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Pharmacy Administration Rotation Presentation Pharmacy Resident June 26 th, 2014.

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Presentation on theme: "Pharmacy Administration Rotation Presentation Pharmacy Resident June 26 th, 2014."— Presentation transcript:

1 Pharmacy Administration Rotation Presentation Pharmacy Resident June 26 th, 2014

2 Opioid iVent Analysis 2

3 Background: The Joint Commission 2012 Sentinel Event Alert Centers for Medicare and Medicaid Services (CMS) 2014 Clinical Standards list opioids as one of the three high- priority target medication classes Objective: Evaluate iVents involving opioid prescribing practices within CS- Link by classifying trends in errors and identify areas of improvement of current prescribing practices Study Period: January 2014- March 2014 3

4 Opioid iVent Analysis Methods: Retrospective review To evaluate trends in inappropriate prescribing practices opioid iVents were categorized based on type of error and medication involved To evaluate trends in units/departments involved opioid iVents were categorized based on physician specialty and location of order verification Inclusion: All life threatening and serious/significant iVents involving an opioid as documented in Epic during the study timeframe Exclusion: All iVents involving non-opioid medications, documented as low capacity for harm or unable to determine were excluded from data collection Sample Size 95 iVents 4

5 Opioid Prescribing Errors by Medication 5

6 Opioid Prescribing Errors by Specialty 6

7 Opioid Prescribing Errors by Department 7

8 8 Opioid Prescribing Errors by Type

9 9 Type of Error and Medications Involved

10 Life-Threatening Opioid iVents: 4% 10 Problem IdentifiedPharmacist RecommendationOutcome Avoided Wrong Route Fentanyl 12.5mg IV Q2hr prn mild pain Clarified route with MD as MD's note the day before stated fentanyl 12 mcg patch (patient was on fentanyl patch 2 days ago) Avoided ADE Wrong Dose Hydromorphone 4 mg/mL soln MD changing from morphine didn't decrease the dose for higher potency Change dose to 1 mgAvoided ADE Wrong dose Fentanyl 1000 mcg/mL ordered ivp Change dose to 100 mcgAvoided ADE Wrong dose Morphine 2 mg/mL IV CRTG MD ordered 1 mg/kg Change dose to 1 mgAvoided ADE

11 Recommendations 11  Wrong dose due to lack of opioid equivalent knowledge can be improved upon by removing hydromorphone 4 mg button in Epic  Reinforce PharmD pain mgmt. principles with questions in Health Stream Competency o Dilaudid conversion o Appropriateness of fentanyl order (duplication of opioid due to fentanyl patch not being removed) o Allergies o Special Populations health competency questions – post-op, elderly, pediatrics  Pediatrics o PCA Narcan Default order for overdose (respiratory depression) o Morphine: change default from SQ to IV o Weight based dosing: Best Practice Alert when order exceeds 40-50 kg o Educate staff on importance of evaluating all pediatric orders (wrong patient)

12 Overview 12 Emergency Department Medication Reconciliation Evaluation (1) Order Verification and Staffing Model (2) Transitions of Care Literature Review

13 1. Emergency Department Medication Reconciliation Evaluation 13

14 Emergency Department Medication Reconciliation Evaluation Background: Emergency department (ED) medication reconciliation is currently being performed by pharmacists, pharmacy technicians and pharmacy residents on weekdays with varying hours of operation. Objective: To evaluate gaps in the current transitions of care staffing model in emergency department medication reconciliation to optimize staffing resources. Methods: A list of ED admissions during the week of 5/12/14-5/16/14 was compiled and evaluated for completion of ED medication reconciliation. Study Period: May 12 th, 2014- May 16 th, 2014 14

