Mid-Winter Meeting February 2020 Creative Solutions and Redneckery - - PowerPoint PPT Presentation

Mid-Winter Meeting February 2020

Creative Solutions and Redneckery

• n the Pharm

Lisa Hoopes, PharmD Director of Pharmacy Bear River Valley Hospital

Disclosure

I have no conflicts of interest to disclose. I will not be discussing off-label use of medications.

Learning Objectives

At the conclusion of this activity, pharmacists should be able to successfully:

• 1. Identify 3 common challenges at a single-pharmacist site
• 2. Describe 3 medication safety strategies for non-24 hour pharmacy sites
• 3. Describe one possible future innovation that would benefit rural sites

Learning Objectives

At the conclusion of this activity, pharmacy technicians should be able to successfully:

• 1. Explain one benefit and one challenge of utilizing temperature tracking

technology

• 2. Design a plan for immediate procurement of medications
• 3. Formulate a plan to reduce pharmaceutical waste

Abbreviations

ADM: automated dispensing machine CAP: community-acquired pneumonia CEO: chief executive officer CMS: Centers for Medicare/Medicaid Services CPA: collaborative practice agreement CT: computed tomography DI: drug information ED: emergency department EMR: electronic medical record ID: infectious diseases

IHI: Institute for Healthcare Improvement IPC: internal process control IPPE: Institutional Pharmacy Practice Experience IV: intravenous MRSA: methicillin-resistant Staphylococcus aureus MRI: magnetic resonance imaging PA: Physician’s Assistant PCA: patient-controlled analgesia PCR: polymerase chain reaction SSTI: skin and skin structure infection US: ultrasound UTI: urinary tract infection

Bear River Valley Hospital

16-bed Rural Community Hospital in Tremonton, Utah Level IV Trauma Center, ~6,ooo ED visits per year Intermediate Inpatient Acute Care Outpatient Infusion Therapy Services Surgical Services and Endoscopy Lab CT / MRI / 3D Mammography/ US Laboratory Services Physical Therapy and Rehabilitation Women and Newborn Work Med / Occupational Health / Sleep Studies Adjoining Medical Clinic

Bear River Valley Hospital

What we are not:

Not Joint Commission accredited Not a critical access hospital Not 340B

Bear River Valley Hospital

Why I love Bear River: Close and collaborative relationship with department managers, CEO Personal Touch: Joint Replacement Class Pre-diabetes class Walk with a Doc Get Well Soon Soup Kitchen staff knows everyone by name and their preferences

Bear River Valley Hospital

Intro to Institutional Pharmacy Practice Experience Micro-environment to experience interactions between departments Clinical experience combined with administrative Rural sites - We go back to our roots! Rural practitioners Rural pharmacy education

O’Conner SK, Fox JM, Joyner PU. Influencing the future of rural‐focused pharmacy education: Identifying factors pertinent to pharmacy practice in rural health environments. Curr Pharm Teach Learn. 2018; 10:439‐45.

Rural health statistics are worse v. urban areas

Mortality, obesity, chronic conditions, tobacco, mental health

The gap is getting bigger, yet rural hospitals are suffering, many closing Better care for more patients Open our minds to innovations for local operational sustainability

Why Rural Pharmacy?

• 1. Frakt AB. Jama Forum: The Rural Hospital Problem; News at JAMA website. https://newsatjama.jama.com/2019/05/01/jama‐

forum‐the‐rural‐hospital‐problem/. Updated May 1, 2019. Accessed Feb 1, 2020.

Type in the name of your rural practice site

Poll Everywhere: Everyone

Image: https://www.amdtelemedicine.com/blog/article/ebook‐how‐telemedicine‐ brings‐better‐access‐rural‐health‐care Image: https://sdaho.org/2019/09/27/small‐rural‐hospital‐transition‐project‐deadline‐oct‐16th/

Poll Everywhere: What challenges are you facing?

Rural Pharmacy Challenges & Solutions

CHALLENGES:

Staffing Non-24 Hour Pharmacy Inventory Access to care

SOLUTION STRATEGIES:

Technology Centralize System sharing Redneckery

It may not be rocket science…

IMAGE: HTTPS://I.PINIMG.COM/736X/8D/C9/D3/8DC9D32D9D577474307F5461F727B960.JPG

Challenge 1: Staffing

Single-pharmacist model, one pharmacy technician Lifestyle job (on call 365 days per year)

Burnout rate is high at rural sites

Two float pharmacists

Must plan very far in advance or be last priority due to their schedule at other sites

One PRN technician

No budgeted hours or set schedule, limited exposure to processes Limited physical space in the pharmacy, no overlapping coverage

