The Impact of Clinical Pharmacy Services on Quality Measures

1. The Impact of Clinical Pharmacy Services on Quality Measures Texas Hospital Association Annual Conference 2012

2. Agenda • Overview of clinical pharmacy programs • Case study from Peterson Regional Medical Center, Kerrville, Texas • Case study from Rolling Plains Memorial Hospital, Sweetwater, Texas

3. The Move To Payment for Quality • Hospital payments are now tied to “quality” in many areas. • Failure to meet the targets will result in lower payments. • Readmissions • Value based purchasing • Hospital acquired conditions • Accountable care organizations

4. The Link to Pharmacy • Many of the quality measures are directly related to the medication management process • Appropriate timing of medications such as antibiotics, VTE prophylaxis • Appropriate choice of medications • Appropriate monitoring of medications • For some measures, the link to pharmacy is not as apparent • Is the patient’s readmission due to poor medication management in the outpatient setting? • Has an inaccurate medication history on admission caused a failed quality measure?

5. The Link to Pharmacy • With the potential for lower payments, hospitals must manage costs at the same time that we work on these quality measures. • Pharmacy impacts the overall cost of care through medication management. • Contracting and purchasing management is not enough to manage the risk of pharmacy costs. Medication management through clinical pharmacy programs is an essential part of managing pharmacy costs.

6. What Is Pharmacy’s Role in the Hospital? • The historical role of pharmacy is managing the dispensing of medications. • While managing dispensing is still very important, the practice of pharmacy has evolved over the past 25 years to include enhanced clinical pharmacy programs. • Pharmacy education has changed to focus more on clinical management • Many pharmacists complete residencies and fellowships and are Board Certified in many different specialties.

7. A Member of the Team • As clinical practice has evolved, pharmacists have become members of the multidisciplinary care team. Pharmacists have different skill sets and augment the care provided by physicians and nurses.

8. Anticoagulation Management Kinetics Dosing Consults Renal Dosing Collaborative Rounding Antibiotic Stewardship Common Clinical Services Provided by Pharmacists Glycemic Management SCIP Measures Review Pain Consultation Medication Reconciliation ED Pharmacist Ambulatory Care Clinics IV to PO Conversions

9. Anticoagulation Management Kinetics Dosing Consults Renal Dosing Collaborative Rounding Antibiotic Stewardship SCIP NPSG’s Readmissions Core Measures Glycemic Management SCIP Measures Review Pain Consultation Medication Reconciliation ED Pharmacist Ambulatory Care Clinics IV to PO Conversions

10. What Literature Says about Clinical Pharmacy • Gattis, et al, found that outcomes in heart failure can be improved with a clinical pharmacist as a member of the multidisciplinary heart failure team. • All cause mortality and heart failure events were significantly lower and more patients reached target range with ACE inhibitors in the patient group with pharmacist interventions than in the control group. Gattis WA, Hasselblad v, et al. Reduction in heart failure events by the addition of a clinical pharmacist to the heart failure management team: results of the Pharmacist in Heart Failure Assessment Recommendation and Monitoring (PHARM) Study. Arch Intern Med 1999; 159(16): 1939-45

11. What Literature Says about Clinical Pharmacy • In a review of published literature on the effects of interventions by clinical pharmacists, Kaboli, et al, found that the addition of clinical pharmacist services resulted in improved care for inpatients. • Adverse drug events, adverse drug reactions, or medication errors were reduced in 7 of 12 trials reviewed. • Medication adherence, knowledge and appropriateness improved in 7 of 11 trials reviewed. • Shorter length of stay was noted in 9 of 17 trials. Kaboli PJ, Hoth AB, et al. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med 2006;166(9): 955-64.

12. What Literature Says about Clinical Pharmacy • 12 randomized trials totaling 2,060 patients were reviewed by Koshman, et al, to determine the effect of pharmacist care on the outcomes of patients with heart failure. • Pharmacist care was associated with significant reductions in the rate of all-cause hospitalizations and heart failure hospitalizations Koshman SL, Charrois TL, et al. Pharmacist care of patients with heart failure: a systematic review of randomized trials. Arch Intern Med 2008; 168(7): 687-94.

13. What Literature Says about Clinical Pharmacy • Bond, et al, found that clinical pharmacy services reduce patient mortality. • Pharmacist-provided drug protocol management resulted in the largest reduction in mortality. • Other clinical services also showing a reduction in mortality included pharmacist admission drug histories, participation on the CPR team, participation in medical rounds, and adverse drug reaction management. Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and hospital mortality rates. Pharmacotherapy 2007; 27(4): 481-493.

14. Narrowing the Focus • Patient focused involvement by pharmacists • For some quality measures, pharmacists take an active role in the medication management process. • Adjusting order times on VTE prophylaxis to meet first post-op day requirements • Reviewing prophylactic antibiotics for appropriateness • Process focused involvement by pharmacists • Development of protocols • Formulary management • Assistance with creation of order sets in EHR • Even with protocols and order sets, pharmacists still must monitor patients to make sure quality measures are met

15. Narrowing the Focus • Glycemic management • Management of anticoagulation • Admission medication histories

16. Glycemic Management • Goal is to have blood glucose less than 200 at 6am on the 1st and 2nd post op days. • Pharmacist developed protocol with appropriate lab orders and insulin orders • Patients meet goal on post op day 1, but occasionally fail on post op day 2. Failures are normally for non-diabetic patients and they are only slightly above target level. • Pharmacist reviewed cases. On post op day 2, patients begin to eat and insulin orders have to be adjusted to compensate for meal. • Additional monitoring added on early morning post op day 2 to allow time for additional intervention if necessary.

