2017 pharmacy education series - proces3.proce.com/res/pdf/chs2017nov15handout.pdf · 2017. 11....

2017 Pharmacy Education Series

November 15, 2017

Pharmacy Pearls 2017

Today’s Presenters

Terry Bracey, RPh

Terry graduated from the University of Louisiana Monroe, School of Pharmacy, and began practicing hospital pharmacy in August of 1990. He took his first hospital Pharmacy Director’s position in July of 1996 and has been the Pharmacy Director at several hospitals over the past 21 years. He enjoys working with physicians, pharmacists, nurses and other healthcare professionals in solving the unique challenges that hospitals face daily while providing high quality and cost effective healthcare services.

Judith Kristeller, PharmD, BCPS

Judith Kristeller is a Professor at Wilkes University and her clinical practice site is Moses Taylor Hospital in Scranton, PA. Her clinical research is focused on the pharmacist’s role in improving the safe and effective use of medications as patients transition from hospital to home. She has received over $300,000 in grant funding for her research. In 2016 she was awarded $150,000 from the Cardinal Health Foundation for a collaborative project between Wilkes University and Moses Taylor Hospital to improve medication management through collaboration between physicians and pharmacists in hospital and community settings.

Ashley M Lockwood, PharmD, BCPS

Ashley M Lockwood, PharmD, BCPS is Infectious Diseases Pharmacist at Bayfront Health St. Petersburg in St. Petersburg, Florida. She received her doctor of pharmacy from the University of Florida. She has completed a pharmacy postgraduate year one residency program (PGY1) at St. Vincent’s Medical Center Riverside in Jacksonville, Florida and a postgraduate year two residency program (PGY2) specializing in Infectious Diseases at Houston Methodist in Houston, Texas. Her focus is Infectious Diseases along with Antimicrobial Stewardship and is the pharmacist leader for the Antimicrobial Stewardship Program at Bayfront Health. She is also a member of the Community Health Systems Professional Services Corporation Antimicrobial Stewardship Task Force. She is an active member of Society of Infectious Disease Pharmacists and serves on the committee for SIDP Education Center. She precepts for student pharmacists completing advanced pharmacy practice rotations and residents completing a pharmacy postgraduate year one residency program (PGY1) with Bayfront Health St. Petersburg.

Greg Michaud, PharmD, MBA, BCPS

Greg Michaud is currently the Clinical Pharmacy Coordinator at Mat‐Su Regional Medical Center in Palmer, Alaska. After spending over a decade in clinical hospital pharmacy Greg has developed an extensive skill set in the practice of pharmacy. Greg has worked in various practice settings since graduating in 2007, from a remote critical access hospital to a large tertiary care center in Anchorage, and now at MSRMC, a community hospital, where he has been since 2010. Greg holds a BS in Microbiology from the University of New Hampshire, a Doctor of Pharmacy degree from Massachusetts College of Pharmacy and Health Sciences, and an MBA in Healthcare Administration from Marist College. Additionally Greg is board certified in pharmacotherapy and has both basic and advanced certifications from MAD‐ID. Greg is also the pharmacy leader for the development, implementation, and growth of the hospitals’ antimicrobial stewardship program since its inception in 2015. Greg has also been an advocate for antimicrobial stewardship at the local level, where he has been involved with the Alaska Antimicrobial Stewardship Collaborative (A2SC), a statewide collaborative to ensure appropriate antibiotic use.

Khalid Mokhtar, PharmD

Khalid Mokhtar is the manager of clinical services at Merit Health Central in Jackson, Mississippi. Khalid completed a Bachelor of Science in Pharmacy at University of Khartoum, Sudan. He received his Doctorate of Pharmacy from the University of Mississippi, and a Master’s of Science in chemistry from Jackson State University, Mississippi. Khalid Completed all requirement for a PhD degree in Clinical Health Sciences from University of Mississippi Medical Center.

Michele C. Musheno R.Ph., MS

Michele is the Director of Pharmacy at Commonwealth Health ‐Moses Taylor Hospital. A graduate of Northeastern University School of Pharmacy and the University of Scranton, she completed an Applied Pharmacoeconomic Fellowship in Disease Management at Geisinger Health Plan with Boerhinger Ingelheim. She is a Past President of Pennsylvania Pharmacists Association. She is a current member of Pennsylvania’s Medicaid Pharmacy & Therapeutics committee, and serves as a preceptor/adjunct faculty for numerous schools of pharmacy.

Maura L. Osborne, PharmD, BCPS

Maura is the pharmacy clinical manager and the co‐chair of the Antimicrobial Stewardship Committee at Regional Hospital of Scranton in Scranton, Pennsylvania. She is a Board‐Certified Pharmacotherapy Specialist and completed the SIDP Antimicrobial Stewardship Program. She is a graduate of the Philadelphia College of Pharmacy and Science and completed a pharmacy practice residency at the University of Maryland Medical Center.

Ferena Salek, PharmD

Ferena Salek has been the Pharmacy Director at Northwest Medical Center for 11 years. She received her PharmD from the University of Arizona College of Pharmacy and completed a PGY1 residency at the Tucson VA Medical Center. Ferena is also a University of Arizona College of Pharmacy Adjunct Clinical Associate Professor. She precepts pharmacy students, and residents on rotation and with PharmD and Quality Improvement projects. In addition, she teaches clinical therapeutics, transitions of care, and medication reconciliation classes at the University of Arizona College of Pharmacy. Ferena is on the University of Arizona College of Pharmacy Admissions Committee, and Preceptor Advisory Board. In 2014 Ferena won the American Association of Colleges of Pharmacy (AACP) National Master Preceptor award.

Christine Viramontes, RPh

Christine Viramontes has worked as a Clinical Pharmacist at Bayfront Health Brooksville Hospital for 20 years. Before that she worked at Huntington Hospital in NY for 10 years as a Staff Pharmacist and 3 years as a Pharmacy Intern.

Pharmacy Pearls 2017CHS Pharmacy Education Series

ProCE, Inc.www.ProCE.com 1


November 15, 2017


Submission of an online post‐test and evaluation is the only way to obtain CE credit for this webinar

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Print your CE statement of completion online

– Credit for live or enduring (not both)

Deadline: December 15, 2017

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– CE credit automatically uploaded to NABP/CPE Monitor upon completion of post‐test and evaluation (user must complete the “claim credit” step)

Online Evaluation, Self-Assessmentand CE Credit

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It is the policy of ProCE, Inc. to ensure balance, independence, objectivity and scientific rigor in all of its continuing education activities. Faculty must disclose to participants the existence of any significant financial interest or any other relationship with the manufacturer of any commercial product(s) discussed in an educational presentation. None of the presenters have any relevant commercial and/or financial relationships to disclose.

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November 15, 2017


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CE Activity Information & Accreditation

ProCE, Inc. (Pharmacist and Pharmacy Technician CE)

– 2.0 contact hours

Funding:This activity is self‐funded through CHSPSC.

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Pharmacy Pearls 2017Introductory Remarks

Trent A. Beach, PharmD, MBA, MHA, BCPS, FASHP, FACHE

Director; Clinical Services and Education

CHS Professional Services Corporation, Franklin, Tennessee

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CHS Pharmacy Pearls 2017

The Use of Perioperative Vaginal Hormones in Vaginal Surgery

Terry Bracey, RPhPharmacy Director

Santa Rosa Medical CenterMilton, Florida

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Objective

• Discuss the use of perioperative vaginal estrogen in vaginal surgery

• Discuss the use of vaginal lubricants for vaginal packing

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Disclosures

• I have no conflict of interests to disclose

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Benefits of perioperative use of vaginal estrogen for vaginal surgery

• Few studies which directly address the issue of vaginal estrogen on perioperative outcome although many expert gynecologic surgeons recommend both pre and postoperative use in postmenopausal patients

• No studies that directly compare the outcome of the surgical procedure in women pretreated with intravaginal estrogen compared to those without treatment with intravaginal estrogen

• Believed to increase the rate of cutaneous wound healing in older women

• Believed to play a role in preventing mesh erosion because estrogen does tend to thicken vaginal mucosa

• No studies regarding the use of estrogen cream intraoperatively

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What We Learned

• We were using Estrace cream intraoperatively at the end of the case when inserting the vaginal packing

