2016 pharmacy education seriess3.proce.com/res/pdf/chs2016nov16handout.pdf · 2016. 11. 16. ·...

2016 Pharmacy Education Series

November 16, 2016Pharmacy Pearls 2016

Today’s Presenters

Margaret Babin, RPh

Margaret Babin is a Pharmacy Clinical Coordinator at Tomball Regional Medical Center (TRMC) since November 2004 and has worked at TRMC since 2003. She has earned her Society of Infectious Diseases Pharmacists (SIDP) training certificate in Antimicrobial Stewardship in October 2016. She completed a Bachelor of Science in Pharmacy at the University of Houston in 1980. She is also preceptor for students completing introductory and advanced practice experiential education rotations with Texas A&M, Creighton, and Lake Erie College of Osteopathic Medicine (LECOM). Margaret is a member of the Houston Infectious Disease Network (HIDN) and the American Society of Hospital Pharmacists (ASHP). She is a contributing author in an upcoming article “Significant publications on infectious diseases pharmacotherapy in 2015” to be published in the American Journal of Hospital Pharmacy (AJHP).

Robley E Bartholomew, PharmD

Dr. Robley Bartholomew completed his Pharm.D. training at the Lake Erie College of Osteopathic Medicine College of Pharmacy in Bradenton, Florida. Upon completion of his Pharm.D. degree, Robley went on onto complete a PGY‐1 Pharmacy Residency at Bayfront Health, a level 2 trauma center in St. Petersburg, FL. Robley is currently training as a PGY‐2 Pharmacy Administration Resident at Community Health Systems in Franklin TN and will be completing this training in June 2017.

James M. Bunch PharmD, BCPS

James Bunch is currently the Director of the Clinical Pharmacy for Mat‐Su Regional Medical Center in Palmer, Alaska. He received his Doctor of Pharmacy degree from Idaho State University in 2005. Since then he spent 3 years serving the Native Alaskan Yupik tribe in Western Alaska by working for the Yukon Health Corporation as an inpatient pharmacist. He has spent the last nine years working in the Mat‐Su Valley where his duties have ranged from staff pharmacist, to clinical coordinator, assistant pharmacy director, and now director of pharmacy. In 2012 he became a board certified pharmacotherapy specialist. In the clinical world his interests lie in critical care and infectious disease.

Jo Ann S. Gibbs, PharmD, BCPS

Dr. Gibbs has been the Director of Pharmacy at Byrd Regional Hospital in Leesville, LA for 8 years. She is sharing a process developed for her facility to keep track of all the paperwork involved in controlled substance auditing. This process has worked well and made our tracking and investigations more meaningful.

Sue V. Ie, PharmD

Sue received her Doctorate of Pharmacy from Touro University California College of Pharmacy. She is currently a postdoctoral fellow in health information and clinical outcomes for Community Health Systems and Wolters Kluwer Health. She is an active member of the American College of Clinical Pharmacy and is pursuing quality improvement and clinical outcomes research. Sue is a strong proponent of utilizing health information technology to streamline clinical workflows and drive clinical initiatives.

George E. Jossell, PharmD

Currently, director of pharmacy services at Lea Regional Medical Center, Dr. Jossell has practiced pharmacy at the management level for 21 years. Graduating from the University of Minnesota School of Pharmacy in 1976, he began his career in retail pharmacy culminating with 6 years as a retail pharmacy manager. Dr. Jossell transitioned to hospital pharmacy practice at Mount Sinai Hospital of Chicago, Illinois, a 400 bed, level 1 acute care center where he served as a decentralized pharmacist in the cardiac critical care unit before becoming assistant director of pharmacy. In this role, as automation project manager, he supervised the automation of the Mount Sinai pharmacy with pick to light medication carousels, remote checking of sterile compounding and a high speed medication re‐packager, to complement AcuDose automated dispensing machines and Narc‐station. Four years later he assumed the role of director of pharmacy at Roseland Hospital in Chicago for two years before accepting his current role at Lea Regional for the past two years. Dr. Jossell is a recent graduate of University of Florida School of Pharmacy where he completed a three year PharmD course, graduating in August, 2016.

Michael Kleinschmidt, PharmD, BCPS

Michael Kleinschmidt is presently the Director of Pharmacy at Brandywine Hospital in Coatesville, Pennsylvania. He is a graduate of the Philadelphia College of Pharmacy, and a Board Certified Pharmacotherapy Specialist. During his tenure as a pharmacist, he has worked in a variety of arenas as a clinical pharmacist, from the ED to General Medicine to Neuro‐Trauma. For the last 2 years, Dr. Kleinschmidt has been in a variety of management positions within the hospital pharmacy field. Pharmacy is undergoing a clinical transformation, and Dr. Kleinschmidt would like pharmacy to be a leader during this transition. As pharmacists, we have an opportunity to change healthcare models to better serve our patients, and this is not a responsibility that should be taken lightly. We possess an outstanding clinical, practical, and prospective ideology that can benefit all aspects of healthcare.

Laura R. Kroon, PharmD

Dr. Laura Kroon is a 2015 graduate from the University of Kentucky College of Pharmacy. She completed her PGY1 pharmacy residency at Frankfort Regional Medical Center in Frankfort, KY. During this time she also completed a teaching certificate through the Sullivan University College of Pharmacy. She is now completing a PGY2 pharmacy admin residency at the Community Health Systems corporate office with responsibilities at the Tennova Healthcare – Clarksville hospital.

Nicole C. Lefever, PharmD

Nicole LeFever, a Clinical Pharmacist with roughly 10 years’ experience in the Acute Care Setting, completed her Doctorate in Pharmacy at the University of Florida in 2007. Nicole spent the first 6 years of her pharmacy career as a Staff Clinical Pharmacist at Wuesthoff Medical Center Rockledge (a 298 bed full service acute care hospital) and 4 years ago transitioned into the role of Clinical Coordinator at Wuesthoff. Nicole has also been a Clinical Assistant Professor with the University of Florida, College of Pharmacy since 2013 and additionally conducts guest lectures at various institutions with primary focuses on Antimicrobial Stewardship, Pain Management, Addiction Medicine, and Psychiatric Pharmacotherapy.

Katherine Smith, PharmD

Dr. Katherine Smith received her Doctor of Pharmacy from the University of Arizona College of Pharmacy in 2011 and then completed a postgraduate year 1 (PGY1) pharmacy practice residency at the Southern Arizona VA Healthcare System in 2012. She is currently serving as the Women’s Center pharmacist at Northwest Medical Center (NMC) in Tucson, AZ. Dr. Smith is actively involved in the Community Health Systems (CHS) Neonatal Intensive Care Unit (NICU) Workgroup, whose mission is to develop evidence‐based, standardized content for neonatal care, as well as the NMC Maternal‐Child Safety Committee. She serves as preceptor for the PGY1 Management Conference residency experience, in addition to precepting Introductory Pharmacy Practice Experience (IPPE) and Advanced Pharmacy Practice Experience (APPE) students.