15 Emergency Department Medication Reconciliation Evaluation Inclusion: Patients admitted from the ED during the week of 5/12/14- 5/16/2014 with admission date and time on record. Exclusion: Patients admitted to: Demographics: 415 patients evaluated 5/12: 95 patients 5/13: 80 patients 5/14: 83 patients 5/15: 88 patients 5/16: 69 patients 15  SICU  OR  Pre-op  PACU  AHSP-PACU/Pre-op  CVIC  CT tapr  GI lab  MRI tapr  NUC  MD Tapr  Rad intervention  US Tapr  Vas U/S Tapr

16 Emergency Department Medication Reconciliation Evaluation 16 Staffing on 5/12/14: 13 med recs completed (14%) Pharmacist: 1100-1930 Pharmacy Technician: 1100-1930 Pharmacy Resident: 1700-2100

17 Emergency Department Medication Reconciliation Evaluation 17 Staffing on 5/13/14: 17 med recs completed (21%) Pharmacist: 1100-1930 Pharmacist: 1630-0200 Pharmacy Technician: 1100-1930 Pharmacy Resident: 1700-2100

18 Emergency Department Medication Reconciliation Evaluation 18 Staffing on 5/14/14: 31 med recs completed (37%) Pharmacist: 1100-1930 Pharmacist: 2030-0200 Pharmacy Technician: 1100-1930 Pharmacy Resident: 1700-2100

19 19 Staffing on 5/15/14: 25 med recs completed (28%) Pharmacist: 1100-1930 Pharmacist: 1600-0100 Pharmacy Technician: 1100-1930 Pharmacy Resident: 1700-2100 Emergency Department Medication Reconciliation Evaluation

20 20 Staffing on 5/16/14: 18 med recs completed (26%) Pharmacist: 1100-1930 Pharmacy Technician: 1100-1930 Pharmacy Resident: 1700-2100 Emergency Department Medication Reconciliation Evaluation

21 21

22 22 Emergency Department Medication Reconciliation Evaluation Recommendations Proposed weekday coverage for ED medication reconciliation staffing: Proposed weekend (Saturday or Sunday, to be determined based on weekend analysis) coverage for ED medication reconciliation staffing: PharmD: 1 FTE 0900-1730 1 FTE 1100-1930 1 FTE 1730-0200 Pharmacy tech: 1 FTE 0800-1630 1 FTE 1530-0000 Pharmacy Residents: M-F 1700-2100 PharmD: TOC pharmacist staffing every 3 rd weekend 1100-1930 Pharmacy tech: 1100-1930 Pharmacy Residents: One day weekend coverage/month Pharmacy interns: to be determined

23 2. Order Verification and Staffing Model 23

24 Order Verification and Staffing Model Background: An evaluation of the current staffing model is needed to ensure trends in workload demands are matched with the appropriate resource allocation and staffing responsibilities. Per labor laws, when an employee works for a period of more than five hours, a meal period must be provided no later than the end of the employee’s fifth hour of work. Objective: Objectively evaluate the current inpatient pharmacy staffing model based on order verification demands to improve workflow using existing resources. Study Period: Weekdays from April 1, 2014 – April 30, 2014

25 Order Verification and Staffing Model Methods: A medication order verification report for April 2014 was extracted from Epic Weekend, pediatric, oncology and ICU order verifications for the month of April were removed from the report The number of pharmacists working each hour was entered into the data collection spreadsheet using the pharmacist staffing model available for April 2014 The average number of orders verified per pharmacist per hour was calculated using the total number of pharmacists scheduled per hour and the total daily verifications per hour Inclusion: Medication order verifications from weekdays in April 2014 Exclusion: Orders verified for pediatrics, AHSP, Oncology (4SW, OCC), ICU beds (Saperstein) Staffing pharmacists for areas excluded from the analysis 25

26 Results: On average, the most order verifications on weekdays occur between 1500-1800 (ranging from 264-304 order verifications/hour/day) On average, the most order verifications per pharmacist per hour occurs from 1800-2000 (19-27 orders per pharmacist) and 0000-0200 (19-22 orders per pharmacist) Results are summarized in the attached spreadsheet: Order Verification and Staffing Model 26