• We worked with urogynecologist to determine the amount of Estrace cream needed for a case which ended up being about half a tube therefore we repackaged the cream into two smaller tubes to decrease cost

• After researching the information available and speaking with the physician it was determined that the intraoperative Estrace cream was really only providing lubrication for ease of removing the vaginal packing and preventing any bleeding associated with removal of the packing

• We researched options for providing a vaginal lubricant/moisturizer that would last long enough the keep the vagina well lubricated/moisturized until the packing was removed, usually done within less than 24 hours

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Cost of Intraoperative Vaginal Estrace Cream

• We were spent $17,000 per year or $134.09 per case on Estrace cream which was only being used by this one physician for some of his surgical procedures

• The cost would have been $34,000 per year or $268.17 per case without us repackaging it into two tubes

• The cost for 2018 could have doubled, i.e. $34,000 per year, as the physician hired a partner and they likely will double their procedures

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Vaginal Lubricant Selected and Cost

• We decided that Replens Long‐Lasting Vaginal moisturizer should work for the intended use and claims to provide vaginal moisture for up to 3 days

• Available in 8 X 6.7 Gm applicators

• Cost $ 1.55 per application

• Cardinal item # 5250998

• CHS 14 Charge code: 41296589

• CHS Legacy Charge code: 1214502

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Outcome

• No longer use any Estrace vaginal cream

• Have had no negative outcomes, i.e. bleeding upon removal of vaginal packing

• Decreased cost by $16,800 per year

• Avoided future incremental cost of $16,800 from increased volume due to additional physician resulting in future annual cost savings equal to or greater than $33,600

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Clinical Opportunities with a Transition of Care Pharmacy Service

Judith Kristeller, PharmD

Professor

Wilkes University

Place of Practice: Moses Taylor Hospital, Scranton, PA

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Learning Objective

At the conclusion of this presentation, participants will be able to discuss opportunities for improving medication management as patients transition from hospital to home.

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Transition of Care Pharmacy Service GoalPromote appropriate, patient‐focused, and evidence‐based use of medications throughout the transition

from hospital to home

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MTM Terminology

• MTM • Patient centered process of care

• Assessment and evaluation of complete medication therapy regimen

• Medication Therapy Review• Comprehensive Medication Review (CMR) reviews medication appropriateness, identifies and resolves MRPs, provides patient education

• Targeted Medication Review is focused on an individual MRP or addresses a specific need for patient education

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Comprehensive Med Review

• Occurs during hospitalization

• Review EHR H&P, consult notes, labs, medications (imported, home, hospital), etc.

• Includes conversation with patient / caregiver

• Verify medication reconciliation / correct home medications in EHR

• Assess acute and chronic medications for indication, effectiveness, safety, adherence

• Develop list of medication‐related problems (MRPs) and plan for resolution

• Identify Targeted Medication Reviews (TMR) to correct/prevent individual MRPs

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Communication to Prevent / Correct MRPs

• Acute Care Call Hospitalist / Attending Physician

• Chronic Care Fax / email* PCP

• Chronic Care Fax / email* Community Pharmacist

• Acute and Chronic Discuss with Patient / Caregiver

*secure email only

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Examples

• Attending• Patient’s home antidepressant was omitted from home medication list and

hospital medication orders• Enoxaparin for DVT prophylaxis ordered as a treatment instead of prophylaxis

dose

• PCP• Consider reducing aspirin from 325mg to 81mg• Consider adding a statin for secondary prevention of MI

• Community Pharmacist Handoff (CMR with TMR)• Monitor BP and decongestant use• Assess inhaler technique• Encourage patient to discuss continued need for pantoprazole with PCP

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Targeted Patients

• High risk for MRPs

• > 5 chronic medications

• Multiple chronic disease

• New onset of chronic disease with new meds

• High risk medications

• Home dwelling

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Goal Outcomes

• Improve medication adherence

• Improve safe and effective use of medications

• Improve patient outcomes

• Improve quality performance goals

• Prevent hospitalization

• Improve patient satisfaction

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Additional Goals

• Promote patient – pharmacist relationship

• Promote collaboration between pharmacists and physicians

• Demonstrate value of clinical pharmacy care in hospital and community settings

• Fill‐in clinical gaps with existing hospital pharmacy programs (antibiotic stewardship, renal dosing, etc.)

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Operational

• 2 hospitals in NE PA (MTH, RHS)

• Pharmacy work‐study students (P2‐P3) screen new admissions for home‐dwelling / > 5 meds / multiple chronic disease

• Two pharmacy APPE (P4) students work up and see eligible patients

• 1 patient/day/student initially during week 1• 2‐3 patients/day/student ideal for remainder of 5‐week block

• Detailed policy and procedures (screening, patient evaluation, communication)

• Hospital pharmacist backup • Corrections to home medications• Clinical support for students when pharmacy faculty unavailable

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Possible through Collaboration and Grant Funding

• Collaboration• Commonwealth Health

• Wilkes University

• Grant Funding (> 300K)• Cardinal Health Foundation

• Community Pharmacy Foundation

• Moses Taylor Foundation

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Potential Workflow Improvements

• Pharmacist / Student in ER would help with medication reconciliation and screening patients faster

• PGY2 Resident would help with operations and administrative functions

• Additional Grant funding • Pharmacy work‐study students• Pharmacy faculty release time• Operational costs / technology• Data management• Networking

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BLOWN AWAY: HURRICANE IRMA AND IV BAG SHORTAGESAshley M Lockwood, PharmD, BCPS

Clinical Specialist - Infectious Diseases

Pharmacy Department

Bayfront Health St. Petersburg

701 6th Street SouthSt. Petersburg, FL 33701

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Disclosure(s)

• There are no financial interest/arrangement or affiliation concerning material discussed in this presentation



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Objective

• At the conclusion of this presentation, participants will be able to recognize the impact of and solutions to IV bag shortages on pharmacy and patient care

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Drug Shortages

• From 2001 to 2011 there was a dramatic increase in shortages• On October 31, 2011 Executive Order 13588 - Reducing Prescription

Drug Shortages

• Since 2011 the number of new drug shortages has declined

Report on Drug Shortages for Calendar Year 2016; FDA U.S. Food

& Drug Administration



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Drug Shortages

• Shortages continue to cause challenges • Endanger patient safety

• Burden medical professionals, hospitals

• Increased healthcare costs

• Particular concern with critical drugs • Cancer treatment

• Parenteral nutrition

• Intravenous solutions

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Causes of Drug Shortages

• Manufacturing Difficulties

• Voluntary Recalls

• Regulatory Issues

• Supply and Demand Issues

• Business and Economic Issues

• Natural Disasters

Ventola CL. P T. 2011 Nov;36(11):740-57.



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Hurricanes Irma & Maria

• Irma – September 8th• Category 5 major hurricane

• Highest winds 185 mph

• Maria – September 20th

• Category 5 major hurricane

• Highest winds 175 mph

https://en.wikipedia.org/wiki/File:Irma_2017-09-06_1745Z.jpg

https://en.wikipedia.org/wiki/File:Maria_2017-09-19_2015Z.png

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Puerto Rico

• A month after the hurricanes• More than a 3rd of the island lacks running water

• Less than 20% of the power grid has been restored

• 75% of antennas are still down leading to unlikely communications

• All hospitals are now open

• Pharmaceuticals• 12 of the top 20 pharmaceutical companies have manufacturing

facilities on the island

• Represented 72% of Puerto Rico's 2016 exports

• 25% of total U.S. pharmaceutical exports!

• Predicted resupply June 2018

http://time.com/4988841/puerto-rico-hurricane-maria-numbers-recovery/https://www.usatoday.com/story/money/2017/09/22/hurricane-maria-pharmaceutical-industry-puerto-rico/692752001/



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Intravenous Bag Shortage

• Solutions Globally• Obtaining extra supply (good luck)

• Ordering empty bags to aliquot (went on backorder)

• FDA importing products from other countries (careful!)

• Drug specific• IV to PO

• IV push

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IV Push Antibiotics

• Many commonly used antibiotics can be given IV push• NOT ALL!

