Why your OR needs YOU

Transcription

1 Why your OR needs YOU Stories from our journey with integrating clinical pharmacy into perioperative services Sara Jordan, PharmD, BCPS Brian Kramer, PharmD Elise Weyrauch, PharmD, BCPS Lauren Wood, PharmD Adam Trimble, PharmD Grant Medical Center, OhioHealth Columbus, OH April 2016 The speakers have no actual or potential conflicts of interest in relation to this presentation.

2 Learning Objectives Pharmacists Identify potential roles for the pharmacist in the perioperative arena Describe clinical pharmacist interventions to optimize perioperative medications Technicians Describe ways the OR pharmacy technician can support clinical pharmacist functions

3 Contents Introduction and beginning of service line Antimicrobial stewardship in the OR Role in massive transfusion protocol (MTP) Role in high risk therapies Role in other perioperative emergencies Service expansion and future directions Summary and recommendations

4 We need this STAT!! Pharmacy This is unacceptable! They can never meet our needs OR Pharmacist Everythingfor them is STAT Why are they always so mean? OR What are they talking about?

5 Hospital Continuum of Care ED ICU Floor Discharge OR?

6 ASHP Guidelines Outdated Operations-focused What are our clinical roles?

7 Perioperative Pharmacotherapy Antimicrobial stewardship High-risk therapies Anticoagulants Antifibrinolytics Vasoactive agents General and regional anesthetics Chemotherapy Medical emergencies Trauma Malignant hyperthermia Local anesthetic systemic toxicity Medication safety Narcotic compliance

8 Grant Medical Center (GMC) OhioHealth hospital in downtown Columbus 640 licensed beds Not-for-profit, community teaching hospital Level 1 trauma center >85,000 ED admissions, ~5500 traumas, and >20,000 surgeries performed annually Inpatient and ambulatory surgery centers and numerous other procedural areas

9 Beginnings of Service Line Resident vector Asking and answering questions Identifying opportunities Improving small processes Building rapport Becoming a point person Gaining allies Demonstrating Need Garnering Support

10 Med Charge Capture Physician Satisfaction Order Volume Post-op Complications Financial Justification Narcotic Compliance Core Measures Throughput

11 Workflow Order processing Clinical Bedside Support Pre-Op Abx Review and Continuity Process Improvement Drug Info Emergency Response Inpatient Profile Review Narcotic Compliance Distribution

12 Antimicrobial Stewardship in the OR Sara Jordan, PharmD, BCPS

13 Preoperative Antibiotics SCIP Optimal Pre-Op Antibiotic Started daily prospective review and optimization Coordinated order set revision Clinical Practice Guidelines Local ASP Surg Infect (Larchmt) Feb;14(1):

14 Story Sitting at the Table Quality review of post-op infection patient developed fevers and elevated WBC, started on ertapenem. Cultures finalized with MRSA. Patient discharged to SNF. Does anyone see any opportunities for improvement in this case?

15 Impacting Outcomes 1-4 expert reviews monthly Average 78 interventions on antibiotics monthly Improved compliance with SCIP core measures Increased charge capture totaling >$1.9 million annualized

16 Improved SCIP Compliance % Reduction in SCIP Misses FY13 579/582 FY14 543/544

17 Order processing Clinical Bedside Support Pre-Op Abx Review and Continuity Process Improvement Drug Info Emergency Response Inpatient Profile Review Narcotic Compliance Distribution

18 Massive Transfusion Protocol (MTP) Adam Trimble, PharmD

19 Massive Transfusion Protocol Purpose Ensure continuous and timely access to blood components for use in the resuscitation of patients with massive hemorrhage Grant Medical Center Definition Patient requires 6 units PRBCs within one hour with continued hemorrhage Patient population Trauma Most common Surgical Post-partum hemorrhage (PPH)

20 OR Pharmacy Role Pharmacist Role Emergency Response Ensures appropriate medications are ordered Facilitates timely medication administration Technician Role Prepare medications Replenish supply of critical medications

21 Tranexamic Acid Ordering and Dosing Appropriate for patient? Trauma dose 1 Bolus mg over 10 minutes Continuous infusion mg over the next 8 hours PPH dose mg bolus followed by second 1000 mg bolus as needed Timely administration 1. Lancet Jul 3;376(9734): Trials. 2010; 11: 40

22 *Citrate binds Ca 2+ * J. Anaesth. 2005;95:

