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

Mid-Winter Meeting February 2020

Creative Solutions and Redneckery on 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 IHI: Institute for Healthcare Improvement ADM: automated dispensing machine IPC: internal process control CAP: community-acquired pneumonia IPPE: Institutional Pharmacy Practice Experience CEO: chief executive officer IV: intravenous CMS: Centers for Medicare/Medicaid Services MRSA: methicillin-resistant Staphylococcus aureus CPA: collaborative practice agreement MRI: magnetic resonance imaging CT: computed tomography PA: Physician’s Assistant PCA: patient-controlled analgesia DI: drug information PCR: polymerase chain reaction ED: emergency department SSTI: skin and skin structure infection EMR: electronic medical record US: ultrasound ID: infectious diseases 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.

Why Rural Pharmacy? 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 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.

Poll Everywhere: Everyone Type in the name of your rural practice site Image: https://sdaho.org/2019/09/27/small ‐ rural ‐ hospital ‐ transition ‐ project ‐ deadline ‐ oct ‐ 16th/ Image: https://www.amdtelemedicine.com/blog/article/ebook ‐ how ‐ telemedicine ‐ brings ‐ better ‐ access ‐ rural ‐ health ‐ care

Poll Everywhere: What challenges are you facing?

Rural Pharmacy Challenges & Solutions CHALLENGES: SOLUTION STRATEGIES: Staffing Technology Non-24 Hour Pharmacy Centralize Inventory System sharing Access to care Redneckery

It may not be rocket science… IMAGE: HTTPS://I.PINIMG.COM/736X/8D/C9/D3/8DC9D32D9D577474307F5461F727B960.JPG

Challenge 1: Staffing

Single Pharmacist Model 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

Pharmacist v. Technician Roles PHARMACIST: TECHNICIAN: Inventory Management Order Verification Clinical Monitoring Automation Management Medication Verification Billing Administrative Functions Stocking Regulatory Compliance Compounding Diversion Control Preceptor Quality Improvement

Single Pharmacist Model CHALLENGE: SOLUTION: Order Verification Delays Technology Codes Lap top Patient counseling Text alerts Meetings Wearable voice pagers Cleaning

Single Pharmacist Solutions CENTRALIZE: PUBLIC RESOURCES: Project ECHO Rural ID Pharmacist University of Utah Drug Information Drug Information Tracers by AMP Internal Process Control / 503B Facilities Internal audits Vendors Supply Chain IHI Open School Automation Team

Rural ID Pharmacist 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

Challenge #2: Non-24-Hour Pharmacy

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

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

Non-24-Hour Pharmacy 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 IMAGE: HTTP://WWW.CLIPARTPANDA.COM/CLIPART_IMAGES/MEDICATION ‐ CLIPART ‐ 63490202

Non-24-Hour Pharmacy 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

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

Non-24-Hour Pharmacy 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

Poll Everywhere Question: Technician How do you obtain medications on short notice? Type in your response

Non-24-Hour Pharmacy 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

Challenge #3: Inventory