Kathryn E. DeSear, PharmD, BCPS, AAHIVP

Dr. Kathryn (Kate) DeSear earned her doctor of pharmacy degree from the University of Florida. She subsequently completed a PGY1 pharmacy practice residency in St. Petersburg, FL at the Bay Pines VA. She completed a second year residency (PGY‐2) in infectious diseases at the University of Florida Health Shands Hospital. Dr. DeSear has practiced as an antimicrobial stewardship specialist since 2012. She joined the corporate CHS team in 2016. She serves as the stewardship manager for CHS facilities and participates in the fellowship and residency learning experiences. She also serves as a preceptor for APPE students at the University of Florida and holds a clinical assistant professor position within the Department of Pharmacotherapy and Translational Research.

Pharmacy Pearls 2016CHS Pharmacy Education Series

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Pharmacy Pearls 2016Introductory 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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ANTIMICROBIAL STEWARDSHIP andRENAL DOSING ENHANCEMENTMargaret Babin, Rph, BS PharmPharmacy Clinical CoordinatorTomball Regional Medical CenterTomball, Texas

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OBJECTIVES Participant will be able to optimize antibiotic dosing utilizing

patient’s renal function in conjunction with culture and sensitivity reports.

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Disclosures

I have no relevant conflict of interests to disclose

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TRMC Renal dosing protocol policy

4CLSI. Performance Standards for Antimicrobial Susceptibility Testing; Twenty-Sixth Informational Supplement. CLSI document M100-S26. Wayne, PA: Clinical and Laboratory Standards Institute ; Online-Accessed May 2016.8Tam, V et al. Pharmacokinetics and Pharmacodynamics of Cefepime in Patients with Various Degrees of Renal Function. AntimicrobialAgents and Chemotherapy. 2003;47(6):1853-1861.17DeRyke CA, Lee SY, Kuti JL, Nicolau, D. Optimizing Dosing Strategies of Antibacterials Utilising Pharmacodynamic Principles. Drugs.2006;66(1):1-14

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Clinical Data Bhat et al

Evaluated 204 episodes of Gram-negative bacteremia treated with 1-2 gm IVPB every 12 hours of cefepime

55% of patients with MIC > 8 mcg/mL died

25% of patients with MIC < 8 mcg/mL died

Bhat SV, et al. Antimicro AG Chemo 2007;51:4390.

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CSLI Recommendations for Cefepime Before 2014 Enterobacteriaceae with MICs < 8 mcg/mL were

considered susceptible (regardless of dose or interval). Since 2014, MICs of 4-8 mcg/mL are considered susceptible

depending on dose of cefepime ordered Susceptible-Dose-Dependent (SDD): “susceptibility of an

isolate is dependent on the dosing regimen that is used in the patient”

Performance Standards for antimicrobial susceptibility testing. Twenty-fourth supplement. CLSI Document M100-S24. Wayne, PA 2014

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Susceptibility test Interpretive Criteria Cefepime

*Isolates of Enterobacteriaceae with intermediate susceptibility, use a dose of 2 gm every 8 hours in patients with normal renal function

Cefepime for Injection [package insert]. Paramus, NG: WG CriticalCare: 2014

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Resources Review CHS Antimicrobial Stewardship March 2016 webinar

Interpreting MIC in Antimicrobial Susceptibility Testing by Thao Nguyen, PharmD, BCPS

CSLI-M-100 document published yearly

New in 2016: read only access available at http://clsi.org/m100/

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BLEEDING RISK STRATIFICATION FOR ANTICOAGULATION SELECTION

IN PCI

Presented By: Robley Bartholomew, PharmD, PGY2 Pharmacy Administration Resident‐‐Clinical Support & Service

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Presentation Objectives

1. Understand current clinical initiative

2. Be able to discuss background information regarding calculator and clinical initiative

3. Utilize the bleeding risk tool to assist in anticoagulation selection

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Angiomax® to Unfractionated Heparin

•ISAR‐REACT/ISAR‐REACT 3A – Reduced loading doses (100 units/kg) result in non‐inferiority to bivalirudin with regard to the composite of death, myocardial infarction, urgent target‐vessel revascularization due to myocardial ischemia with in 30 days, or major bleeding

•HEAT‐PPCI – Reduced incidence of major adverse ischemic events including composite of all‐cause mortality, cerebrovascular accident, reinfarction, or unplanned target lesion revascularization with no increase in bleeding complications when comparing heparin 70 units/kg against bivalirudin

•MATRIX – Similar impact on composite of urgent target‐vessel revascularization, definite stent thrombosis, or net adverse events when compared against bivalirudin with heparin doses of 70 to 100 units/kg

•ISAR‐REACT/ISAR‐REACT 3A – Reduced loading doses (100 units/kg) result in non‐inferiority to bivalirudin with regard to the composite of death, myocardial infarction, urgent target‐vessel revascularization due to myocardial ischemia with in 30 days, or major bleeding

•HEAT‐PPCI – Reduced incidence of major adverse ischemic events including composite of all‐cause mortality, cerebrovascular accident, reinfarction, or unplanned target lesion revascularization with no increase in bleeding complications when comparing heparin 70 units/kg against bivalirudin

•MATRIX – Similar impact on composite of urgent target‐vessel revascularization, definite stent thrombosis, or net adverse events when compared against bivalirudin with heparin doses of 70 to 100 units/kg

Heparin versus Bivalirudin:

7/17/2015 18

*Angiomax® (bivalirudin) use during PCI is associated with significant increase in medication cost when compared with unfractionated heparin

(~$500/vial versus <$10/vial)

C

* Details Available on the CHS Pharmacy Intranet Page

Heparin Dosing:With GPIIb/IIIa

inhibitor: 50‐70 units/kg

Without GPIIb/IIIaInhibitor:

70‐100 units/kg

Other Health Systems Using Heparin over bivalirudin:‐Ross Heart Hospital, The Ohio State University Medical Center‐The Cleveland Clinic‐Beth Israel Deaconess Medical Center

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Background

• 2013 AHA/ACC Guideline for the Management of ST‐Elevation Myocardial Infarction– “Bivalirudin preferred over UFH with GP IIb/IIIa receptor antagonist in patients at high risk of bleeding”

– Class IIa recommendation (Level of Evidence B)

• 2014 AHA/ACC Guideline for the Management of Patients With Non–ST‐Elevation Acute Coronary Syndromes – “In patients with NSTE‐ACS undergoing PCI who are at high risk of bleeding, it is reasonable to use bivalirudinmonotherapy in preference to the combination of UFH and a GP IIb/IIIa receptor antagonist”

