Importance of Clinical Leadership in Pharmacy

Transcription

1 Importance of Clinical Leadership in Pharmacy Rita Shane, Pharm.D., FASHP, FCSHP Chief Pharmacy Officer Cedars-Sinai Medical Center, Los Angeles Assistant Dean, Clinical Pharmacy UCSF School of Pharmacy

2 Objectives Describe why clinical leadership in pharmacy is essential to advance pharmacy practice Describe the characteristics and priorities of clinical leaders Recognize the clinical elements of the medication use process Provide examples demonstrating the clinical value of pharmacists

3 Why clinical leadership is essential Key global challenges in healthcare and pharmacy are clinical ones: reducing drug costs and improving the quality and safety of medication use in our patients We must resolve issues of medication safety, such as medication use across the continuum of care and the reconciliation of medications for specific patient populations. The pharmacy director or manager must serve as a clinical leader adapted from William Gouveia. Clinical Leadership Am J Health-Syst Pharm. 2005; 62:805.

4 Why clinical leadership is essential? 2015 Revised FIP Basel Statements on the Future of Hospital Pharmacy The overarching goal of hospital pharmacists is to optimize patient outcomes through collaborative, inter-professional, responsible use of medicines and medical devices. Hospital pharmacists should serve as a resource regarding all aspects of medicines use and be accessible as a point of contact for patients and health care providers.

5 Characteristics of Clinical Leaders Context: Maintains understanding of current healthcare priorities and needs of patients Recognizes implications of priorities for pharmacy profession Relevance: Develops programs and services which meet needs of patients (pts) and healthcare system

6 Leadership Context Health Care Health- System Pharmac y

7 Characteristics of Clinical Leaders Places patients at the center of decision-making Interprets and translates healthcare priorities into pharmacy strategic initiatives Committed to lifelong learning Creates expectations Communicates effectively to decision-makers, clinicians and staff Possesses team skills Passion accessed 10/13/16

8 Clinical Leadership Physician Pharmacist Nurse

9 Characteristics of Clinical Leaders Sees problems as opportunities

10 Why Pharmacy Leadership is a Clinical Role Financial Management Multidisciplinary Collaboration Clinical Mind Medication Use Process Human Resources Management Safety and Quality

11 Financial Management Managing and Justifying Pharmacy Expenses Drugs Costly new drugs Exponential increase in generic drug prices People Drug Distribution Clinical Services Automation Robots, automated dispensing machines

12 Responsibility for the Medication Use Process

13 Medication Use Process PHYSICIANS PHARMACY STAFF Prescriber Order Entry Pharmacist Evaluation and Verification Pharmacy Robot Unit dose packager Liquid packager Infusion Pump Automated Cabinets Med Cart Sterile Compounding Carousel E-MAR Documentation NURSES BCMA

14 Medication Use Process What are the risks at each step? Selection & Procurement Wrong concentration sent by wholesaler-kcl 40meq/15 cc received Preparing & Dispensing Immediate release dispensed instead of sustained release Storage Heparin 10,000 units /ml stocked instead of 100 units/ml Administering Morphine and Hydromorphone -Look alike/sound alike Chlorpromazine given as IV Push Ordering & Transcribing Omitted chemotherapy medication Enoxaprin ordered in pt with renal failure Monitoring Patient on antibiotics; culture and sentiviities show resistance

15 Quality and Safety Underuse Overuse Misuse Healthcare Problems

16 Preventing Medication Errors: $21 Billion Opportunity 1 Average pt >65 is on 15 medications Up to 20% of readmissions are medication-related 700,000 ED visits and 120,000 hospitalizations are due to medications $3.5 billion in annual health care costs to treat adverse drugs events

17 Priorities for Patient-Centered Medication Management Patient care services for all patients Review of lab values to identify drug-related problems Medication reconciliation when pts transfer to a different level of care Daily review of medication profile Patient care services for high risk patients/therapies Pharmacist-managed dosing services Antimicrobial stewardship Focus on critical care, pediatric, oncology, etc.

