Pharmacy News

Entries for September 2018

Clostridium difficile Guideline Update

By Maxwell Trombly, Pharm.D.; Ashley Liakos, Pharm.D.; Janelle Dykstra, Pharm.D.; Alexandra Simon, Pharm.D., PGY1 residents, Mercy Health Muskegon

Clostridium difficile is a gram positive, anaerobic, spore-forming rod that is the leading cause of healthcare-associated diarrhea. The prevalence of gastrointestinal colonization and subsequent infection with Clostridium difficile has been documented to be near 20 percent of all hospitalized patients in some reports and is highly correlated to the use of antimicrobial agents.1 Clostridium difficile infections (CDIs) are associated with significant morbidity and mortality, especially in patients greater than 65 years of age.2 The economic impact of this infectious agent is also vast, with over one billion dollars being attributed to CDI treatment in the United States alone.3 Given all these factors, increasing efforts are being dedicated to the treatment and prevention of CDI in our healthcare systems.

Published in 2018, the Infectious Disease Society of America provided a long-awaited update to their 2010 CDI guidelines. Major highlights from the update include advocacy for the use of oral vancomycin or fidaxomicin over metronidazole for all incidences of CDI, whenever possible (strong recommendation, high quality of evidence). This is a large change from the 2010 guidelines in which metronidazole was regarded as a first-line therapy for the treatment of mild and moderate CDI. Although no longer a first-line therapy, metronidazole still retains its use in specific populations, including pediatric patients, for use intravenously alongside vancomycin for fulminant presentations or if access to vancomycin/fidaxomicin is limited (weak recommendation, high quality of evidence). In addition to therapeutic agent selection, duration of therapy has been decreased to 10 days from the previous 10 to 14, as there was no effect observed in reduction of recurrence rates when a longer regimen was selected. Current recommendations also discuss the preference of tapered/pulsed vancomycin over standard dosing to reduce recurrence rates.

Treatment choices for recurrent CDI have also been changed from the previous guidelines. Though a weak recommendation with low/moderate quality of evidence, it is now recommended that patients with a recurrent CDI be treated with a pulsed and tapered regimen of vancomycin or a 10-day course of fidaxomicin over standard 10-day vancomycin courses. In addition, the guidelines make a strong case for fecal microbiota transplantation for patients that have had multiple recurrences despite appropriate antibiotic therapy (strong recommendation, moderate quality). One of the clinical definitions for CDI has been updated in the new guideline; what was previously termed “initial episode, severe complicated” is now referred to as “initial episode, fulminant.” Regarding probiotic use, the new guidelines do not provide a recommendation for or against their use, in contrast to 2010's low recommendation against their use. Although this is a minor change, caution still should be used regarding their use due to the lack of evidence on the subject. 

There are several consistencies between the previous CDI guideline and the new guideline that are important to highlight to ensure proper treatment continues to be implemented in conjunction with the new updates. Patients who are asymptomatic should not have a stool test performed to prevent unnecessary treatment, and additionally, repeat testing of stool should not be performed during the same episode of diarrhea. Contact precautions, private rooms, gowns and gloves should be used to prevent transmission to other individuals. Vancomycin 500 mg is only indicated for patients who initially have a fulminant presentation, defined as patients with hypotension, shock, ileus or megacolon.  Antimicrobial stewardship is an important intervention for lowering rates of CDI, as antibiotic use increases risk for CDI. Limiting the number, frequency and duration of high risk antibiotics prescribed can reduce the risk of CDI (strong recommendation, moderate quality of evidence)4. Antibiotics considered high-risk for CDI include fluoroquinolones, clindamycin and broad-spectrum penicillins and cephalosporins; however, any antibiotic can increase risk for CDI.

Pharmacists play an important role in recommending evidence-based drug therapy and stewardship of antibiotics. As this update has provided changes in standards of care for patients with CDI, pharmacists have an opportunity to intervene and educate if out-of-date guidelines are utilized. Stay up-to-date on guidelines, provide updated recommendations when necessary and ensure the appropriate treatment of CDI.

