Pharmaceutical Services Report to Joint Conference Committee September 21 Background: Pharmaceutical Services staffing has increased by 31 FTE from 26 due to program changes and to comply with regulatory requirements. The following report highlights the effectiveness of staff additions in managing medication use. 1. Inpatient Order Process Time In January 26, Inpatient Pharmacy was staffed with eight inpatient pharmacists and six clinical pharmacists and the turn around time (time when orders are received in pharmacy to medication available for nurses) was 127 minutes. In March 28, staffing was increased to nine pharmacists and twelve clinical pharmacists. Workflow changes and the increase in staffing reduced the turn around time to 3 minutes. This was sustained until late 28 when pharmacist review of all ED orders prior to drug administration was made necessary via regulatory mandate, and the turn around time increased by 35% to 4 minutes. In September 29, clinical pharmacists were reassigned to ED to enter orders and we received additional staffing with the end result of gradual turn around time declining to 31 minutes by April 21. Pharmacy Order Processing Time 14 127 min 12 1 8 6 68 5 3/8 - Workflow change and staffing 62 increase 12/8 Increase workload anf staff inc 9/9 ED order entry and staff incr Jan-6 Apr-7 Jun-7 Aug-7 Dec-7 Mar-8 Apr-8 May-8 Sep-8 Nov-8 4 35 3 29 27 3 34 42 39 42 38 33 31 Dec-8 Jan-9 Mar-9 2 Sep-9 Feb-1 4/1/21
2. Prescribing errors prevention CT patients allergy and profile review In 28, in response to Joint Commission standards for medication management, allergy and profile review of Outpatient Scheduled CT patients by a pharmacist was introduced. Pharmacists notified the Radiology department of patients taking metformin or using a patch. The rationale for review is to prevent patients on metformin from receiving contrast media unless they have been off metformin for at least 24 hours and to remind Radiology staff to remove the patch before CT. During April to June 21, pharmacy identified and notified radiology of 165 patients or 1% of scheduled CT patients at risk for potential medication error and harm. Medication error prevention for CT patients (Apr - June 21) 18 16 14 12 1 8 6 4 2 1659 134 31 Total # pts Pts on metformin Pts on patch
3. Impact of Clinical Pharmacist activities in Emergency Department In February 28, a clinical pharmacist was assigned to the ED to provide medication management consultation. In Sept 29, with the addition of a second clinical pharmacist, order entry in addition to medication consultation began in the ED and 1 hours per day coverage was provided. A snap shot of their impact and the number and types of order entry problems encountered revealed their effectiveness at significantly reducing problem orders from 29 to 21. Emergency Dept Med Order Problems Pre and Post ED pharmacy % of Med Orders with Problems 5 45 4 35 3 25 2 15 1 5 29 (Pre) 21 (Post) Year Emergency Dept Order Writing Problems Problems per 1, orders 35 3 25 2 15 1 5 No dose/freq/route No date/time No CHN#/sig Unapproved Abbrev/trailing zero Non-formulary Questionable dose "Bedside" med 29 21 Issue
4. Anticoagulation Monitoring Program A clinical pharmacist was hired in August 28 to bring the hospital into compliance with Joint Commission National Patient Safety Goal 3.5 (reduce the likelihood of patient harm with the use of anticoagulant therapy). The clinical pharmacist began monitoring all patients placed on warfarin, with special focus on patients with an INR of 4. or greater. In the past 18 months, 161 pharmacist interventions representing 3% of all patients in the hospital on warfarin therapy were documented. The highest number of interventions relate to dose adjustment. These interventions ensure that patient harm is reduced. Clinical pharmacist anticoagulants interventions - 29 18 16 14 12 1 8 Warfarin 6 4 2 Dose adjustment Lab Drug-lab interactions Other interactions Total interventions
5. Pharmacists interventions Pharmacists are actively involved in reviewing medication orders to prevent illegible orders, incomplete orders, and ensure compliance to the Joint Commission medication management standards. Recording and quantifying this activity is part of the Pharmacy Department 21 Performance Improvement Plan, and starting in April 21, data for this activity is collected on one selected day per week and tracked. The following is a summary of data collected since April 21: Pharmacist interventions (April - June 21) 4 35 3 25 2 15 1 5 April May June Total The significant increase in pharmacist interventions required in June is attributed to new medical interns starting their rotations that month. Pharmacist interventions - elements of order (April - June 21) 4 D -- Incorrect drug 35 3 25 2 15 1 5 April May June H -- Incorrect dose I -- Incorrect or missing dosage form J -- Incorrect or missing frequency K -- Incorrect or missing indication L -- Incorrect or missing route M -- Incorrect or missing unit U -- <3 Patient Identifiers Elements of order (name of drug, dose, route, sig) had the most significant increase from April to June 29. Data collection in Sept Oct will stratify this information by unit and service so that the pharmacy staff can target and tailor interventions specific to the problems identified.