27 Recommendations: Recommend scheduling lunch for med/surg AM staff in 2 shifts: ₋1 st shift: 1145-1230 ₋2 nd shift: 1245-1330 Recommend scheduling lunch for med/surg PM staff in 2 shifts: ₋1 st shift: 1600-1645 ₋2 nd shift: 1645-1730 Order Verification and Staffing Model Recommendations 27

28 Overview Anticoagulation iVent Analysis (3) Daptomycin Medication Use Evaluation (4) Risk Assessment of Procedural Areas (5) Ready to Administer Dosage Forms Analysis (6) Readmission Prediction Score Analysis (7) Naloxone Medication Use Evaluation and Screening Tool (8) 28

29 3. Anticoagulation iVent Analysis 29

30 Anticoagulant iVent Analysis Background: Although anticoagulants can be life-saving therapies, there are serious risks associated with improper use By evaluating anticoagulation prescribing errors intercepted by pharmacists, the value of pharmacy services can be demonstrated and common errors can be evaluated for prevention strategies. Objective: To evaluate iVents involving anticoagulants, classify trends in errors and identify areas of improvement for current prescribing practices. Methods: Retrospective review of all life-threatening and serious/significant iVents involving anticoagulants as documented in Epic Study Period: January 1 st, 2014 through March 31 st, 2014 30

31 iVents Evaluated: 200 iVents were included in the analysis ⁻11 Life-Threatening ⁻189 Serious/Significant 31 Anticoagulant iVent Analysis

32 32 Anticoagulant iVent Analysis

33 33 Anticoagulant iVent Analysis

34 34 Anticoagulant iVent Analysis

35 35 Anticoagulant iVent Analysis

36 36 Anticoagulant iVent Analysis

37 37 Problem Identified RX Recommendation Outcome AvoidedSeverity Ranking Patient with anaphylaxis allergy to heparin was ordered heparin prophylaxis Discontinue therapyAnaphylaxis Life Threatening Patient that received TPA was ordered heparin prophylaxis Discontinue therapyHemorrhage Heparin 10 units/mL was ordered for infant as PICC line flush Correct concentrationHemorrhage Heparin order placed for 600 units/kg/hour Correct rateHemorrhage Patient continued on heparin flush with positive PF4 Discontinue heparinThrombus Duplicate treatment dose anticoagulant orders  2 Rivaroxaban and heparin drip  2 Dabigatran and heparin drip  Rivaroxaban and tx enoxaparin  Dabigatran and tx enoxaparin Discontinue one of the therapies Hemorrhage; inhibiting multiple anticoagulation pathways

38 38 Anticoagulant iVent Analysis Recommendations 1.Allow pharmacists to discontinue prophylactic heparin or enoxaparin when treatment anticoagulation is initiated (i.e. dabigatran, rivaroxaban, and apixaban) 2.In patients on warfarin and heparin/LMWH per pharmacy, allow pharmacists to discontinue heparin drip/LMWH in the setting of a therapeutic INR for two days and at least 5 days of overlapping therapy 3.Continued education for providers, especially for the General Internal Medicine service 4.Pharmacists should initiate and discontinue ordering of “No IM injections”, “No ASA >162mg” and “RN to notify physician and pharmacists for signs/symptoms of bleeding” when all anticoagulation is ordered or discontinued.

39 4. Daptomycin Medication Use Evaluation 39

40 Daptomycin Medication Use Evaluation Background: Daptomycin is a bactericidal, lipopeptide antibiotic used for the treatment of serious gram-positive infections Daptomycin is currently restricted for use in: ₋ MRSA bacteremia/right-sided endocarditis and severe vancomycin allergy ₋ Documented MRSA SSTI and severe allergy to vancomycin In FY13, the total daptomycin expenditure was $478,988.50 Objective: To evaluate daptomycin use Methods: Retrospective review of daptomycin orders in April 2014 to evaluate for proper dose and indication Study Period: April 2014 40