To learn more information and access the most up-to-date practice guidelines visit the Infectious Disease Society of America website at www.idsociety.org.

References:

1.      Aljarallah, KM. Conventional and alternative treatment approaches for clostridium difficile infection. Int J Health Sci (Qassim). 2017;11(1):1-10.

2.      Burke, K; Lamont J. Clostridium difficile infection: A worldwide disease. Gut Liver. 2014; 8(1):1-6.

3.      Dubberke E; Olsen M. Burden of Clostridium difficile on the healthcare system. Clin Infect Dis. 2012;55(Suppl 2):S88-S92.

4.      Infectious Diseases Society of America. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases. IDSA website. http://www.idsociety.org/Guidelines/Patient_Care/IDSA_Practice_Guidelines/Infections_By_Organ_System-81567/Gastrointestinal/Clostridium_difficile/.

5.      Cohen, SH; Gerding, DN; et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(5):431-455.

 

Posted in: Professional Practice
Together We Can Make a Difference – Emergency Preparedness

By Mary Beth O’Connell, Pharm.D., BCPS, FASHP, FCCP, FNAP, AGSF, professor, Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences, Detroit


Every year, disasters and public health threats affect various populations and geographical areas. Since 1953, Michigan has experienced 37 disasters (see Figure 1).1 During disasters and threats, healthcare is needed to meet acute, chronic and preventive health needs. Paid healthcare and government employees coordinate and oversee these healthcare services, but most of the care comes from volunteers for medical, technical, and logistical tasks.  Medications play a critical role in overcoming disasters and public health threats; therefore, pharmacists, pharmacy technicians and student pharmacists are needed at these events. Having a database of volunteers facilitates the engagement of personnel and resources in a timely and organized manner. What follows is information about disasters and public health events and how to join the Michigan Volunteer Registry database. Pharmacy personnel are a critical component of interprofessional healthcare teams to improve the health and well-being of citizens during disasters, so registering with the database is incredibly important. Currently about 325 pharmacy personnel are in the registry, but the goal of MSHP/MPA is to have 1,000 pharmacy-focused volunteers by the end of the year. Non-pharmacy volunteers are also needed, so sign up with a colleague, family member, friend or alone.  Join those of us who have accepted this important healthcare obligation. When you are called on to volunteer, you will make an important contribution to society, but if you are not available at the time you are called, you can always say you are unable to volunteer at this time.

Figure 1. Number and Location of Michigan Disasters1

11 Floods

9 Severe storms

6 Tornados

5 Snow

1 Drought

1 Fire

1 Freezing

1 Hurricane

1 Toxic substances

1 Other

 

Disasters are common and are classified as natural, technological and man-made. Natural disasters include hurricanes, tornados, fires, earthquakes, floods, etc. Technological disasters can include power grid outages or computer problems. Man-made disasters can be intentional or unintentional including biological terrorism, disease outbreaks, nuclear, radiologic or chemical terrorism, and violence from bombs and mass shootings. As Virginia Zimmerman, Coordinator of the Michigan Volunteer Registry states, “It is not a matter of if but when” a disaster strikes. For example, in 2017 there were four hurricane created natural disasters. During the initial response phases for these four hurricanes, 4,674 personnel were deployed to help 36,370 patients!2 During these disasters people experience trauma or new illnesses, find themselves without their chronic medications due to evacuation or fleeing, or are unable to get more medications due to destruction of community pharmacies. During Hurricane Katrina 68 to 80 percent of shelter evacuees needed replacement medications.3 During Hurricane Sandy, 95 percent of ambulatory care clinics in the affected area needed to close or relocate.4 Only 37 percent of the community pharmacies in that area had a back-up generator; therefore, most pharmacies were not able to operate fully. Seventy-four percent of the pharmacies had damage limiting pharmacy services, and 44 percent of the pharmacy staff had transportation issues getting to work. As demonstrated, during most disasters, temporary community pharmacies are needed with additional pharmacy personnel. Sometimes the need results from the spread of a contagious disease such as the hepatitis A outbreak in the Southeast Michigan area, which required public health events to mass immunize large numbers of citizens at risk of getting the disease. In cases of bioterrorism, a stockpile of medications exists that would require mass dispensing of antibiotics or antidotes quickly. You have the skills and expertise to help during these times.