Solution: Centralize

Eg, Larger hospital provides remote coverage after hours for non-24 hour sites

Single Pharmacist Model

Pharmacist v. Technician Roles

PHARMACIST:

Order Verification Clinical Monitoring Medication Verification Administrative Functions Regulatory Compliance Diversion Control Preceptor Quality Improvement

TECHNICIAN:

Inventory Management Automation Management Billing Stocking Compounding

Single Pharmacist Model

CHALLENGE:

Order Verification Delays Codes Patient counseling Meetings Cleaning

SOLUTION:

Technology Lap top Text alerts Wearable voice pagers

Single Pharmacist Solutions

CENTRALIZE:

Rural ID Pharmacist Drug Information Internal Process Control / Internal audits Supply Chain Automation Team

PUBLIC RESOURCES:

Project ECHO University of Utah Drug Information Tracers by AMP 503B Facilities Vendors IHI Open School

Clinical support Regulatory support Education – collaborative and distributive Quality improvement projects Dashboards Develop system-wide protocols

Rural ID Pharmacist

Regulatory – New CMS Condition of Participation Antimicrobial Stewardship activities CDC Core Elements checklist Annual reports documenting stewardship activities

• 2. CMS Final Rule on Antibiotic Stewardship Programs; American Society for Microbiology Website. https://www.asm.org/Articles/Policy/CMS‐Final‐

Rule‐on‐Antibiotic‐Stewardship‐Programs. Updated Oct 18, 2019. Accessed Feb 1 , 2020.

• 3. The Core Elements of Hospital Antibiotic Stewardship Programs Checklist; Centers for Disease Control and Prevention Website.

Accessed Feb 1, 2020. https://www.cdc.gov/antibiotic‐use/healthcare/pdfs/checklist.pdf

Rural ID Pharmacist

Antimicrobial Stewardship Quality Improvement Projects Local Projects: UTI and ASB management in the ED (Bear River) CAP Improvement project (Fillmore) System Projects: MRSA nasal swabs & Vancomycin de-escalation Outpatient IV antibiotics

Rural ID Pharmacist

Challenge #2: Non-24-Hour Pharmacy

Nurses prepare 100% of IV medications Solution: Technology

Tele-Pharmacy monitors in both medication rooms Pediatric dilution project – standardized instruction template

Redneckery

Extra labels and instructions Email, posters, video

Non-24-Hour Pharmacy

Poll Everywhere

Question: Pharmacist

Which of the following are NOT medication safety strategies employed at Bear River? A: Labeling medications with dilution instructions B: Telepharmacy monitors C: Standardized dilution templates for pediatric medications D: YouTube Search

PROPOSED USP <797> guidelines: Immediate-use product can be used up to 4 hours. All individuals who prepare sterile compounds need education Utah DOPL has fined Utah hospitals Central Valley Medical Center 503B Facilities PharMEDium closed

Non-24-Hour Pharmacy

Locating medications and local formulary awareness Solution: Technology Electronic inventory system Pharmacy access reports Redneckery: Manual list Pharmacy Access Binder

Non-24-Hour Pharmacy

IMAGE: HTTP://WWW.CLIPARTPANDA.COM/CLIPART_IMAGES/MEDICATION‐CLIPART‐63490202

Many pharmacist clinical duties not done on weekends and holidays Medication histories Medication education, discharge counseling Possible future solution: Centralize clinical services on weekends/holidays to include medication histories & discharge counseling via Tele-Health services

Non-24-Hour Pharmacy

Poll Everywhere

Question: Pharmacist

Which of the following innovations would benefit rural hospitals: A: Centralized Pharmacy Clinical Services via TeleHealth B: Dukes of Hazard rocket launchers C: PharmD/PA combination degree

Rural Environment

Community pharmacies are not 24-hour either

Solutions:

Stat courier service (other hospitals, Home Care) Dispense TO-GO packs

Redneckery:

I am the courier sometimes

Non-24-Hour Pharmacy

Poll Everywhere

Question: Technician

How do you obtain medications

• n short notice?

