Pharmacy Forecast 2016-2020

The ASHP Foundation released a "Pharmacy Forecast: 2016-2020" Strategic Planning Advice back in December. My first thought is a pause thinking how long I have been out of pharmacy school. I start counting on my fingers from '99 and think, wait, what? SEVENTEEN years. I am officially the pharmacist I stood beside in one of my first pharmacy jobs. I considered him wiser. Maybe I am wiser, but I still sometimes feel like school was not too terribly long ago.

This is the fourth edition of this particular report, and I generally try to read every edition. This one somehow slipped by until this past week when I found it and read it rather quickly. There are some applicable topics for today's healthcare pharmacist that I want to dive into.

Strategic Planning versus Reactive Planning

I have not seen a lot of strategic planning within the hospital pharmacy model. We do a lot of reactive planning based on other departments mostly in line with cost management and saving money. We plan operations in how we staff our departments based solely on how many patients are in the hospital but do not use other metrics such how complicated medically is the patient? What if the patient comes in with a chronic infection versus the patient who comes in as a first-time infection? What if the patient has 20 or more home medications on board? Census is more than just number of patients. What if it is measured by a formula of disease states both acute and chronic along with number of hospital admissions in the past 5 years plus number of medications? A patient doesn't equal a patient. Maybe this applies in a surgical patient, but not in a patient with COPD, ARDS and decompensating on a ventilator due to a hospital-acquired infection.

Opening the report is a timely introduction:

"Since the start of the pay-for-performance movement1 and passage of the Patient Protection and Affordable Care Act (ACA), there has been intense pressure on healthcare organizations to improve quality while reducing costs. The stress created by this pressure has been exacerbated by proliferation of expensive specialty medications, egregious price increases for some sole-source drug products, and the escalation of generic drug prices. In response to this environment, many healthcare organizations are pursuing mergers and acquisitions in an attempt to create economies of scale without the cost of new construction. Another tactic is to partner with outside entities such as chain pharmacies."

Specifically what caught my eye this time was the section on work force. Change in practice models claim a shift from inpatient to ambulatory type practice.

"THE SHIFT TO AMBULATORY CARE As healthcare organizations respond to payment reforms that aim to lower costs and improve patient outcomes, health-system pharmacy practice leaders are challenged to optimize the role of the pharmacy work force in new models of care. One area of challenge is the shift in emphasis from inpatient to ambulatory care.1 Reflecting this change, three-fourths of Forecast Panelists (FPs) agreed that over the next five years, in at least 25% of health systems, patient care pharmacists will have umbrella responsibilities for both inpatients and outpatients (survey item 1). Further, 69% agreed that at least 25% of health systems will reallocate 10% or more of inpatient pharmacy positions to ambulatory-care positions (item 2). Consistent with anticipated growth in ambulatory care, 65% of FPs predicted a vacancy rate of greater than 10% for ambulatory-care pharmacy leadership positions over the next five years (item 5). Pharmacy staff development programs should ensure that there are adequate opportunities for education and training in management of ambulatory care pharmacy practice, transitions of care, and medication management of chronic illnesses. "

How do we lose money? Readmissions, using more inpatient days than necessary due to reasons in and out of our control, and not following certain standards that are attached to payment or removed when standards are not met while in-patient. 

Did you notice one thing? The salaries of newly hired entry-level pharmacists will decline by 10% while pharmacist technician salaries will increase?

You know I get excited about this one:

"PHARMACISTS AS PROVIDERS Nearly 80% of FPs predicted that at least 25% of health systems will have a formal plan for including pharmacists, along with nurse practitioners and physicians assistants, in advanced roles that allow primary-care physicians to care for more patients (item 4). Supporting the high level of agreement with this statement is the shortage of primary-care physicians, proposed federal legislation to grant provider status to pharmacists, and the large number of states that authorize pharmacists to establish collaborative practice agreements with physicians. 2 Recent changes in reimbursement rules related to complex chronic care and transitional care management3 support the addition of pharmacists to primary-care teams. Many health systems will be establishing a privileging process for pharmacists to ensure that those with expanded patient care roles have the necessary competence for those roles."

I suggest you read through the report. It is mostly put together through surveys, but has some very timely information for the next 4-5 years in pharmacy.

PHARMACY FORECAST 2016-2020

Sepsis and Septic Shock Guidelines

One of the main guidelines in sepsis is the Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock from 2012 (updating the 2008 guidelines).

