1. RISHP SHOWCASE 2015 C. MAXWELL M. KELLEY Minimizing Polypharmacy: Addressing Therapeutic Duplications

2. Objectives Technician Objectives:  Understand when therapeutic duplications occur in the ordering of PRN medications.  Provide an example of a therapeutic duplication.  Understand how guidelines can be developed to categorize severity of common psychiatric PRN indications for medications to avoid therapeutic duplications.

3. Objectives Pharmacist Objectives:  Describe the process of guideline/order set development for PRN indications of anxiety, agitation, psychoses, nausea/vomiting and constipation in a specialized psychiatric hospital and community hospitals.  Explain how use of PRN reasons defined by a guideline/order set facilitates compliance with Joint Commission standards and regulations.  Choose the appropriate PRN reason for psychiatric symptoms utilizing the provided guideline.

4. Therapeutic Duplication occurs when: More than 1 med is ordered for a single indication The level, degree, or the severity for the indication is not specified There is not hospital policy or guideline to guide nursing staff on when a med is to be administered

5. Corrective Action Steps Clarify some definitions of specific PRN Reasons in Power Plans Revise the default PRN Reasons for some PRN orders in Power Plans Create Hospital Guidelines that define the Degree of Severity of some common psychiatric symptoms

6. Guidelines for Psychiatric PRN Reasons Guidelines are developed to categorize some common symptoms for which PRN meds are indicated Anxiety and Severe Anxiety Agitation and Severe Agitation Psychosis and Severe Psychosis

7. ANXIETY SEVERE ANXIETY Anxious, apprehensive, movements not aggressive Physical distress, or feelings of panic Nausea or abdominal distress Mild trembling or shaking Feeling tense or “wound up” Restlessness Physical distress leading to impairment of ADL Inability to sit still or sleep Marked trembling or shaking Fear of losing control Fear of dying Feelings of panic with somatic complaints (sweating, shortness of breath, hyperventilation, chest pain, palpitations, tachycardia,) Paresthesia (numbness or tingling sensations) Feeling dizzy, unsteady, light-headed or faint Physical distress leading to impairment of ADL Inability to sit still or sleep Marked trembling or shaking Fear of losing control Fear of dying Feelings of panic with somatic complaints (sweating, shortness of breath, hyperventilation, chest pain, palpitations, tachycardia,) PRN Guideline: Anxiety

8. AGITATION SEVERE AGITATION Impulsive, impatient, low tolerance for pain or frustration Uncooperative, resistant to care, demanding Rocking, rubbing, moaning or other self- stimulating behavior Restlessness, pacing, excessive movement Rapid, loud or excessive talking Sudden changes of mood Violent, combative and/ or threatening violence toward people or property Explosive and/ or unpredictable anger Self- abusiveness, physical and/or verbal Immediate danger to self or others PRN Guideline: Agitation

9. PSYCHOSIS SEVERE PSYCHOSIS Auditory or Visual Hallucinations Delusions Paranoid Thoughts Auditory or Visual Hallucinations with threats of harm to self or others Delusions with threats of harm to self or others Paranoid Thoughts with threats of harm to self or others PRN Guideline: Psychosis

10. Oral IM Anxiety – Benzodiazepines, Antihistamines Agitation - Antipsychotics Severe Anxiety – Benzodiazepines, Antihistamines Severe Agitation - Antipsychotics Default PRN Reasons in Power Plans

11. PRN Guidelines: Nausea/Vomiting Order of use defined in the PowerPlans  Ondansetron: Use first for N/V  Promethazine: Use for N/V refractory to ondansetron  Metoclopramide: Use for N/V refractory to ondansetron and promethazine

12. PRN Guidelines: Constipation Order of use defined in the PowerPlans  Colace: PRN reason for stool softening  All laxatives below given with colace  Senna: Use first for constipation  MOM: Use if patient still constipated 24 hours after Senna  Bisacodyl PO/PR: Use if patient still constipated 12 hours after MOM  If both PO/PR ordered, use least invasive route first  Miralax: Use if patient is still constipated after 48hours from initial laxative dose

13. Therapeutic Duplications: Next Steps Therapeutic Duplication Policy  Define order of preference for medications by indication  Set criteria for IV or PO options  Allow pharmacists to clarify orders per “policy/protocol” Pharmacist responsibility at time of verification Continual monitoring  Regular audits of duplicates and corrective steps

14. Summary TJC and DOH are focused on Therapeutic Duplications Most commonly found duplicate orders:  Pain  Agitation/anxiety  Nausea/vomiting  Constipation Creation of PowerOrders and a policy  Minimize prescribing of duplications  Provide clarification when duplications exist Goal is to minimize patient harm, adverse drug events and unclear orders