conference 2013 conference 2013 conference 2013 … · 2013. 5. 29. · ramipril 5mg daily. she...

1 CHARLOTTETOWN, PEI • CPhA 2013 FINAL PROgRAm

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sunday,JunE 2

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CPhA 2013

conference 2013conference 2013June 1-4 • Charlottetown, PEIDelta Prince Edward Hotel & Charlottetown Civic Centre

Charlottetown Rocks!

The Link Between the Heart and the Kidneys: Implications for Pharmacists Marisa Battistella Marisa graduated from the Faculty of Pharmacy at the University of Toronto in 1998 and completed her pharmacy residency at Sunnybrook and Women’s Health Sciences Centre in 1999. She has worked at the University Health Network since 1999 in various positions, including cardiology and internal medicine. In 2002, Marisa completed her Pharm D thru Idaho State University. She has worked as a clinical pharmacist specialist in the hemodialysis unit at the University Health Network since 2002. In the past 10 years, Marisa has published several papers and given many presentations on drug therapy in the area of nephrology. Recently, Marisa has accepted the position of Clinician Scientist jointly between the University Health Network and the Leslie Dan Faculty of Pharmacy where she will focus much of her time on clinical research in the area of nephrology. Objectives:

• Describe the tests used to define the stages of chronic kidney disease (CKD) • Provide examples of drug dose modification in CKD • Understand the importance of managing cardiovascular risk in patients with CKD

Presentation Summary During this 45-minute presentation, the stages of CKD and how to adjust doses of medications based on these stages will be described. Pharmacists will also understand their role in managing cardiovascular risk factors in patients with various stages of CKD. Case examples will be used to illustrate the role of pharmacists in managing these patients with their expanded scope of practice.

The Link Between The Heart and the Kidney:

Implications for Pharmacists Marisa Battistella, BSc Phm, Pharm D, ACPR

Pharmacy Clinician Scientist Assistant Professor

Leslie Dan Faculty of Pharmacy, University of Toronto Clinical Pharmacist-Nephrology

University Health Network

DISCLOSURE STATEMENT

No actual or potential Conflict of Interest

Objectives • Describe the tests used to define the

stages of chronic kidney disease (CKD) • Provide examples of drug dose

modification in CKD • Understand the importance of managing

cardiovascular risk in patients with CKD

Definition of CKD

Stages of CKD

KDIGO 2012

Assessing Kidney Function

Assessment of Kidney Function • Chemical Analysis of Urine • Serum urea • Serum creatinine • Serum cystatin C • Timed urine collections

– Creatinine clearance – Exogenous markers

• Inulin clearance • Iothalamate Clearance • Iohexol • Radiolabeled markers

Presenter

Presentation Notes

Urinalysis is an important tool for detecting and monitoring various aspects of kidney disease such DM, GN and chronic UTIs. Chemical Analysis of Urine- pH, glucose, protein or albumin, ketones, leukocyte esterases and of course there is the microscopic analysis of urine Serum Urea- urea undergoes glom filtration followed by reabsoption and the reabsorption rate is predominatly dep on reaabs of water – therefore sign of dehydration Serum creatinine- The conc of creatinine in serum is a function of Cr production and renal excretion. Cr is eliminated primarily by glomerular filtration and as GFr declines the serum Cr Conc rises BUT many things affect Sr Cr: aging (decreased), female sex (decreased), blacks (increased) Hispanic and Asian (deceased), amputation (decreased), muscular (increased) obesity- no change, malnutrition or neuromuscuara diseases- decreased, diet- vegetarian (decreased) and ingestion of cooked meat (increased). Drugs also interfere with sr cr conc by inhbiting tubular secreation of cr – cimetidine and trimethoprim are most common Serum Cystatin C- amino acid that is freely filtered at the glomerulus but may also be altered by age, nutritional status, gender, wt, ht, smoking CRP and steroid tehreapy. The test is expensive; does not provide quantitiative index for GFR but may provide useful info for evaluation of health and CVD Timed urine collections have been studied and used for measurement of GFR and include both exogenous and endogenous compounds. Those administered as exogenous agents such as inulin, iothalamte and iohexol and radiosiotopes require specialized administration techniques but generally provide a more accurate measure of GFR. Methods that employ endogenous compounds such as creatinine require less technical expertise but produce results with greater variability and are prone to error.

The perfect marker • Endogenous • Freely filtered • Not secreted or reabsorbed • Inexpensive to measure • Not impacted by non-renal influences

Such a marker does not exist

Assessment of Kidney Function • Calculated GFR approximations

– CrCl by Cockcroft Gault formula – eGFR by MDRD formula (Modification of

Diet in Renal Disease) – eGFR by CKD EPI formula (Chronic

Kidney Disease Epidemiology Collaboration)

Cases Demonstrating Equations SCr Gender Age IW CG

(ml/min) MDRD

(ml/min 1.73m2)

CKD EPI (ml/min/1.73m2)

130 M 40 70 66.1 56 59

130 M 80 60 34 49 44

130 F 80 50 24.1 37 33

Presenter

Presentation Notes

Ask: which one to use for drug dosing??

Clinical Pearls for Dose Adjustments Balance efficacy and toxicity • Disease (HTN vs depression vs infection)

– Type & Location of infection – Severity (Outpatient vs. ICU)

• Pharmacokinetics • Pharmacodynamics • Toxicity • Ability to monitor levels

Drug Dosing Case • 64 yr old male with Stage 4 CKD (eGFR

25ml/min) • PMH: HTN, DM 2, CAD • Diagnosed with shingles and comes to

you with prescription for acyclovir 200mg 5x/day

• Is this appropriate dosing?