Pocket Guide

Key recommendations and suggestions:

• Early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C)
• Blood cultures before antibiotic therapy (1C)
• Imaging studies performed to confirm a potential source of infection (UG)
• Administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B)
• Infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C)
• Initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C)
• Initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to acheive a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C)
• Fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG)
• Norepinephrine as the first-choice vasporessor to maintain mean arterial pressure >/= 65 mm Hg (1B)
• Epinephrine when an additional agent is needed to maintain adequate blood pressure (2B)
• Vasopression (0.03 U/min) can be added to NE to either raise MAP to target or to decrease NE dose but should not be used as the initial vasopressor (UG)
• Dopamine is not recommended except in highly selected circumstances (2C)
• Dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite acheiving adequate intravascular volume and adequate MAP (1C)
• Avoiding use of IV hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C)
• Hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B)
• Low tidal volume (1A) and limiation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS)
• Application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B)
• Higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C)
• Recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C)
• Prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of </= 100 mm Hg in facilities that have experience with such practicees (2C)
• Head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B)
• A conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C)
• Protocols for weaning and sedation (1A)
• Minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B)
• Avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C)
• A short course of neuromuscular blocker (no longer than 48 hours) for patients with early ARDS and a PaO2/FIO2 < 150 mm Hg (2C)
• A protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose </= 180 mg/dL (1A)
• Equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B)
• Prophylaxis for deep vein thrombosis (1B)
• Use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B)
• Oral or enteral (if necessary) feedings, as tolerated, rathern than either complete fasting or provision of only IV glucose with the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C)
• Addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hours of intesive care unit admission (2C). 

Osteoporosis: Topic of the Day

The National Osteoporosis Foundation released an update to its Clinician's Guide to the Prevention and Treatment of Osteoporosis last year (April 2014). 

The current version (2014) was released April 1, 2014. The 2014 version of the Clinician’s Guide stresses the importance of screening vertebral imaging to diagnose asymptomatic vertebral fractures; provides updated information on calcium, vitamin D and osteoporosis medications; addresses duration of treatment; and includes an expanded discussion on the utility of biochemical markers of bone turnover and an evaluation of secondary causes of osteoporosis.

Osteoporosis Guidelines

Postmenopausal women and men age 50 and older

National Osteoporosis Foundation (2014) U.S. Preventative Services Task Force among other organizations

Postmenopausal women

 American Association of Clinical Endocrinologists (2010) – North American Menopause Society (2010)

Men

Endocrine Society (2012)

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Review of the 2014 NOF Clinician's Guide

• Approach to the diagnosis and management of osteoporosis
• Universal Recommendations 
• Pharmacotherapy (Who) and FDA indications
• Sequential and combination therapy
• Duration of treatment

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Dual‐energy Absorptiometry (DXA) Bone Density Testing: Indications

• NOF guideline
  • Women > 65 years old and men > 70 years old
  • Younger postmenopausal women, women in the menopausal transition, and men age 50‐69 years old with clinical risk factors for fracture • e.g., current smoker, low body weight, history of osteoporosis, low trauma fracture in a first‐degree relative
  • Adults who have a fracture after age 50 years
  • Adults with specific conditions or medications associated with bone loss
• Other – Women 50‐ 64 years old with FRAX overall fracture risk > 9.3% (USPSTF) – 

WHO Definition of Osteoporosis Based on Bone Mineral Density testing results:

• Normal 
  • BMD within 1 SD of the mean level for a young-adult reference population
  • T-score at -1.0 and above
• Lone Bone Mass (Osteopenia)
  • BMD between 1.0 and 2.5 SD below that of the mean level for a young-adult reference population
  • T-score between -1.0 and -2.5
• Osteoporosis
  • BMD 2.5 SD or more below that of the mean level for a young adult reference population
  • T-score at or below -2.5
• Severe or Established Osteoporosis
  • BMD 2.5 SD or more below that of the mean level for a young adult reference population
  • T-score at or below -2.5 with one or more fractures

Imaging Recommendations

• Vertebral Imaging recommended for women age 70 and older and all men age 80 and older if BMD T-score at the spine, total hip or femoral neck is </= -1.0
• Women age 65-69 and men age 70-79 if BMD T-score at the spine, total hip or femoral neck is </= -1.5
• Postmenopausal women and men age 50 and older with specific risk factors: low trauma fracture during adulthood (age 50), historical height loss of 1.5 inches or more (4 cm), prospective height loss of 0.8 inches or more (2 cm), or recent or ongoing long-term glucocorticoid treatment.