17. Management of Anticoagulation • NPSG 03.05.01 requires an anticoagulation management program • Pharmacist managed protocols for appropriate use • Baseline INR and ongoing monitoring • Dosing adjustments by protocol • SCIP VTE prophylaxis • Pharmacists select dosing times for post-op enoxaparin. Although many hospitals have standard administration times that won’t meet the SCIP guidelines of a dose within 24 hours of surgery end time, the pharmacist can adjust the immediate post-op dosing time to meet the guideline, then schedule subsequent doses at the standard times.

18. Admission Medication Histories • If a patient’s medication history is inaccurate, decisions affecting the patient’s care can be compromised. • In a pilot study, over 90% of medication histories for patients admitted through the emergency department had at least one error. • Risk stratification showed that 1.7% of the errors found could result in patient harm and possibly prolong the length of stay. • Many errors in diabetic medications and cardiac medications

19. Admission Medication Histories • Pharmacists took responsibility for completing medication histories on as many patients admitted through the ED as possible. • Reduction in inappropriate medications dispensed, resulting in 1.5 fewer doses per patient per day. • Physician and nursing surveys showed that the process improved patient safety and physician and nursing satisfaction.

20. Admission Medication Histories

21. Challenges • Smaller hospitals may not have the staff to add new programs • Larger hospitals within a system may not have the structure in place to provide support to smaller hospitals • Must have administrative and medical staff support of enhanced clinical pharmacy programs

22. Challenges • Lack of recognized metrics for clinical pharmacy programs • Productivity systems do not give additional credit for clinical programs • In a survey of eight health systems across Texas, no pharmacy productivity system includes a metric for clinical programs. Half of systems use billed doses and the other half use patient days or adjusted patient days. When clinical programs reduce doses billed or length of stay, there is less credit for the additional work to accomplish the goal.

23. Pharmacy Involvement in the Patient Discharge and Medication Reconciliation Process Peterson Regional Medical Center Kerrville, Texas

24. Hospital Information • 125 bed, general, acute care • Not for profit • 60 miles northwest of San Antonio, serving Kerr and 6 surrounding counties • ACC, Home Care, Hospice, and Acute Rehabilitation • 30,000 ED visits per year • 62% of Inpatient Admissions from the ED

25. PROJECT R.E.D. • “Re-Engineered Discharge” • Boston University • Reduce readmissions • Bundle: • DC plan, start on admission • Discharge advocate • Checklist • Education, Literacy level • Reinforce post DC • CQI

26. PROCESS • Multidisciplinary PI team • Physician champion • Advocate role • Target population • Adapted checklist • Training

27. BARRIERS • Additional position? • Inaccurate home medication history • Split responsibilities for discharge process

28. RESULTS • Redesigned discharge process • Pharmacy-based medication reconciliation trial in ED • Clinical Pharmacist involvement • Computerized discharge checklist • Pre-discharge order form • Post discharge phone call script • Live 12/5/11

29. METRICS • Discharges, • ED visits within 72 hours, ED visits within 72 hours due to medication issues • 30 day related readmits, 30 day all cause readmits, 30 day medication readmits • ALOS, Index and Readmit • Patient Satisfaction

30. The Role of Pharmacy in Medication Safety and Quality Measures Presented by Rolling Plains Memorial Hospital

31. Medication Safety and Quality Measures

32. Medication Safety • Look-alike / sound alike medications • High risk medications Heparin Insulin Potassium Opiates • Anticoagulants • Medication Errors

33. Quality Measures • Community Acquired Pneumonia and Surgical Care Improvement Project • Correct antibiotic regimen • Antibiotic timing

34. RPMH looked at ways to improve the medication administration process - focusing on automated systems and technology. • Automated dispensing systems • Bar code technology • CPOE and E-Sign • Medication reconciliation software

35. Funding Sources • CLIF Grant - $50,000 with a 10% match from RPMH • THIE Patient Safety Grant for $5,000 • Adjunct grant from TCQPS and Cardinal for $10,000 • RPMH Capital Budget

36. Timeline 4th Q 2009 - Purchased and installed PYXIS units on Med-Surg and in ICU 1st Q 2010 – Purchased and installed med verify (bar coding) software 3rd Q 2010 – Purchased and installed CPOE 2nd Q 2011 – Purchased and installed med reconciliation software

37. Barriers to Progress • Physician buy-in for CPOE • Cardiopulmonary access to PYXIS for medications • Bar coding / scanning issues • “Work a-rounds” • Time constraints with Med-Rec software

38. Response to Barriers • One-on-One training with physician’s on CPOE and E-sign • Educated staff not to do “work a-rounds” and how they affect patient safety • Added Med-Verify utilization on medication error follow up form • Continued education for nursing staff on computer documentation to speed up Med-Rec process at time of patient discharge

39. Medication Administration Reports • RPMH uses the NCC MERP Index for Categorizing Medication Errors • With the added technology we noticed a 15% increase in Category A and Category B medication errors being reported in 2011.

40. The Results 54% decrease in reported medication errors from 1Q 2010 to 4Q 2011

41. The Results

42. The Future • Continue to monitor medication safety processes • Continue to monitor & report medication errors • ACT upon any variance to our processes or systems

43. Contacts • Randy Ball, Texas Health Harris Methodist Hospital Fort Worth, randyball@texashealth.org • Larry Nelson, Peterson Regional Medical Center, lnelson@petersonrmc.com • Mickey Williams, Rolling Plains Memorial Hospital, mickeyw@rpmh.net

44. Questions???