Minimizing Polypharmacy : Addressing Therapeutic Duplications

1. Minimizing Polypharmacy: Addressing Therapeutic Duplications RISHP Showcase 2015 C. Maxwell M. Kelley

2. Objectives • Technician Objectives: • Understand when therapeutic duplications occur in the ordering of PRN medications. • Provide an example of a therapeutic duplication. • Understand how guidelines can be developed to categorize severity of common psychiatric PRN indications for medications to avoid therapeutic duplications.

3. Objectives • Pharmacist Objectives: • Describe the process of guideline/order set development for PRN indications of anxiety, agitation, psychoses, nausea/vomiting and constipation in a specialized psychiatric hospital and community hospitals. • Explain how use of PRN reasons defined by a guideline/order set facilitates compliance with Joint Commission standards and regulations. • Choose the appropriate PRN reason for psychiatric symptoms utilizing the provided guideline.

4. Therapeutic Duplication occurs when: • More than 1 med is ordered for a single indication • The level, degree, or the severity for the indication is not specified • There is not hospital policy or guideline to guide nursing staff on when a med is to be administered

5. Corrective Action Steps • Clarify some definitions of specific PRN Reasons in Power Plans • Revise the default PRN Reasons for some PRN orders in Power Plans • Create Hospital Guidelines that define the Degree of Severity of some common psychiatric symptoms

6. Guidelines for Psychiatric PRN Reasons • Guidelines are developed to categorize some common symptoms for which PRN meds are indicated • Anxiety and Severe Anxiety • Agitation and Severe Agitation • Psychosis and Severe Psychosis

7. PRN Guideline: Anxiety ANXIETY SEVERE ANXIETY • Anxious, apprehensive, movements not aggressive • Physical distress, or feelings of panic • Nausea or abdominal distress • Mild trembling or shaking • Feeling tense or “wound up” • Restlessness • Physical distress leading to impairment of ADL • Inability to sit still or sleep • Marked trembling or shaking • Fear of losing control • Fear of dying • Feelings of panic with somatic complaints (sweating, shortness of breath, hyperventilation, chest pain, palpitations, tachycardia,) • Paresthesia (numbness or tingling sensations) • Feeling dizzy, unsteady, light-headed or faint • Physical distress leading to impairment of ADL • Inability to sit still or sleep • Marked trembling or shaking • Fear of losing control • Fear of dying • Feelings of panic with somatic complaints (sweating, shortness of breath, hyperventilation, chest pain, palpitations, tachycardia,)

8. PRN Guideline: Agitation AGITATION SEVERE AGITATION • Impulsive, impatient, low tolerance for pain or frustration • Uncooperative, resistant to care, demanding • Rocking, rubbing, moaning or other self- stimulating behavior • Restlessness, pacing, excessive movement • Rapid, loud or excessive talking • Sudden changes of mood • Violent, combative and/ or threatening violence toward people or property • Explosive and/ or unpredictable anger Self- abusiveness, physical and/or verbal • Immediate danger to self or others

9. PRN Guideline: Psychosis PSYCHOSIS SEVERE PSYCHOSIS • Auditory or Visual Hallucinations • Delusions • Paranoid Thoughts • Auditory or Visual Hallucinations with threats of harm to self or others • Delusions with threats of harm to self or others • Paranoid Thoughts with threats of harm to self or others

10. Default PRN Reasons in Power Plans Oral IM • Anxiety – Benzodiazepines, Antihistamines • Agitation - Antipsychotics • Severe Anxiety – Benzodiazepines, Antihistamines • Severe Agitation - Antipsychotics

11. PRN Guidelines: Nausea/Vomiting • Order of use defined in the PowerPlans • Ondansetron: Use first for N/V • Promethazine: Use for N/V refractory to ondansetron • Metoclopramide: Use for N/V refractory to ondansetron and promethazine

12. PRN Guidelines: Constipation • Order of use defined in the PowerPlans • Colace: PRN reason for stool softening • All laxatives below given with colace • Senna: Use first for constipation • MOM: Use if patient still constipated 24 hours after Senna • Bisacodyl PO/PR: Use if patient still constipated 12 hours after MOM • If both PO/PR ordered, use least invasive route first • Miralax: Use if patient is still constipated after 48hours from initial laxative dose

13. Therapeutic Duplications: Next Steps • Therapeutic Duplication Policy • Define order of preference for medications by indication • Set criteria for IV or PO options • Allow pharmacists to clarify orders per “policy/protocol” • Pharmacist responsibility at time of verification • Continual monitoring • Regular audits of duplicates and corrective steps

14. Summary • TJC and DOH are focused on Therapeutic Duplications • Most commonly found duplicate orders: • Pain • Agitation/anxiety • Nausea/vomiting • Constipation • Creation of PowerOrders and a policy • Minimize prescribing of duplications • Provide clarification when duplications exist • Goal is to minimize patient harm, adverse drug events and unclear orders