6. Adverse Drug Reaction/Trigger Drug Reporting A clinical pharmacist, hired in Sept 29, oversees all aspects of trigger drug use and identifying, reporting and monitoring adverse drug events. The following graph is an example of the type of report generated by this pharmacist. Trigger Drug Report - 29-21 4 35 3 25 2 15 1 5 4 1 2 27 22 1 1 9 12 2 2 3 1 1 2 1 1st Q 29 2nd Q 29 3rd Q 29 4th Q 29 1st Q 21 Digibind Protamine Naloxone Glucagon Flumazenil
7. Controlled Substances Compliance Audits Especially in the ED, clinical pharmacists are actively involved in reviewing the use of controlled substances especially resolving issues where pharmacy did not receive an order. In general, the clinical pharmacists were able to resolve over 6 percent of these issues. The pharmacists are working with ED providers to resolve remaining unresolved issues. ED override audit by pharmacy and nursing (Jan - Aug 21) 2 18 16 14 12 1 8 6 4 2 19 18 182 178 163 165 145 114 61 64 62 63 54 57 56 34 24 27 18 23 25 15 18 1 Jan Feb Mar Apr May June July Aug # required clinical review # unable to resolve by clinical # unable to resolve by RN % unresolved/total dispense.9%.8%.7%.6%.5%.4%.3%.2%.1%.% Jan Feb Mar Apr May June Jul Aug % unresolved/total dispense
9. Other significant impact of clinical pharmacists in the hospital inpatient setting includes: a. Antipsychotic Polypharmacy Drug Usage Evaluation DPH wide use of antipsychotic use and polypharmacy prevalence in various DPH settings b. Chemotherapy Manual Complete review and revision of this on-line tool to assist in decreasing the potential for error with chemotherapy administration c. SCIP improving pre- and post-surgical antibiotic selection and duration of use d. Nicotine replacement therapy at discharge Clinical pharmacists communicate with physicians of patients wanting to continue use of NDT upon discharge. 71% of discharge patients with smoking history were placed on NRT e. HIV meds monitoring clinical pharmacist reviewed all ARV forms and assisted admitting team to ensure patient s home regimen was being followed and dosing was appropriate. f. Audits on compliance to Black Box Warning on erythropoietin Identified dose titration was not followed properly and created preprinted order sheet to ensure compliance with FDA guidelines. g. Implemented standard IV concentrations and worksheet for neonates and pediatrics provided easy to follow calculations and standard IV concentrations to prevent dosing errors. h. Medication Administration Record verification - Clinical pharmacists compare Siemens pharmacy medication profiles with doctors orders per day as part of pharmacy s 21 quality improvement activity. Discrepancies and reasons for discrepancies are logged and corrected. Reasons for discrepancies are collected in order to target possible areas of improvement. i. Member of ACE team Clinical pharmacists time was allocated to cover both ACE teams j. Medication error prevention program for BHC led by a clinical pharmacist, this group reviews recently reported medication errors in the BHC and develops plans and programs to prevent future occurrences and to improve patient safety k. Creation of preprinted order form to ensure medication safety: a. Pediatric antibiotic order sheet b. Intensive Care Nursery emergency Medication sheet c. Emergency Room code blue order sheet