Summary for Dosing in CKD • All 3 equations are helpful in determining

renal function • Most pharmacokinetic studies have used

CG equation • Important to consider the equations but the

patient too! • Treat the patient and not the number!

Etiology Of ESRD

Diabetes 50.1%

Glomerulonephritis 13% 10%

Other

Hypertension 27%

US Renal Data System. USRDS 2004 Annual Data Report: Atlas of ESRD in the United States.

Causes of Death in CKD Patients

CVD

Renal Causes

Other Causes

Neoplasms

54% 17%

12% 17%

CVD is the most common cause of death in CKD Patients

*GFR=mL/min/1.73 m*GFR=mL/min/1.73 m22..Go et al. Go et al. N N EnglEngl J Med.J Med. 2004;351:12962004;351:1296--1305.1305.

GFR Is an Independent Risk Factor for GFR Is an Independent Risk Factor for Death, CV Events, and HospitalizationDeath, CV Events, and Hospitalization

n= n= 1,120,2951,120,295

0246810121416

≥60 45-59 30-44 15-29 <15Estimated GFR*

A

Rate

of D

eath

Fro

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Hosp

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atio

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020406080100120140160

≥60 45-59 30-44 15-29 <15Estimated GFR*

0510152025303540

≥60 45-59 30-44 15-29 <15Estimated GFR*

CV E

vent

s Rat

e (p

er 10

0 per

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B

C

Data adjusted for ageData adjusted for age--standardized ratesstandardized rates..

Presenter

Presentation Notes

Key Talking Points Go and colleagues examined medical records from the Kaiser Permanente Renal Registry to investigate the association between CKD and the risk of hospitalization. The patient population consisted of adults within a large healthcare delivery system in whom serum creatinine (SCr) had been measured between 1996 and 2000 and who had not undergone dialysis or kidney transplantation. Using longitudinal measures of estimated GFR, they examined the effect of the severity of kidney dysfunction on the risks of death, cardiovascular events, and hospitalizations from 1996 to 2000. Panel A=rates of death from any cause Panel B=cardiovascular events Panel C=hospitalization A cardiovascular event was defined as hospitalization for CHD, heart failure, ischemic stroke, or peripheral arterial disease. Median follow-up was approximately 2.84 years. The rate of events data presented has been age-standardized. However, even after adjusting for sociodemographic characteristics and the presence or absence of prior CVD, hospitalizations, diabetes mellitus, hypertension, dyslipidemia, cancer, a serum albumin level of 3.5 g/dL, dementia, cirrhosis or chronic liver disease, chronic lung disease, documented proteinuria, and the initiation of dialysis, an independent, graded association was observed between reduced GFR and death from any cause, cardiovascular events, and hospitalization.

Treatment of Cardiovascular Disease in CKD

Case One • 72 yr old female has a new prescription for

ramipril 5mg daily. She questions you about the new drug and her bp pressure target. She says she has been fine on her water pill (HCTZ 25mg daily) with her BP around 140/85 mmg Hg. She tells you that her Family MD has told you that her kidney function is working at 30% and there is “some protein in her urine”

• What do you want to tell her about her bp target and management?

Presenter

Presentation Notes

Cipro resistant rates- for Ecoli~50%

Case Two • 64 yr old male with Stage 4 CKD (eGFR

25ml/min) • MPH: HTN, DM 2, CAD • BP: 145/95 • Meds:

– ECASA 81mg; Ramipril 5mg od; metoprolol 50mg bid; amlodipine 5mg od; atorvastatin 40mg od

– What BP target and what agent do you use

Traditional vs Chronic Kidney Disease-Related Factors Potentially Related to an Increased Risk for CVD

The Role of Different Risk Factors at Different CKD Stages

Stage Predominant type of risk factor

G1 Traditional

G2

G3a/b Traditional and non-traditional

G4

G5 Non-traditional and modality specific

Traditional vs Chronic Kidney Disease-Related Factors Potentially Related to an Increased Risk for CVD

Prevention of CVD in CKD?

Overall Treatment Goals • HTN • Proteinuria • Diabetes • Dyslipidemia

Hypertension

Management of Hypertension in Non Diabetic CKD patients

• . CHEP 2013 KDIGO 2012

Target BP < 140/90 mm Hg (Grade B)

Target BP < 140/90 mm Hg (1B) If urine albumin excretion of > 30mg/24 hr target BP < 130/80 (2D)

www.hypertension.ca; www.kdigo.org

http://www.hypertension.c/

Summary of Trials- why 140/90? MDRD AASK REIN-2

N 840 1094 338 CKD stage 3-5 3 3-4 Target BP 125/75 vs 140/90 125/75 vs 140/90 130/80 vs DBP < 90 1° Endpt Rate of Change of

GFR ESRD

Kidney Failure

HR 0.76 (CI 0.52 to 1.1) P=0.15

RR 6% (CI -29% to 31%); p=0.72)

23% vs 20% p=0.62

GFR decline/yr (ml/min)

1.6 less in low target group; p=0.18

0.26 less in low target group; p=25

0.22 vs 0.24; p=0.62

Mortality% 2 (tight) vs 1; p=ND

2 (tight) vs 2 p=ND 2 (tight) vs 1; p=ND

CVD events RR 1.03 (CI 0.59 to 1.79)