41 Daptomycin Medication Use Evaluation 41 Daptomycin MUE Demographics Number of Patients (#)28 Average Age (years) 63 ± 13 Gender14 males, 14 females Average number of doses (#) 5 ± 3.4 Unit breakdown (%) Inpatient (89%):  ICU: 5 patients  4 th floor: 3 patients  5 th floor: 4 patients  6 th floor: 3 patients  7 th floor: 6 patients  8 th floor: 4 patients Outpatient (11%)  Procedure Center: 3 patients

42 Daptomycin Medication Use Evaluation 42 Summary of inpatient daptomycin UseN=25 # of patients followed by ID physician (%)25/25 (100%) # of treatment courses meeting criteria0/25 # of treatment courses with an acceptable indication or dose 21/25 (84%) # of treatment courses approved by AUR (%)9/25 (36%)

43 Daptomycin Medication Use Evaluation 43 PatientErrorIndicationDose Total doses Approved by AUR 1Incorrect Dose MRSA joint infection with vancomycin allergy described as flushing, PVCs, SOB 2.3-6 mg/kg 7No 2Incorrect Indication Neutropenic patient spiking fever on vancomycin (likely drug fever) with no culture growth 5mg/kg9No 3Incorrect Indication Prosthetic joint infection with no culture growth; MRSA and VRE screens negative 6mg/kg9No 4Incorrect DoseMRSA osteomyelitis5mg/kg2No

44 Daptomycin Medication Use Evaluation 44 Daptomycin has been shown to cause myopathy and the manufacturer recommends creatine phosphokinase (CPK) monitoring at least weekly. Analysis of weekly CPK Monitoring for orders > 7 days Patients with CPK monitoringYes3/7 (43%)

45 Daptomycin Medication Use Evaluation 45

46 46 Daptomycin Medication Use Evaluation Recommendations The following changes to the daptomycin use criteria are recommended: – Remove “Documented MRSA SSTI and severe allergy to vancomycin” indication – Add “Documented infection with VRE and resistant to ampicillin/penicillin/linezolid or severe allergy to linezolid” Reinforce requirement of pharmacy staff to call AUR for approval of all daptomycin orders that do not meet CSMC criteria. Future directions: Reevaluate the drug-drug interaction severity between linezolid and other serotonergic medications.

47 5. Risk Assessment of Procedural Areas 47

48 Risk Assessment of Procedural Areas Background: The Joint Commission (TJC) in its Hospital Program, Medication Management Chapter, Standard: MM.05.01.01 EP1 states: “Before dispensing or removing medications from floor stock or from an automated storage and distribution device, a pharmacist reviews all medication orders or prescriptions unless a licensed independent practitioner controls the ordering, preparation, and administration of the medication or when a delay would harm the patient in an urgent situation (including sudden changes in a patient's clinical status), in accordance with law and regulation.” Objective: To evaluate medication stock of all procedural areas for compliance with TJC standards 48

49 Risk Assessment of Procedural Areas Methods: Floorstock lists for all included procedural areas were reviewed for indication and compliance with TJC standards. Any questions were clarified with pharmacy and nursing staff of the procedural areas. A Pyxis optimization report was utilized to determine the use requirements of questionable medications Study Period: April 2014 49

50 Risk Assessment of Procedural Areas 50 Summary of procedural area medications evaluated Total number of medication formulations evaluated (#) 199 Summary of medication dosage forms  38 oral agents  4 capsules  8 suspensions  26 tablets  21 topical products  124 injectable agents  12 inhaled products  4 suppositories

51 Risk Assessment of Procedural Areas 51

52 Risk Assessment of Procedural Areas 52 Reason for Lack of Pharmacist Review* Reason# of MedicationsMedication Location Managed by LIP65 medications Nursing Protocol15 medications Urgent Medication157 medications No longer stocked1 medications Ammonia Inhalant GI Lab No indication7 medications Acetylcysteine 600mg capsules Cath Lab Ibuprofen Pediatric suspensionProcedure Center Pyxis Ibuprofen 400mg tablet Procedure Center Pyxis Methylprednisolone sodium 1000mg IV solution 7Stone Pyxis Prednisone 5mg tabletProcedure Center Pyxis Ranitidine 150mg tabletCath Lab Triamcinolone 0.1% topical cream Procedure Center Pyxis *Please note that some medications have multiple reasons