– Class IIa recommendation (Level of Evidence B)19

Risk Stratification Tool

• NCDR Report– Rao et al. 2013 – CathPCI Registry– Over 1 million PCI procedures from 1142 sites– Most predictive factors were:

1. female sex 2. shock 3. salvage PCI

• Developed a Pre‐Procedure Bleeding Risk Model• Utilizes a 10 variable scoring system

• Stratification and anticoagulant selection

• Rao SV, McCoy, LA, Spertus JA, at al. An updated bleeding model to predict the risk of post‐procedure bleeding among patients undergoing percutaneous coronary intervention. JACC: Cardiovascular Interventions, VOL 6, No. 9, September 2013:897‐904 20



PCI Pilot

• Results from bleeding risk pilot at Deaconess Hospital in Spokane, WA

Risk Stratification for Anticoagulant Use for PCI Bleeding

July 2016 August 2016September 14,

2016Post‐Implementation

Heparin Bival % Bival Heparin Bival Heparin Bival Heparin Bival% Use of Suggested

Low Risk0 5 100% 5 1 1 0 6 1 85.7%

Medium Risk0 18 100% 23 1 7 0 30 1 96.7%

High Risk0 7 100% 2 7 0 2 2 9 81.8%

Total Patients0 30 100% 30 9 8 2 38 11 91.8%

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NCDR Bleeding Risk Stratification Tool

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Conclusion

• Heparin for low to moderate bleeding risk patients

• Guideline recommendations for bivalirudin in PCI for high bleeding risk patients

• NCDR Report

– Bleeding Avoidance Strategies

– Simplified Model

• Calculator provides objective method for stratification

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References

• Schulz S, Mehilli J, Neumann FJ, et al. ISAR‐REACT 3A: a study of reduced dose of unfractionated heparin in biomarker negative patients undergoing percutaneous coronary intervention. European Heart Journal, 2010; 1‐10.

• Shahzad A, Kemp I, Mars C, et al. Unfractionated heparin versus bivalirudin in primary percutaneous coronary intervention (HEAT‐PPCI): an open‐label, single centre, randomised controlled trial. Lancet 2014; 384: 1849–58

• Valgimigli M, Frigoli E, Leonardi S, et al. Bivalirudin or unfractionated heparin in acute coronary syndromes. NEJM 2015: 1‐13.

• Rao SV, McCoy LA, Spertus JA, et. al. An updated bleeding model to predict the risk of post‐procedure bleeding among patients undergoing percutaneous coronary intervention. Journal of the American College of Cardiology 2013;6: 897‐904.

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IDSAPPA²SC’s Infectious Disease Specialist Access Pilot Project

Presented by James Bunch PharmD BCPS

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Objectives Explain some of the unique challenges to

implementing a true ASP in a community hospital.

Define A²SC Define IDSAPP

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Developing an ASP Can be Challenging

One of the biggest challenges we had here was lack of ID trained professionals.

We have no ID trained Physicians. We have no ID trained Pharmacists. Once our ASP began our lead and our

other pharmacists continually found themselves past the scope of their knowledge base and comfort level.

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Tackling our Challenge We enrolled most of our pharmacists in

SIDPA classes or MAD-ID basic. We sent our ASP leader to MAD-ID

advanced.◦ BUT we still found ourselves deficient of one key ingredient.◦ Luckily for us many hospitals in our state had the same problem…no easy access to ID consult.

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The Alaska Antimicrobial Stewardship Collaborative

Is a collaboration of acute care and long-term care hospitals across the state.

Strives to develop strategies to ensure appropriate antibiotic use.

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A2SC’s Goal To see that “all patients in Alaska will

receive the right antibiotic at the right time and only when necessary.”

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Some of the Benefits of A²SC Shared clinical pathways for treatment of

infections. Pooled data for regional antibiograms. Networking IDSAPP

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Infectious Disease Specialist Access Pilot Project (IDSAPP)

IDSAPP is a 6 month/1year pilot Designed to help bridge the gap between

local talent accessing trained infectious disease specialists and their expertise.

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Requirements for Participation Membership in ASHNHA Provide a CEO Letter of Commitment to

support antimicrobial stewardship activities.

Assemble Antimicrobial Stewardship Program team including a pharmacist and/or physician.

Collect basic Infectious Disease Specialist utilization data.

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Goal of IDSAPP Enhance infectious disease case review. Help to optimize antibiotic treatment. Strengthen local ID resources through:◦ Education ◦ Training

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Education Benefits of IDSAPP: Six educational monthly webinars led by

an ID physician. ◦ Antibiotic stewardship prospective audit and feedback: basic structure and approach◦ Respiratory tract infections◦ Skin and soft tissue infections◦ Urinary tract infections◦ Fever, neutropenia, and sepsis without a source◦ Osteomyelitis, septic arthritis, and endocarditis

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Training Benefits of IDSAPP: In addition to the monthly webinars there

are weekly/bi-weekly case review calls with ID Specialist.

These calls are designed to provide expert opinion as well as train others on how to approach treatment of infections from a local antimicrobial stewardship standpoint.

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References: www.ashnha.com

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Access DatabaseIt’s utility in managing pharmacy controlled substance auditing.

Jo Ann Gibbs, Pharm D, BCPS

Byrd Regional Hospital

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Objectives

The purpose of this discussion is to demonstrate the capabilities of a simple Access Database and show how it can be used to capture documents, run reports, and provide accountability in your controlled substance auditing process.

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Learning Objectives

• The learner will be able to:

– Recognize the basic capability of Access.

– Recognize the advantage of the document storage function.

– Recognize utility of the query function.

– See the possible utility in a controlled substance auditing program.

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Access• Access is a Microsoft Program that is part of the Office group of tools like Word and Excel. You should be able to activate it on your computer.

• It has expanded functions, but works like Excel from a table that can be sorted.

• It assigns each row with a unique ID number that can be deleted, but cannot be re‐used.

• You can design queries that download requested data into an Excel file that can be further manipulated.

• You can attach documents to the file, allowing you to eliminate hunting for paperwork.

• It is independently managed.

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Overview of Our Database

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Table

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Data Entry Form

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Add a Record

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Adding Documents

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Save File

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Record Search

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Query

Right Click

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Query‐cont.

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Data Analysis in Excel

• You can sort by date range, nurse involved, and drug.

• Helpful in proactive diversion reporting to nursing.

• Send a report of open discrepancies to the CNO. If she doesn’t become involved in helping clear up the issues copy the CEO.

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Sample# LastName Acct DrugName Strength Qty Date Nurse SummaryOfEvent Unit

234 . . Hydrocodone/Apap 7.5/325mg 1 08‐Aug‐16 Ashley HNeed to find out which patient the medication was administered to..

