has it s own recommendation for timing Timing for when to administer the anticoagulant and when to administer the medication with epidural/intrathecal route. Clopidogrel/Ticagrelor Direct thrombin inhibitors discontinue 7 days prior to neuraxial blockade -Insufficient information: recommend against the performance of neuraxial techniques (Grade 2C) -Needle placement 8-10 hrs after dose (GSAICM) N/A Delay subsequent doses 2-4 hrs after needle placement 52 Vanderbilt Clinical Decision Support Alert 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. Anticoagulant-Epidural Alert Need due to lack of notification in our EHR Improve our generic epidural alert Discussed with anesthesiologists Guidelines developed Referenced ASRA, GSAICM, ACCP 2 Alerts built per anticoagulant Prior to catheter administration After catheter removal Gupta RK et al. Using An Electronic Clinical Decision Support System to Reduce the Risk of Epidural Hematoma. Am J Ther Oct 19. [Epub ahead of print]

10 Anticoagulant-Epidural Warning after VTE-1: Venous Thromboprophylaxis Assesses 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 VTE Prophylaxis Increase in VTE prophylaxis orders Order sets Core measures Patients with a therapeutic INR Guidance/Legislation/EHRIncentivePrograms/Downloads/2014_CQM_EH_FinalRule.pdf Elevated INR Alert Quality Improvement Data Alert fires from 3-11/month Reported quarterly to Medication & Nutrition Committee 15/19 (79%) appropriate interventions Modify alert so an over-ride reason is required Alerts fired Non-med induced INR elevation Medication induced INR elevation Pharmacist interventions Bypassed alerts/ missed intervention Oct Nov Dec

11 Conclusions An interruputive renal task is beneficial to clinical pharmacy services Correction of weight documentation errors can prevent dosing errors Anticoagulation safety can be improved with specific drugdrug and drug-lab alerts Review Questions A combination of rules and a task list can help improve a pharmacy s renal dosing program. True or False TRUE Review Questions Which of the following can cause weight documentation errors? a. Documenting in pounds vs kg b. Typographical errors c. Another patient s weight d. Height and Weight transposed e. Estimated weight is never updated f. All of the above ALL OF THE ABOVE Review Questions There is an increased risk of spinal bleeding when some anticoagulants are administered to patients that have received an epidural/intrathecal medication. TRUE OR FALSE TRUE