18 Objectives Priorities for Patient-Centered Medication Management CSMC Clinical Service Plan Ensure consistent approach to clinical services Defines the elements of the initial review and daily review Defines the minimum level of clinical services each patient receives each day Describes the clinical role of pharmacists to Executive Management 18

19 Clinical Service Plan Evaluation of New Orders and Daily Review Drug allergies Review of prior to admission vs current medication list for discrepancies, potential errors Evaluate drug-drug interactions, duplicates, relevant lab orders.. Appropriateness of the drug, dose, frequency, dosage form, route of administration and duration Evaluate drugs with safety warnings Evaluate anticoagulation therapy Target drugs

20 Clinical Service Plan Participate on the Code Blue Team, Code Brain, Participate in rounds (ICUs, Oncology, Pediatrics, Progression of Care etc.) Provide patient education (e.g. CHF, warfarin, antiplatelets) Antimicrobial Stewardship Frail patient evaluation Pharmacist dosing protocols Participate in transitions of care activities 20

21 Human Resources Anything is possible with great people Clinical pharmacy=one individual at a time Knowledge and skills Intellectually curious Committed to learning Passion Professionalism Ensuring competency

22 Ensuring Consistency: Inpatient Competencies Basic life support Code Blue Drug Therapy Stroke and tpa kit Antimicrobials Pharmacokinetics (aminoglycosides/ vancomycin) Medication Safety Anticoagulation Transplant Congestive Heart Failure Assessing renal function Oncology Transitions of Care Pediatrics

23 Supporting Growth Career Ladders to advance patient care and individual growth Pharmacists Technicians Teaching opportunities Setting stretch goals

24 Multidisciplinary Collaboration Every encounter is an opportunity

25 DEMONSTRATING VALUE: Measuring Impact Of Pharmacists Clinical Contributions

26 Pharmacist Evaluation Process for Medication Orders Pharmacist evaluation of medication orders: Prior to Admit Medication List Drug Indication Dose Route Frequency Dosage form Duration Rate Pt Demographics Age (peds/ geriatrics) Gender Ht Wt Allergies Renal/Hepatic Function Current labs Previous admissions Current Medication List Drug-drug interactions Drug-disease interactions Duplicate therapy Contraindications, ADRs, BBW Medications needed but not prescribed Optimize medication therapies Monitoring requirements Prioritization based on: High risk patients or therapies such as: Chemotherapy Pediatrics ICU Anticoagulation Dosing per pharmacy protocol Antimicrobials Medication Dispensed -

27 Categories of Errors Prevented ADR Detected Allergy Drug-Drug Interaction Duplicate Therapy Incompatibility Incomplete Order Omission of Medication on Transfer Recommended Initiation Medication Wrong Rate Wrong Route Wrong Concentration Wrong Dosage Form Wrong Dose Wrong Duration Wrong Frequency Wrong Medication Ordered Wrong Patient

28 Methodology Life Threatening Low Capacity for Harm Serious/Significant 28*

29 Severity of Prescribing Errors Life Threatening Intercepted Based on NCCMERP Category G: The identified and intercepted error may have contributed to or resulted in permanent patient harm Category H: The identified and intercepted error may have required intervention necessary to sustain life Category I: The identified and intercepted error may have contributed to or resulted in the patient s death Serious/Significant Category D: The identified and intercepted error could have reached the patient and would have required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm

30 Prescribing Errors Intercepted 2000 Jan'15 - Feb' Life Threatening Serious/Significant Low Capacity for Harm Jan feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb 30

31 Prescribing Errors Prevented Order Ordered clopidogrel 600mg daily MD ordered insulin infusion at a rate of 4.5 units/kg/hr (408 units/hr) Precedex infusion ordered based on weight of 150kg when patient s actual weight was 43kg Drug Related Problem (DRP) Identified & Pharmacist Actions Loading dose ordered as maintenance dose Recommended 600mg x 1, followed by 75mg daily MD meant to order 4.5 units/hr Dose corrected Incorrect patient weight entered in medical record Confirmed actual patient weight and modified Precedex dose Avoided Outcome Potential increased risk of bleeding Potential increased risk of hypoglycemia Potential Precedex overdose and bradycardia 31