ER

236 Smith 103123 Hydrodocone/Apap 10/325mg 1 13‐Aug‐16 Elizabeth Found no charting for the medication indicated, see attached form

MS2

235 Will 363123 Hydromorphone 2mg/ml 1 10‐Aug‐16 Julie Found no order or charting for the medication indicated…see attached form

ER

238 Mouse 363123 Hydromorphone 1mg/ml 1 16‐Aug‐16 Loree

Found no charting for the medication pulled @10:02…the 10:00 pull was charted…found no return or waste..see attached form

MS2

240 Duck 363123 Ketorolac 30mg/ml 2 16‐Aug‐16 David MFound no return or waste for the medication indicated, chart states that the patient refused the med

ER

243 Watson 3641232 Hydrocodone/Apap 10/325mg 1 24‐Aug‐16 Loree AFound no charting for the medication indicated..see attached form

MS2

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Reporting by Date and Nurse

0 1 2 3 4 5

Amanda

Katherine

Crystal

Kristen

Lance

Ashley

Megan

Julie

Elizabeth

Jennifer

Lorie

David

Number of Issues by NurseJuly & August 2016

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My Experience

• We have a group folder on the shared drive that can only be accessed by pharmacy. We keep this data in that folder.

• Anyone who is doing your controlled substance auditing can fill out the form.

• The data is stored from the form to the table, which can be queried.

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My Experience

• When a question arises during the audit:– Info is entered in the form.

– The Pyxis report is scanned and attached to the form in the database.

– A copy of the form is printed.

– The Pyxis report is stapled to the printed form and given to the nurse manager.

– They write on the form and send it back to me. We scan and attach the information in our database.

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My Experience

• If they don’t respond, I do a query each week and send open requests in a table to the CNO.

• If they say, I can’t find the info it is easy to recreate from the database.

• If it can be closed, we simply close it in our database.

• If it needs to go to a Theft/Loss report, we update our form and scan and attach any pertinent data.

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My Experience

• This has organized my data so it can be used in a meaningful way.

• It has given the CNO specific information to react to when I need her assistance with motivation.

• It is not perfect, but it has made my job of oversight much easier.

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Conclusion• If you would like to learn more about Access there are free tutorials on You Tube.

• I have a template that can be shared if you are interested in it. You can simply use a copy of mine and start entering your own information on the Data Entry Form.

• There is a learning curve. It took us about 2 months, but I started with You Tube tutorials.

• It is not perfect, but it worked for me.

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Sentri7® Tips and Best Practices

Sue V. Ie, PharmD

Fellow, Health Information and Clinical Outcomes

Community Health Systems and Wolters Kluwer Health

Franklin, TN

November 16, 2016

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Disclosure

Postdoctoral Fellow for Community Health Systems and Wolters Kluwer Health

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Objective

Share Sentri7 tips and solicit best practices to share within the health system

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Standardize rule names to allow for streamlined sort and display when viewing patient rule matches

Order your rules and tabs using the Position Icons in the Rules Tab Note: Not available if the rule was created and shared by another administrator

Basic Optimization of Sentri7®

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Sort and view Rule Matches by the priority of the rules in Sentri7® when working in the Patients Tab

Assign priority levels to the rule set Note: Default priority level is Medium


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Work efficiently in the Patient Card to view all Rule Matches for a patient and document interventions directly


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Reduce the variances and numbers of criteria for current and future alerts

Minimize “Advanced Logic” in your alerts

Click “Select Lab Names”

Select value based on the string in the search box

See multiple values added to the alert

Results added to the alert will not appear if already included

Chemistry/Lab Criteria Enhancements

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Use the envelope icon to turn on and off email notifications Note: Notifications are user‐specific and rule‐specific

Tip: Use the Notifications Center to turn on and off all notifications with one click and perform a retrospective patient review

Email Notifications

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Relevant Drugs – appears for any rules that include drug name criteria Helps to identify the drug(s) that qualified a patient on an alert Displays active and discontinued medications from the past 7 days that were mentioned in the drug name criteria

Tip: Clean up columns in the relevant drugs display by using the widget

Relevant Drugs Link

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Shows culture information

View Options: last 24 hours, last 3 days, last 7 days [default], last 30 days, or all

View preliminary results or click Show Final Only

Tip: Do a side‐by‐side comparison by clicking View Multiple

Microbiology Link

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Tip: Embed hyperlinks to outside references or on your intranet

Use this HMTL example for your own links:

<br><a href="www.Sentri7.com" target="_blank"> XXXXX</a>

*Replace www.Sentri7.com the URL you would like to reference

*Replace XXXXX with the text you would like to appear for the link

Suggested Action

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Review = Temporary Record, “Virtual Sticky Note” Patient is “greyed‐out” on dashboard for length of reset interval

Temporary, removed when the patient disqualifies for the rule

Enable “Advanced Review Options” This allows next steps to be set

Enable Advanced Review Options

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http://tinyurl.com/sentri7form

Purpose Provide all CHS Sentri7 users with a centralized method of communication with the CHS Sentri7 Advisory Committee

Solicit and compile Sentri7 tips and best practices to share within the health system

Identify areas of interest for Sentri7 educational materials and webinars

Online CHS Sentri7 Form

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Actions Available Sign‐up for Sentri7 mailing lists with tips, best practices and announcements

Submit requests, share best practices, provide feedback for all matters related to Sentri7

Online CHS Sentri7 Form

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Sentri7® Help and Training Link Announcements

Training Videos and Manuals

Direct Support (800) 341‐0450 7:00AM‐7:00PM CT

[email protected]

CHS Sentri7® Advisory Committee http://tinyurl.com/sentri7form

Help & Training

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Questions or Feedback?

Submit them online at:


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Medication ReconciliationA Pharmacy‐Led Proposal

George Jossell PharmDCandidate 2016 77

What are we doing now?

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Rationale for change

The rationale for introducing pharmacy-led medication reconciliation is to improve our quality of care. This is truly patient centered care where metrics become more that just a number with impersonal measures.

Patient centered care means we place the patient’s needs above all else.

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Evidence to Support Change

Pharmacists are uniquely skilled to provide optimum medication information to the staff which can be offset by the many task-hours spent intervening to obtain patient demographics of height, weight, and allergy profiles from front-line caregivers. Performing this functionality upon admission would not only improve patient outcomes, but also satisfy frustrations throughout the hospital staff by the provision of these parameters including patient medication histories.

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Evidence

81

Statistical Analysis to Support Change

Totals Pharmacy

1/25 – 2/26/16

ED staff

(previous 30dys)

# Histories taken 66/80 (82.5%) 189/244 (77.45%)

# M‐F 66/66 (100%) N/A

Average time (1) 0.25 hours 0.25 hours

Daily hours 2.0 2.0

24 hour metric 66/66 (100%) 65%

Core measure

50% threshold

Exceeded Met

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Pharmacy Process

Advanced pharmacy practice experience students (APPE), under my supervision will guide this project with the assistance of staff certified pharmacy technicians. The project began in January 2016, continuing as a pilot project through February 2016.