2% vs 3%; p=ND ---

Ann Intern Med, 2011;154:541-548

Summary of Current Evidence • Lower BP targets (i.e < 130/80) do not

provide greater benefits compared to targeting < 140/90

• In patients with proteinuria, evidence of benefit with lower BP targets < 125/75) is low quality (post hoc or observational data)

• Participants in lower BP target groups required more antihypertensive medications and had slightly higher rate of adverse effects

Ann Intern Med, 2011;154:541-548

Back to Case 1- Targets and Treatment

• 72 yr old female has a new prescription for ramipril 5mg daily. She questions you about the new drug and her bp pressure target. She says she has been fine on her water pill (HCTZ 25mg daily) with her BP around 140/85 mmg Hg. She tells you that her Family MD has told you that her kidney function is working at 30% and there is “some protein in her urine”

• What do you want to tell her about her bp target and management?

• eGFR= 30ml/min; 100mg/day albumin in urine • BP target < 130/80 and drug of choice ACE in/ ARB

•

Management of Hypertension for Patients

WITH Diabetes

Case 2 • 64 yr old male with Stage 4 CKD (eGFR

25ml/min) • PMH: HTN, DM 2, CAD • BP: 145/95 • Meds:


– What BP target and what agent do you use?

Management of Hypertension for Patients WITH Diabetes

American Diabetes Associations 2013

KDIGO 2012 (DM with CKD)

CHEP 2013 & Canadian Diabetes Association 2013

Target for many people with diabetes & HTN should be < 140 mmHg Lower SBP < 140 mmHg may be appropriate for certain individuals such as younger pts if it can be achieved without undue treatment burden

If urine albumin excretion < 30mg/24 hrs, then target < 140/90 If urine albumin excretion > 30mg/24 hrs, then target <130/80 (2D)

Target SBP < 130 mmHg (Grade C) and DBP < 80 mmHg (Grade A)

Diaetes Care 2013; 36:S1-S110; CHEP 2013; Can J Diabetes 201 (suppl 1)S1-S212

Diastolic BP Target- HOT Trial Effects of intensive blood pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial Study Design Multi-centre, randomized study; average follow up:3.8 yrs Patient population 19, 193 pts aged 50-80 yrs with HTN & DBP 100-115 mmHG (n= 1501 DM pts) Intervention Randomized to one of 3 DBP targets: <90mmHg; < 85mmHg <80 mmHg

Lancet 1998:351:1755-1762

HOT Trial

Hansson et al. Lancet 1998; 351: 1755-1762.

Systolic BP Target • Lack of direct evidence from studies for

SBP target • Target < 130 mmHg not from RCTs • Observational studies suggest lower

SBP is better • CHEP guidelines recommendation for

SBP – grade C

ACCORD BP Study Design

Multi-centre, randomized unblinded study; average follow-up:4.7 yrs

Patient Population

4733 patients with DM2 age> 40 yr with CVD

Intervention

Randomized to intensive vs control: SBP < 120 mmHg vs 140 mmHg

Endpoints

1° composite: non-fatal MI, non-fatal stroke or death from CVD

NEJM 2010; 362:1575-85

ACCORD BP TRIAL

Bangalore et al : Meta-Analysis Studies • 13 RCTs enrolling DM2 pts (N=37,736) with follow up > 1 yr • Achieved intensive SBP < 135 mmHg vs achieved < 140 mmHg Outcome Measures Micro & macro vascular outcomes

• Intensive BP control was associated with: • 10% reduction in all cause mortality (OR 0.9; CI 0.83-0.98) • 17% reduction in stroke (OR 0.83; CI 0.73-0.95) • 20% increase in serious adverse effects (OR 1.2; CI 1.08-1.32)

• No difference: • CVD mortality, MI, heart failure

Circulation 2011; 23:2799-2810

Summary of Current Evidence • Significant reductions in major CVD events

and CVD mortality for patients with target DBP < 80 vs < 90

• Intensive SBP control not shown to reduce major CVD events or CVD mortality

• Intensive SBP control is a trade-off between decreased risk of stroke vs potential increase in adverse effects (hypotension, syncope, bradycardia)

Back to Case 2: Target and Treatment • 64 yr old male with Stage 4 CKD (eGFR 25ml/min) • PMH: HTN, DM 2, CAD • BP: 145/95 • Meds:


– What BP target and what agent do you use?

• Target: 130/80 • Management: Increase doses of

antihypertensives

Targets for Very Elderly Patients (>80 yrs)

CHEP 2013 Recommendation: the very elderly

In the very elderly (age 80 yrs and older, the target for systolic BP should be < 150 mmHg (Grade C)

CHEP 2013

SBP < 150 in the Very Elderly: What is the evidence?

HYVET Study Design

Multi-centre, RCT, DB study; ITT analysis Patient Population Men & Women > 80 yrs with persistent HTN (SBP> 160mmHg (N= 3845) Exclusion SCr> 150 umol/L Treatment Indapamide SR 1.5mg vs placebo + perindopril or placebo Outcomes 1° endpt: fatal or non-fatal stroke (not including TIA)

2° endpt: all cause mortality, CVD death, death from stoke, death from cardiac causes

NEJM 2008;358(18): 1887-98

BP 15/6.1 mmHg lower in treatment group

Summary of Current Evidence • Previous evidence found conflicting findings of

decrease in non-fatal events with potential increase in fatal events

• Epidemiologic evidence suggests U-shaped curve with lower BP targets associated with lower rates of survival

• Exact BP targets remains uncertain & mainly expert opinion

• HYVET suggests in healthy very elderly pts target SBP < 150 mmHg provides reductions in all cause mortality and CVD events

Dyslipidemia

Lipid Profiles in CKD Patients Lipoprotein Nephrotic Syndrome

End-Stage Renal

Disease

LDL ↑ Normal

HDL Normal or ↓ ↓

Triglycerides Normal or ↑ ↑

VLDL Normal or ↑ ↑

Remnants Normal or ↑ ↑

Apo B ↑ ↑

Lp(a) ↑ ↑

Seliger SL et al. Kidney Int 2002;61:297-304.