32 Ensuring Safe Transitions of Care Patient-Centered Reduce Preventable Admissions Prevent Adverse Drug Events Reduce Length of Stay Medworxx.com, accessed 7/2/14

33 Medication History Errors Lead to Errors During Admission Up to 67% of patients on medications have a medication history error or discrepancy on their medication list 39% of these have the potential to cause moderate to severe harm Evaluation of hospitalized patients demonstrated that >30% had errors in medication orders of which 85% originated from the medication history Shane R. Why Universal Precautions are needed for medication lists. BMJ Qual Saf doi: /bmjqs

34 Medication Errors at Discharge 14-80% of patients experienced at least 1 medication discrepancy or error post-discharge 19% of patients experienced an adverse event within 3 weeks of hospital discharge, 67% were attributed to medications and 12% of the adverse drug events were preventable

35 Safe Medication Transitions Methodology Patient meets high risk criteria* Pharmacy staff performs medication reconciliation and assesses MedAL score^ Patients with MedAL score < 6, pharmacist follow up within 72h post discharge Drug-related problems identified are resolved with prescribing MD(s) and/or pt Pharmacists identify pts with significant DRPs that may result in 30d readmission (MACEs)++ MedAL: medication adherence and literacy *High risk criteria: > 10 chronic meds, on anticoagulant, diagnosis of CHF w/ EF< 40%, pneumonia ^MedAL score: CSMC algorithm to assess patient s medication adherence and medication literacy ++Physician validation of likelihood of readmission

36 Post-Discharge Follow Up Results Jan-May 2016 Jan 16 Feb 16 Mar 16 Apr 16 May 16 Number of patients evaluated % significant/lifethreatening Drug- Related Problems 69.6% 72.7% 81.4% 71.0% 73.9% (DRPs)/DRPs total DRPs/pt % readmissions prevented validated by 80.0% 79.4% 85.2% 76.7% 82.6% MDs

37 Examples of Post Discharge (Drug-Related Problems) DRPs Identified and Resolved Case DRPs Identified and Pharmacist s Actions Avoidable MACE CC: 91 yo F w/ PMH of CVA, afib on rivaroxaban, aortic stenosis, seizure, presenting w/ UTI 1) Bradycardia: metoprolol increased to 50mg BID but medication history states 25mg BID.. Pt also started on digoxin. Family reports HR in the 40s. 2) Pt on levofloxacin for 5-day based on dirty UA. Denies symptoms; culture results suggests colonization. 3) Pt prescribed rivaroxaban 20 mg daily. Recommended dose for pt w/ CrCL 29ml/min is 15 mg. Readmission due to bradycardia, bleeding 77 yo F w/ PMH of DM2, CAD, HTN, presenting with w/ hyperglycemia (BG 649 on admission) Recommendations: 1) Recommend hold metoprolol, and D/C digoxin or check level. 2) Recommend D/C levofloxacin 3) Recommend rivaroxaban dose change to 15mg daily. 1) Pt was not using insulin glargine 10 units or checking BG after discharge. Pt reports no insulin or supplies at home. 2) Pt not taking simvastatin Recommendations: 1) Found the most affordable insulin. Educated pt about compliance. 2) Called in prescription for simvastatin, test strips and lancets. Readmission with hyperglycemia due to med non-compliance

38 Safe Medication Transitions Results 7.4 medication history errors/high risk pt on admission Pts with low and intermediate adherence have a 2.54-fold higher odds of readmission compared those with high adherence (p=0.05). 4.3 drug-related problems/patient post-discharge Approximately 50% of problems are pt. related and 50% are prescriber-related High likelihood of readmissions without pharmacist follow up (based on physician validation)

39 Patient-Centered Clinical Leadership Each problem represents an opportunity Committed to Lifelong Learning Creates expectations Team- Focused Demonstrates passion

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