• Majority are beta-lactams



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IV Push Antibiotics

• At Bayfront Health St. Petersburg - first 2 weeks• Transition some of the antibiotics that can be pushed

• Limited to 3 minute pushes• Minimized burden to nurses and transition them to the process

• Excluded any extended infusion antibiotics

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IV Push Antibiotics

• Over the following next weeks started to include:• Antibiotics with 5 minute pushes

• Ceftriaxone 2 gram (gm)

• Non beta-lactams• Daptomycin

• Extended infusion • Cefepime started on IV push

• Changed to extended infusion if patient had an MDR pathogen with high MICs or sepsis

• Meropenem started with extended infusion • Change to IV push if non MDR pathogen or patient not septic



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IV Push Antibiotics

• Current• All patients started on IV push regardless if extended infusion

antibiotic • Exception meropenem 2 gram doses

• MDR or septic patients

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Essentials• Education

• Prescribers• Nursing staff

• Preparation• Administration• Risks of IV push

• Pharmacy

• Communication• Changes! Almost daily depending on what shipments and

allocations received • Expectation patients

• Stocking Medication dispensing cabinets• Over-ride on sterile water for injection• Antibiotics



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Lessons

• Switch to 5 minute push antibiotics earlier

• Change to extended infusion algorithm earlier• Cefepime IV push select patients changed to extended infusion

• Meropenem extended infusion select patients changed to IV push

• Communication is key

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ENGAGING NURSES IN ANTIBIOTIC STEWARDSHIP

Greg Michaud PharmD, MBA, BCPS

Pharmacy Clinical Coordinator



Objective

At the conclusion of this presentation, participants will be able to identify the importance of nursing education to antimicrobial stewardship and describe potential areas to focus educational efforts.

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Obtained from: CDC. Core Elements of Hospital Antimicrobial Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC. 2014. Retrieved from: https://www.cdc.gov/antibiotic-use/healthcare/pdfs/core-elements.pdf

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Nursing’s Role•“Nurses can assure that cultures are performed before starting antibiotics. In addition, nurses review medications as part of their routine duties and can prompt discussions of antibiotic treatment, indication, and duration.”1

CDC Core Elements (2014)

•“Educates staff and licensed independent practitioners”2

•“Multidisciplinary team that includes: Infectious disease physician, Infection preventionist(s), Pharmacist(s), Practitioner”2

•“Regularly reporting information on the antimicrobial stewardship program, which may include information on antibiotic use and resistance, to doctors, nurses, and relevant staff.”2

TJC Antimicrobial Stewardship Standard (2016)

•“Educational strategies should include medical, pharmacy, physician assistant, nurse practitioner, and nursing students and trainees.”3

IDSA/SHEA Guidelines (2016)

•“Among 900 publications on antimicrobial stewardship, only 11 appeared in nursing journals”4

•“The failure of ASPs to enlist the US nursing workforce of over 2 million healthcare professionals as proponents of antimicrobial stewardship is both an operational and strategic oversight.”4

Olans, R, et. al. CID. (2016)

•“Review [of 468 articles] identified 13 studies addressing or including staff nurses in stewardship programming efforts”5

•“Ten studies indicated the need to enhance nursing knowledge, education, and information support to strengthen ASP practices.”5

Monsees, E, et. al. (2017)

1) CDC. Core Elements of Hospital Antimicrobial Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC. 2014. 2)The joint Commission. New Antimicrobial Stewardship Standard. Joint Commission Perspectives. 2016; 36(7):1-8. 3) Barlam, TF, et. al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016; 62:51-77. 4) Olans, RN, et. al. The critical role of the staff nurse in antimicrobial stewardship: Unrecognized, but already there. Clin Infect Dis. 2016; 62(1):84-89. 5) Monsees, E, et. al. Staff nurses as antimicrobial stewards: An integrative literature review. Am J Infect Control. 2017; 45:917-22.

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Educational Focus:Microbiology

Specimen collection

Interpreting microbiology results

Antibiogram: introduction and application

Understanding infection vs colonization

ANA & CDC. Redefining the antimicrobial stewardship team: Recommendations from the American Nurses Association/Centers for Disease Control and Prevention workgroup on the role of registered nurses in hospital antibiotic stewardship practices. Silver Spring, MD: American Nurses Association and US Department of Health and Human Services, CDC. 2017. Retrieved from: http://www.nursingworld.org/ANA-CDC-AntibioticStewardship-WhitePaper 48



Educational Focus:Pharmacology

Allergy assessment and reconciliation (emphasis on PCN)

Antibiotic interactions and compatibilities

Antibiotic adverse reactions (emphasis on C.diff)

General antibiotic review on spectrum of activity

Therapeutic drug monitoring & timing of levels

IV to PO conversion

ANA & CDC. Redefining the antimicrobial stewardship team: Recommendations from the American Nurses Association/Centers for Disease Control and Prevention workgroup on the role of registered nurses in hospital antibiotic stewardship practices. Silver Spring, MD: American Nurses Association and US Department of Health and Human Services, CDC. 2017. Retrieved from: http://www.nursingworld.org/ANA-CDC-AntibioticStewardship-WhitePaper 49

Additional Areas of Education

Infection control / prevention

Educating the patient/family on antibiotics

Specific stewardship efforts (e.g. S. aureus bacteremia)

Core measures: sepsis, vaccination

Antibiotic de-escalation

1) Olans, RN, et. al. The critical role of the staff nurse in antimicrobial stewardship: Unrecognized, but already there. Clin Infect Dis. 2016; 62(1):84-89.2) Monsees, E, et. al. Staff nurses as antimicrobial stewards: An integrative literature review. Am J Infect Control. 2017; 45:917-22.

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Patient Case: Penicillin AllergyZM is a 65 yo M being treated for a purulent skin infection with vancomycin. Micro calls you with the culture results from the abscess: Methicillin sensitive Staphylococcus aureus (MSSA).

Based on the patient allergy profile to the left, can we change the patient to a cephalosporin?

Answers:A) YesB) NoC) MaybeD) Who cares, it’s sensitive to clindamycin just use that

Understanding Adverse Drug Reactions (ADRs)

Type A Type B

Rollins, DE. Adverse drug reactions in Remington: The Science and Practice of Pharmacy, 20th edition. 2000. Lippincott Williams & Wilkins, Washington DCPichler, WJ. Drug allergy: Classification and clinical features. UpToDate. Last updated 2015.

• Up to 85-90% of adverse reactions

• THESE ARE NOT ALLERGIES

– Extension of usual medication effect/ known reaction based on pharmacology properties

– May be dose dependent, often predictable, may be avoidable

– Example: GI upset/diarrhea with Augmentin

• About 10-15% of adverse reactions

• THESE ARE ALLERGIES

– Idiosyncratic/hypersensitivity reactions , not an extension of the medications effect

– Unrelated to dose, unpredictable, rarely avoidable

– Requires further investigation to clarify type of reaction

– Allergies are broken down into Type 1-4 hypersensitivity reactions

• We are most concerned with distinguishing a type I allergy from types II-IV, as type I represents anaphylaxis

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Use Clarifying Questions

1• What was the reaction, can you

describe it?

2• How soon after you took the

medication did the reaction develop?

3• How long ago did this occur

(childhood, last year, etc.)?

4

• If PCN allergy: Have you ever taken cephalosporins (e.g. Ancef, Rocephin, Keflex, Omnicef, Ceftin), if so did you tolerate them?

***Document in EMR***

IV to PO ABX Changes

Improved patient safety

• Decreased exposure to infections/complications from IV access

Improved patient mobility and comfort • No IV lines hindering patient

Decreased nursing/pharmacy labor • No admixture by pharmacy required

Cost savings• Parenteral route comes at a greater cost as compared to PO• (e.g. linezolid PO $3.57/600 mg tab and IV $35.79/ 600 mg bag)

Decreased length of stay

CHS. Pharmacy IV to PO Conversion Program. 2014 54



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IV to PO: Nursing’s Role

Table 1 (Antibiotics)

AzithromycinClindamycinFluconazoleLevofloxacin / CiprofloxacinLinezolidMetronidazole

Table 2 (Exclusion Criteria)

Unable to swallow

NPO

Refusing PO meds Aspiration risk

Ileus /malabsorption

Severe N/V

Clinical deterioration

Endocarditis

Meningitis

Staph aureus bacteremia

Prosthetic infections

Immunocompromised

Patient is receiving one of the antibiotics in Table 1 via the parenteral route?