Can you see yourself helping out? Pharmacy personnel have unique skills that other healthcare professionals do not have that are needed during disasters and public health events. The major categories of pharmacy activities during disasters and public health threats are medication supply, patient management, policy coordination and response integration.5 A recent review of literature has expanded these categories to professional practice, population health planning, direct patient care, legislation and communications.6 So many roles and steps exist, such as setting up an emergency based pharmacy, procuring and storing medications, managing pharmacy volunteers, doing patient interviews to identify and resolve medication related problems, labeling, dispensing and administering medications, counseling and educating patients, answering healthcare professional's drug information questions, providing team care, assisting with computer support, prehospital triaging during mass-casualties, enhancing communications, and decreasing panic and fear with patients, families and providers. Some pharmacy curriculums are even adding emergency preparedness to pharmacy student training. Many pharmacy organizations are adding this type of training to their annual meetings. All pharmacies are encouraged to have a plan for operations during a disaster.

Please join the Michigan Volunteer Registry at MiVoluntterRegistry.org. Michigan is fortunate to have such a registry. The registry is managed the Michigan Department of Health and Human Services. Dianne Malburg, Michigan Pharmacists Association (MPA) chief operations officer and Farah Jalloul, MPA emergency preparedness coordinator, are administrators for the database. The process required to enroll is done online and can be done in parts. You will need to enter your pharmacy license number and information about immunization, CPR and other types of certifications. The registry is dynamic, which means you can change your ability and responsibilities over time. Enrollment does not commit you to any disaster. If a disaster occurs, they might contact you and you can say “yes, I am available”, “no, I am not available”, or “I need to take care of my family or place of employment first.”

The value of an emergency preparedness database is state personnel can validate licensure to have practice-ready, licensed healthcare professionals they can call upon immediately versus trying to validate personnel during the actual disaster. The database can identify volunteers by skills so the appropriate people are requested by healthcare needs. Outcomes after a disaster are better for states that are ready and have plans and personnel ready to engage.6

Ready to volunteer but have some reservations? Watch the recruitment video that was developed for pharmacy personnel at https://youtu.be/OzdREGEsAc4. You can also visit to the MiVolunteerRegistry.org website and read the frequently asked questions sections as well as some of the references below. You are also welcome to contact Farah Jalloul, MPA emergency preparedness coordinator, at Farah@MichiganPharmacists.org for any additional information or question. Here are some answers to common concerns.

1)       I don’t know enough. Incorrect. Each of us can assist during a disaster or public health threat by providing skills in the area of management, operations, supply chain, patient education, dispensing, etc.

2)       I don’t have the time. You can volunteer for just a half day or for a couple days or a week – it’s all up to you.

3)       I have a busy life. When they call, you can say sorry, I can’t volunteer this time.

4)       I won’t be able to take care of my family. Incorrect. You can take care of your family first; remember this is a volunteer function that you have the right to say, “sorry, hopefully next time.”

5)       I am uneasy about working with trauma patients or during a chemical or bioterrorism event. You get to choose what type of activities you volunteer your expertise. You can just list immunizations at a public health event and not volunteer for disasters.

6)       I am not trained to do disaster care. At any disaster, medical experts and law enforcement are there to oversee the situation. They direct operations and assignments, so you always have resources and information during a disaster. They have access to safety gear and preventive health medications, if needed.