FRAX was developed to calculate a 10-year probability of a hip fracture and the 10-year probability of a major osteoporotic fracture (defined as clinical vertebral, hip, forearm or proximal humerus fracture). FRAX algorithm available at www.nof.org as well as at www.shef.ac.uk/FRAX.

FRAX is for postmenopausal women and men age 50 and older. In patients being pharmacologically treated for osteoporosis, clinical judgment must be use in interpreting results. No treatment in 2 years could be interpreted as untreated. Femoral neck BMD is preferred in calculating FRAX.

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Diagnosis of Osteoporosis (WHO Criteria) (Postmenopausal women and men >/= 50 years of age)

• T‐score at ‐1.0 or above  (SD) Normal
• T‐score between ‐1.0  and ‐2.5 (SD) - Low bone mass (Osteopenia)
• T‐score at or below ‐2.5 (SD) - Osteoporosis
• T‐score at or below ‐2.5 (SD) with one or more fractures - Severe or established osteoporosis SD = standard deviation

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Diagnosis of Osteoporosis (International Society for Clinical Densitometry 2007 Guidelines)*

• Z‐score above ‐2.0 (SD) “Within the expected range for age”
• Z‐score at or below ‐2.0 (SD) “Low bone mineral density for chronological age” or “Below the expected range for age” SD = standard deviation Premenopausal Women, Men < 50 Years of Age, and Children * These criteria are never used alone to diagnose osteoporosis in these populations

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RECOMMENDATIONS IN ALL PATIENTS:

Several interventions to preserve bone strength can be recommended to the general population. These include an adequate intake of calcium and vitamin D, lifelong participation in regular weight-bearing and muscle-strengthening exercise, cessation of tobacco use, identification and treatment of alcoholism, and treatment of risk factors for falling. 

Bone‐Healthy Lifestyle:

• Calcium - Recommended elemental calcium intake should be obtained ideally through dietary sources + supplements
• Age Group Recommended Daily Intake Maximum Daily Intake
  • 19-50 years 1000 mg
  • 50-70 years 2000 mg Men = 1000 mg Women = 1200 mg
  • ≥ 71 years 1200 mg

According to the updated 2014 National Osteoporosis Foundation guideline, intakes of calcium in excess of 1200 to 1500 mg per day could place a patient at increased risk for kidney stones, cardiovascular disease (CVD), and stroke. (J Bone Metab 2014;29:531‐3; J Bone Metab 2014;21:21‐8; Am J Clin Nutr 2011;94:270‐277)

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Vitamin D: This is the amount needed to maintain the majority of healthy patients within the sufficient range

• Age Group Recommended Daily Intake
  • National Osteoporosis Foundation (2014)
    • <50 years 400-800 units (4000 units max daily intake) 
    • ≥ 50 years 800-1000 units (4000 units max daily intake)
• Institute of Medicine (2010)
  • ≥ 71 years 800 units (4000 units max daily intake)
  • 51-70 years 600 units (4000 units max daily intake)
  • 19-50 years 600 units (4000 units max daily intake)

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When to Consider Drug Treatment

• History of (low trauma) hip or vertebral fracture
• T‐score - ‐2.5 at femoral neck, hip, or spine by central DXA
• Postmenopausal women and men 50 years of age if T‐score between –1 and –2.5 and 10‐year hip fracture probability of 3% or a 10‐year all major osteoporosis‐related fracture probability of 20%

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Bisphosphonates:  inhibit osteoclastic bone resorption and reduce osteoclast activity and beneficial effect on osteoblasts.

• Drug holidays are being considered for bisphosphonates to prevent which serious long‐term adverse effects 
• Show residual effects after discontuation
• Evidence for efficacy beyond 5 years is limited, whereas rare safety concerns become more common beyond 5 years. 
• Reasonable to discontinue after 3-5 years in patients who have a modest risk of fracture after the initial treatment period, but in high risk, continued treatment or alternative treatment should be considered.

Non-Bisphosphonates: produce temporary effects that wane with discontinuation.