Atorvastatin in Patients with Type 2 Diabetes Undergoing Hemodialysis (4D)

Wanner et al. N Engl J Med 2005; 353: 238-48

Study Design

Multi-centre, randomized double-blind study;

Patient Population

Patients with DM2 on dialysis (n= 1255); aged 18-80 yrs; median follow-up:4 yrs

Intervention

Randomized to atorvastatin 20mg vs placebo

Endpoints

1° composite death from cardiac causes, nonfatal MI or stroke

Primary Endpoint

0

5

10

15

20

25

30

35

40

PrimaryEndpoint

CardiacDeath

Non fatalMI

FatalStroke

Non fatalStroke

% o

f Pat

ien

Placebo

Atorvastatin

NS

NS

NS

NS p=0.04

Wanner et al. N Engl J Med 2005; 353: 238-48

AURORA: Rosuvastatin and Cardiovascular Events in Patients Undergoing Hemodialysis

Fellstrom et al NEJM 2009;360;14:1395-1407

Study Design

Multi-centre, randomized double-blind study;

Patient Population

Patients on dialysis (n= 2776); aged 50-80 yrs; average follow-up:3.8 yrs

Intervention

Randomized to rosuvastatin 10mg vs placebo

Endpoints

1° composite death from CV causes, nonfatal MI or nonfatal stroke

AURORA Trial

Fellstrom et al NEJM 2009;360;14:1395-1407

The effects of lowering LDL cholesterol with simvastatin plus ezetimibe in patients with chronic kidney disease (Study of Heart and Renal Protection): a randomised

placebo-controlled trial (SHARP)

Study Design Multi-centre, RCT, DB study; Patient Population 9270 CKD patients (3023 on dialysis)- no known prior CVD

Treatment Simvastatin 20mg + ezetimibe 10mg vs placebo Outcomes 1st major atherscelerotic event (non-fatal MI or coronary death, non haemorrhagic stroke or any arterial revascularization

Lancet 2011

Lancet 2011

First Major Atherscelerotic Event

Major Atherscelerotic Events

Lancet 2011

CARE Post Hoc Analysis • Creatinine clearance <75 mL/min

(mean 61.3 mL/min) • N = 1711 participants • Primary endpoint:

– CHD death or symptomatic nonfatal MI • Secondary endpoints:

– Major coronary event, all-cause mortality, stroke, revascularization

• No increase in side effects in CKD

Tonelli M et al. Ann Intern Med 2003;138:98-104.

CARE Post-Hoc Analysis

Tonelli M et al. Ann Intern Med 2003;138:98-104.

Pravastatin Pooling Project • WOSCOPS, CARE, LIPID • GFR=30-59.9 mL/min/1.73m2

0

5

10

15

20

25

30

35

Fatal/nonfatal CAD,CABG or PTCA

Fatal/nonfatal CAD,CABG, PTCA or stroke

All-cause mortality

% o

f Pat

ien

PlaceboPravastatin

Tonelli et al. Circulation 2004; 110: 1157-63

SS SS

SS

Summary of Statin Use in CKD In Practice • Start pts with early stages of CKD on statins • New KDIGO guidelines – this summer!! • For the most part, we do not stop or start

statins in dialysis patients – probably will not harm but the benefit is unknown

Overall Summary • Drug Dosing should not only look at

eGFR but the patient. • CV risk reduction is key to survival

– HTN (including proteinuria) – DM – Dyslipidemia

• Educate the patient

Pharmacy Practice 3.0 – Putting Prescribing In Perspective Matt Tachuk BSc Pharm. RPh Over the past 5 years Matt has worked closely with pharmacists engaged in practice change and change management. He has worked with a wide variety of pharmacists in both BC (BC Medication Management Project – BCMMP) and Alberta (Pharmacy Practice Models Initiative – PPMI), which allowed him to understand the challenges and success strategies needed by pharmacists who wish to excel at providing patient focused services. He is currently doing work with the Alberta Pharmacists’ Association (RxA) in the area of professional development, which includes developing, facilitating, instructing and mentoring students as part of the Preparing to Apply for Additional Prescribing Authorization course. Presentation Description: A changing landscape for community practice means that pharmacists more than ever need to be investing in their own employability. It’s no longer acceptable to just fill prescriptions. Pharmacists have an obligation to meet the patient’s need for prescription drug therapy which may require initiating, adjusting, modifying, adapting, and/or discontinuing a prescription therapy. Learn how to confidently implement prescribing as a practice tool to meet your patient’s needs.

Pharmacy Practice 3.0 – Putting Prescribing in

Perspective

Learning Objectives

At the end of this presentation, you should be able to:

1. Describe the variation in prescribing across Canada;

2. Understand the importance of including prescribing in your practice;

3. Describe the foundational elements of the prescriptive thought process and how to meet them;

4. Understand how to prepare yourself and your

practice to incorporate prescribing activities.