7)       I’m afraid of liability issues. During disasters state and federal laws exist to cover healthcare professionals, with the coverage varying by profession. Some pharmacy malpractice insurance companies cover humanitarian efforts, so check your plan. MPA is working to get even greater coverage for pharmacy personnel during disasters. The rules are constantly changing. For information about insurance coverage, see reference four, and also the frequently asked questions at www.MiVOlunteerRegistry.7

8)       My employer won’t let me volunteer. You should double-check with your employer to see if you can get release hours from work or could use vacation time. Some pharmacy chains actually set up their own pharmacy units so you might be able to work within your own company during a disaster.

9)       I can’t afford to volunteer. That might be true. During these events you generally have to pay for your own travel, lodging and food. Volunteers are not paid for their services. Generally costs for local events are minimal and less than national events. Sometimes organizations donate food and discount lodging to keep costs affordable.

Using your pharmacy skills and training during a disaster will help save lives and improve healthcare outcomes. Wouldn’t you want the state of Michigan to have a plan to help you and your family in an emergency? In order for that to happen, we have to have pharmacy personnel from all counties in Michigan ready to step up and provide medications and save/improve lives and health outcomes. So please register today at www.MiVolunteerRegistry.org. We need you! Recruit others from your practice. Together we can make a big difference!!

References

1. FEMA. Data Visualization: Disaster Declarations for States and Counties. FEME website. https://www.fema.gov/data-visualization-disaster-declarations-states-and-counties.

2. Assistant Secretary for Preparedness and Response. ASPR Year in Review. Public Health Emergency website. https://www.phe.gov/about/Documents/2017-Year-in-Review-Infographic.pdf.

3. Carameli KA, Eisenman DP, Blevins J, d’Angona B, Glik DC. Planning for chronic Disease Medications in Disaster: Perspectives From Patients, Physicians, Pharmacists and Insurers. Disaster Med Public Health Prep. 2013;7(3):257-65.

4. Ford H, Dallas CE, Harris C. Examing Roles Pharmacists Assume in Disasters: A Content Analytic Approach. Disaster Med Public Health Prep. 2013; 7(6):563-572.

5. Arya V, Medina E, Scaccia A, Mathew C, Satrr D. Impact of Hurricane Sandy on Community Pharmacies in Severely Affected Areas of New York City: A Qualitative Assessment. Am J Disaster Med. 2016;11(1):21-30.

6. Alkhalili M, Ma J, Grenier S. Defining Roles for Pharmacy Personnel in Disaster Response and Emergency Preparedness. Disaster Med Public Health Prep. 2017;11(4):96-504.

7. Frequently Asked Questions (FAQ) About Legal and Regulatory Issues Pertaining to the MI Volunteer Registry. Michigan.gov website. http://www.michigan.gov/documents/mdch/LEGAL_ISSUES_258700_7.pdf.

Posted in: Innovative Practice
Demonstrating Our Value: Customer Service

By Dana Staat, Pharm.D., clinical pharmacy specialist, Spectrum Health, Grand Rapids


Customer service? In hospital pharmacy? What does that even mean?

When I Googled, “pharmacy customer service,” I was faced with over nine million results. While I didn’t delve into each one, none of the 20+ articles that I saw referred in any way to hospital pharmacy. The articles and websites routinely discussed retail pharmacy and how to improve service to “customers,” or what I would consider “patients.” I believe that most pharmacists, in any practice area, would consider our patients our primary customers. While I completely agree that patients should be our focus, I have recently thought a lot about the other customers that pharmacists serve and how they dramatically help improve patient care. I would like to challenge you to consider that providing customer service to other healthcare providers strongly demonstrates our value. Today I will focus on nurses, who Pharmacy Times described as “above all, health-system pharmacists’ team members in patient care.”