53 53 Medications NOT Meetings TJC Standards Medication IndicationLocationComments Acetylcysteine 600mg capsules IV contrast nephrotoxicity prophylaxis Cath Lab  Not urgent, should be verified by pharmacist Ibuprofen Pediatric suspension Pain, fever Procedure Center Pyxis  Oral pain medication not urgent  Pyxis optimization report shows no use in the last year Ibuprofen 400mg tablet Pain, fever Procedure Center Pyxis  Oral pain medication not urgent  Pyxis optimization report shows last use is 6/21/2013 Methylprednisolone 1000mg IV solution Unclear7Stone Pyxis  Procedural center RNs unsure of indication and need in procedural area  Pyxis optimization report shows medication was first stocked 9/17/13 and has not been used since Prednisone 5mg tabletUnclear Procedure Center Pyxis  Procedural center RNs unsure of indication  Pyxis optimization report shows no use since December 2013 Ranitidine 150mg tablet Heartburn, ulcer prophy Cath Lab  Oral medication not urgent; IV ranitidine is available for urgent use Triamcinolone 0.1% topical cream Skin irritation Procedure Center Pyxis  Topical product is not urgent and is verified by pharmacists occasionally  Pyxis optimization report shows product was used 6 times in past year. Last used in April. 53

54 54 Risk Assessment of Procedural Areas Recommendations Recommend removing ammonia inhalant from procedural area floorstock list on intranet Recommend removal of the following medications from procedure center floor stock: – Ibuprofen Pediatric suspension – Ibuprofen 400mg tablet – Methylprednisolone sodium 1,000mg IV solution – Prednisone 5mg tablet – Ranitidine 150mg tablet – Triamcinolone 0.1% topical cream Recommend development of an Acetylcysteine use protocol

55 6. Ready-to-Administer Dosage Form Analysis 55

56 Ready-to-Administer Dosage Form Analysis Background: The Joint Commission (TJC) update to its Hospital Program, Medication Management Chapter, Standard: MM.03.01.01 released in December 2013 states: “Medications in patient care areas are available in the most ready-to-administer forms commercially available or, if feasible, in unit doses that have been repackaged by the pharmacy or a licensed repackager.” Objective: To evaluate medications dispensed to patient care areas to ensure compliance with TJC standards. Methods: Daily dispense reports for January 29 th through January 31 st, 2014 were run and filtered for bulk and bulk liquid medication dispenses. Each bulk medication dispensed was evaluated for compliance to TJC standards Study Period: January 29 th, 2014-January 31 st, 2014 56

57 Ready-to-Administer Dosage Form Analysis 57 Results are summarized on the following slides: 589 bulk orders were dispensed from January 29 th to January 31 st 111 bulk medications were reviewed

58 Ready-to-Administer Dosage Form Analysis 58

59 Ready-to-Administer Dosage Form Analysis 59 Summary of bulk order compliance with TJC Standards Compliance with TJC Standards Description of Compliance Number of Products (n=111) Yes Dispensed smallest commercially available product size, unable to unit dose 69 Unit dosed16 Dispensed from Pyxis6 Compounded product5 Size dispensed required for order3 Other  Medrol dose pack  Chlorhexidine solution 2 No Products with recommendations for change 10

