Providence Pharmacy PGY1 Program at Providence Milwaukie and Providence Newberg Medical Centers 2021
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Evaluation of Medication History Technician (MHT) Expansion at a Large Tertiary Medical Center
Sarah Auer, Rochelle Castrillo, and Tony Lucchi
Background
• The yearly joint commission National Patient Safety Goals for 2020 and 2021 stress the importance of using medications safely which includes an emphasis on medication reconciliation and decreasing medication discrepancies. 1,2 o Pharmacy Medication History Technicians (MHTs) work as an integral part of the medication reconciliation process to gather complete medication histories o The goal of medication reconciliation is to decrease medication discrepancies decreased medication related adverse events improve patient outcomes • Pharmacist run medication reconciliation programs have shown decreased medication errors by over 80% when compared to standard medication reconciliation performed by nurses or other healthcare providers. 3 • Cost of a preventable adverse drug event (ADE) is between $4,800 10,375 per event. 5 • Each documented medication history is valued at $642 • Large tertiary medical center MHT expansion: o Adds two additional MHTs to the already existing team of four MHTs o Funded by medical center hospitalists group o Goal of capturing a larger proportion of medication histories in additional settings • Many studies have assessed the impact of the implementation of a MHT program, however there is a lack of knowledge when it comes to the effect of adding additional MHT to an existing program.
Purpose
• This study aims to evaluate the impact of the addition of two MHTs to an already existing program as well as evaluate how outside factors ( i.e. quantity of medications, verification of methadone dose) involved in the medication reconciliation process effect productivity metrics.
Objectives
• Primary Objectives: o Determine the number of medication histories completed and the number of opportunities missed o Identify the percent of time medication histories are complete within 12 and 24 hours of the patient being set for admission o Evaluate the accuracy of medication histories completed by medication history technicians • Secondary Objectives: o Identify effect of predetermined factors such as quantity of medications and availability of MARs on the number of medication histories completed by medication history technicians o Calculate the cost savings associated with technician completed medication histories compared to hospitalist completed medication histories o Calculate the cost savings associated with number of medication histories completed o Evaluate provider satisfaction with medication history technician program and medication history service
Methodology
• IRB status: Approved; Study2020000877 • Study design: Prospective/Retrospective chart review • Study timeline: Pre expansion; November 2020 April 2021 (6 Months) • Inclusion criteria: Patient’s admitted through the emergency department • Exclusion criteria: Patients that do not meet the inclusion criteria • Patients will be screened for eligibility via EPIC data analysis admissions data and intervention (I vent) documentation • Productivity factors will be documented using I vent documentation with custom dotphrases in EPIC • Pharmacists: • Number of corrections made by RPh • Technicians: • Medication administration record (MAR) faxed • Quantity of medications on medication list • Methadone verification needed • Discrepancies of note • Provider satisfaction will be determined through a Microsoft forms survey
Discussion
• January Findings: o Most completed = Friday/Saturday o Most missed = Tuesday/Saturday o The busiest shift seems to be MHT2 from 1730 0000 this is also when most med hxs are missed o 33.8% of medication histories missed were when there were no MHT present (111 out of 328) o Turnaround time on completed med hxs was on average 2.5 hours shorter when MHT were completing the medication histories vs. providers o All average and median turnaround times are within the preferred 24 hour timeframe • Study Limitations: o No post expansion data analysis due to time constraints and expansion go live date o Limited productivity factor data collection due to time constraints and expansion go live date o Productivity factor data: Implementation of a new dotphrase that is different from what the MHT were trained to use may result in inconsistent documentation in I vents o Turnaround time analysis uses different start times depending on the admission scenario ED to DC IP bed requested + med hx Med hx + IP bed requested o Due to scheduling challenges, there may or may not be MHT overlap for the entire time from 1330 1730
Preliminary Conclusions• A much higher percentage of medication histories were missed when MHTs were not present in the ED • The presence of MHTs noticeably reduced the turnaround time of medication histories completed • On average, if a medication history was completed it was completed within the 24 hour preferred timeframe • The additional MHT coverage as a part of the expansion will help to capture more medication histories • Future direction: o Post expansion data analysis o 24 hour MHT coverage
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An Evaluation of the Use of Tranexamic Acid in the Treatment of Bradykinin-Mediated Angioedema in the Emergency Department
Sarah YB Kim and Carol Keller
Background
Bradykinin mediated angioedema is an overarching term that includes idiopathic angioedema, angiotensin converting enzyme inhibitor (ACEi) induced angioedema and hereditary angioedema (HAE). •This is an emergent condition that must be treated with the utmost urgency due to the fatal outcomes associated with the rapid constriction of the throat. •Bradykinin mediated angioedema is treated differently from histamine associated angioedema due to its resistance to corticosteroids and antihistamines. •HAE and ACEi induced angioedema are treated similarly but there is a lack of unanimity in the first line pharmacologic treatment. •Current treatment options include fresh frozen plasma, bradykinin-2 receptor antagonists, plasma-kallikrein inhibitors and C1 esterase inhibitors. •Tranexamic acid (TXA) has been used for moderate cases of angioedema but is not well established in the emergent setting. •TXA has a 2270-fold lower cost compared to the preferred agent at this large multicenter hospital organization, Berinert.