The Albertan Experience

The Albertan Experience

Primary Barriers 1. Confidence 2. Time 3. Documentation 4. Compensation 5. Support

1. Confidence 2. Think like a prescriber 3. Using Tools and Templates 4. Documenting “What”? 5. Make a decision

Key Learning

Drivers of Change

Rx

Pharmacists’ Medication Management Services, Environmental Scan of Canadian and International Services. Canadian Pharmacists Association; August 2012

Drivers of Change • Regulation

Less

Risk

More

Drivers of Change • Pharmacy Compensation

Dispensing fee revenue ($$) + Generic Rebate Revenue ($$$$) Pharmacist Salary ($$$$$$)

Dispensing fee revenue ($$) + Generic Rebate Revenue ($) ↓ Pharmacist Salary ($$$???)

Dispensing fee revenue ($$) + Generic Rebate Revenue ($) + Billable Patient Services ($$$) Pharmacist Salary ($$$$$$)

What every salaried pharmacist should know; An open letter to Alberta’s Pharmacists. Alberta Pharmacists’ Association. The Capsule. April 18, 2013 Issue.

Drivers of Change • Fees for Services

Patie

nt

Ass

essm

ent

Service Compensation Administration of Drugs by Injection

$20

Adaptation of Rx Medication

Prescription Renewal

Prescribing in an Emergency

Refusal to Fill

Trial Prescription

Prescribing for Initial Access or Managing Ongoing Therapy $25 (APA only)

CACP

CACP - Initial $100 (non APA)

$125 (APA)

CACP – Follow-up (no limit) $20 (non APA)

$25 (APA)

SMM

A SMMA – Initial $60 (non APA)

$75 (APA)

SMMA – Follow-up (no limit) $20 (non APA)

$25 (APA)

Ministerial Order; Compensation Plan for Pharmacy Services. Alberta Health. Available online http://www.rxa.ca/Content_Files/Files/MO_2013.pdf Accessed May 2013

http://www.rxa.ca/Content_Files/Files/MO_2013.pdf

Drivers of Change • Employability Rx

Prescribing Activities

Initial Access (unrestricted)

Initial Access (with restrictions)

Adapting existing Rx

• Initial Access Prescribing

• Managing therapy

• Emergency Rx • Minor Ailments

• Renewal • Therapeutic Sub • Change dose/form

Foundational Elements

Prescribing Professional Relationship

Assessment

Care Plan/ Decision Making

Monitoring/ Evaluation of

Progress

Collaboration

Documentation

Your Comfort Zone

Reasonable Relevant Risk

Professional Relationship

Assessment



Progress

Collaboration

Documentation

Establishing Relationship




Progress

Collaboration

Documentation

Information

Access Process Address

Assessment



Progress

Collaboration

Documentation

Planning Care • Goal for Therapy

• Prioritizing and

Resolving Problems

• Use of Practice Tools

• Make a decision

Assessment




Progress

Collaboration

Documentation

Follow-up and pay it forward

Assessment



Progress

Measuring Success



Progress

Collaboration

Documentation

Assessment



Progress

Outcome Status Is progress being made towards the Goal of Therapy?

Is a change in drug therapy required?

Resolved Yes Yes

Stable Yes No

Improved Yes No

Partially Improved Yes Yes

Unimproved No No

Worsened No Yes

Failure No Yes

Cipolle, RJ et al. Pharmaceutical Care Practice: The Clinician’s Guide - 2nd edition. McGraw-Hill Companies, Inc 2004

Measuring Success



Progress

Documentation

Assessment



Progress

Collaboration

Dentists Veterinarians Pharmacists

Optometrists Midwives Nurse Practitioners

Dental Hygienists

Physicians and Surgeons Podi

atris

ts

Die

ticia

ns

Communication



Progress

Assessment



Progress

Collaboration

Documentation

Charting The What … …not the Why… … and How much is enough?



Progress

Charting

Practice Standards - Example

Assessment



Progress

Collaboration

Documentation Standards of Practice for Pharmacists and Pharmacy Technicians. Alberta College of Pharmacists. Avail online. https://pharmacists.ab.ca Accessed May 2013.

https://pharmacists.ab.ca/



Progress

CACP

Assessment



Progress

Collaboration

Documentation CACP/SMMA Template. Alberta Pharmacists’ Association. Avail online. http://www.rxa.ca/PharmacyServicesFramework/Pharmacist.aspx Accessed May 2013.

http://www.rxa.ca/PharmacyServicesFramework/Pharmacist.aspx



Progress

Chat, Check, Chart Assessment



Progress

Collaboration

Documentation Chat, Check, Chart Toolcard. Alberta College of Pharmacists. Avail online. https://pharmacists.ab.ca/Content_Files/Files/ccctoolscard_web.pdf Accessed May 2013.

https://pharmacists.ab.ca/Content_Files/Files/ccctoolscard_web.pdf

Environment

•Infrastructure

•Workflow

•Staffing

•Resources

•Administration

Moving Forward

Improve Productivity in Community Pharmacy through Workflow and Design Wayne M. Caverly: Our speaker is an expert in the field of dispensary design with more than 25‐ years of pharmacy design, workflow and automation experience. He is an active member of the Retail Design Institute and several pharmacy associations including the Canadian Pharmacist’s Association, the American Pharmaceutical Association, the Association of Health‐Systems Pharmacists. Our presenter is a published author, who has written more than 50 timely articles on the subjects of pharmacy design, technology, and dispensary errors. Wayne is a contributor to the textbook, Pharmacy Management in Canada (2nd Ed.) and Focus on Safe Medication Practices (2008 Lippincott, Williams & Wilkins, Baltimore, MD.). Objectives: Upon completing the seminar, participants will be able to: 1. Recognize the environmental and workflow factors that can lead to production

inefficiencies and dispensing errors 2. Examine how changes in pharmacy practice, including but not limited to the changes in

what tasks technicians can perform, will lead to changes in our pharmacies workflow, and therefore how our pharmacies are laid out / designed.

