Presentation Outline

Transcription

1 Pharmacist Practice Expectations Weighing Value and Setting Priorities Nick Honcharik, Pharm. D. Presentation Outline Pharmacist Practice Expectations Background/rationale Development Selective examples Application 2010 Management Model Application Refinement of PE Future Direction 1

2 Purpose Assist in standardization and prioritization of practice activities across acute care sites. Provide a tool for individuals to selfevaluate their practice. Assist in the orientation/education of new staff. Development Initial Working Group Prioritize activities for internal medicine practice sites Med Safety Application Develop activity list which would influence patient safety 2

3 Initial Working Group Objective: Prioritize activities for internal medicine practice sites 11 members 8 front line staff 1 Pharm. D. 2 Managers (facilitators) Collated existing site-specific policies regarding the role and practice expectations of Pharmacists Collated clinical tools from sites Initial Working Group Developed a list of core (must do) and desirable (should do) activities Focus groups, discussion, Delphiconsensus Evolution to activities for all decentralized acute care pharmacists A living document 3

4 Med Safety Working Group Created based on recommendation from Regional Medication Safety Committee. Objective: Develop list of activities to influence patient safety. Developed guidelines for pharmacist assessment/prioritization of high alert medications; renal dysfunction dosage adjustment. Use of site best practices e.g. otovestibular toxicity monitoring for aminoglycosides Activities to Be Strived For at All Acute Care Sites Decentralized role of pharmacists Pharmacist rounding with patient care team Pharmacotherapy monitoring Provision of drug information Selective patient interview Selective patient education 4

5 Rationale for Activities Chosen Evidence to help determine priorities Bond Papers Decreased mortality/med errors with specific activities Literature on team rounding Minimization of adverse drug events ISMP, IOM recommendations Core Activities ( Must ) Identify/resolve DRP s actual potential Individualize Tx High alert meds Per PK, organ function Rounding Monitoring/follow-up DI immediate Continuity of care within site Selective patient interview to clarify allergy and issues at order entry Documentation Order entry Med order review/triage Formal consults Med error investigation Medication reconciliation?? 5

6 Desirable Activities ( Should ) Prepare therapeutic plan and associated recommendations Selective patient interview and education Education to health professionals DI not needed immediately Continuity of care between sites & community pharmacies Drug use management Review of MAR Committees Regional/site initiatives Team Rounding - Rationale Positive impact Decrease med errors Identify need for addition of a med Influence med orders at time of writing Obtain more clinical information Opportunity for education Part of the team 6

7 High-alert Medications Aminoglycosides Phenytoin Clozapine Digoxin Lithium Anticoagulants Hypoglycemics Opiates Chemotherapy Additional agents per pharmacist discretion High Alert Medications Rationale Increased risk of harm to patient Targeted by ISMP Usually drug distribution activities Target activities to minimize patient harm Pharmacist can minimize patient harm Aim to identify actual/potential DRP s Opportunity to review all meds/drp s Activities Rounds Proactive review of chart and med orders Ongoing monitoring/follow-up 7

8 Aminoglycosides Targeted Activities Assess initial orders Dosage based on CrCl Predicted Cp 2 mg/l contact prescriber Monitoring/Follow-up Develop monitoring plan to minimize Cp 2 mg/l and Cr s increased > 40umol/L Identify pt duration > 7 days assess for otovestibular damage Aminoglycosides Targeted Activities Monitoring/Follow-up Develop monitoring plan: Who will monitor How monitoring will occur How frequent to monitor Duration of monitoring Ensure communication of monitoring plan 8

9 Evaluate: Opiates Targeted Activities appropriateness of long-acting formulation dosage Change in dosage impacting potential for adverse events Change in opiate agent Change in route of administration Dosage based on renal/hepatic function Drug interactions Application Viewed as practice to strive towards Training of new staff Prioritization of activities Standardization of activities among pharmacists Tool for self-development Suggestions for how to incorporate PE into individual pharmacist s practice Development of practice directives Mandatory versus voluntary 9

10 Prioritization Things to keep in mind You can not do everything Each day will be different Patient mix Types of meds, problems Unforeseen circumstances Use of rounds to help filter issues and prioritize activities Temper team priorities with your priorities Utilize a to-do list Communicate issues which need follow-up Peers, nursing/physician staff Prioritization Things to keep in mind Urgency of the issue, situation, DRP Likelihood of occurring e.g pt at risk for Time course of event Consequences of delaying intervention How much time to spend on an activity Know when to seek assistance With additional experience you will Increase personal database Prioritize activities more quickly Accomplish more on a daily basis 10

11 Self-Development Outline Review of PE document self evaluate Activities not performed consistently Prioritize Incorporate into practice» Literature review targeted topics» Discuss with colleague(s)» Incorporate into normal routine Individualize Medication Therapy Dosage adjustment for kidney dysfunction An actual or estimated CrCL should be obtained to ensure that drug doses are adjusted for renal dysfunction for the following types of patients: 65 years of age Diagnosis of renal dysfunction or renal failure (per medication order sheet) Patients who receives medications of a type or in a dose or schedule that suggests impairment of renal function 11

12 Individualize Medication Therapy Dosage adjustment for kidney dysfunction The following meds MUST have CrCl and dosage assessed with the initial order: Aminoglycosides Vancomycin Pipercillin, pipracillin/tazobactam Ceftazidme Ciprofloxacin/gatifloxacin Cotrimoxazole Allopurinal Digoxin Etc. Meds which SHOULD have CrCl and dosage assessed with initial order. Pharmacist Documentation of Medication Allergy Directive Known allergy information must be added to computer profile Unable to determine allergy status - Follow-up with patient if possible Add description or nature of allergy to the computer profile if available (must) Allergy identified with a new med order Must verify, clarify or identify type of reaction prior to dispensing Call RN and advise not to give until clarified 12

13 Pharmacist Documentation of Medication Allergies Directive New allergy information obtained by you Decentralized Pharm. must document info in the chart All Pharm. should update medical information database as appropriate Pharmacist Documentation of Medication Allergies Directive Desirable decentralized Pharm. activities Determine allergy status of patients with no known allergy information Determine type of reaction to patients with known allergies to antibiotics and opiates (which have not yet been prescribed) Via chart, patient/caregiver interview 13

14 2010 Management Model Support Structure Regional Clinical Practice Teams Critical Care, Renal Program Pediatrics, Neonatology, Women s Family Medicine, Ambulatory Care, Emergency Medicine, Kidney Transplant, HIV Clinic, ID Surgery, Prehab, Oncology, Nutrition Long Term Care, Rehab Mental Health 2010 Management Model Support Structure Clinical Practice Team members Pharmacists Clinical Resource Pharmacist Clinical Manager Clinical Practice Council Regional Education Team 14

15 Practice Expectations and 2010 Model Refinement Collaborative Team building Specific for clinical practice area Review what pharmacists are doing Content/Prioritization Evidence CSHP 2015 Priorities/objective of clinical programs High value quality action» Bruchet et al, CJHP 2011; 64:42-47 Future Directions Mandatory versus voluntary Influence of clinical programs Link to competency and performance appraisal Quality indicators Impact on outcome 15

16 Questions? 16