Taking PO/FT meds (or)

Tolerating full liquid diet/enteral diet for > 24 hrs (or)

Tolerating tube feeds

Clinical status is improving.

(Improving WBC, afebrile, etc.)

Does not have exclusion criteria listed in Table 2.

Contact your friendly

pharmacist for possible

change to PO.

CHS. Pharmacy IV to PO Conversion Program. 2014

C. difficileWhat is C.diff?

• Gram Positive spore-forming anaerobic bacteria• Spores are very resilient and resist heat and various antiseptics• Spores can maintain viability for up to 5 months outside the body

From Jan. through Sep. of 2017 there have been 38 positive C. diff tests at MSRMC. • Only a small number of these have been classified as hospital acquired.• Positive test for C.difficile greater than three hospital days since admission

• If patient presents with diarrhea and test performed after 3 days = HAI (reported to NHSN)

1) Fernanda, L, et al. Burden of Clostridium difficile Infection in the United States. N Engl J Med 2015; 372:825-834.2) Mccomas, P. Clostridium difficile infection: What nurses need to know. Johns Hopkins Nursing. 2011. Retrieved from: http://magazine.nursing.jhu.edu/2011/12/clostridium-difficile-infection-what-nurses-need-to-know/

$4,000,000,0001

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C. difficile: Risk FactorsModifiable Risk Factors

• “The most important modifiable risk factor for the development of CDI is exposure to antimicrobial agents”1

• “Both longer exposure to antimicrobials as opposed to shorter exposure, and exposure to multiple antimicrobials, as opposed to exposure to a single agent, increase the risk of CDI.” 1

• Gastric acid suppression (PPI use)

Non-Modifiable Risk Factors

• Age (over 65)• Healthcare exposure

(Inpatient/LTAC)• Chemotherapy• Critical illness• GI comorbidity & GI surgery• Tube feeding• Immunosuppression

Gastric acid suppression (PPI use): “Increasing levels of pharmacologic acid

suppression are associated with increased risks of nosocomial C difficile

infection.”2

YES my patient needs a PPI:

“Use the lowest dose and shortest duration of PPI therapy appropriate for

the condition being treated”3

Does my patient have an indication necessitating acid suppression with a PPI?• GERD refractory to H2B, upper GI bleed or PUD in

prior 8 weeks, hypersecretory disease, H. pylori, SUP in ICU

• If not STOP PPI, if yes proceed to next box

1) Cohen, S, et al. Clinical practice guidelines for Clostridium difficile infection in Adults. Infect Control Hosp Epidemiol 2010;31(5):431-4552) Howell MD et al. Iatrogenic Gastric Acid Suppression and the Risk of Nosocomial Clostridium difficile Infections. Arch Intern Med. 2010;170(9):784-90.3) FDA. FDA drug safety communication: Clostridium difficile associated diarrhea can be associated with stomach acid drugs known as prton pump inhibitors (PPIs). Warning Published February 8, 20124)CHS. Proton pump inhibitor (PPI) pharmacist driven de-escalation protocl. 2017.5) Mccomas, P. Clostridium difficile infection: What nurses need to know. Johns Hopkins Nursing. 2011. Retrieved from: http://magazine.nursing.jhu.edu/2011/12/clostridium-difficile-infection-what-nurses-need-to-know

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C. difficile: Identifying, Testing, Prevention

Identifying C.diff Patients

• “3 or more unformed stools in 24 or fewer consecutive hours”1

• Recent antibiotic exposure and/or risk factors present for C.diff(elderly, chemo, etc..)

• Additional clinical presentation/symptoms: leukocytosis, fever, abddiscomfort, etc.

Testing

• Only test patients with active diarrhea • Not on laxatives• Only unformed stool

(formed stool will not be tested = do not send to lab)

• Repeat testing is discouraged as is test for cure

• MSRMC batches C.diff testing with tests performed twice daily

• Testing now uses LAMP technology from Illumigene: a molecular based test that detects for genetic sequences unique to toxigenic strains

Prevention

• Must identify and isolate patients with C.difficile rapidly

• Proper isolation and PPE use (gloves and gowns)• Contact precautions

until the resolution of diarrhea, at minimum1,3

• Proper handwashing with soap and water

• Proper disinfection of equipment with sporicidal agents

• Gatekeepers for other personnel and family entering the room

1) Cohen, S, et al. Clinical practice guidelines for Clostridium difficile infection in Adults. Infect Control Hosp Epidemiol 2010;31(5):431-4552) Auwaerter, PG. Johns Hopkins Guide: Clostridium difficile. Unbound Medicine. 2017. 3) Surawicz, CM, et. al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108:478-4984) Mccomas, P. Clostridium difficile infection: What nurses need to know. Johns Hopkins Nursing. 2011. Retrieved from: http://magazine.nursing.jhu.edu/2011/12/clostridium-difficile-infection-what-nurses-need-to-know/

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C. difficile: Patient/Family Education

Wash hands with soap & water before and after using the restroom or eating.

Spread through fecal/oral route. Disinfect surfaces/devices that become contaminated.

Try to use separate restroom if possible.

Finish entire course of treatment for C.difficile. Generally 10-14 days as prescribed by your provider.

Recurrence may require different dosing, taper.

Stop other abx and antacids as instructed by provider

Do not use anti-motility agents1) Mccomas, P. Clostridium difficile infection: What nurses need to know. Johns Hopkins Nursing. 2011. Retrieved from: http://magazine.nursing.jhu.edu/2011/12/clostridium-difficile-infection-what-nurses-need-to-know/2) Auwaerter, PG. Johns Hopkins Guide: Clostridium difficile. Unbound Medicine. 2017. 3) CDC. Clostridium difficile infection information for patients. US Department of Health and Human Services, CDC. 2015. Retrieved from: https://www.cdc.gov/hai/organisms/cdiff/cdiff-patient.html

59

Catheter Associated Urinary Tract Infections (CA-UTIs)Diagnosis of CA-UTI

• Signs or symptoms consistent with UTI • No other source of infection• Bacteria in the urine

• ≥103 colony forming units (CFUs) of ≥ 1 bacterial species• Properly obtained from urinary catheter (or)• Clean catch urine specimen that has had catheter removed within 48 hours

When in doubt get it out; remove as soon as it’s no longer needed• “The most important predisposing factor for nosocomial UTI is urinary catheterization” 2

• “Post-op surgical patients should have catheter discontinued by Post Op day two, unless physician has documented a continued need.”1

• “Duration of catheterization is the most important risk factor for the development of CA-bacteriuria.”2

Cloudy or smelly urine does not equal UTI• “No studies have demonstrated that odorous or cloudy urine in a catheterized individual,

even if these findings are new, has clinical significance. Thus, odorous or cloudy urine should not be used alone to determine the presence of CA-bacteriuria” 2

1) MSRMC. Prevention of catheter associated urinary tract infection. Policy 3749225. Update 2017.2)Hooton, TM, et. al. Diagnosis, Prevention, and Treatment of Catheter- Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010; 50:625-663.3) Garibaldi, RA, et. al. Factors predisposing to bacteriuria during indwelling urethral catheterization. N Engl J Med. 1974;291(5):215-219. 60



Sampling from Urinary Catheter:

DO NOT collect specimens from the drainage bag

• “Poor correlation with true urinary pathogens”1

Prior to collecting specimen replace urinary catheter if it’s been in place for more than 48 hours (use aseptic technique)

• Colonization of catheters occurs at a rate of 3-8% per day2,3

Use the sampling/drainage port for specimen collection

• “Perform Hand Hygiene.• Gloves should be worn for specimen collection.• Cleanse the port with a disinfecting solution prior to withdrawing a specimen.• Using aseptic technique, withdraw urine using a small gauge safety needle or

approved blunt needle to collect the specimen.• Specimen should be labeled with the appropriate identifiers and transported

immediately to the laboratory in a biohazard specimen bag.• Document in medical record.”1

1) MSRMC. Prevention of catheter associated urinary tract infection. Policy 3749225. Update 2017.2)Hooton, TM, et. al. Diagnosis, Prevention, and Treatment of Catheter- Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010; 50:625-663.3) Garibaldi, RA, et. al. Factors predisposing to bacteriuria during indwelling urethral catheterization. N Engl J Med. 1974;291(5):215-219.