Customer Service: Nurses

I recently encountered a new hospital pharmacist discussing interactions that she had with various nurses over the course of her day. I won’t describe the conversation in detail, but I will say that the statements were not positive. I asked myself the following questions: When did nurses and pharmacists become enemies? Are we providing the nurses with the customer service that they need and deserve? In what ways can we demonstrate our value to our nurse colleagues?

I won’t pretend that I have never been frustrated with a nurse. I have. I know they have been frustrated with me, in return. Commonly, those frustrating interactions have been over the phone with a nurse that I can’t see and probably haven’t met before. Things changed when I moved to working on the nursing unit. When nurses approached me face-to-face with a problem, we were both nicer and more considerate of each other. I was also more willing to run to the pharmacy and hand-deliver that medication they had already called for three times. We don’t always have time for things like hand delivery or is that just what we tell ourselves? Is it possible to push through our daily frustrations to give nurses the customer service they need? Personalized problem solving (with a positive attitude) is essential to nurse customer service.

I once had a nurse describe me as “her pharmacist.” The conversation was probably about eight years ago, but I still remember and value it. What did I do for the nurse who considered me her pharmacist? I answered her questions, discussed her medication concerns, contacted providers and sometimes did less exciting things like finding missing medications or fixing the Pyxis machine. Whatever it was, it helped us to form a relationship, become team members, and eventually become friends.

I also share an office with two nurse care managers. Each care manager focuses on patient care in a different way. I collaborate with one care manager on day-to-day patient discharges, while the other care manager consults me (and other pharmacists) on transitions of care issues and alerts us of medication lists that need a review prior to discharge. I have learned from these two care managers that it is sometimes the little things I do that make the most impact. The five minutes that I spent calling the patient’s pharmacy saved my care manager 30 minutes of time. The 15 minutes I spent reviewing a patient’s chart and calling a physician saved hours of care management time. The minute I spent pulling up Lexicomp answered a question they had been worried about all day. Helping where I could made all the difference, even if I didn’t see it at the time.

It is all easier said than done, isn’t it? This year, as I demonstrate my value in a variety of ways, I have made myself a goal to provide “exemplary customer service” to all the nurses I encounter. I truly believe that this will lead to better “customer” care, both for our patient-customers and our nurse-customers.

Goals for Customer Service

·         Personalized problem solving

·         Foster relationships

o   Take a personal interest

o   Create a team

·         Help where we can

·         Good attitude

Posted in: Professional Practice
Utilizing the Electronic Health Record to Assist with Transitions of Care

By Matthew Enell, Pharm.D., clinical informatics pharmacist, Michigan Medicine, Ann Arbor

 

Transitions of care (TOC) occur when a patient moves from one level of care to another. These transitions can be complicated and patients are at a higher risk for medication errors. The Centers for Medicare and Medicaid services estimates that one in five Medicare patient discharges (about 2.6 million patients) are readmitted within 30 days, at a cost of over $26 billion every year.1

 

Pharmacists can play a key role in decreasing medication errors and help to prevent hospital readmissions. In a study conducted at Hennepin County Medical Center, they found that pharmacists on their TOC team helped to reduce readmission rates from a baseline of 23 percent to eight percent.2

 

Here at Michigan Medicine, we have established a number of different transitions of care initiatives to help better serve our patients. Our TOC team, composed of pharmacy technicians and pharmacists, works to identify and resolve medication access barriers including assisting with obtaining prior authorizations, co-pay checks to ensure patients can afford their medications and bedside delivery of discharge medications to help facilitate discharge. From an informatics perspective, our informatics team has worked with the TOC team to identify opportunities in the EHR to streamline their workflow. These include patient lists identifying patients with an upcoming discharge and/or medications that often require a prior authorization, automated pages to the TOC team when a patient has a discharge order and prescriptions to be filled by our ambulatory pharmacy and tools to communicate prior authorization statuses to other team members.