3. Identify the types of improvements that can be made to the physical layout and indoor environment of the pharmacy to enhance productivity, reduce errors, and allow all members of the pharmacy healthcare team to achieve their goals.

4. Develop a plan to modify a pharmacy environment to achieve higher production rates, lower error rates and more cost‐effective renovations without high cost acquisitions, installation and ongoing renovations.

Topics: The seminar will cover: 1. The demographics of Canadian pharmacy customers and changes in their prescription usage rates. 2. The impact of dispensary errors and how changes in workflow and design can help contain them. 3. The opportunities and challenges posed by installing advanced technologies. 4. The changes in pharmacy practice and how they affect the design of our pharmacies. 5. Keeping costs down: Intelligent approaches to pharmacy design and the selection of fixtures &

millwork to optimize investments.

Importance to Pharmacists: There are many challenges and concomitant opportunities for pharmacists today ‐ forcing a change from product distribution to patient care and disease management. While there are many barriers to a successful shift, improving dispensary operations through automation, re‐design and more efficient use of clerical and professional staff can help free valuable pharmacist's time and enhance patient‐pharmacist interaction. This seminar will explore new ideas in the approach to community pharmacy design as well as new concepts in pharmacy fixtures and millwork that allow community pharmacies to cost‐effectively maintain an appropriate dispensary design in changing and challenging times.

© 2013 The Efficient Pharmacy Institute

IMPROVE PRODUCTIVITY IN COMMUNITY PHARMACY

Wayne Caverly Executive Director

Efficient Pharmacy Institute


EVERYONE'S GETTING OLDER

Impacts design Lighting Ergonomics Technology


RX USAGE PER CAPITA

P A S T

In 1950s 2.4

Early 90s 7.8

P R E S E N T

Currently around 14


RX USAGE PER CAPITA

“If you just open your doors every morning your Rx volume will grow 3 – 5% annually”.

Rx volume increasing + static pharmacist pool = need efficiencies

FUTURE


RX USAGE PER CAPITA

Need designs that are: Task-oriented

Work station based

Flexible

Modifiable

FUTURE, continued


THE VOICE OF THE CUSTOMER

P A S T

Fill my prescription P R E S E N T

Fill my prescription AND give me

information about my Rx and OTC needs

AND give me clinics AND…


One stop shopping

Wellness visits

In store clinics

FUTURE, continued



24/7 access IVR Drive-through Internet

Privacy Multi-levels of counselling

Flexibility

FUTURE



HOW PHARMACISTS SPEND THEIR TIME

P A S T

Manufacturing their own tablets and capsules

Total involvement in the entire dispensing process (from reception to cash)

P R E S E N T

Reducing their involvement by enabling technicians

More emphasis on verification, DUR and clinical


HOW PHARMACISTS SPEND THEIR TIME

Leave all but (verification) & clinical services to technicians.

Ability to perform many functions remotely (centralized)

FUTURE, continued


PRESCRIPTION ERRORS

P A S T

Not talked about

System errors

To err is human

Process errors


PRESCRIPTION ERRORS

P A S T P R E S E N T

Problem recognized Public issue Advance systems design Use technology Catching & correcting is

not enough

Not talked about

System errors

To err is human

Process errors


WORK OVERLOAD = ERRORS

30% can be automated 30% can be delegated


PHARMACIST INVOLVEMENT WHEN AN ERROR OCCURS

Picking 76% vs 41%

Counting 62% vs 4%

Place in vial 62% vs 19%


PREPARING AN RX FOR VERIFICATION (LICK, STICK, COUNT & POUR)

P A S T

Typewriters

Tray & spatula

Many notes on scraps of paper


P R E S E N T

Advanced computer systems

Some counting automation

Some workflow-enabling software



More dispensing technologies

Technician only

Bar code, bar code, bar code

Stock bottle verification

FUTURE



AUTOMATE VIAL FILLING


AUTOMATE COMPLIANCE PACKS


WILL CALL P A S T

Throw them in a drawer

Impossible to keep orders together

Very difficult to purge

No pre-purge attempt to contact patient

P R E S E N T

In drawer or in hanging bags

Difficult to keep orders together

Very difficult to purge

No pre-purge attempt to contact patient


WILL CALL


DESIGNING FOR AUTOMATION

Canadian Pharmaceutical Journal

Caverly W. Walk This Way. The Canadian Pharmaceutical Journal Oct 2002;46


Canadian Pharmaceutical Journal

100 Rx * 1 metre

2 trips each (there and back)

= 200 metres per day

= 73,000 metres per year

= 73 Km.

= 33 hours of lost time!

DESIGNING FOR AUTOMATION


MAPPING

“Mapping” where staff are directed to the products.

“Re-Mapping” where

products are located in relation to their frequency of use.


RE-MAPPING


Retrieve / Replace


150 RX = 2 KM +


RESULTS

42232 per year, 116 per day.