61

Sepsis Core MeasureNote: Vancomycin is not an approved monotherapy option. Must be combined with another agent from Column A or Table 1.

*If thinking MRSA then vancomycin is your drug linezolid and daptomycinare not first line

• Blood cultures must be drawn prior to antibiotic administration.

• All antibiotics must be given IV. Some have an oral formulation, but the IV formulation must be used, at least initially.

• Antibiotics must be started or given within 3 hours of presentation of severe sepsis.

The Joint Commission. Specifications manual for national hospital inpatient quality measures. Version 5.2a. 2016. 62



Strategies to Improve Antibiotic Compliance

Ensure the core measure approved

agent(s) are administered

first

May give cefepime,

ceftriaxone, or meropenem as

IV push

Understand infusion times• Pip/tazo over 30

min• Levofloxacin 60-

90 min • Loading doses of

vancomycin can take over 2 hours

63

Antibiogram & Sepsis Core Measure

• Avoid FQs (if possible) & amp/sulbactam for empiric Gram negative coverage (eg. intraabdominal infections)• E. coli susceptibility continues to decline for FQs (82% susceptible) and

amp/sulbactam remains low (66% susceptible)• Hint: ensure thorough allergy/ADR reconciliation to avoid inappropriate FQ use

• Anaerobes (e.g. Bacteroides) are not included on the antibiogram as sensitivity testing is not routinely performed• Metronidazole, pip/tazo, and meropenem all provide excellent coverage of

Bacteroides species• No need to combine these agents for additional anaerobic coverage

Solomkin SJ, Mazuski JE, Bradley JS, et al. Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010;50:133-164

64



References• CDC. Core Elements of Hospital Antimicrobial Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC.

2014. Retrieved from: https://www.cdc.gov/antibiotic-use/healthcare/pdfs/core-elements.pdf• The Joint Commission. New Antimicrobial Stewardship Standard. Joint Commission Perspectives. 2016; 36(7):1-8.• Barlam, TF, et. al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society

for Healthcare Epidemiology of America. Clin Infect Dis. 2016; 62:51-77. • Olans, RN, et. al. The critical role of the staff nurse in antimicrobial stewardship: Unrecognized, but already there. Clin Infect Dis. 2016;

62(1):84-89.• Monsees, E, et. al. Staff nurses as antimicrobial stewards: An integrative literature review. Am J Infect Control. 2017; 45:917-22. • ANA & CDC. Redefining the antimicrobial stewardship team: Recommendations from the American Nurses Association/Centers for Disease

Control and Prevention workgroup on the role of registered nurses in hospital antibiotic stewardship practices. Silver Spring, MD: American Nurses Association and US Department of Health and Human Services, CDC. 2017. Retrieved from: http://www.nursingworld.org/ANA-CDC-AntibioticStewardship-WhitePaper

• Rollins, DE. Adverse drug reactions in Remington: The Science and Practice of Pharmacy, 20th edition. 2000. Lippincott Williams & Wilkins, Washington DC

• Pichler, WJ. Drug allergy: Classification and clinical features. UpToDate. Last updated 2015. • CHS. Pharmacy IV to PO Conversion Program. 2014• Cohen, S, et al. Clinical practice guidelines for Clostridium difficile infection in Adults. Infect Control Hosp Epidemiol 2010;31(5):431-455• Fernanda, L, et al. Burden of Clostridium difficile Infection in the United States. N Engl J Med 2015; 372:825-834.• Surawicz, CM, et. al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol.

2013;108:478-498.• Auwaerter, PG. Johns Hopkins Guide: Clostridium difficile. Unbound Medicine. 2017. • Mccomas, P. Clostridium difficile infection: What nurses need to know. Johns Hopkins Nursing. 2011. Retrieved from:

http://magazine.nursing.jhu.edu/2011/12/clostridium-difficile-infection-what-nurses-need-to-know/• CDC. Clostridium difficile infection information for patients. US Department of Health and Human Services, CDC. 2015. Retrieved from:

https://www.cdc.gov/hai/organisms/cdiff/cdiff-patient.html• Hooton, TM, et. al. Diagnosis, Prevention, and Treatment of Catheter- Associated Urinary Tract Infection in Adults: 2009 International

Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010; 50:625-663.• Garibaldi, RA, et. al. Factors predisposing to bacteriuria during indwelling urethral catheterization. N Engl J Med. 1974;291(5):215-219.• The Joint Commission. Specifications manual for national hospital inpatient quality measures. Version 5.2a. 2016. Retrieved from:

https://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx• Solomkin SJ, Mazuski JE, Bradley JS, et al. Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children:

Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010;50:133-164.

65

Review of Vancomycin Induced Nephrotoxicity and Dosing in Intermittent Hemodialysis

Khalid Mokhtar, PharmDClinical Manager

Merit Health CentralJackson Mississippi

66



Learning Objectives

At the conclusion of this presentation, Participants will be able to:

• Identify risks associated with vancomycin nephrotoxicity

• Describe important issues with vancomycin dosing in individuals receiving intermittent hemodialysis

67

History of Vancomycin Nephrotoxicity

• Nephrotoxicity issues started since vancomycin approval in 1958

• impurities were considered the major reason for the nephrotoxicity “Mississippi mud”

• Current preparations contain ∼90–95% active moiety (improved purification process)

• Rate of nephrotoxicity in modern preparations varies between 0% to over 40%.

68



Vancomycin Associated Nephrotoxicity

• (VANT): “A rise in serum creatinine of 0.5 mg/dL or 50% above baseline on two consecutive measurements with no other apparent cause”

• Other more sensitive definitions:

– (RIFLE): Risk‐Injury‐Failure‐Loss‐ESRD

– (AKIN): Acute Kidney Injury (AKI) Network

69

Pharmacokinetics & Pharmacodynamics • Bactericidal activity of vancomycin is time‐dependent

• AUC/MIC: Ratio of the 24‐h AUC to the minimum inhibitory concentration is best correlated with effectiveness

– AUC/MIC of ≥400 is recommended by guidelines for MRSA & by recent literature (Song et al., 2015; Men et al., 2015)

– Depends on methods of MIC determination: Automated Broth Micro‐Dilution (BMD) or E‐test

• Trough serum levels at steady‐state are considered surrogate for AUC/MIC

• Volume of distribution of 0.4–1.0 L/kg

• Elimination half‐life of 3–6 h (Eliminated unchanged in the urine)

70



Vancomycin Associated Nephrotoxicity (VANT)

Potential risk factors for development VANT• Factors directly related to vancomycin exposure:

– Trough level

– Total daily dose

– Duration of therapy

– Method of administration

– Area under the concentration vs. time (AUC) curve

• Patient‐related Factors:

– Obesity & other comorbidities

– Preexisting kidney disease

– Severity of illness

– Concurrent nephrotoxins

71

Trough Levels & Efficacy

• Guidelines & recent literature recommend keeping trough levels >10mg/L to prevent emergence of resistant organisms (Hale et al., 2016)

• ASHP/IDSA guidelines, 2009 & 2011: A trough level of 15–20 mg/L is recommended for more serious infections (for AUC/MIC ≥400)

• Recent studies showed that over 50% of patients achieving AUC/MIC ≥400 had trough levels <15 mg/L (Ghosh et al., 2014; Neely et al., 2014; & Hale et al., 2016)

72



Trough Levels & Efficacy

• Steinmet et al., 2015 (meta‐analysis): NO significant benefit of higher trough concentration on mortality or treatment failure (≥15 mg/L vs. <15 mg/L).

– There was a higher rate of microbiologic failure in the low trough group

• Tongsai et al., 2016 (meta‐analysis‐ pts with MRSA): No significant difference with levels ≥15 mg/L in clinical success or mortality

• Barriere et al., 2014 (retrospective post hoc): Levels ≥15 mg/L were found to correlate strongly with nephrotoxicity

73

Trough Levels & NephrotoxicityIs elevated trough level, a sign of kidney injury or a causative factor?