60 Ready-to-Administer Dosage Form Analysis 60 Summary of products not in compliance with TJC standards Product Quality dispensed Proposed dispensed product Cost Difference 1 Bacitracin-polymyxin B (POLYSPORIN) ointment 1 oz tube0.5 oz tube-$1,176.53 2Bacitracin ointment1 oz tube0.5 oz tube$8,555.81 3Phenol throat spray (CHLORASEPTIC) spray4 oz bottle1 oz bottle$12,360.30 4 Trypsin-balsam-castor oil (GRANULEX) topical spray 1 spray 4 oz spray bottle2 oz spray bottle$1,130.49 5Ketorolac (ACULAR) Ophthalmic Solution 0.5%5 mL drop bottle3 mL drop bottle-$34.48 to $327.58 6Lidocaine (XYLOCAINE) 2 % jelly30 mL tube5 mL tube $32,458.3 to $43,572.78 7 Multivits-mins-coenzyme Q10 (AQUADEKS) 400 mcg/mL oral drops 10mL bottleUnit dose 8Pediatric multivitamin (POLY-VI-SOL) oral drop10mL bottleUnit dose 9 Pediatric multivitamin-iron (POLY-VI-SOL with IRON) drop 10mL bottleUnit dose 10 Pediatric ferrous sulfate oral solution 10mL bottleUnit dose

61 61 Ready-to-Administer Dosage Form Analysis Recommendations Smaller product sizes should be purchased for: – Bacitracin-polymyxin B (Polysporin®) ointment – Bacitracin ointment, phenol throat spray – Trypsin-balsam-castor oil (Granulex®) topical spray – Ketorolac ophthalmic solution Smaller lidocaine 2% jelly tubes (5mL) should be purchased for procedural areas and emergency department to limit use on multiple patients

62 7. Readmission Prediction Score Analysis 62

63 Readmission Prediction Score Analysis Background: Organization has developed a 30 day readmission prediction score containing 9 patient specific variables:  Number of prior to admission (PTA) medications  Use of opioids, anticoagulants, digoxin  Dialysis dependency  Oncology diagnosis  Last hemoglobin  Last blood sodium  Recent emergency department visits/hospital admissions A score of ≥ 23 is considered High Risk of 30 day hospital readmission in the model. Objective: To determine the utility of the Readmission Prediction Daily Report for pharmacy staff use in transitions of care services. 63

64 Readmission Prediction Score Analysis 64 Hospitalized patients with a Readmission Prediction score of ≥23 Analysis A (n=25) Analysis B (n=43) Patients with score ≥23 who met pharmacist criteria for medication reconciliation 15/25 (60%)28/43 (65%) Patients meeting pharmacist criteria for medication reconciliation received one during their admission 8/15 (53%) 12/28 (43%) 5 patients were assessed for MedAL: 3/5 qualified for post DC follow-up

65 Readmission Prediction Score Analysis 65 Hospitalized patients with a Readmission Prediction score of <23 (n=275) Patients with score <23 who met pharmacist criteria for medication reconciliation 127/275 (46%) Pharmacist inclusion criteria On >10 medications PTA116/127 (91%) On anticoagulants and >10 medications PTA11/127 (9%)

66 Readmission Prediction Score Analysis Conclusion: Only ~60% of patients with score ≥23 meet pharmacist criteria for medication reconciliation. The Readmission Prediction Score includes all over-the- counter medications, duplicate medications and as needed medications in the number of PTA medications Current pharmacist medication reconciliation criteria identifies more medication related high risk patients while not including patients that are at high risk of readmission for non-medication related problems. Recommendation: Pharmacists should continue to utilize inpatient medication reconciliation criteria. As more resources are allocated to enhanced transitions of care pharmacy services, we will be better able to prevent medication related readmissions. 66

67 8. Naloxone Medication Use Evaluation and Screening Tool 67

68 Naloxone Medication Use Evaluation and Screening Tool Background: The Joint Commission 2012 Sentinel Event Alert as well as the Centers for Medicare and Medicaid Services (CMS) 2014 Clinical Standards focused on the need for safe opioid prescribing practices and the risk associated with opioid use. Naloxone is a pure opioid antagonist used to counter the effects of opioid overdose By evaluating the use of naloxone,we can evaluate preventable prescribing errors associated with opioid use and determine if naloxone is being used correctly Currently, all patients at must be evaluated by nursing for airway risk to determine their risk of respiratory depression following administration of opioids. Objective:To evaluate the use of naloxone and develop a simple screening tool to assess patients from naloxone usage reports and compliance to all regulatory requirements. 68