Purpose The purpose of this study is to examine whether TXA is a viable first-line treatment option for bradykinin-mediated angioedema in the emergency department.
Objectives
Determine whether TXA is a viable treatment option for bradykinin-mediated angioedema •Evaluate the cost-effectiveness of TXA in comparison to Berinert •Examine the incidence of use of TXA versus other pharmacologic agents used to treat bradykinin-mediated angioedema •Identify the optimal or standard dose of oral TXA for patients presenting to the emergency department with bradykinin mediated angioedema
Methodology
Institutional Review Board (IRB)-approved •Electronic health record (EHR)-based retrospective chart review of patients admitted to any of the eight emergency departments in a large multicenter hospital organization •Data was narrowed down by the inclusion criteria and the “SlicerDicer” tool within EPIC was utilized to extract the included study population. •Study period: October 1, 2019–October 1, 2020 •Inclusion criteria: patients admitted for either ACEi induced angioedema or HAE and treated with either TXA or Berinert during their emergency department visit. •Exclusion criteria: patients <18 years of>age, patients with suspected or confirmed pregnancy, those with an allergy or intolerance to TXA or Berinert, patients who were treated with any other drug besides TXA or Berinert, those with personal or religious objections to receiving blood products and finally patients with stage one angioedema. •Primary outcomes: admission to the ICU, intubation rate and length of stay (LOS).
Discussion
Patient Population •Average patient was a 60-year-old Caucasian male weighing 101 kg with a history of a home use of an ACEi with a chief complaint of tongue swelling. •The mean age was 56 years (range 39-67 years) in the TXA group and 76 years (range 65-88 years) in the Berinert group. •94.4% of patients in total reported taking a home ACEi (83.3%) or ARB (11.1%) prior to admission. Clinical Outcomes •In the TXA cohort, 50% (n=7) patients were admitted to the hospital with 35.7% of patients in this cohort (n=5) admitted to the ICU. The remaining patients, 14.3% (n=2) were admitted to the medicine floor. •The average LOS for patients treated with TXA was 1 day (range of 1 day) and there was no incidence of bleeding in this group. •Patients in the Berinert cohort had a 25% incidence of intubation (n=1). 50% (n=2) of patients were admitted to the hospital with both patients being admitted to the ICU. •The average LOS for patients treated with Berinert was 2.5 days (range of 1-4 days) and 25% (n=1) patient was reported to have copious amounts of blood from his mouth. There was no charting to explain the etiology of the bleed in this particular patient. •For both cohorts, there was no incidence of mortality, anaphylaxis or thrombosis. Financial Implications •The average cost of 1 gram dose of TXA is $6 compared to $13,617 for Berinert. If one were to estimate an arbitrary 15 incidences of bradykinin mediated angioedema cases in a year, the average cost of TXA would be $90 compared to an estimated annual cost of $204,255 of Berinert. •This is a 2,270-fold price difference. Study Limitations •Retrospective chart review •Disproportionate sizes of cohorts •The study did not reach the sample size required for adequate power to assess the primary outcomes of ICU admissions, intubation rate, and LOS.