 

Another program that we have implemented is our LACE (Length of stay, Acuity of admission, Comorbidities, Emergency department visits) Initiative. This is a scoring tool within our electronic health record that is used to identify patients that are at a high risk of readmission or death within 30 days of discharge. A LACE score is auto-calculated throughout a patient’s stay, and it predicts if a patient is at a low, medium or high risk of readmission. The LACE score can be found in our patient lists, reports and the discharge summary and is color coded to easily identify high risk patients at a glance. High risk patients then receive an inpatient care manager evaluation and are provided bedside pharmacist discharge medication education. After the patient is discharged, a TOC pharmacist will obtain a medication history, perform medication reconciliation, complete a comprehensive medication review (via a phone call with patient), and document any recommendations that providers should follow-up on during the post-discharge primary care provider appointment.

 

As the number of transitions of care activities continue to grow, the tools we can provide within the electronic health record will become even more important to our care teams as they work to assist our patients through these complicated transitions. What have you done to address transitions of care issues at your institution?  Please share at our Michigan Society of Health-System Pharmacists Google Group Listserve or email mshp-informatics@googlegroups.com.

 

References

1.       Centers for Medicare and Medicaid Services. Community-Based Care Transitions Program Fact Sheet. CMS website. https://innovation.cms.gov/Files/fact-sheet/CCTP-Fact-Sheet.pdf.

2.       American Society of Health-System Pharmacists. ASHP-APhA Medication Management in Care Transitions Best Practices. ASHP website. https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/quality-improvement/learn-about-quality-improvement-medication-management-care-transitions.ashx?la=en&hash=2E319CAC9BF04C20CD4C7C8E19AF132AF35B4890. February 2013.

 

Posted in: Professional Practice
Capital Area Pharmacist Association Update

By Cathleen Edick, Pharm.D., CDE, pharmacy program manager, McLaren Greater Lansing, central regional representative

 

Prior to the busy summer months when the Capital Area Pharmacists Association (CAPA) is usually fairly quiet, CAPA was able to hold a continuing education (CE) and a social event during the month of May. On May 10, the Meijer pharmacy residents, Alexander Proux, Pharm.D. and Aaron LePoire, Pharm.D., delivered a very informative CE regarding the newest 2017 hypertension guidelines. Then on the afternoon of May 20, 34 CAPA members and their families enjoyed an educational program, and some snacks, then toured  Potter Park Zoo. Luckily for us, the rain mostly held out that day to enjoy the zoo and snacks! CAPA had also planned to hold a legislative breakfast at Karoub Associates on May 22; however, the legislature’s schedule did not allow them to step away and this event was cancelled. Despite the busyness of summer, some CAPA members were able to find the time to volunteer to serve dinner on June 30 at the Advent House in Lansing.

 

Although summer may be almost done, CAPA is gearing up for the fall and winter months. Even though the CAPA e-board will not be meeting until mid-September, there are a few dates that can be put on your calendars now. Make plans to join us on Oct. 22 at the Michigan Pharmacists Association headquarters in Lansing for dinner, a presentation of the two CAPA scholarship winners and an application based CE titled “Wits and Wagers.” It is sure to be a fun evening as teams battle to win! In addition to the dinner and CE during pharmacy week, CAPA also plans to promote pharmacy awareness through their usual “That’s My Pharmacist” banners above two busy Lansing roads, as well as a possible radio spot and a community outreach event, with location still to be determined. The last few years have not been very busy at the Lansing City Market, so CAPA is looking for some other locations to use on either the Saturday before or after pharmacy week to have a community outreach booth. 

 

For those who are CAPA members, keep watch for more specific dates in the CAPA newsletter which will most likely arrive in your email inbox sometime toward the end of September. Until then, tentatively plan for Dec. 5 for a law CE at the Sparrow Professional Building, a possible fundraising event at Blaze Pizza again during October or November as well as the following Saturday afternoon Advent House dates: Sept. 29 and Dec. 29. Add these dates to your calendar now!

 

Posted in: Member News
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