Download HEN Readmission Affinity Call

Intermountain-led
CMS Hospital Engagement Network
Adverse Drug Event Prevention
September 23, 2014
Affinity Call
Jason Trahan, Pharm.D.
Director of Pharmacy – Medication Safety,
Baylor Scott & White
Lucy Savitz, Ph.D., M.B.A.
HEN Director
Outline for Discussion
•
•
•
•
Review of the HEN ADE work
“Just-one-thing” Recommendations
High performers
Pharmacy Patient Safety at Baylor Scott &
White
• Q & A/ Discussion
Overall Progress Through Q1 2014
Intermountain HEN 2012-Q1 2014
ADE w/ Harm
Intermountain HEN 2012-Q1 2014
ADE w/ Harm
Intermountain HEN 2012-Q1 2014
ADE per 1000 Patient-Days
Intermountain HEN 2012-Q1 2014
ADE per 1000 Patient-Days
Intermountain HEN 2012-Q1 2014
PSI 12 Post Operative PE or DVT
Intermountain HEN 2012-Q1 2014
PSI 12 Post Operative PE or DVT
Intermountain HEN 2012-Q1 2014
• ADE Due to Opioids
• Controlled Postoperative Serum Glucose
• Excessive Anticoagulation with Warfarin
– Low Reporting
Just One Thing Matrix
Recommendations
Getting Started
Working Harder
Ahead of the Curve
Identify accountable
teams to review all
ADEs and work on
performance
improvement.
(moderate level of
evidence)
Build in automated
medication
administration alerts
and processes, i.e.,
bar coding.
(low level of
evidence)
Automate ADE
triggers and
implement into
pharmacy work flow
with patient specific
alerts.
High Performing Hospital Highlight…
ADE w/ Harm
Most Improvement
Lowest Rates
SANPETE VALLEY HOSPITAL - CAH
SUTTER MATERNITY & SURGERY CENTER OF
SANTA CRUZ
MILLS PENINSULA HEALTH SERVICES
SUTTER MATERNITY & SURGERY CENTER OF SANTA
CRUZ
DENVER HEALTH MEDICAL CENTER
LOS BANOS MEMORIAL HOSPITAL
SOCORRO GENERAL HOSPITAL
PARK CITY MEDICAL CENTER
BEAR RIVER VALLEY HOSPITAL
MENLO PARK SURGICAL HOSPITAL
EDEN MEDICAL CENTER
LINCOLN COUNTY MEDICAL CENTER
RIVERTON HOSPITAL
SEVIER VALLEY MEDICAL CENTER
DIXIE REGIONAL MEDICAL CENTER
HEBER VALLEY MEDICAL CENTER
VALLEY VIEW MEDICAL CENTER
GARFIELD MEMORIAL HOSPITAL
SUTTER ROSEVILLE MEDICAL CENTER
UPPER CONNECTICUT VALLEY HOSPITAL
High Performing Hospital Highlight…
ADE per 1000 Patient-Days
Most Improvement
Lowest Rates
SANPETE VALLEY HOSPITAL - CAH
MENLO PARK SURGICAL HOSPITAL
MENLO PARK SURGICAL HOSPITAL
GARFIELD MEMORIAL HOSPITAL
DENVER HEALTH MEDICAL CENTER
SANPETE VALLEY HOSPITAL - CAH
SEVIER VALLEY MEDICAL CENTER
SUTTER MATERNITY & SURGERY CENTER OF
SANTA CRUZ
DENVER HEALTH MEDICAL CENTER
SUTTER SOLANO MEDICAL CENTER
BEAR RIVER VALLEY HOSPITAL
MILLS PENINSULA HEALTH SERVICES
ALTA BATES SUMMIT MEDICAL CENTER
SEVIER VALLEY MEDICAL CENTER
NOVATO COMMUNITY HOSPITAL
LOS BANOS MEMORIAL HOSPITAL
SUTTER MATERNITY & SURGERY CENTER OF SANTA
CRUZ
ALTA BATES SUMMIT MEDICAL CENTER
UTAH VALLEY REGIONAL MEDICAL CENTER
SUTTER COAST HOSPITAL
High Performing Hospital Highlight…
PSI 12 Post Operative PE or DVT
Most Improvement
Lowest Rates
SUTTER LAKESIDE HOSPITAL
LOGAN REGIONAL HOSPITAL
SUTTER SOLANO MEDICAL CENTER
SUTTER AUBURN FAITH HOSPITAL
SUTTER AUBURN FAITH HOSPITAL
SUTTER SOLANO MEDICAL CENTER
VALLEY VIEW MEDICAL CENTER
PARK CITY MEDICAL CENTER
LDS HOSPITAL
SUTTER DAVIS HOSPITAL
MCKAY DEE HOSPITAL CENTER
HILLCREST BAPTIST MEDICAL CENTER
PROVIDENCE ST VINCENT MEDICAL CENTER
RIVERTON HOSPITAL
UTAH VALLEY REGIONAL MEDICAL CENTER
VALLEY VIEW MEDICAL CENTER
SUTTER MEDICAL CENTER OF SACRAMENTO
ESPANOLA HOSPITAL
DENVER HEALTH MEDICAL CENTER
SUTTER TRACY COMMUNITY HOSPITAL
Pharmacy Patient Safety
September 23, 2014
Jason Trahan, Pharm.D.