• Lodise et al., 2009: A 5% rate of nephrotoxicity if the initial trough was <10 mg/L compared to (21% for troughs of 10–15 mg/L), (20% for 15–20 mg/L), and (33% for >20 mg/L) (P < 0.05)

• Horey et al., 2012: Nephrotoxicity rates of (5% for troughs of 5–10 mg/L), (3% for 10.1–15), (11% for 15.1–20), (24% for 20.1–35), and (82% for >35)

• Cano et al., 2012: Nephrotoxicity increased from 7% at initial trough <10 mg/L, but increased up to 34% at >20 mg/L (P = 0.0003)

• In contrast, Kullar et al., 2011: found no more significant nephrotoxicity with troughs of 15–20 mg/L (13%) compared to 10–15 mg/L (17%) and <10 mg/L (15%)

74



Loading Dose (LD) & Nephrotoxicity

• Guidelines recommend consideration of a loading dose up to 25–30 mg/kg actual body weight for serious infections

• Rosini et al., 2016 (retrospective): Higher loading doses (>20 mg/kg) were not associated with an increased rate of nephrotoxicity vs. low dose (≤20 mg/kg)

• Rosini et al., 2015‐ RCT: Compared 15 to 30 mg/kg LD, found no difference in the 2ry endpoint of VANT

• No evidence to associate loading doses with increased nephrotoxicity

75

Duration & Nephrotoxicity

• Some studies found no significant relation of nephrotoxicity to duration of therapy (Prabake et al., 2012; Meaney et al., 2014)

• Multiple other research found positive correlation (Bosso et al., 2011; Hall et al., 2013)

• Cano et al., 2012: significant 12% increase in odds ratio (OR) for each additional day of therapy

• Available evidence suggests that < 48–72 hr. is less likely sufficient to cause nephrotoxicity.

76



Administration & Nephrotoxicity

• Guidelines recommend intermittent infusion as the preferred method

• A trend for reduced nephrotoxicity was found with continuous infusion vs. intermittent

• Hao et al., 2016 (meta‐analysis): Nodifferences in treatment failure or mortality

77

Comorbidities & Nephrotoxicity

• Independent risk factors for kidney injury

• Studies found association between the following comorbidities and VANT:

–Hypotension

–Heart failure

– Cancer

–Prior acute kidney injury

78



Concurrent Nephrotoxins

• Potential toxins include:– Aminoglycosides, amphotericin, acyclovir, chemotherapy, and intravenous contrast

• Other agents capable of affecting kidney function include:– Vasopressors, loop diuretics, etc.

• Agents most extensively studied include aminoglycosides & piperacillin‐tazobactam (PTZ)

79

Concurrent NephrotoxinsOpposing outcomes resulted from studies analyzing the added nephrotoxicity with addition of PTZ to vancomycin

• Giuliano et al., 2017 (meta‐analysis of RCTs): Overall OR of 3.65 (95% CI 2.16–6.17, P < 0.001) for development of nephrotoxicity or AKI with vancomycin and PTZ compared to vancomycin ± β‐lactam

• Navalkele et al., 2017: Compared vancomycin + PTZ to vancomycin + cefepime , AKI rates of 29% and 11%, respectively (P < 0.0001)

• Rutter et al. 2017: Same comparison (different study size), AKI rates of 21.4% and 12.5%, respectively (P < 0.0001)

• Moenster et al., 2014, &Hammond et al., 2016: Both could not find a significant difference for AKI with the addition to vancomycin of either PTZ or cefepime

80



Intermittent Hemodialysis (IHD)

• Infection is the 2nd leading cause of death in patients receiving intermittent hemodialysis

• Vancomycin is generally considered to be a 1st

empirical agent for vascular infections in hemodialysis pts

• Vancomycin is often sub‐optimally dosed in this population

81

Vancomycin Clearance in IHD

• Dialysis dependent factor affecting clearance of vancomycin:– Type of dialyzer filter

– Flux membrane

– Duration of dialysis

– Ultrafiltration rate

– Blood and dialysate flow rates

• High‐flux hemodialysis removes 30–40% of vancomycin in a 3‐5 hours session

82



Vancomycin Clearance in IHDNO “one‐size‐fits‐all” approach to vancomycin in HD settings• Important factors to consider when dosing pts on IHD:

– Appropriate loading dose

– Monitoring of vancomycin levels (before hemodialysis vs. after)

– Timing of doses (before, after, or during hemodialysis)

– Dialysis type

– Site & severity of infection

– Target serum vancomycin concentration

– Pharmacokinetic features:

• Prolonged distribution phase

• Redistribution phase

• Residual renal function

• Non‐renal clearance

– Rebound effect after completion of hemodialysis (results in a 20–40% increase in plasma levels)

– Pts with residual renal function (creatinine clearance of 10–15 mL/min) may have vancomycin serum levels up to 40% lower than in anuric patients

83

Monitoring During IHD

• Post‐hemodialysis monitoring: Measured after the redistribution phase (4‐6hrs after dialysis)

• Pre‐hemodialysis monitoring: practical, more efficient, and avoids misinterpretation (morning prior to hemodialysis)

84



Loading Dose in IHD • The use of a weight‐based loading dose is becoming more common among published vancomycin protocols

• Vancomycin loading doses are independent of renal function and should not be modified for patients receiving hemodialysis (Vandecasteele et al., 2010)

85

Intra‐Hemodialysis Dosing• Many protocols were suggested for intermittent HD vancomycin (post

or intra‐hemodialysis dosing)

• Intra‐hemodialytic (ambulatory care settings) vancomycin dosing protocol, vary in terms of when during the dose is infused (last 60min of HD)

• Panais et al., 2010: Weight based loading dose, then maintenance dose of 500mg (all given intra‐hemodialytic). 97% of participants achieved level of 10‐20 before the 5th dose

• Zelenitsky et al., 2012: Weight based loading dose and weight based maintenance ( intra‐hemodialytic dosing). 35.2% of pts would achieved a pre‐hemodialysis level of 15‐20

86



Post‐Hemodialysis Dosing• Multiple algorithms for post‐hemodialysis dosing

• Levels drawn prior to hemodialysis sessions

• Weekly pre‐hemodialysis when 2 consecutive therapeutic levels are obtained

• Routine monitoring of troughs before each hemodialysis session is strongly discouraged

87

Post‐Hemodialysis Dosing

• We found success with the following protocol:

• 20mg/kg loading dose (with preset maximum)

• Weight based maintenance dose (3 different weight groups with predetermined dose)

• Target level of 10‐20mg/dL (per indication)

• First trough in the AM of next HD

• Same maintenance dose is continued if 2 consecutive levels fall within target trough (once weekly troughs thereafter)

• For levels <10mg/dL, a loading dose is ordered after the next HD, increased maintenance to the next higher dose

• For levels <15mg/dL, maintenance dose increased to the next higher dose

• For levels >20mg/dL, next maintenance dose decreased to the next lower dose, or dose decreased by 50%

• Levels are reordered with each dose adjustment (the morning prior to next HD)

88



Incorporating Sentri 7/ Cerner Stats into Performance Appraisals

ReviewsMichele C. Musheno R.Ph, MS

Director of Pharmacy

Commonwealth Health ‐Moses Taylor Hospital

89

Reports Required

Quantifi

Global Report

Evaluation Period

Total Dollars

Total Interventions

Total Follow‐up

Detailed Report

Hard Dollars Savings

Each Pharmacist

Cerner

Workload report

Turn Around Time

90



An employee's evaluation shall be sufficiently specific to inform and guide the employee in the performance of her/his duties.

Employee Satisfaction

See their accomplishments over the year

Why Incorporate?

91

Establish Objective Quality Goals

SMART is an acronym to guide goal setting ( clear & reachable).

Specific. What will the goal accomplish? How and why will it be accomplished?

Measurable. How will you measure whether or not the goal has been reached

Achievable. Is it possible? Have others done it successfully? Do you have the necessary knowledge, skills, abilities,

Relevant/Results‐focused. What is the reason, purpose, or benefit of accomplishing the goal? What is the

Time‐bound. What is the established completion date and does that completion date create a practical

How to Accomplish ?

