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1 Sonali Muzumdar Pharm.D., CPHIMS Informatics Pharmacist Mercy Hospital and Medical Center Comprehensive Pharmacy Services Leveraging Rules and Alerts to Improve Patient Safety and Clinical Pharmacy Services

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2 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 Objectives

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Audience Poll How many sites have CPOE? 3

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4 Mercy Hospital & Medical Center Chicago, Illinois

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5 Mercy Overview History and Mission MAPS Timeline Applications Healthcare Information Management & Systems Society Stage 6 Hospital Recognition The Leapfrog Group

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479 Licensed Beds 286 Staffed Beds 16,353 Annual Inpatients 14 Offsite locations 252,630 Outpatient Visits 56,172 ED Visits 1,503 FTEs 100 Interns and Residents Quick Facts

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7 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

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8 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

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9 Pharmacy Clinical Services Renal dosing Automatic IV-PO conversion Anticoagulation management service Pharmacokinetic monitoring Inhaler training Anticoagulant counseling Medication profile review

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10 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

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11 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

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12 Outline Mercy Hospital and Medical Center Overview Renal Rule Weight Change Anticoagulant Counseling Anticoagulant alerts

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13 Renal Dosing Gap Identified Adjust medications for impaired renal function at order verification Built in stop datesCreatinine clearance changes over time Medications readjusted at time of renewal verification or medication profile review

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14 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

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15 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

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16 RIFLE Criteria Bellomo et al. Crit Care 2004. 8:R204-212

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17 Pilot Testing Change in Serum Creatinine Time Period (hours) Resulted in a Meaningful Medication Review 50%241/5 (20%) 30%246/15 (40%) 30% (lower limit of 0.8)245/10 (50%) 30% (lower limit of 0.8)7210/15 (67%)

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18 Design of Renal Rule Age >= 18 yrs Patient has an active order for a renally excreted medication Serum creatinine >= 0.8 mg/dL Patient does not have any hemodialysis orders Subsequent serum creatinine has changed Change in serum creatinine is at least 30% Change has occurred within a 72 hour period Pharmacy Renal Evaluation order is fired Task fires to the pharmacy task list

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Real time testing Have the alert go to your email Review rules prior to turning them on for the department Review alert fatigue 19

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20 Testing/Building Rules Evaluate encounter specificity Evaluate the medication order type

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21 Task List Example

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22 Interventions

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23 Quality Improvement Data Reported quarterly to Medication and Nutrition Committee Data for one weeks audit Task fired 49 times 17/49 had medications that needed adjustment

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24 Ongoing Changes Utilize Cockcroft-Gault Creatinine Clearance (CrCl) Medication specific CrCl cutoffs

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25 Outline Mercy Hospital and Medical Center Overview Renal Rule Task Weight Change Task Warfarin Counseling Task Senior ED Task

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26 Audience Poll Who has a weight problem?

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27 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

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28 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

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29 Documentation Errors Pounds instead of kilograms Typographical errors (105 cm vs 150 cm) Height & Weight numbers are transposed Estimated weight is never updated Another patients weight entered in the system ISMP newsletter. August 2010.

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30 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.

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31 Height & Weight Documentation

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32 Documenting Weight Based Drips Clinical Weight automatically defaults for weight based dosing

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33 Height & Weight Documentation The Clinical Weight is updated by the floor nurse/CNA to match the Measured Weight On the floor Measured Weight is performed and documented In the ED Estimated Weight & Clinical Weight documented

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34 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

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35 Design of Weight Task Rule Clinical Weight documented Subsequent Measured Weight documented Task fires if there is more than a 15% change

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36 Future Height & Weight Documentation Clinical Weight can only be updated by pharmacy On the floor Measured Weight is performed and documented In the ED Estimated Weight & Clinical Weight documented

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37 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

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38 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

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39 Monthly Pharmacy Weight Tasks

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40 Weight Task Changes Averaging 15 tasks per week Significant pharmacist time Correction did not occur quickly Alert for RN/CNA built

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41 Alert for nurse and cna

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42 Outline Mercy Hospital and Medical Center Overview Renal Rule Task Weight Change Task Anticoagulation Counseling Task Anticoagulant Alerts

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43 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

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44 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.

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45 Quality Measure Documentation

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46 Improvement in Patient Counseling % Patients counseled from Jan 2012-Dec 2013

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47 Limitations of the task list Task list is not front & center for the pharmacis t s Keeping up with the task list Duplicate tasks

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48 Outline Mercy Hospital and Medical Center Overview Renal Rule Task Weight Change Task Warfarin Counseling Task Anticoagulation safety

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49 Audience Poll Does your EHR alert you when your patient has received an epidural morphine injection and enoxaparin is ordered?

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50 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 non- steroidal 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

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Anticoagulants and Spinal Anesthesia Increased risk of spinal hematoma when used in conjunction with epidural/spinal procedures Each drug has its own recommendation for timing Timing for when to administer the anticoagulant and when to administer the medication with epidural/intrathecal route.

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Anticoagulants and Epidurals DrugAnticoagulant on profile Epidural on profile Heparin IVMay remove catheter 2-4 hrs after last heparin dose May heparinize 1 hr after neuraxial technique Clopidogrel/Ticagrelordiscontinue 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

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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]Am J Ther. 53

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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

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Anticoagulant-Epidural Warning 55 after

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57 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-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/2014_CQM_EH_FinalRule.pdf

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VTE Prophylaxis Increase in VTE prophylaxis orders Order sets Core measures Patients with a therapeutic INR 58

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Elevated INR Alert 59

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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 60 Alerts fired Non-med induced INR elevation Medication induced INR elevation Pharmacist interventions Bypassed alerts/ missed intervention Oct 31221 Nov 110 83 Dec 51450

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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 drug- drug and drug-lab alerts 61

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Review Questions A combination of rules and a task list can help improve a pharmacys renal dosing program. True or False TRUE 62

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Review Questions Which of the following can cause weight documentation errors? a. Documenting in pounds vs kg b. Typographical errors c. Another patients weight documented d. Height and Weight transposed e. Estimated weight is never updated f. All of the above ALL OF THE ABOVE 63

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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