Transcript Project Kickoff - Western Michigan Society Of Health

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
1
Objectives
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
documented weight changes
List pharmacy clinical services that can be
improved by use of rules and alerts
2
Audience Poll
How many sites have CPOE?
3
Mercy Hospital & Medical Center
Chicago, Illinois
4
Mercy Overview
History and Mission
MAPS Timeline
Applications
Healthcare Information Management & Systems
Society
Stage 6 Hospital Recognition
The Leapfrog Group
5
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
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
7
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
8
Pharmacy Clinical Services
Renal dosing
Automatic IV-PO conversion
Anticoagulation management service
Pharmacokinetic monitoring
Inhaler training
Anticoagulant counseling
Medication profile review
9
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.
http://www.jointcommission.org/assets/1/18/SEA_42.PDF
10
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.
http://www.jointcommission.org/assets/1/18/SEA_42.PDF
11
Outline
Mercy Hospital and Medical Center Overview
Renal Rule
Weight Change
Anticoagulant Counseling
Anticoagulant alerts
12
Renal Dosing Gap Identified
Adjust medications for impaired renal
function at order verification
Built in stop dates
Creatinine clearance changes over time
Medications readjusted at time of renewal
verification or medication profile review
13
History
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
McCoy et al. Am J Kidney Dis 2010. 56:832-41
14
Renally Adjusted Medications
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
15
RIFLE Criteria
Bellomo et al. Crit Care 2004. 8:R204-212
16
Pilot Testing
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%)
17
Design of Renal Rule
Age >= 18 yrs
Change in serum
creatinine is at
least 30%
Change has
occurred within
a 72 hour period
Patient has an
active order for a
renally excreted
medication
Subsequent
serum creatinine
has changed
Pharmacy Renal
Evaluation order
is fired
Serum creatinine
>= 0.8 mg/dL
Patient does not
have any
hemodialysis
orders
Task fires to the
pharmacy task
list
18
Real time testing
Have the alert go to your email
Review rules prior to turning them on for the
department
Review alert fatigue
19
Testing/Building Rules
Evaluate encounter specificity
Evaluate the medication order type
20
Task List Example
21
Interventions
RENAL INTERVENTIONS
300
20% Increase
250
200
150
227
273
258
100
50
0
Q12012
Q12013
Q12014
22
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
23
Ongoing Changes
Utilize Cockcroft-Gault Creatinine Clearance (CrCl)
Medication specific CrCl cutoffs
24
Outline
Mercy Hospital and Medical Center Overview
Renal Rule Task
Weight Change Task
Warfarin Counseling Task
Senior ED Task
25
Audience Poll
Who has a weight
problem?
26
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
http://www.ismp.org/tools/bestpractices/TMSBP-for-Hospitals.pdf
27
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
28
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
ISMP newsletter. August 2010.
29
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 2010.
30
Height & Weight Documentation
31
Documenting Weight Based Drips
Clinical Weight
automatically
defaults for
weight based
dosing
32
Height & Weight Documentation
In the ED
Estimated
Weight &
Clinical Weight
documented
On the floor
Measured
Weight is
performed and
documented
The Clinical
Weight is
updated by the
floor nurse/CNA
to match the
Measured
Weight
33
Medication Safety Committee Review
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
34
Design of Weight Task Rule
Clinical Weight
documented
Subsequent
Measured
Weight
documented
Task fires if
there is more
than a 15%
change
35
Future Height & Weight Documentation
In the ED
Estimated
Weight &
Clinical Weight
documented
On the floor
Measured
Weight is
performed and
documented
Clinical Weight
can only be
updated by
pharmacy
36
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
37
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 (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)
Enoxaparin
120 mg Q12H to 100 mg Q12H
Cefepime
2 gram Q8H to 2 gram Q12H
38
Monthly Pharmacy Weight Tasks
140
February 2013 to March 2014 Pharmacy Weight Tasks
120
100
80
60
40
20
0
Changed task to look at a 15% weight change
from 5kg weight change
39
Weight Task Changes
Averaging 15 tasks per week
Significant pharmacist time
Correction did not occur quickly
Alert for RN/CNA built
40
Alert for nurse and cna
41
Outline
Mercy Hospital and Medical Center Overview
Renal Rule Task
Weight Change Task
Anticoagulation Counseling Task
Anticoagulant Alerts
42
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
43
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.
44
Quality Measure Documentation
45
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
10
Jul-12
20
Jun-12
30
May-12
100
Apr-12
60
Mar-12
70
Feb-12
Jan-12
Improvement in Patient Counseling
% Patients counseled from Jan 2012-Dec 2013
90
80
Goal = 50%
50
40
Counseling
task fired
9/2012
0
46
Limitations of the task list
Task list is not front & center for the pharmacists
Keeping up with the task list
Duplicate tasks
47
Outline
Mercy Hospital and Medical Center Overview
Renal Rule Task
Weight Change Task
Warfarin Counseling Task
Anticoagulation safety
48
Audience Poll
Does your EHR alert you when your
patient has received an epidural
morphine injection and enoxaparin is
ordered?
49
Black Box Warning
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
50
Anticoagulants and Spinal Anesthesia
 Increased risk of spinal hematoma when used in
conjunction with epidural/spinal procedures
 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.
Anticoagulants and Epidurals
Drug
Anticoagulant on
profile
Epidural on profile
Heparin IV
May remove catheter 2-4 May heparinize 1 hr
hrs after last heparin
after neuraxial
dose
technique
Clopidogrel/Ticagrelor
discontinue 7 days prior
to neuraxial blockade
N/A
Direct 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
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.
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]
53
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
54
Anticoagulant-Epidural Warning
after
after
55
56
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
http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/Downloads/2014_CQM_EH_FinalRule.pdf
57
VTE Prophylaxis
Increase in VTE prophylaxis orders
Order sets
Core measures
Patients with a therapeutic INR
58
Elevated INR Alert
59
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
Non-med
Medication
Alerts induced
induced INR
fired
INR
elevation
elevation
Oct
Nov
Dec
3
11
5
1
0
1
2
11
4
Pharmacist
interventions
2
8
5
Bypassed
alerts/
missed
intervention
1
3
0
60
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
61
Review Questions
A combination of rules and a task list can help
improve a pharmacy’s renal dosing program.
True or False
TRUE
62
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 documented
d. Height and Weight transposed
e. Estimated weight is never updated
f.
All of the above
ALL OF THE ABOVE
63
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
64