92



# Interventions and $$ Saved Turn Around Time ( TAT) # Orders entered

Data is Manageable, Obtainable and tangible Individualized per pharmacist Standardized for every pharmacist

FTE status ( FT vs PT vs PD)

Combine ‐ depends on their objective performance What is the # of orders per interventions documented How many medication errors has the person had compared to the

orders completed and TAT

Evaluate on Objective/Quality Data

93

Pharmacist Hard Dollars Total Dollars

Bartell, Jonathan $ 17,406.00 $ 423,693.00

Beecham, Renee $ 556.00 $ 215,103.00

Bui, Ngoc $ 17,264.00 $ 554,769.00

Carozzoni, Kim $ 18,487.00 $ 971,695.00

Cella, Stacy $ 8,737.00 $ 331,311.00

Ferraro, Ralph $ 40.00 $ 22,947.00

Gualtieri, Michelle $ 15,889.00 $ 302,731.00

Hood, Gregory $ 11,475.00 $ 140,490.00

Hubert, Jeffery $ 454.00 $ 14,879.00

Lucarelli, Karen $ 4,709.00 $ 248,853.00

Nozzi, Lori $ 1,246.00 $ 46,729.00

Pak, Diana $ 9,511.00 $ 172,206.00

Pollick, Christopher $ 4,420.00 $ 235,451.00

Riccardo, Deb $ 10.00 $ 49,642.00

Rupp, Sara $ 7,412.00 $ 284,937.00

Sands Wellings, Faith $ 14,338.00 $ 281,761.00

TOTAL $ 131,954.00 $ 4,297,197.00

Min $ 10.00 $ 14,879.00

Max $ 18,487.00 $ 971,695.00

Median $ 8,074.50 $ 242,152.00

Average $ 8,247.13 $ 268,574.81

Frank Smith Pharmacist $ 17,406.00 $ 423,693.00

Quantifi/Sentri 7 ReportsComparison Table for Graph

Pharmacist Interventions(#) Follow‐Ups (#)

Bartell, Jonathan 2749 343

Beecham, Renee 1256 48

Bui, Ngoc 3535 446

Carozzoni, Kim 5594 614

Cella, Stacy 1944 369

Ferraro, Ralph 136 10

Gualtieri, Michelle 2068 291

Hood, Gregory 1131 196

Hubert, Jeffery 121 135

Lucarelli, Karen 1409 232

Nozzi, Lori 308 70

Pak, Diana 1146 236

Pollick, Christopher 1323 241

Riccardo, Deb 323 49

Rupp, Sara 1645 318

Sands Wellings, Faith 1679 263

TOTAL 26,367 3,861

Min 121 10

Max 5,594 614

Median 1,366 239

Average 1,648 241

Frank Smith Pharmacist 2749 343

94



95

Cerner – TAT and Orders and Interventions

Pharmacists

Ave TAT ( minutes) # Orders # Interventions

Bartell, Jonathan Pharmacist 20.87 35931 2749

Beecham, Renee Pharmacist 22.17 12668 1256

Bui, Ngoc Bao Pharmacist 17.77 38618 3535

Carozzoni, Kimberly A Pharmacist 20.06 39177 5594

Cella, Stacylynn Pharmacist 17.63 39097 1944

Ferraro, Ralph B Pharmacist 16.95 27404 136

Gualtieri, Michelle Pharmacist 20.35 28737 2068

Heard, Sara R Pharmacist 18.37 49232 1645

Hood, Gregory Pharmacist 16.03 2964 1131

Hubert, Jeffrey O Pharmacist 26.57 9406 121

Lucarelli, Karen Pharmacist 20.31 30861 1409

Nozzi, Lori S 19.19 17265 308

Pak, Diana Pharmacist 14.26 10060 1146

Pollick, Christopher G Pharmacist 17.57 37133 1323

Riccardo, Deborah Mgr Pharmacy 18.97 20198 323

Wellings, Faith Sands Pharmacist Clinical 17.63 27999 1679

TOTAL

Frank Smith Pharmacist 17.63 27999 1679

Average 19.04 26672 1648

Median 18.67 28368 1366

MAX 26.57 49232 5594

MIN 14.26 2964 121

96

17.6319.04 18.67

26.57

14.26

0.00

5.00

10.00

15.00

20.00

25.00

30.00

FS RPh Average Median MAX MIN

Ave TAT min

27999 26672 28368

49232

29641679 1648 13665594

1210

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

FS RPh Average Median MAX MIN

Orders to Interventions

# Orders

Interventions



# Interventions were part of Evaluation

First year including

TAT; # Orders;

Intervention/Follow‐up Comparison

Charts and Graphs are attached to Performance Evaluation

Discussion with each pharmacist about their progress

Discussion on Goals for Next Year

# Interventions

TAT

# Orders

Medication Variances

Evaluation

97

SMART GOAL Example:

Sentri 7 Interventions:

• Specific: Increase AS knowledge to increase Sentri 7 documentation

• Measure: # document/shift = >18= 5; 15.9‐18 = 4; 14.1‐15.8 = 3; 10‐14 = 2; <10 = 1 ( Score on evaluation 1 – 5)

• Achievable: min 15 interventions documented per shift worked

• Relevant: Important for Joint Commission, CDC

• Time bound : Accomplish by next evaluation period TAT/#Orders: Goal to maintain or improve time above the median

Educational Program: Pharmacist Staff must develop a pharmacy or nurse educational competency or presentation

All of the above can be incorporated into the Pharmacists General Duties of the Evaluation

SMART Goalsfor Performance Evaluation

98



Quality

Breakdown by Intervention Class

IV to PO

Antimicrobial Stewardship

Anticoagulation

Future

99

Contact if need directions to generate reports:

[email protected]

100



ASSESSING PENICILLIN ALLERGY IN ADULT PATIENTS AT REGIONAL HOSPITAL OF SCRANTON

MAURA L. OSBORNE, PHARMD, BCPSCL IN I CAL MANAGER , DEPARTMENT OF PHARMACY,

REG IONAL HOSP I TAL OF SCRANTON

JANARA KOEHLER, MD CLASS OF 2020GE I S INGER COMMONWEALTH SCHOOL OF MED IC INE

101

ObjectiveAt the conclusion of this presentation, participants will be able to describe how to assess a patient with a penicillin allergy.

102



National Statistics• 10% of U.S. population have a reported penicillin allergy

• <1% of population as a true allergy

o 0.005% of population will have an anaphylactic reaction

• 80% have negative skin test after 10 years

Apter AJ, Kinman JL, Bilker WB, et al. Is There Cross‐Reactivity Between Penicillin and Cephalosporins? The American Journal of Medicine. 2006;119(4):354e.311‐354e.319.Blanca M, Torres MJ, García JJ, et al. Natural evolution of skin test sensitivity in patients allergic to B‐lactam antibiotics. Journal of Allergy and Clinical Immunology. 1999;103(5):918‐924.

103

Methods• Screening tool developed from data available via CDC, Dynamed, and published studies• Characterization of reaction

• Symptoms

• Focused patient history

• Interviewer questions

• Generate list every day of patients who report penicillin allergy

• Interviewed adult, acute care in‐patients with reported penicillin allergy

• 5‐10 minute survey administered via Google Forms

• Compiled data

104



Characterization of Reaction

105

Characterization of ReactionHow many years ago did you last have a reaction to this medication?

Blanca M, Torres MJ, García JJ, et al. Natural evolution of skin test sensitivity in patients allergic to B‐lactam antibiotics. Journal of Allergy and Clinical Immunology. 1999;103(5):918‐924.

1%2%5%

8%

84%

Time Since Last Reaction

<1 year

1‐4 years

5‐9 years

10‐19 years

106



How long after you took the medication did a reaction occur?

Penicillin allergy. EBSCO Information Services; 2015. http://web.a.ebscohost.com.ezproxy.tcmc.edu/dynamed/detail?vid=2&sid=1174bddf‐3f55‐4185‐aef8‐e7692fb9aa10%40sessionmgr4009&hid=4209&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d ‐ AN=205236&db=dme.

Characterization of Reaction

39%

35%

1%

1% 5%

0%19%

Time to Reaction

< 1 hr

Within 24 hrs

> 48 Hrs

> 72 hrs

4‐7 days

1‐3 weeks

Unknown

107

Symptoms

108



Focused Patient History

109

Interviewer Questions

1. Length of time since last reaction2. Timing of reaction3. Severity of symptoms

110



Interviewer QuestionsIn your opinion, what is the likelihood that this person will have a true allergic reaction to penicillin today?