23 MTP Supportive Measures Acidosis Calcium replacement Antimicrobial prophylaxis Selection and initial dosing Intra-operative re-dosing when EBL>1500mL Surg Infect (Larchmt) Feb;14(1):

24 Other Hemostatic Strategies Commonly considered coagulation factors Recombinant Factor VIIa(NovoSeven ) Prothrombin complex concentrate (Kcentra ) Recommend optimal selection and dosing Prevent inappropriate use and unnecessary waste Facilitate safe and timely administration Crit Care. 2013; 17(2): R76

25 MTP Story 48yom presented with injuries related to MVC My role Facilitated administration of tranexamic acid Recommended administration of sodium bicarbonate and calcium chloride Reminded need to re-dose cefazolin Recommended optimal coagulation factor for refractory bleeding

26 Role in High Risk Therapies Elise Weyrauch, PharmD, BCPS

27 Additional Involvement Pharmacy participates in high risk situations to improve safety Examples: Cardiothoracic surgery (CTS) Use of direct thrombin inhibitors Malignant hyperthermia PACU complications Chemo

28 Cardiothoracic Surgery (CTS) Pharmacy Drug distribution and safety Anesthesia Maintain stability of patient Surgeon Needs support of others to accomplish task Perfusion Cardiopulmonary bypass (CPB)

29 OR Pharmacist Roles in CTS Preparation/distribution Cardioplegia Anesthesia drips and antibiotics Safety evaluation IV pumps Clinical support Antibiotic evaluation Drug shortage management

30 Heparin Allergy or Intolerance Cardiac and vascular procedures often require anticoagulation during operation Alternative therapy is required for patients who cannot have the preferred therapy with heparin Options: Bivalirudin Argatroban

31 Open Heart Bivalirudin typically used Pharmacy provides drug products needed IV preparation for anesthesia CPB preparation Irrigation if needed for coronary artery bypass graft (CABG) Coordinate care between providers Perfusion Jan;24(1):7-11. Chest Feb;141(2 Suppl):e495S-530S.

32 Vascular Bivalirudin Dosing same as percutaneous coronary intervention (PCI) dosing 0.75 mg/kg initial bolus 1.75 mg/kg/hr continuous infusion Monitoring Activated clotting time (ACT) measured 5 minutes after initial dosing and dose changes Additional boluses provided if needed Bivalirudin PI. The Medicines Company Mar.

33 Vascular Bivalirudincontinued Special considerations Adjust infusion for renal clearance CrCl<30 ml/min 1 mg/kg/hr HD 0.25 mg/kg/hr Post-op dosing If only running <4 hours, continue same infusion rate If running 4 hours, decrease rate to 0.25 mg/kg/hr Bivalirudin PI. The Medicines Company Mar.

34 Vascular Argatroban Dosing same as PCI 350 mcg/kg initial bolus 25 mcg/kg/min continuous infusion Monitoring ACT measured intraoperatively Additional boluses and changes in rate may be required Special considerations Hepatic metabolism Decrease dose to 2 mcg/kg/min post-op Argatroban PI. GlaxoSmithKline Jan.

35 Malignant Hyperthermia (MH) Lauren Wood, PharmD

36 Malignant Hyperthermia (MH) Rare side effectofinhaledanesthetics and succinylcholine Malignant Hyperthermia Association of the United States (MHAUS) Pharmacist s role Called to bedside during every MH crisis Drug selection and preparation Drug procurement Updated allergy list Other supportive therapy Malignant Hyperthermia Association of the United States

37 Process Improvement Formulary management Addition of Ryanodex MH emergency box Locations Content Education Pharmacist Anesthesiologist Nursing Supplies/articles/ FDA-fast-tracks-RYANODEXdevelopment-for-treatment-of-exertional-heat-stroke/ -you-see-this/2014/04/jhppharmaceuticals-dantrium-iv-formalignant-hyperthermia

38 Dantrolene Dosing: 2.5 mg/kg IVP with repeat doses up to 10 mg/kg Followed by 1mg/kg IVPB every 4-6 hours for at least 24 hours Formulations: Revonto /Dantrium : dantrolene 20 mg per vial Reconstitute with 60 ml sterile water Ryanodex : dantrolene 250 mg per vial Reconstitute with 5 ml sterile water Malignant Hyerthermia Association of the United States Lexi-comp. Dantrolene drug monograph. Accessed 24 Mar 2016.