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Associated Cost Metrics

Pharmacy can absorb the hours associated with medication reconciliation as determined in the pilot.

We anticipate an investment of 2 hours per 8 hour work day which can be built into our current tasking since pharmacy has some task associated downtime from minimizing the sterile compounding tasks and ordering premixed medications.

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Improvements Anticipated

MU Measures 0% 20 40 60 80 100

CPOE for medication orders

CPOE for laboratory

CPOE for radiology ePrescribe (eRX) and transm

SoC ‐ eTransmit (all disch)

Patient education resources

Medication reconciliation

Patient data available online

Last 6 M th

% Met Denominator Met Not met

86.73 4356 3778 578

58.44 3682 2152 1530

68.99 329 227 102

0 1143 0 1143

30.14 272 82 190

45.33 236 107 129

77.45 244 189 55

100 261 261 0

5.36 261 14 247

Record Demographics

Record vital signs

Record smoking status

Maintain allergy list

Maintain active medication lis

Last 6 M th

% Met Denominator Met Not met

97.88 236 231 5

87.28 236 206 30

89.47 209 187 22

95.76 236 226 10

99.15 236 234 2

97.88 236 231 5

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Marketing Perspective: Safety Profile

Based on the meaningful use measures published on the previous slide, a pharmacy-led medication reconciliation team would improve the quality of care on this metric between 5 – 22.5 %

These improvements would provide a potential marketing honor when compared to similar hospitals on the basis of safety.

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Conclusion

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Conclusion

These results and the accompanying evidence from studies cited show that medication and pharmacy are important partners in the health care forum.

Pharmacy personnel can and will improve the quality of care from a medication reconciliation perspective.

The evidence is clinically significant.

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The End

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Heparin and ImpellaThe Systemic Question

Michael Kleinschmidt, PharmD, BCPSDirector of PharmacyBrandywine Hospital

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• Background

• Indications

• Scenarios

Heparin and Impella

Overview and Discussion Points

91

Impella Device

• Percutaneous left ventricular assist device

• Used in percutaneous interventions to take workload off heart

• Also used in instances of cardiogenic shock

• Myocardial infarction

• Myocarditis

• Endocarditis

• Drug Overdose

Heparin and ImpellaBackground

92



Impella Device

• LV end diastolic pressure, wall tension, work and myocardial oxygen demand

• Mean arterial pressure, diastolic pressure, cardiac output

• Pulmonary capillary pressure and right ventricular afterload

Heparin and Impella

93

Impella Device

Heparin and Impella

Operational Screen

Actual Device

94



Impella Device

• Heparin purge solution is needed to keep Impella device patent and non‐occluded

• Concentrations range from 6.25 units/mL to 50 units/mL

• Brandywine Hospital normal concentration = 50 units/mL

• Purge rate can only fluctuate from 4 – 20 mL/hour

• Will give covering RN units of heparin/hour on main screen

Heparin and ImpellaBackground

95

1. High Risk PCI

• Impella Device does not travel with patient to floor

• Only systemic heparin (25000 units/250 mL to be used)

• No need for heparin Purge Solution

2. Cardiogenic Shock

• Impella Device does travel with patient to floor – ICU only

• 2 Unique Heparin Solutions

• Purge • 25000 units/500 mL

• Systemic • 25000 units/250 mL

Heparin and ImpellaIndications

96



Heparin and Impella

For all Scenarios consider

Therapeutic aPTT range 50‐70 seconds

97

Heparin and ImpellaScenario 1

• Patient arrives to ICU from Impella procedure

• Physician orders systemic heparin

Solutions

• STAT aPTT

98




• Impella running in ICU

• Purge Solution actively running

• Baseline aPTT in unit = 80 seconds

Solutions

• DO NOT START SYSTEMIC INFUSION

• Change concentration of Purge solution• Consider 25 units / mL (12500 units / 500 mL)

• Redraw aPTT in 4 hours

99


• Impella running in ICU

• Purge Solution actively running

• Baseline aPTT in unit = 15 seconds

Solutions• START SYSTEMIC INFUSION• Determine which systemic heparin to use

• VTE or Cardiac/Non‐VTE• Calculate the total units/hour to be delivered = Number B

• Obtain units/hour being delivered from Impella device = Number A

Number B – Number A = Total units/hour needed from systemic heparin infusion100




• Impella running in ICU• Purge Solution and systemic heparin actively

running• Impella Purge solution flow rate adjusted

Solutions• STAT aPTT• Obtain units/hour being delivered from Impella device = Number A• Look at which systemic heparin is in use:

• VTE or Cardiac/Non‐VTE• Calculate the total units/hour to be delivered = Number B

Number B – Number A = Total units/hour needed from systemic heparin infusion101


• Impella stopped in ICU

• Purge Solution and systemic heparin actively running

Solutions

• Stop Purge solution

• Obtain aPTT

• Adjust systemic heparin according to protocol

102



Taking Flight on Fighting Inappropriate EPINEPHrine Use

Laura Kroon, PharmD

PGY2 Pharmacy Administration Resident

[email protected]

103

Objective

• Discuss epinephrine best practices for preparation and administration within the hospital.

104



EPINEPHrine

• Mechanism of Action:

– sympathomimetic catecholamine acting on alpha‐and beta‐adrenergic receptors

• Indications: ‐ Anaphylaxis‐ Adjunct for local anesthesia‐ Asthma‐ Blood coagulation disorder‐ Congestion of mucosa‐ Cardiopulmonary

resuscitation

‐ Excessive uterine contractions

‐ Glaucoma‐ Hypersensitivity reaction‐ Syncope

Epinephrine. In: DRUGDEX® System105

Concerns of EPINEPHrine

Drug shortages

Concentration(i.e. 1:10,000 vs. 1:1,000)

Confusion with ePHEDrine

Route of administration(i.e. IM/subQ vs. IV infusion vs. IV push)

Cost

106



Error‐prone EPINEPHrine Kit

• Proposed by a physician practicing emergency medicine in Ohio

• Includes: empty Altoids® tin, EPINEPHrine 1 mg ampule or vial, alcohol pad, syringe

• ISMP’s Acute Care Medication Safety Alert®: Not recommended for use

Safety brief: An EPIPEN replacement idea that’s likely to lead to dosing errors. Acute Care ISMP Medication Safety Alert.107

Polling Question

True or False

A patient experiencing an anaphylactic reaction should receive EPINEPHrine 1 mg/mL via IV push.

