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Engaging the C-suite to Advance Pharmacy Practice Providing quality patient care through progressive pharmacy practice Executive Management: Examples of.

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Presentation on theme: "Engaging the C-suite to Advance Pharmacy Practice Providing quality patient care through progressive pharmacy practice Executive Management: Examples of."— Presentation transcript:

1 Engaging the C-suite to Advance Pharmacy Practice Providing quality patient care through progressive pharmacy practice Executive Management: Examples of Data and Indicators Rita Shane, Pharm.D., FASHP, FCSHP Chief Pharmacy Officer Cedars-Sinai Medical Center Assistant Dean, Clinical Pharmacy Services, at the University of California, San Francisco, School of Pharmacy

2 Pharmacy Core Functions: Safe, Effective, Efficient Medication Use Patient Care and Risk Reduction Resource Management Transitions of Care Medication Management and Regulatory Compliance

3 Drug Expenditures

4 Total Variance $6,915,000 Drug Expense Variance FY11 Year to Date

5 Drug Cost Summary – 2011 Price Increases DrugPrice↑Primary Use Porfimer sodium624% Photodynamic therapy of tumors; Barrett’s esophagus Factor VII33%Cardiac surgery, liver pts, factor deficiency Alteplase11%Stroke Infliximab21%Rheumatoid Arthritis, Crohn’s, Ulcerative Colitis Basiliximab66%Kidney transplant induction Bortezomib53% Transplant desensitization/rejection, multiple myeloma Aldesleukin38%Renal Cell Carcinoma, Metastatic Melanoma Nesiritide78%Acute decompensated heart failure Filgrastim13%Chemo-induced neutropenia Mycophenolate IV1560% Heart, lung, kidney transplant immunosuppression

6 Inpatient Drug Expenditures and Transplant Volumes Heart Transplant ↑ 230%, Allogenic BMT ↑ 81% from FY09 to FY12

7 Epoetin (000) Pharmacy Protocol to start medication on day #8 and reduce standard dose to 50 units/Kg three times/week Pharmacy Protocol to limit dose to 10,000 units

8 Hepatitis B Immune Globulin (both inpatient and outpatient) 6.2 Doses/Pt 2.2 Doses/Pt (000)

9 Value Examples MedicationOpportunity Identified and Pharmacist InterventionCost Savings CMV-IVIG Pt with CMV viremia who had response to change in antiviral from ganciclovir to foscarnet. Intervention: Discontinued CMV-IVIG $75,000 GlucarpidasePt with methotrexate toxicity. Intervention: Dose rounding $24,805 Panhemitin Pt without lab confirmation of acute intermittent porphyria. Intervention: Hold therapy pending lab results. Labs returned negative. $24,984 IVIGPt with HIV, hepatitis C, ITP; received 3 doses of IVIG as outpatient. Admitted with bruising and headache, platelet count of 9000/µL. MD ordered 2 more doses, however platelets were increasing. Intervention: Discontinue IVIG order $15,074 IdursulfasePt with VP shunt malfunction repair. Receives idursulfase weekly as an outpatient. Intervention: Contacted patient’s medical geneticist to administer dose post-discharge. $10,500

10 Medications Prior to Admit Medication List As well as new orders DrugIndicationDoseRouteFrequency Dosage form Duration Patient Characteristics Age-Pediatrics-GeriatricsGenderHeight/WeightAllergies Kidney/Liver Function Current labs Previousadmissions Current Medication List Drug-drug interactions Drug-disease interactions Drug-food interactions Duplicate therapy Contraindications Medications needed but not prescribed Monitoring requirements Special Considerations High risk patients or therapies such as: Chemotherapy Blood thinners Antibiotics Drugs with narrow therapeutic index ICU Pharmacist’s Role in Evaluating Medications

11 Prescribing Errors Intercepted September ‘11 – June ’13 Sept - Feb Average/Month: 1633 (76.6/1,000 pt days) Prescribing Errors Intercepted/1,000 Orders IOM: 2.87 CSMC: 10.4 (pre-CPOE) Prescribing Errors Intercepted/1,000 Orders IOM: 2.87 CSMC: 15.6 (post-CPOE) May ‘12-June’13 Average/Month: 2431 (116/1,000 pt days) 49% Increase

12 Methodology Low Capacity for Harm Serious/Significant Life Threatening

13 Prescribing Errors Intercepted by Pharmacists ORDER RECEIVEDACTION TAKENOUTCOME AVOIDEDSEVERITY RATING HYDROmorphone PCA dose 2.4mg q8 minutes. Current dose= 0.2mg Recommended 0.3mgNarcotic overdose, leading to respiratory failure and possible death. Life Threatening MD note included plan to start antibiotics for R/O meningitis. No antibiotics ordered. Recommended to start antibiotics at meningitis dosing. Potential undertreatment of meningitis Life Threatening Methotrexate 10mg daily and patient on weekly dose for RA. Recommended continuing weekly dose. Potential antineoplastic overdose and possible death. Life Threatening Fentanyl patch ordered upon admission. Per SNF, patient was not on fentanyl patch Recommended discontinuing. Potential narcotic overdose, leading to respiratory failure and possible death. Life Threatening

14 Medication Reconciliation Across Transitions of Care Changing clinical conditions require continually evaluating the medication lists at each transition

15 15 40% of resolved DRPs were classified as life-threatening or serious/significant 7.4 Drug-Related Problems Identified Per Patient Based on Medication History 21% of inpatient orders were changed due to DRPs identified Resolution of Drug-Related Problems (DRPs) in High-Risk Hospitalized Patients