Alphabetical: 551 kilometers annually. Reduced to 375 kilometers. Average distance per Rx reduced by 31%


PHARMACY DESIGN 101


WORKFLOW / WORKLOAD FACILITIES DESIGN

P A S T

Linear, no work stations First in, first out No task allocation Difficult to find Rxs All work performed in the

physical pharmacy Pharmacists up 8”


P A S T P R E S E N T

Linear, no work stations First in, first out No task allocation Difficult to find Rxs All work performed in the

physical pharmacy Pharmacists up 8”

Work stations and fill islands Layouts used properly? Bar code scanning (beg) Rx and pill images (beg) Rx tracking improving Work still in pharmacy “Workaround” workflow


Workflow fully integrated

Extensive use of technology

Flexible fixtures & millwork

Customizable fixtures & millwork

FUTURE


REDUCING COSTS

High density shelving makes most efficient use of space and is highly reconfigurable

Modular under counter “inserts” make most efficient use of space and are highly reconfigurable


HIGH-DENSITY SHELVING

16 inches with slat wall-style backing

30% more storage space

Flexible

Easily and quickly adjusted to size


Backless Better visibility Ventilation Shipping costs



Sliders


Shelves & printer stands


LINE OF SIGHT

Avoid check-out counter in direct line of sight from the entrance

Must refer patients to correct counter

Must accept Rx Cash

Reception

Entrance


USE SIGNAGE TO REINFORCE - NOT FORCE TRAFFIC FLOW

choose a logical location for dispensary reception

Reception


VISIBILITY

limit dispensary-front shelving to ≤ 54 inches


SEPARATE RECEPTION AND CASH/PICK-UP AREAS

Curtails patient confusion No waiting due to

lingering patients No waiting for pick-ups Improves work flow


ENOUGH WORK SPACE

For automated equipment For individual needs To accommodate traffic flow around work stations


EASY ACCESS IN AND OUT OF DISPENSARY

To assist clients in store front Will not block or disturb other workers No undue walking


SHOULD WE ADD A FILL ISLAND?


LIGHTING


Type of Work Examples Recommended (lx)

General Storeroom 80 – 170

Moderately precise Packing, simple assembly 200 – 250

Fine Work Reading, writing, laboratory technician, assembly of fine equipment

500 – 700

Very Fine to precision work Technical drawing, colour proofing, watchmaking

1000 - 2000

EXAMPLES OF SUITABLE LIGHTING LEVELS

Kroemer KHE, Grandjean E., Fitting the task to the human, page 301, table 18.2


VENTILATION

Work stations need proper ventilation Adequate ventilation often overlooked Consult interior designer with retail experience


TEMPERATURE


NOISE

Old Printers Telephones Ventilation People (especially children) White (ambient) Noise Music


CARPETING & NOISE

Carpeting reduces noise Position printers,

telephones carefully Distracting sounds may

hinder productivity, lead to dispensing errors


SUGGESTIONS

Sound absorbing materials Laser printers Reduce phone traffic – IVR Work Stations White Noise


RECOMMENDED CRITERIA FOR NOISE LEVELS IN THE WORKPLACE*

Office Area Noise Level [dB(A)]

Characterization

Executive Office 35 Very quiet office, large conferences (50), telephone use

Private / Semi-private 43 Quiet office, smaller conferences (20), telephone use possible

Medium Office 48 Satisfactory for 8 ft. table, Industrial business, normal voice at 12 ft.

Engineering & Drafting 55 Satisfactory for 5 ft. table, slight difficulty for telephones, normal voice at 6 ft.

Business / typing 63 Unsatisfactory for conferences (>3), Accounting, Slightly difficult telephone use, Normal voice at 2 ft.

Not recommended 65 Very noisy and unsatisfactory

*Lewis, Frank A. “Noise levels in the office” Enviros, September 1991


MATCHING PAINT COLOURS WITH FURNITURE, FABRICS AND CARPETING


COLOUR & PERCEPTION


“White walls are an optical strain and psychological hazard”.

Louis Cheskin Founder of the Color Research

Institute


76% of consumers make “where to shop” decisions based on emotional factors

86% of retail customers say music makes a difference in where they shop


Improvement in accuracy rates,

Compared to Silence

Radio: 2.3%

Muzak: 25.8%


10-Minute Maze

After 4-weeks of:

Mozart: 90 seconds

No music: 5 minutes

Heavy metal: 30 minutes


THE FUTURE OF PHARMACY DESIGN

Computer assisted design

Computer assisted modeling

Flexible fixtures & millwork

Designs for older workers and older patients


REDUCING COSTS

Using pharmacy designer vs. generic Computer designed and tested designs = faster

prototype to install AutoCAD Systems modeling Optimization programs


EVERY PHARMACY IS A SNOWFLAKE

Staff Clientele Physical restrictions


LOW VOLUME SITE

IS ONE DESIGN ENOUGH?


IS ONE DESIGN ENOUGH?

HIGH VOLUME SITE


LOW TO HIGH VOLUME, OVERNIGHT


HIRING A PHARMACY DESIGNER

Excellent knowledge of practice of pharmacy

Interior designer on staff or hired as consultant


Recommended Reading:

http://pages.infinit.net/wcaverly/writings.html

http://www.rogerspublishing.ca/subscribe/subscriptions_business.htm

http://www.canadianhealthcarenetwork.ca/


THANK YOU!