108



EPINEPHrine for Emergent SituationsIndication Dose Route

EPINEPHrine 1 mg/mL (vial/ampule)

Anaphylaxis/Hypersensitivity reaction

0.2‐0.5 mg IM or subQ

EPINEPHrine 1 mg/mL (vial/ampule used to prepare infusion)

Severe refractory bradycardia, cardiac arrest, VF, VT

2‐10 mcg/min (titrated to effect)

IV infusion

EPINEPHrine 1 mg/10mL (prefilled syringe)

Cardiac arrest 1 mg IV push

VF = Ventricular fibrillation; VT = Ventricular tachycardia110

EPINEPHrine Anaphylaxis/Hypersensitivity Reaction Kit

Kit contents:

1 mL vial or ampule (include filter needle if ample) of EPINEPHrine 1 mg/mL

1 mL syringe

alcohol wipe

IM/subQ needle for administration

kit label with administration instructions

What price must we pay for safety? Excessive cost of EPINEPHrine auto‐injectors leads to error‐prone use of ampuls or vials and unprepared consumers. Acute Care ISMP Medication Safety Alert.

EPINEPHrine Anaphylaxis Dosing Concentration:1 mg/mL

Adults: 0.2 mg (0.2 mL) – 0.5 mg (0.5 mL) IM or subQ q5 min PRN

Infants/Children/Adolescents: 0.01 mg/kg/dose IM or subQ

** Filter if from ampule** DO NOT GIVE IV

Weight15‐29 kg (33‐66 lbs) ≥ 30 kg (≥ 66 lbs)0.15 mg (0.15 mL)

q5 min PRN0.3 mg (0.3 mL) q5 min PRN

111



EPINEPHrine Kit for Cardiac Indications

Kit contents:

1 mL vial or ampule (include filter needle if ampule) of EPINEPHrine 1 mg/mL OR10 mL syringe of EPINEPHrine 1 mg/10mL

normal saline 250 mL

3 mL syringe

alcohol wipe

needle

kit label with administration instructions

EPINEPHrine for Cardiac Use ‐ ADULT

Dilute 1 mg EPINEPHrine *1 mg/mL vial/ampule OR1 mg/10mL syringe* in 250mL NS

Adults: 2‐10 mcg/minute (30‐150 mL/hour) IV infusion titrate PRN (max 120mcg/minute)

1 mg EPINEPHrine in NS 250 mL (4 mcg/mL)*Undiluted EPINEPHrine 1 mg/mL cannot be given IV push*

112

References

Epinephrine. In: DRUGDEX® System [database on the Internet]. Greenwood Village, CO: Thomson Micromedex; 2016.

Hauser C. Epinephrine injection kit for under $10. abc22now. http://abc22now.com. Accessed October 26, 2016.

Pennsylvania Patient Safety Authority. An update in the “Epi”demic: events involving EPINEPHrine. Pa Patient Safe Advis. 2009;6(3):102‐3.

Safety brief: An EPIPEN replacement idea that’s likely to lead to dosing errors. Acute Care ISMP Medication Safety Alert. September 08, 2016:1–2.

What price must we pay for safety? Excessive cost of EPINEPHrine auto‐injectors leads to error‐prone use of ampuls or vials and unprepared consumers. Acute Care ISMP Medication Safety Alert. http://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=1145. Published August 11, 2016. Accessed October 26, 2016.

113



Vasopressin Optimization

Nicole LeFever, PharmD

Clinical Pharmacy Coordinator

Wuesthoff Medical Center Rockledge

Clinical Assistant Professor ‐ University of Florida

114

Objectives

•Vasopressin Brief Overview

•Vasopressin in Septic Shock

•Vasopressin removal from ACLS Guidelines

•Vasopressin Product History

115



Vasopressin:Basic Pharmacology

•Vasopressin (arginine vasopressin, AVP; antidiuretic hormone, ADH)

•Nonapeptide hormone formed in the hypothalamus and released from the posterior pituitary.

•Primary function is to regulate extracellular fluid volume by affecting renal handling of water

•A potent vasoconstrictor

Product Information: Vasostrict(TM) intravenous injection, vasopressin intravenous injection. Par Pharmaceutical Companies (per FDA), Spring Valley, NY, 2014. 116


• Principal sites of action• Blood vessels and kidney• At doses > 0.04 units/hr may decrease GI blood flow

• Works on V1 & V2 receptors

• Vasoconstriction ‐ Vascular V1 receptor stimulation• V1 receptors are coupled to phospholipase C

• The downstream effect causes a calcium release • Causes contraction of vascular and other smooth muscles

• Subsequently causes vasoconstriction• Increases Blood Pressure

• Anti‐diuresis ‐ V2 receptor stimulation• V2 receptors are coupled to adenyl cyclase

Product Information: Vasostrict(TM) intravenous injection, vasopressin intravenous injection. Par Pharmaceutical Companies (per FDA), Spring Valley, NY, 2014. 117




•Side Effects• Common

• Cardiovascular: Bradyarrhythmia, Tachyarrhythmia• Endocrine metabolic: Hyponatremia

• Serious• Cardiovascular: Atrial fibrillation, Cardiac arrest, Decreased cardiac function, Hemorrhagic shock, Myocardial ischemia, Right heart failure

• Dermatologic: Gangrenous disorder, Cutaneous• Gastrointestinal: Mesenteric vascular insufficiency• Renal: Renal impairment, acute• Respiratory: Pulmonary edema

• Renal excretion • Elimination Half life of 10 minutes or less

Product Information: Vasostrict(TM) intravenous injection, vasopressin intravenous injection. Par Pharmaceutical Companies (per FDA), Spring Valley, NY, 2014.118

Vasopressin:in Septic Shock

• Proposed for use in septic shock because it is an endogenous peptide with potent vasoactive effects and its circulating levels are depressed in septic shock.

• Indicated for adult patients who are still hypotensive with vasodilatory shock despite proper fluid resuscitation and catecholamine administration.

•According to the Surviving Sepsis Campaign guidelines:

• “Vasopressin should not be the single initial vasopressor, but should be reserved for salvage therapy”.

Dellinger RP et al. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock, 2012. Crit Care Med 2013 Feb; 41:580. 119



Septic Shock:Hypotension Management

•Surviving Sepsis Campaign recommendation:

• Initial fluid challenge in patients with sepsis‐induced tissue hypoperfusion with suspicion of hypovolemnic

•Start with ≥ 1000 mL of crystalloids

•Achieve a minimum of 30ml/kg of crystalloids in the first 4 to 6 hours.


Septic Shock:Hypotension Management

• If refractory to fluid resuscitation. . .• Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure (MAP) ≥65mmHg)

• Catecholamine (norepinephrine or phenylephrine) is first‐line agent.

• Vasopressin as second‐line agent to reduce need for other pressors.

• After first‐line treatment, Vasopressin 0.03 Units/min may be added to norepinephrine (NE)

• Anticipated effect equivalent to that of NE alone.