Type in your response

Intermountain Rules for TO-GO packs in Utah: Community pharmacy is closed Urgent/Emergent need for the medication 72 hour supply Report CS to Utah CSDB Medication counseling, dispensed by LIP Medication is dispensed with a child-resistant cap Labeled with all outpatient requirements

Non-24-Hour Pharmacy

Electronic temperature monitoring Waterfall alert sequence: Director  ED nurses desktop Alert failure when desktops had been swapped out and IP address not updated Solution Notification to pharmacy when computers are changed

Non-24-Hour Pharmacy

Rural hospital culture Creative problem solvers Calling remote pharmacist is a barrier Lack of exposure to high risk processes Solution: Skills Pass-Offs Standard work k-Cards

Non-24-Hour Pharmacy

Challenge #3: Inventory

Required inventory and antidotes are relatively large portion of budget 48% Inventory cost is required AND highly likely to outdate Solutions: Credit / consignment programs GPO contracts Solutions: System Sharing Shared short-dated list – voluntary participation

Inventory - Required

Limited medications in stock, unpredictable need Limited physical space for drugs Mitigate outdates Solutions: Technology Locked cabinets to allow for limited medication storage in cabinets Redneckery: Share with another facility Borrow a couple of doses from another facility White boards

Inventory: Limited On-Hand

HTTPS://YA‐WEBDESIGN.COM/EXPLORE/MARKER‐CLIPART‐SMALL‐WHITEBOARD/

Date bins with outdates within a year Return to wholesaler (within parameters) Rotate locations or to other facilities, as possible

• Watch for expiring meds 6 months out

Evaluate meds as they expire Evaluation of physical inventory at end of year for total item cost Adhering to purchasing contracts (rebates may apply) Credit programs, look for consignment opportunities

Pharmaceutical Waste Reduction

Poll everywhere

Question: Technician

Which of the following are waste reduction strategies? Select all that apply: A: Date bins that expire within a year B: Return items to wholesaler C: Rotate locations D: Physical inventory reports E: Buy more expensive contract items

Challenge #4 – Access to Care

Solution: Tele-Health Emergency department Tele-Stroke Tele-Crisis Hospitalists are using Tele-Health for after-hour admissions (7pm to 7am) Tele-ID Tele-Critical Care

Access to Care

MOVE KNOWLEDGE, not people Solution: Force Multiplication Project Echo (Extension for Community Healthcare Outcomes) Started in Rural New Mexico with a Hepatitis C clinic Goal is to educate and mentor the local providers Goal to touch 1 Billion lives by 2025

Access to Care

Antibiotic Stewardship Project

Implementation of Automatic MRSA nasal swab for suspected pneumonia Rapid de-escalation of vancomycin in patients being treated for pneumonia with negative PCR

Empowered front-line pharmacists to make intervention

Force Multiplication

PharmD/PA joint degree now being offered in US

This may allow pharmacists in rural settings to expand their services

University of Washington, Rhode Island

Access - ASHP Forecast

ASHP Pharmacy Forecast 2020 Executive Summary. ASHP Foundation website. https://www.ashpfoundation.org/‐ /media/REF/Leadership‐Development/PDFs/Pharmacy‐Forecast‐Executive‐Summary‐ Final.ashx?la=en&hash=AA5675CACBE3ADC8872656C07B0177EB10BCC22D. Accessed Feb 1, 2020.

Frakt AB. Jama Forum: The Rural Hospital Problem; News at JAMA website. https://newsatjama.jama.com/2019/05/01/jama‐forum‐the‐ rural‐hospital‐problem/. Updated May 1, 2019. Accessed Feb 1, 2020. CMS Final Rule on Antibiotic Stewardship Programs; American Society for Microbiology Website. https://www.asm.org/Articles/Policy/CMS‐Final‐Rule‐on‐Antibiotic‐Stewardship‐Programs. Updated Oct 18, 2019. Accessed Feb 1 , 2020. The Core Elements of Hospital Antibiotic Stewardship Programs Checklist; Centers for Disease Control and Prevention Website. https://www.cdc.gov/antibiotic‐use/healthcare/pdfs/checklist.pdf. Accessed Feb 1, 2020 ASHP Pharmacy Forecast 2020 Executive Summary. ASHP Foundation website. https://www.ashpfoundation.org/‐/media/REF/Leadership‐ Development/PDFs/Pharmacy‐Forecast‐Executive‐Summary‐Final.ashx?la=en&hash=AA5675CACBE3ADC8872656C07B0177EB10BCC22D. Accessed Feb 1, 2020. O’Conner SK, Fox JM, Joyner PU. Influencing the future of rural‐focused pharmacy education: Identifying factors pertinent to pharmacy practice in rural health environments. Curr Pharm Teach Learn. 2018; 10:439‐45. Strasser R, Mitchell D, Logozzo J, Preston P, Walker N. Challenges of capacity and development for health system sustainability. Heathc Pap. 17 (3):18‐27. Taylor SM, Glass BD. Scoping the impact of curriculum and placement on the rural pharmacy workforce. Aust J Rural Health. 2018; 26:384‐ 93.

References