Duration of Treatment and Drug Holiday

• Alendronate: Duration of treatment 5 years. Assessment for reinitiation: 1-2 years
• Risedronate: Duration of treatment 5 years. Assessment for reinitiation: 1 year
• Zoledronic acid: Duration of treatment 3 years. Assessment for reinitiation: 2-3 years

Denosumab Role in Therapy

• FDA osteoporosis indications
  • Postmenopausal women and men with high fracture risk (Osteoporosis fracture, multiple risk factors, can’t use other meds)
  • Androgen deprivation therapy for nonmetastatic prostate cancer
  • Adjuvant aromatase inhibitor for breast cancer
• AACE guideline – first line
• Increases BMD for at least 8 years
• Vertebral, hip, & nonvertebral fracture prevention
• Quicker reversal with medication discontinuation
• Adverse effects: Common adverse reactions (> 5% and diff placebo)
  • Back, shoulder, leg, and musculoskeletal pain – Increased cholesterol – Cystitis
  • Cases of MRONJ and atypical fractures

Raloxifene Role in Therapy

• FDA indications
  • Osteoporosis prevention and treatment
  • Postmenopausal women with osteoporosis and/or at high risk for invasive breast cancer
• AACE guideline –Second‐ and third‐line therapy
• Dose ‐ 60 mg daily
• Contraindications ‐ active or past history venous thromboembolism
• Precaution – risk for stroke
• Adverse effects – Vasomotor symptoms (hot flushes) – Leg cramps – Breast tenderness – Spotting – Venous thromboembolism – Box warning – fatal stroke

Teriparatide Role in Therapy

• FDA indications
  • Postmenopausal women at high risk for fracture
  • Men with primary or hypogonadal osteoporosis at high risk for fracture
  • Glucocorticoid‐induced osteoporosis
  • High fracture risk
    • Previous fracture
    • Extremely low BMD (T‐score < ‐3.5)
    • Multiple risk factors for fracture
  • Teriparatide Dose, Selection, and Common Adverse Effects
    • 20 mcg subcutaneously daily for 24 months
    • Once weekly injection in trials – ? Start antiresorptive agent before end of therapy
    • Contraindications – Skeletal muscle radiation, bone cancer, hypercalcemia, Paget’s disease
    • Common adverse effects
      • Orthostasis – first doses
      • Nausea, arthralgia, leg cramps
      • Hypercalcemia (check calcium at baseline)
      • Box warning ‐ osteosarcoma (animal data)

Calcitonin: Role in Therapy, Efficacy, Dose, and Adverse Effects

• FDA indication – osteoporosis treatment for women   5 years post menopause with low bone mass
• AACE guideline – fourth‐line therapy
• Only vertebral fracture prevention
• Dosing –Intranasal ‐ 200 units daily alternating nares
• Adverse effects –Nasal – rhinitis, epistaxis, irritation –Subcutaneous – pain, redness –Other – nausea, allergic response, backache, headache –FDA post‐marketing analysis for cancer risk

References:

• National Osteoporosis Foundation (2014)

• U.S. Preventive Services Task Force – calcium vitamin D (2013)

• Ann Intern Med 2013;158:691‐696

• U.S. Preventive Services Task Force – screening (2011) – www.uspreventiveservicestaskforce.org/uspstf/uspsoste.htm

• International Society for Clinical Densitometry (2013) – www.iscd.org/documents/2013/07/2013‐iscd‐official‐ positions‐adult.pdf

• American Association of Clinical Endocrinologists(2010)

• Endocr Pract 2010;16(Suppl 3):1‐37

• North American Menopause Society (2010) – www.menopause.org/docs/default‐document‐ library/psosteo10.pdf?sfvrsn=2

• Endocrine Society (2012) – J Clin Endocrinol Metab 2012;97:1802‐1822

CPOE Implementation: A Status Report

Back in 1999, the Institute of Medicine (IOM) published the article "To Err is Human: Building a Safer Health System," which focused on preventing adverse drug events (ADEs).

Computerized Physician Order Entry (CPOE) was touted as a tool to reduce ADEs. Subsequent studies pointed out how it would help prevent medication errors and improve patient safety.

The US government has pushed computerization, as well.

"To improve the quality of our health care while lowering its cost," President Barack Obama said back in January 2009, "we will make the immediate investments necessary to ensure that, within 5 years, all of America's medical records are computerized."

It has now been 6 years, and medical records are still not 100% computerized.

Implementation of CPOE has been slow due to its complexity and huge cost. To further entice hospitals to jump on board with electronic health records (EHR), the US Centers for Medicare and Medicaid Services (CMS) sends money to facilities that meet set goals.

EHR systems are not something that can be rushed, but for dollars, workarounds happen. There is also the threat of penalties if systems are not implemented.

As the EHR market has matured, the once-crowded field of vendors has narrowed significantly.