Vasopressin: Dosage and Administration•Septic shock 0.01‐0.07 units/min

•Do NOT discontinue catecholamine • i.e. norepinephrine

•Central line preferred due to risk of skin necrosis


Vasopressin:Place in ACLS. . .or not•2015 ACLS update

•Vasopressin removed from the ACLS treatment algorithm for cardiac arrest

•No need to routinely stock Vasopressin in Emergency Medicine Carts •aka “Crash Carts”

Link MS, Berkow LC, et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S444‐64.

123



VasopressinProduct History•Available until late 2014 as Pitressin®

• No refrigeration was needed

•NDA approved by FDA for Vasostrict® with new refrigeration storage requirement

•Vasostrict® available for purchase late 2014•Vasopressin Pricing History

Timeline Product Pricing (per vial)

Through end of 2014 Pitressin® ~ $3.00

Nov 2014 Vasostrict® ~ 45.00

Oct 2015 Vasostrict® ~ $85.00

Oct 2016 Vasostrict® ~ $120.00

Note: Vasopressin pricing history based on local acquisition costs; your facility pricing may not reflect these numbers124

References

• Product Information: Vasostrict(TM) intravenous injection, vasopressin intravenous injection. Par Pharmaceutical Companies (per FDA), Spring Valley, NY, 2014.

• Dellinger RP et al. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock, 2012. Crit Care Med 2013 Feb; 41:580.

• Link MS, Berkow LC, et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S444‐64.

• http://www.fda.gov/downloads/forhealthprofessionals/articlesofinterest/ucm446992.pdf

125



Review of Tdap and Influenza Vaccination in Obstetric Patientsat Northwest Medical Center

Katherine Smith, PharmDWomen’s Center at Northwest Medical Center in Tucson, AZCHS Clinical Pearls PresentationNovember 16, 2016

126

Objective

• Describe the current CDC guidelines for Tdap and influenza vaccination in obstetric patients, and discuss the maternal and fetal benefits of prenatal vaccination.

127



Tdap Vaccination During Pregnancy

• CDC1

• Provide Tdap during 3rd

trimester of each pregnancy• Protective antibodies are

highest 2 weeks after vaccination• Transplacental transfer of

antibodies provides protection until infant starts DTaP series at 2 months of age

• If not given during pregnancy, provide immediately postpartum

• ACOG2

• Tdap can be safely administered during any stage of pregnancy, but 3rd

trimester is optimal• May vaccinate earlier in

pregnancy due to:• Ongoing epidemics• Wound management• Unknown or incomplete

tetanus vaccination history• All immediate family and

direct caregivers should be vaccinated at least 2 weeks prior to delivery or contact with infant

128

Why is this important?1

• In 2012, there were 48,277 reported cases of whooping cough, the most in over 60 years• Includes 2,269 cases in infants less than 3 months

• 15 infants died

• Half of infants less than 1 year old with pertussis are hospitalized• 67% will have apnea• 23% develop pneumonia• 1-2% will die

• Other serious and life-threatening complications in infants include cyanosis, seizures, and encephalopathy

• Maternal vaccination during pregnancy can protect up to 90% of infants against pertussis

129



Influenza Vaccination During Pregnancy

• CDC3

• Inactivated influenza vaccine recommended during every flu season (October - March)

• Any time before or during pregnancy

• Nasal spray SHOULD NOT be given (live vaccine)

• ACOG4

• “It is critically important that all obstetrician–gynecologists and all providers of obstetric care advocate for influenza vaccination, provide the influenza vaccine to their pregnant patients, and receive the influenza vaccine themselves every season. This will send a powerful message to all pregnant women that vaccination is very important for the protection of themselves and their unborn children.”

130

Why is this important?5

• Pregnant women are more prone to severe illness, complications, hospitalizations, and death

• Antibodies from maternal vaccination can provide protection up to 6 months after birth and can reduce a child’s risk of contracting influenza ~50%

• CDC Internet panel survey during the 2014-2015 influenza season6

• Among 1,702 pregnant women, 50.3% reported receiving influenza vaccination before pregnancy or during pregnancy

Influenza vaccination rate in pregnant womenwith at least one visit to a health care provider

Provider recommended AND offered 67.9%

Provider recommended but did not offer 33.5%

No recommendation 8.5%131



Medication Use EvaluationWomen’s Center at Northwest Medical Center

Tucson, AZ

132

Women’s Center at NMC

• Freestanding facility located in Tucson, Arizona• 13 labor and delivery rooms

• 17 mother-baby rooms

• 17-bed Level IIE Special Care Nursery

• Average census: 8 labor patients and 15 mother-baby couplets

• Average 8 deliveries per day, 235 births per month• Primary c-section rate: 12.7% (overall: 26%)

• Average 9.3 patients per month with no prenatal care

133



Purpose

• To evaluate the timing and appropriateness of Tdap and influenza vaccination in our obstetric population, as according to CDC guidelines

134

Methods

• Report of all births at NMC from 1/1/16 to 3/31/16• FIN number• Patient Age• Delivery Date• Gestational Age• Delivering Physician

• Sorted patients chronologically by delivery date, and chose a convenience sample of 100 patients starting on 1/1/16

• Date range: 1/1/16 – 1/13/16

135



Methods Continued• Data collected from Cerner EMR:

• Delivery Type • Outpatient Obstetrician• Insurance Coverage• Immunization history:

• Tdap

• When?

• Where was it received?

• If Tdap was not given, why?

• Where was the information

obtained?

• Inactivated Influenza Vaccine (IIV)

• Did the patient receive IIV

during their pregnancy?

• Where was it received?

• If vaccine was not given,

why?

• Where was the information

obtained?

• Patient was called if information was missing from Cerner profile using a standardized script.

136

Summary of DemographicsPatient Age (years)

(n=100)

Average 27.4 ± 5.0

Youngest 18

Oldest 40

Delivery Type(n=100)

Spontaneous Vaginal 65

Induced Vaginal 7

Scheduled C-Section 18

Emergent C-Section 10

Gestational Age at Delivery (weeks) (n=100)

Average 39.0 ± 1.4

Youngest 32.5

Oldest 42.2

Insurance(n=100)

Medicaid 50

Private 41

Self-Pay 7

Tricare 2

137



Tdap DataWhen did patients receive Tdap vaccination? (n=100)

During pregnancy

1st Trimester (weeks 1-12) 1

2nd Trimester (weeks 13-26) 3

3rd Trimester (weeks 27-36) 49

Received vaccine, but unsure when 1

After delivery 6

Patient did not receive vaccine 13

No information 27

For those that received Tdap, where? (n=60)

Outpatient OB 52 (86.7%)

Northwest Medical Center 6 (10.0%)