16 PTA Drug-Related Problems (DRPs) 16 Medication on PTA List Drug-Related ProblemDRP Type Capacity for Harm FlecainidePTA List: Med not listed on PTA med list Finding: Pt reports taking flecainide 50 mg BID Omission of Medication Life-Threatening PlavixPTA List: Med not listed on PTA med list Finding: Pt reports taking Plavix 75 mg daily Omission of Medication Serious/Significant PrednisonePTA List: Prednisone 20 mg daily Finding: Pt reports it was d/ced by MD 6 months ago Extraneous Medication Serious/Significant FurosemidePTA List: Furosemide 40 mg BID Finding: Pt reports taking 60 mg BID (CHF pt) Wrong DoseSerious/Significant MycophenolatePTA List: Mycophenolate 360 mg BID Finding: Pt reports taking 720 mg BID Wrong DoseSerious/Significant MidodrinePTA List: Midodrine 100 mg TID Finding: Pt reports taking 30 mg TID Wrong DoseLife-Threatening

17 Hospitalist-Pharmacist Transitions of Care Collaboration

18 Evaluation of Medication List Accuracy, Adherence, and Literacy Identify High- Risk Patients Validate Medication History ∙∙∙∙ Assess Adherence and Literacy ∙∙∙∙ Educate Patient Notify MD Regarding DRPs Identified along with Recommend- ations Post- Discharge Follow-Up within 72 Hrs: -Med Rec -Adherence & Literacy Reinforcement -Education Additional Calls up to 30 Days Based on Risk Assessment

19 Criteria to Determine Need for Post-Discharge Follow-Up Medication Adherence and Literacy Literacy Adherence High literacy Intermediate literacy Low literacy High adherence No post-DC f/u needed Educate pt. No post-DC f/u needed Post-DC f/u needed Intermediate adherence Educate pt. No post-DC f/u needed Educate pt. No post- DC f/u needed? vs. Post-DC f/u needed? Use clinical judgment Post-DC f/u needed Low adherence Post-DC f/u needed

20 Post-Discharge Metrics 20 Post-DC f/u Call Completed Readmissions Prevented* # of Patients20716% Average DRPs/Pt2.9 *Validated by MD Review Post-Discharge Findings 58% of pts had discrepancies between their discharge medication list and what they were taking 33% of pts were taking more medications than were prescribed (excludes vitamins, herbals, etc)

21 Examples of Post-Discharge Follow-up 21 Reason for AdmissionDrug-Related Problems Identified Post- Discharge and Pharmacist Intervention Adverse Outcome Prevented 54 y/o w/ HTN & DVT admitted for sickle cell crisis & left parietal stroke Issue discovered: Pt had self-d/ced warfarin, amlodipine, and carvedilol Intervention: Contacted MD and confirmed that warfarin and anti-hypertensives should be re- started. Pharmacist contacted pt and instructed to take all meds as was prescribed at d/c; do not self-start, self-d/c, self-dose, or adjust any med w/o speaking to MD first; educated pt on the importance of compliance to avoid complications Avoided potential occurrence of thromboembolism, readmission, and/or death 92 y/o w/ altered mental status found to have a UTI & toxic digoxin level, also w/ arrhythmias & low blood pressure Issue discovered: Pt had continued taking medications that had been stopped, including digoxin, metoprolol, and zolpidem Intervention: Instructed patient to d/c these medications Avoided potential drug toxicity, life- threatening arrhythmias, recurrence of confusion, and/or death

22 Enhanced Care Program for Skilled Nursing Facilities (SNF)

23 Identification of Patients Discharged to SNF Medication Reconciliation: Discharge Medication List vs SNF MAR - Pharmacist Clinical Evaluation - NP consults Drug-Related Problems Communicated to NP for Follow Up SNF Post-Discharge Follow-Up

24 Data Period: 1/22/13 -6/30/14 ECP Pharmacy Data Summary 20131 st Quarter 2014 2 nd Quarter 2014 Total # of Patients708241 223 1172 # of Serious/ Significant Drug- Related Problems (DRPs) Identified 560275 245 1080 (14 were life- threatening) % of Patients Requiring Intervention 41% (293/708) 56% (134/241) 54% (120/223) 47% (547/1172)

25 25 Reason for Hospital Admission Drug-Related Problems Identified Post-Discharge and Pharmacist Intervention Adverse Outcome Prevented 98 y/o M from home w/ hip fracture and multiple medical issues. Issue discovered: Pt was a new start on fentanyl 25mcg in house. Dose was increased to 50mcg 1 hour prior to discharge. Intervention: Called SNF to d/c fentanyl 50mcg order. Informed SNF RN that the patch was already placed on the pt. SNF RN was unaware. Avoided severe respiratory depression or death due to potential supra-therapeutic dose of fentanyl. 79 y/o M w/ ESRD - HD on TuThSat - with catheter- related S. aureus bacteremia. Issue discovered: Per ID, vancomycin after dialysis to be continued after d/c and was on discharge medication list. There was an order at the SNF for vancomycin but not at the dialysis center. Pt dialyzed on Sat after d/c but did not receive vancomycin. Intervention: Ensured vancomycin administration occurred. Avoided progression of bacteremia and catheter re-infection d/t missed doses of antibiotics. 89 y/o F w/multiple medical problems including pulmonary hypertension. Issue discovered: Sildenafil 25mg PO TID was listed on discharge medication list but not continued at the SNF. Intervention: Pharmacist recommended re-initiation of medication for the pt, who also required an oxygen mask at the SNF. Avoided worsening of respiratory status and potential progression of condition and organ damage. Examples of ECP Pharmacist Post-Discharge Follow-Up

26 Readmissions Dashboard 26 BaselineJan 2013Feb 2013Mar 2013 SNF 30-day All-Cause Readmissions Rate 20%17%21%12% 6SE Heart Failure 30-day All-Cause Readmissions Rate 21%22%18%15% Interdisciplinary Team Results


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