90%

9%

1%

Likelihood of Penicillin Allergy

Low

Moderate

High

111

Interviewer QuestionsIn your opinion, what patients could be recommended for skin testing?

84%

15%

1%Skin Test Recommended

Yes

No, no signs ofallergy

112



Next Steps• Provider education

• In‐take assessment of penicillin allergy

• Removal of inappropriate allergy from EMR

• Skin‐testing Protocol

• Penicillin desensitization Protocol

113

Incorporating IPPE Students Into Essential Patient Care Services

114



Northwest Medical Center, Tucson Arizona IPPE students who they are and why they started

ASHP Foundation Pharmacy Forecast 2017 recommendations

Training and Oversight Northwest Medical Center, Tucson Arizona IPPE student responsibilities

Time Commitment Results

115

300 bed hospital Approximately 50% Medicare patients OB/NICU Rehab unit Medical Oncology Two outpatient surgery centers Four urgent Cares One Free Standing ED and an additional one opening January 2018

Students/Residents: University of Arizona College of Pharmacy partnership and standard

CHS contract agreement▪ PGY 1 (three per year), PGY2 Emergency Medicine (international)▪ APPE (4th year students)‐‐‐4 per year▪ IPPE

116



IPPE: Introductory Pharmacy Practice Experiences within the first three years of the PharmD program

300 hours

Balanced between community and health‐system setting

60 hours can be through simulations

117

Pharmacy Work Force: Shift in Roles, Responsibilities and Training

“When building pharmacy practice models for health systems forethought should be given to how students will be incorporated as productive team members of the pharmacy team.

“Students should not simply be layered on top of existing operations without clearly defining how they will contribute to the work of the pharmacy department.”

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Approximately 50 students per year Minimum 120 hours 2nd/3rd year pharmacy students

Summer and Winter rotations (3 weeks duration): Four students each rotation

▪ Three students during the day (0800‐1730) Monday‐Friday▪ One student afternoon evening (1200‐2130) Monday‐Friday

Fall/Spring rotations (entire semester): 10 students each rotation

▪ Four students every Friday 0800‐1730▪ Six students twice a week 1700‐2130

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Patient Counseling Heart Failure Pain Tobacco Cessation Fluoroquinolone

Admission Home Medication Lists

Medication Use and Guideline/Protocol Evaluations120



Standard email describing the rotation and documents required.

Pre‐reading and quiz for all patient counseling types to be completed prior to the start of the rotation.

Written protocols on all aspects of each responsibilities from identifying patients, checklist of items to do, information provided to the patient, script, standard progress note.

Role playing with script for tobacco cessation, HF patients Partnership with AshLine (Arizona Smokers Helpline)

Partner students during training

Pharmacist/med rec tech oversight on home medication lists

Standard timeline/process used for all drug and protocol evaluations.

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Inpatient Counseling Identified by admission diagnosis/symptoms Counsel patients on: HF meds, weight monitoring, tobacco use,

sodium intake, medications to avoid, adherance/compliance Teach back method Pill Boxes HF book Patient monitoring form created

Discharge Phone Call Inpatient counseled patients Confirm patient is taking meds, weighing continues and follow

up physician appointment made

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Identification of the patient through nurse screening on admission

Counseling following the ASHP Guidelines

AshLine (Arizona Smokers Helpline) Verbal Consent

Nicotine patch initiated per hospital protocol (pharmacist ordered)

Nicotine patch counseling123

Patient Identification:

Ortho‐Surgical Patient unit only (hip/knee replacements, bariatric, etc).

Discuss the following with patients:

pain medications available to patient, side effects, medications to counter effect side effects.

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Patient identification through EHR report (Cerner) to identify active orders.

Standard antibiotic information provided to patient

Patient reviewed for potential switch from IV to PO and if so, Sentri7 note opened for pharmacist follow up

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Hours: Evening hours in the ED Day hours on the inpatient units

Patient identification: Computer system to identify patients who were admitted

Pharmacist triage, or Med Rec Tech triage

Pharmacist final verification for all completed home medication lists.

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Non‐Complex Topic identified based on need

Students complete the following: Background reading/discussion of topic Completion of a data collection spreadsheet Data collection for a few patients and discussion Completion of data collection, finalization of a powerpoint presentation, practice presentation

Presentation to P&T Committee and relevant committee (i.e. infectious diseases, OB, anesthesia)

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Medication/Drug Class reviews: Use of calcitonin injection Discharge opiate prescription trends in the OB population ED Opiate use in the ED and upon discharge in the pediatric

patient TDAP and Influenza use in the OB patient population

Protocol/Treatment Evaluation: Neonatal abstinence withdrawal protocol CroFab/rattlesnake bite protocol Treatment of hypoglycemia in the newborn Antibiotic use in chorioaminionitis Glycemic control in surgical patients

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Training and orientation for each rotation Approximately 8 hours pharmacist time which includes an initial 1 hour

orientation of the hospital, rotation goals and objectives Approximately 4‐6 hours of med rec technician time.

Pharmacist sign off on all admission home medication lists (5 minute each)

Director/Clinical Pharmacy Coordinator discussions for MUE 4 hours per project

Patient counseling is autonomous and follows standard script Resident review of student counseling only if resident available.

Midpoint and Final Review as a group One hour per group Individual feedback only as needed.

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Sentri7 Interventions for all activities

In a year we have been able to….

Get an additional 5600 hours of patient care activities completed (2.7 FTEs)

Complete approximately

▪ 5,500 patients counseled

▪ 2700 home medication lists completed

▪ 6 medication use/protocol evaluations completed

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Cost Savings Initiative in the Treatment of Nonmuscle Invasive

Bladder Cancer

Christine Viramontes, RPh

Bayfront Health Brooksville

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Situation

• Treatment of Superficial Transitional Cell Carcinoma of Bladder with IntravesicalChemotherapy

• Escalating cost of Mitomycin C, specifically over the last three years

• Doxorubicin use as an alternative therapy

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Background

• Bayfront Health Brooksville is not a cancer center and only treats low risk patients

• 2 urologists on staff who infrequently perform TURB and have utilized mitomycin for several years

• Mitomycin cost increase of 485% in 3 years

– November 2014 $185 /dose

– September 2017 $1080/dose

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Background

• Using Dynamed Plus, we researched alternative therapies to Mitomycin for bladder instillation

• For low‐risk tumors, a single immediate instillation of chemotherapy (mitomycin, epirubicin, or doxorubicin) after TUR is recommended as a complete adjuvant treatment (Strong recommendation). (Cite this from Dynamed Plus)

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BackgroundMitomycin C 40 mg cost

Doxorubicin 50 mg cost

Epirubicin50‐80 mg cost

BCG 50 mg cost

11/14 $184.72/dose

9/17$15.58/dose

9/17$110.00/dose

9/17$152/dose

9/15 $661.68/dose

9/17$1080.00/dose

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Assessment

• Multiple studies assessing multiple agents

• Several different agents that had been studied compared cost

• Studies relatively small in patient numbers

• Based on that, it’s tough to make a clinical judgment on the superiority of one agent over another

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Recommendation

• Call urologist to obtain order to change Mitomycin C 40 mg to Doxorubicin 50 mg for bladder instillation

• Cost savings > $1000 per order

• Time < 2 minutes per phone call

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• References:• Chou R, Selph S, Buckley D, Fu R, Griffin JC, Grusing S, Gore

JL. Intravesical therapy for the treatment of nonmuscleinvasive bladder cancer: a systematic review and meta‐analysis. The Journal of Urology. 2017; 197: 1189‐1199.

• Addeo R, Caraglia M, Bellini S, Abbruzzese A, Vincenze B, Montella L, Miaragliuolo R, Guarrasi R, Lanna M, CennamoG, Faiola V, DelPrete S. Randomized phase III trial on Gemcitabine versus Mitomycin in recurrent superficial bladder cancer: evaluation of efficacy and tolerance. Journal of Clinical Oncology. 2010; 28: 543‐548.

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Jerry H. Reed, MS, RPh, FASCP, FASHP

Senior Director, Pharmacy Services

Community Health Systems

Update on Current Pharmacy Initiatives and Strategies

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2017 pharmacy education series - proces3.proce.com/res/pdf/chs2017nov15handout.pdf · 2017. 11....

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