69 Naloxone MUE and Screening Tool Study Period: May 2014 Methods: Naloxone intravenous (IV) push usage reports were processed for May 2014. All naloxone IV push administrations were evaluated for patient risk factors and indication. Results: 23 naxolone IV push administrations occurred in May 2014 8 of which were not included in the analysis because the naloxone was administered for nausea/vomiting or itching Results are summarized in the following slides 69

70 Naloxone MUE and Screening Tool 70 Study Demographics (n=15) Average age (years) ±SD57 ± 20 Weight (kg) ±SD72.5 ±17 Gender8 females/7 males Naloxone Dose 0.04 mg1 patient 0.1 mg1 patient 0.2 mg3 patients 0.4 mg9 patients 0.5 mg1 patient Patient identified as an airway risk using current protocol Yes2 No10 Not Assessed3 Average 24 hour Morphine Milligram Equivalent (MME) 79 (0-300)

71 Naloxone MUE and Screening Tool 71 * received intermittent/ scheduled/ combination intermittent & scheduled IV/PO opioids

72 Naloxone MUE and Screening Tool 72 Summary of naloxone response Vital Sign Prior to naloxone administration After naloxone administration Average Heart Rate (n=13)91.4 (80-114)103.6 (80-136) Average Respiratory rate (n=15)18 (6-30)24 (10-39) Average O2 sat (n=13)99 (94-100)98 (89-100) Average Pain score (n=4)1.75 (0-4)2.5 (0-10) Attempted to assess sedation scale pre- and post-naloxone administration: Pre-naloxone administration:  3 patients assessed with Aldrete Score  4 patients with GCS  1 patient with RASS  7 not assessed Post-naloxone administration:  1 patient assessed with Aldrete Score  6 patients with GCS  1 patient with RASS  7 patients not assessed

73 Naloxone MUE and Screening Tool 73

74 Proposed Screening Tool 74 Risk Factors: (yes/no) Opioid Naïve Scr ≥1.3 Age ≥60 years Smoking history Surgery in last 24hrs Concomitant* Opioids Cardio/ pulmonary disease Sedatives in past 24 hrs MME in past 24hrs Yes or No answers are recorded # for cases reviewed (n=16) 1078611 512 80 (0-300) Average number of risk factors per patient = 4.7 (3-7) *received intermittent/ scheduled/ combination intermittent & scheduled IV/PO opioids

75 Proposed Screening Tool 75 Vital signs prior to naloxone administration Vital signs after naloxone administration Pulse Ox (y/n) O2 satHRRRPain ScoreO2 satHRRRPain Score

76 Naloxone MUE and Screening Tool 76 Summary of Findings Evaluation of the naloxone IV push administration records in May 2014, showed limited evidence that over-prescribing of opioids at CSMC is contributing to naloxone use The Airway Risk assessment tool currently being used does not accurately identify patients at high risk of respiratory depression secondary to opioid use Patient vital signs prior to and immediately after naloxone administration are inconsistently documented Naloxone indication and time of administration can be difficult to obtain from a retrospective chart review Use and type of sedation scale varies when patients are assessed for AMS secondary to opioid use.

77 Naloxone MUE and Screening Tool 77 Recommendations Naloxone orders should require a drop-down menu to specify indication for use Pain management should be consulted to establish a naloxone use policy. The policy should include: Naloxone use criteria Required naloxone vital sign documentation and standardized sedation scale New risk assessment tool to accurately identify patients at risk for respiratory depression following opioid use Nursing should be educated on need for complete and consistent vital sign documentation in patients requiring naloxone use. Daily naloxone use reports should be validated and filtered to not include administrations for itching and nausea/vomiting.

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