Director of Pharmacy – Medication Safety
Presentation Outline
• Focus on Pharmacist involvement in two of ten
patient safety areas:
– Adverse Drug Events
– Use of Data
» Vancomycin
– Response to current literature
» Fentanyl Patches
» Haloperidol Intravenous Use
– Injuries from Falls
• Response to current literature
– Zolpidem
16
Adverse Drug Events
• Changes evaluation from facility specific to
enterprise-wide in 2013.
– Increased usefulness of data and trending
• Reported Quarterly at enterprise and facility
meetings.
17
18
Vancomycin
• Facility specific practices collected / analyzed.
• Pharmacy and Therapeutics Committee
approval to standardize infusion times to 10
mg/min.
• Implementation in Electronic Health Record,
IV Pump Library, Order Sets, etc.
• Fully implemented first quarter 2014.
19
Proactive Use of Data
• Facility specific practices collected / analyzed.
• Pharmacy and Therapeutics Committee
approval to standardize infusion times to 10
mg/min.
• Implementation in Electronic Health Record,
IV Pump Library, Order Sets, etc.
• Fully implemented first quarter 2014.
20
Response to Current Literature
Fentanyl Patch Disposal
• FDA Alerts:
– April 2012 (Accidental Exposure)
– September 2013 (Patch Writing Color Change)
• Institute for Safe Medication Practices:
– August 2013 (“Bystander Apathy – We ALL have a
role in prevention”)
• Action Plan
– Outpatient
– Inpatient
21
Action Plan
Fentanyl Patch Disposal
• Outpatient Baylor Health Enterprises Pharmacies
– Pharmacists Utilizing standardized teaching tool
emphasizing disposal
• Tool can be found: www.ismp.org/AHRQ/default.asp
• Inpatient Care
– Nursing Education for Fentanyl, Fold, and Flush
– Consistent message across continuum of care
22
http://www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/UCM337803.pdf
23
Haloperidol Use
• Society of Critical Care Medicine
– Revised Guidelines Published January 2013
– Prior to update, the use of haloperidol for the
treatment of delirium was in the guidelines (Level
C Recommendation)
– “There is no published evidence that treatment
with haloperidol reduces the duration of delirium
in adult ICU patients”
24
Haloperidol Use
• Action Items:
– Removed from Enterprise ICU Delirium Order
Sets.
– Recommended that patients receiving via the
intravenous route of administration considered for
telemetry monitoring.
25
Zolpidem
• Journal of Hospital Medicine 2013;8:1-6
“Zolpidem is Independently Associated with
Increased Risk of Inpatient Falls” – Published
January 2013.
• FDA Drug Safety Communication – January
2013
– FDA Requires lower recommended doses…
26
Zolpidem
• Action Plan:
– Electronic Health Record Changes
• Revise order sets to remove pre-selection of prn
insomnia medication.
• Dose revision to remove 10 mg ordering option
– Only 5 mg on order sets
– Removal of 10 mg order sentence for quick ordering
27
28
AHRQ eLearning Lesson on Preventing ADE
“Preventing ADE: Individualizing Glycemic Targets Using Health
Literacy”
An interactive eLearning course offered by the Office
of Disease Prevention and Health Promotion, teaches
providers how to:
• Apply health literacy strategies to provide personalized care for
patients with diabetes, and to help them understand and act on
information to prevent hypoglycemia
• Apply current, evidence-based guidelines for individualizing
glycemic target goals
• Adopt the teach back method and shared decision-making in the
health care setting
Continuing education (CME, CNE, CEU and CPE) is available
Visit http://health.gov/hai/training.asp#preventing_ades to participate