Wayne Morgan Caverly Executive Director, Efficient Pharmacy Institute

www.efficientpharmacy.com e-mail: [email protected]

1-888-864-9322

Please direct your questions regarding CEUs to Phil Emberley, Director of Pharmacy Innovation, CPhA, [email protected].

Continuing Education Form

CPhA National Conference 2013 June 1 – 4, 2013, Charlottetown, PE

The Canadian Council on Continuing Education in Pharmacy has approved CPhA as an Accredited Provider of continuing education. The conference has been accredited under program number 8002-2013-115-C-P for a total of 12.75 CEUs.

PLEASE NOTE: • Sessions indicated by an asterisk (*) are sponsored. These sessions are not accredited under the conference

program number. The sponsor will provide accreditation information at the session. • Pre-conference workshops are not accredited under the conference program number, nor listed on this

form. Participants will receive their Statement of Participation at the workshop(s).

Delegates are encouraged to use this form to track their learning. For delegates who must submit CEUs to their licensing body, please make a copy of this form for your files and submit the original to your provincial licensing body.

Name: __________________________________________________________________________________________

Province: _____________________________________ License #: ___________________________________

SUNDAY, JUNE 2, 2013

Time Session Speaker/Sponsor CEUs 7:00 am-8:30 am CE Satellite Breakfast Presentation* 1.0*

11:45 am-1:00 pm Luncheon Presentation – Learn How to Interpret Your Financials

Teva Canada 0.75*

1:15 pm-2:00 pm Balancing Risk & Benefits of Hormone Therapy for Menopause

Anne-Marie Whelan 0.75

1:15 pm-2:45 pm Pharmacy Practice Research – Oral Presentations Oral Abstract Presenters 1.5 1:15 pm-2:45 pm Canada’s Drug Review Processes Brian O’Rourke 1.5 2:00 pm-2:45 pm The Link Between the Heart and the Kidneys Marisa Battistella 0.75 3:00 pm-4:30 pm Pharmacy Practice Research – Oral Presentations Oral Abstract Presenters 1.5 3:00 pm-4:30 pm Improve Productivity in Community Pharmacy through

Workflow and Design Wayne Caverly 1.5

3:00 pm-4:30 pm Pharmacy Practice 3.0 – Putting Prescribing in Perspective

Matt Tachuk 1.5

Maximum daily CEUs under conference accreditation: 3.00 *Maximum daily CEUs from sponsored CE sessions: 1.75

mailto:[email protected]

Please direct your questions regarding CEUs to Phil Emberley, Director of Pharmacy Innovation, CPhA, [email protected].

MONDAY, JUNE 3, 2013

Time Session Speaker/Sponsor CEUs 7:00 am-8:30 am CE Satellite Breakfast Presentation* Disease

Interrupted: Tobacco Reduction & Cessation Charl Els, Jane Ling LifeScan Canada

1.0*

8:30 am-9:30 am New Oral Anticoagulant Therapy: Is Newer Better? Bill Semchuk 1.0 8:30 am-9:30 am e-Health: A Cross Country Check-Up Justin Bates 1.0 8:30 am-9:30 am CPJ Session – Translating Research Evidence into

Australian Pharmacy Practice: Successes & Challenges Ines Krass 1.0

10:00 am-12:00 pm Pharmacy Practice Innovation Showcase Bareham, Barnes, Gray, Jorgenson, Sadowski, Taylor

2.0

2:30 pm-3:30 pm Looking Back, Looking Forward: The Public Policy Landscape in Pharmacy

Jeff Morrison 1.0

2:30 pm-4:30 pm Diabetes Mini Sessions (CANRISK, Diabetic Foot Care, 2013 CDA Guidelines)

Kerry Mansell, Rob Roscoe 2.0

3:30 pm-4:30 pm Debt Management for Pharmacy Students and New Practitioners

Michèle Seaton-Gascon 1.0

Maximum daily CEUs under conference accreditation: 5.00 *Maximum daily CEUs from sponsored CE sessions: 1.0 TUESDAY, JUNE 4, 2013

Time Session Speaker/Sponsor CEUs 7:00 am-8:30 am CE Satellite Breakfast Presentation* D-lemmas of

Vitamin D: Who Needs It and How Much? Stephanie Atkinson Kellogg Canada

1.0*

8:45 am- 9:45 am Managing Chronic Non-cancer Pain (CNCP): Finding Pearls & Avoiding Pitfalls

Loren Regier .75

8:45 am-10:15 am Pharmacy Practice Research – Oral Presentations Oral Abstract Presenters 1.5 8:45 am-10:15 am Connect and CARE: Engaging Patients Over-the-

Counter in Canada’s New Pharmacy Environment Lisa Guirguis, Sherrill Johnson

1.5

9:45 am-10:15 am Pharmacist’s Role in Shingles Vaccination Kathryn Slayter .75 10:30 am-11:15 am Parkinson’s Disease: Optimization of Medication

Management Janice Irvine-Meek .75

10:30 am-11:45 am Pharmacy Trends-A Time of Global Change Jeff Poston 1.25 11:15 am-11:45 am Managing Behavioural & Psychological Symptoms of

Dementia Susan Bowles .5

12:00 pm-1:30 pm Luncheon Presentation – from Pharmacist to Premier Hon. Darrell Pasloski (invited)

1.0

1:45 pm-2:45 pm The Multi-Generational Workplace David Foot 1.0 Maximum daily CEUs under conference accreditation: 4.75 *Maximum daily CEUs from sponsored CE sessions: 1.0

mailto:[email protected]

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