Other 2 (3.3%)138

Tdap DataFor those that DID NOT receive Tdap, why not? (n=13)

Patient choice 7 (53.8%)

Qualified, but did not receive at NMC 2 (15.4%)

Severe allergy 1 (7.7%)

Unknown 3 (23.1%)

Not including the severe allergy and NMC miss, who were the OBs for those that DID NOT receive Tdap? (n=10)

Physician A 2 (16.7%)

Physician B 3 (25.0%)

Physician C 2 (16.7%)

Physician D 1 (8.3%)

Physician E 1 (8.3%)

Physician F 1 (8.3%)

For those we had information on, where was the information obtained? (n=73)

Health record 60 (82.2%)

Phone interview 13 (17.8%)

139



Influenza DataDid the patient receive the influenza vaccine? (n=100)

Yes 62

No 36

Unknown 2

For those that received influenza vaccine, where? (n=62)

Outpatient OB 42 (67.7%)

Northwest Medical Center 7 (11.3%)

Other 4 (6.5%)

Unable to determine 9 (14.5%)

For those that DID NOT receive influenza vaccine, why not? (n=36)

Patient choice 33 (91.7%)

Severe allergy 1 (2.8%)

Qualified, but did not receive at NMC 1 (2.8%)

Unknown 1 (2.8%)

140

Influenza DataNot including the severe allergy and NMC miss, who were

the OBs for those that DID NOT receive the vaccine? (n=34)

Physician A 2 (5.9%)

Physician B 4 (11.8%)

Physician C 9 (26.5%)

Physician D 4 (11.8%)

Physician E 2 (5.9%)

Physician F 3 (8.8%)

Physician G 1 (2.9%)

Physician H 2 (5.9%)

Physician I 4 (11.8%)

Physician J 3 (8.8%)

For those we had information on,where was the information obtained? (n=95)

Health record 90

Phone interview 5141



Conclusion• Of 73 patients with definitive information available, 49 (67.1%) confirmed as

receiving Tdap vaccine during the 3rd trimester• 13 patients (17.8%) confirmed as not receiving Tdap vaccine at any point

• Of 98 patients with definitive information available, 62 (63.3%) confirmed as

receiving influenza vaccine during pregnancy• 36 patients (36.7%) confirmed as not receiving influenza vaccine

• 2 patients should have received the Tdap vaccine and 1 patient should have

received the influenza vaccine at NMC after delivery, but was never given

• For both Tdap and influenza, patient choice was the most common reason

for not receiving the vaccine

142

Limitations• Incomplete prenatal records

• Some outpatient OB documents lacked the dates of immunization, had conflicting information, or no mention of vaccines at all.

• Improper categorization during admission process• For example: A patient who had already received a flu shot could be

marked as “declined/patient choice” instead of “already received during current flu season.”

• Difficult to reach patients by phone• 29 patients with missing information

• Language barrier

• Small sample size: 100 patients over 13 days143



How can we improve?

• More consistent prenatal records between providers• Specific section for immunizations • An option for declination, as well as a reason why

• Physician and/or nurse in charge of discharge required to go through final screen and offer missing vaccinations

• Stress the importance of receiving recommended vaccinations during pregnancy• Patient and provider education regarding the benefit of

immunization • Automatic alerts for physicians

144

Project Outcomes

• MUE presentation• Antimicrobial Stewardship Program (ASP) team

• Perinatal Committee

• Pharmacy & Therapeutics Committee

• Nursing education• Staff meetings and daily interaction

145



Acknowledgements

• Ferena Salek, PharmD, Pharmacy Director, Northwest Medical Center

• Linda Calkins, RPH, MPH, Pharmacy Clinical Coordinator, Northwest Medical Center

• Joseph Howdeshell, PharmD Candidate 2019

• Joseph Murata, PharmD Candidate 2019

146

References1. Pregnancy and whooping cough. Centers for Disease Control and

Prevention. http://www.cdc.gov/pertussis/pregnant/index.html. Updated 27 Jan 2015. Accessed 13 Oct 2016.

2. Update on immunization and pregnancy: tetanus, diphtheria, and pertussis vaccination. Committee Opinion No. 566. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:1411-4.

3. Pregnant women & influenza (flu). Centers for Disease Control and Prevention. http://www.cdc.gov/flu/protect/vaccine/pregnant.htm. Updated 28 Sept 2016. Accessed 13 Oct 2016.

4. Influenza vaccination during pregnancy. Committee Opinion No. 608. American College of Obstetricians and Gynecologists. Obstet Gynecol2014;124:648-51.

5. Flu vaccine safety and pregnancy. Centers for Disease Control and Prevention. http://www.cdc.gov/flu/protect/vaccine/qa_vacpregnant.htm. Updated 25 Aug 2016. Accessed 13 Oct 2016.

6. Ding H, Black CL, Ball S et al. Influenza vaccination coverage among pregnant women: United States, 2014-15 influenza season. Morbidity and Mortality Weekly Report. 18 Sept 2015. 64(36):1000-5.

147



Antimicrobial Stewardship Updates

Kate DeSear, PharmD, BCPS, AAHIVP

Antimicrobial Stewardship Manager

148

Formulary Updates

• Gram Positive strategy • On pharmacy intranet under Antimicrobial Stewardship Initiatives: Legacy and CHS14

• Includes change in formulary status (category B) & restrictive criteria for daptomycin, ceftaroline, linezolid

• You should have reviewed this with your local AS Committee and passed through local P&T, embed into EHR if possible

• Other formulary and clinical initiatives• Topical acyclovir, penciclovir, docosanol category C with block

• Lipoglycopeptides (dalbavancin & oritavancin) category C with block 149



Gap analyses sent – please review and prioritize next steps for your AS program

Toolkit now available



Survey and Transcript Key

152

Download Helpful Tools

153



Upload your facility examples

Attach your examples and/or enter description of relevant process…

154

Gram Positive Strategy• Gram Positive Toolkit

• Clinical decision algorithm• Description: Flow chart walking through clinical decision process to navigate criteria for use with flow on front and short explanation on back

• Intent: For use by pharmacists with order verification job duty to aid in impromptu discussions with prescribers

• Features: • Short explanations of clinical decisions• May be printed on 1 page, front and back

• Expanded evidence summary• Description: Further breakdown and explanation of literature behind clinical decisions on algorithm

• Intent: For use after discussion with prescribers for pharmacist self‐edification to feel more comfortable in future discussions

• Features: • All sections hyperlinked to algorithm, click on any decision point for further explanation

• Daptomycin Physician Support Tool• Description: A detailed literature review of common unapproved indications used by

prescribers• Intent: For use by antimicrobial stewardship lead to discuss with outlier prescribers

155



2

2

1

3

158

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

Senior Director, Pharmacy Services

Community Health Systems

Update on Current Pharmacy Initiatives and Strategies



159