Next Steps
This small study showed the potential for utilization of intravenous TXA as a first line agent for bradykinin-mediated angioedema. • A larger study population would need to be assessed to confirm the benefits of using intravenous tranexamic acid over a C-1 esterase inhibitor such as Berinert as a first line agent for bradykinin-mediated angioedema. • By utilizing a more cost effective and possibly safer agent such as tranexamic acid, providers may not only improve outcomes for patients but also reduce costs for a large multicenter healthcare system.
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Impact of the Geriatric Mini-Fellowship on Prescribing Patterns of the Primary Care Providers
Amy Zahn and Sharon Leigh
Background
• Geriatric patients are likely to experience adverse drug events related to high-risk medication use. Polypharmacy is also common and has a significant impact on the health of older adults. •The American Geriatric Society Beers Criteria lists potentially inappropriate medications for older adults.1 •Current literature suggests that Implementing interventions and deprescribing practices have a role in reducing costly hospitalizations. •STOPP (Screening Tool of Older People’s Prescriptions) was designed to address polypharmacy.2 •Medication review and follow-up services for older, polypharmacy patients lowered medication-related costs.3 •Projections suggest there is an insufficient supply of geriatrician services.4 •Per person personal health care spending for people 65 years and older is three times higher than spending per working-age adult.4 •Individuals aged 65 and older are expected to increase from 14.5 percent of the U.S. population in 2014 to 21.7 percent by 2040.5 •In 2018, a Geriatric Mini-Fellowship Program was implemented. The program was designed to: •Increase primary care provider competencies in managing geriatric syndromes. •Train PCP’s to be geriatric medicine leaders to share awareness of geriatric care in their respective clinics. •The program curriculum focused on the “Four M’s” of geriatric care. •Medication, Mobility, Mentation, What Matters •Two cohorts of fellows have graduated from the program.
Purpose
• Quantify the prescribing pattern changes of high-risk medications of the geriatric fellows before and after completing the program. •Identify the geriatric fellows’ perceptions on deprescribing after completing the program.
Study Design
• Four high-risk medication drug classes were identified for an increased fall risk and were selected for this study.1 •Urinary Agents, Tricyclic Antidepressants, Muscle Relaxants, and Z-drugs •Study Period •May 2017 to May 2020 •Fellowship Cohort 1: Start Date April 16, 2018 •Pre-intervention: As of May 2018 •Post-intervention: As of May 2019 •Fellowship Cohort 2: Start Date April 20, 2019 •Pre-intervention: As of May 2019 •Post-intervention: As of May 2020 •Inclusion Criteria •Adults aged 65 years and older •Enrolled in the outpatient care of a geriatric fellow •Participated in at least one PCP office visit in the pre-intervention period and one visit in the post-intervention period. •Primary Endpoints •Number of patients on a high-risk medication in the identified classes •Number of high-risk medications in the Pre period •Number of high-risk medications in the Post period
Discussion
Conclusions High-Risk Medication Data: •For most drug classes studied, deprescribing occurred more often than new starts. •Continuing high-risk medication use was very common across all drug classes. Chart Review Data: •The retrospective chart review identified cases of deprescribing that were not captured in the initial analysis. •Dose decrease occurred more often than dose increases. Qualitative Survey Data: •Geriatric fellowship respondents felt that they frequently attempted to deprescribe high-risk medications in older adults. Limitations •Randomized selection of continued high-risk medication cases only estimates the distribution of the population. •Limited number of primary care providers participating in the program. Data can easily be skewed by the practice of individual providers. •The degree of life-limiting illness or patient life expectancy was not identified and would influence the potential for a medication to be inappropriate.6 •The cost impact of the Geriatric Mini-Fellowship program cannot be calculated from the results of this study. •Literature suggests that deprescribing interventions implement in patients with limited life expectancy have potential for mortality reduction and cost savings.6
Future Steps
• Identify a method for obtaining a control group. • Compare prescribing pattern of primary care providers before and after participation in the Geriatric Mini-Fellowship. •Describe the impact of the program on patient outcomes and cost. •Investigate prescribing of other high-risk medication classes. •Develop a plan to target high-risk medications that are considered most difficult to deprescribe.