39 Drug Preparation and Procurement Ryanodex : mixed at bedside by pharmacist Ensure enough product present Revonto /Dantrium : prepared in IV room for follow-up doses OR Pharmacist alerts the IV room MH crisis Ensure IV techs have adequate supply to provide doses for follow-up period

40 MH Box Contents Description Par Level Amiodarone 150mg/3mL vial 5 Dantrolene Sodium (Ryanodex) 250 mg vial 1* Dextrose 50%, 50-mL syringe 2 Furosemide 10 mg/ml, 10-mL vial 2 Metoprolol 5mg/5mL vial 3 Sodium Bicarbonate 8.4%, 50-mL syringe 6 Calcium Gluconate 10%, 10-mL vial 2 Sterile Water for Injection PF, 20-mL vial 2 Syringes (10mL), needles, sterile gauze Stock List Malignant Hyerthermia Association of the United States

41 The Process of MH MH crisis called Pharmacist to beside with MH box Ensure discontinuation of offending agents Update allergy list Advise on supportive therapy Prepare dantrolene dose Facilitate follow up dosing as appropriate Facilitate restocking and procurement

42 PACU Complications Example Local Anesthetic System Toxicity (LAST) Brain Kramer, PharmD

43 PACU Complications My story Local Anesthetic Systemic Toxicity (LAST) Treatment

44 Local Anesthetic System Toxicity (LAST) 67 yof s/p orthopedic procedure and recipient of peripheral nerve block Heart rate and blood pressure declining in PACU Anesthesiologist thinks LAST, wants to administer IV lipids calls OR Pharmacist

45 Symptoms CNS Signs (may be absent or subtle) Excitation Depression Nonspecific Cardiovascular Signs Hypertensive Progressive hypotension Conduction block, bradycardia Ventricular arrhythmias Anesthesiology Jul;117(1):180-7

46 Treatment Airway management Seizure suppression Alert the nearest cardiopulmonary bypass center Arrhythmia management (ACLS) Avoid CCBs & BBs Reduce epinephrine doses to < 1mcg/kg Reg Anesth Pain Med Jan-Feb;37(1):16-8

47 Treatment Lipid (20%) Emulsion Bolus 1.5 ml/kg (lean body mass) IV over 1 min ~100 ml (2 x 50 ml syringes) in 70 kg patient Continuous infusion 0.25 ml/kg/min (can be doubled) Bolus can be repeated once or twice Continue infusion for at least 10 minutes after patient stable Reg Anesth Pain Med Jan-Feb;37(1):16-8

48 PACU Complications PACU complications can be life threatening OR pharmacists need to be prepared OR pharmacists fill a vital role in the management of complications such as LAST

49 Service Expansion and Future Directions Sara Jordan, PharmD, BCPS

50 Service Expansion Increasingly valued by anesthesia, surgery, and nursing Do you think the implementation of the Clinical OR Pharmacist position has improved perioperative care of our patients at Grant Medical Center? Yes- Strongly agree Yes - Agree No - Disagree No - Strongly Disagree

51 Service Expansion

52 Where are we now? 2 Pharmacist FTEs: Mon-Fri CPhT FTEs: Mon-Fri Direct report to operations manager OR Pharmacy Team Manager Team Lead CPhTs Pharmacists

53 Committee and Project Work Operational process changes Distribution, narcotic compliance CPOE, Pyxis Anesthesia Clinical quality improvement Post-op infection reviews, workgroups Formulary advisory Prescribing guidelines, order sets, MUEs Representation at all committee levels Research, education, precepting

54 Future Directions Piloting new role at orthopedic surgery center Focus on reducing post-op complications Increasing precepting and educational roles PGY1, PGY2 pharmacy residents APPEs, IPPEs Other disciplines Presenting and publishing work

55 Summary and Recommendations The pharmacist s clinical role in perioperative areas is valuable to patients and providers Pharmacy technicians play an important supporting role Financial justification can be achieved through a variety of means Assess your perioperative medication use and get involved in improving both daily patient care and institutional processes

56 Special Thanks to Our Team Additional OR Pharmacists: Desta Borland, PharmD Brent Mulholland, RPh, BCPS Leadership: Brad Petersen, PharmD, MS Jeff Cook, PharmD, MSPharm, MBA Curt Passafume, MBA, RPh Chanda Drake, CPhT Derek Mills, CPhT OR Pharmacy Technicians: Marsha Lott, CPhT Roxie Nelson, CPhT Jackie Steele, CPhT Jennifer Wilson, CPhT Ashley Morris, CPhT Stephen Sharp, CPhT Ben Holesapple, CPhT Miland Jenkins, CPhT Vonna Bailey, CPhT

57 Questions and Discussion