At the end of 2013, just 10 vendors accounted for about 90% of the hospital EHR market: Epic, MEDITECH, CPSI, Cerner, McKesson, Healthland, Siemens, Healthcare Management Systems, Allscripts and NextGen Healthcare, according to Becker's Hospital Review.

No CPOE standardization

CPOE systems are all different, so how are they compared? A hospital may have implemented a CPOE, but does that equate to a sufficient system? Do groups like Leapfrog take into account CPOE errors or just the percentage of usage by prescribers? Do we rate CPOE systems like we rate hospitals?

Data show vendor CPOE market share, but there are no rating systems to evaluate the systems after implementation, or even a list of hospitals that decided to change systems due to issues.

Limited medication profiles

Another issue with CPOE is its lack of a coherent view of a patient’s profile while entering medications. It is also difficult to verify orders without a comprehensive view of the medications that the patient is taking.

This lack of a full picture causes the user, whether prescriber or verifier, to rely on the software alone, rather than a comprehensive approach. Seeing the whole picture while entering and verifying orders would probably decrease errors.

Alert fatigue

When CPOE systems are used for other tasks aside from entering and verifying orders, there is more alert fatigue.

On the pharmacist verification end, it is common to see alerts of different significance with nothing to differentiate high importance from low. For example, the same type of alert may be used to discuss inventory, prior authorization, and other messages that take away from the verification role, even though many of these alerts previously happened at order entry.

Pharmacists should not have to think pharmacologically and pharmacokinetically about how a medication works along with alerts dealing with inventory, cost, and formulary status that once occurred at the front end. There should be a way to differentiate these alerts and have them fire at appropriate times, rather than during actual medication review. 

Tailoring the CPOE to be more user-friendly for the prescriber often comes at the expense of more frustration on the back-end with verification. For example, a CPOE may allow a prescriber to free type directions for medications taken irregularly (3 days a week, different strengths on different days), choose non-formulary medications rather than built-in CPOE formularies, and remove alerts that need to be seen at order entry.

In this way, verification becomes more of an order entry “fix” role that pulls attention from clinical aspects of verification.

CPOE software is also designed under the assumption that prescribers and verifiers are working in a quiet environment, but both sides are working in noisy environments. When a phone is ringing, a patient is yelling, and a nurse is asking a question, quick pop-up alerts may not be enough of a warning. Even the most focused individual will make mistakes.

More duplicate orders

The Journal of the American Medical Informatics Association published a study pre and post-implementation of a CPOE in an ICU and found that duplicate medication ordering errors increased after implementation (pre: 48 errors, 2.6% total; post: 167 errors, 8.1% total; p<0.0001).

Sometimes, there is a lack of integration between laboratory values, both inpatient and home medications, and other data or different modules that do not communicate smoothly.
 
Last but not least, if the staff is not happy with the CPOE software that is implemented, they are not going to use it as designed. - See more at Pharmacy TImes.

Pharmacists in the ER Equals Better Patient Care

One of the biggest impacts a pharmacist can make in the hospital setting is in the emergency department (ER). There has been a growing interest and trend in placing pharmacists in the ER to review medications, both reconciliation of home medications and medications administered in the ER to ensure correctness and cut down on medication errors and drug interactions that contribute up to 7,000 yearly deaths in the US. A pharmacist in the ER can review real-time orders that are typically bypassed by staff pharmacists due to the urgency of an ER patient.

Pharmacists can also improve flow of patients through the ER, educate prescribers and staff development about medications and their costs and also utilize the ER as a place to precept and mentor students and residents. Pharmacists can participate in codes, help with admissions in home medications and help with discharge medication reconciliation. Pharmacists in the ER can also be involved with the ER department in providing presentations, publications and other activities to the department. Pharmacists can monitor the use of expensive medications to make sure use is consistent with approved criteria (Factor VII, alteplase, etc.) and conduct MUEs in the emergency room setting. These pharmacists could also be involved with microbial culture follow-up. The emergency department is usually a place of unpredictability in acute illnesses and patient volume. High risk medications are used more often and a greater chance of a medication error reaching the patient.

Currently in most hospital settings, hospitals use a clerk to fill out a home medication sheet which typically can include errors in drug name, drug strength and directions. Many times staff pharmacists are clarifying home medications days later than what is optimal. I have personally witnessed mistakes in high-risk medications like warfarin that are discovered days later. In short, when a patient is admitted, they are prescribing for themselves with no oversight from a pharmacist, and physicians do not want to take ownership of what the patient takes at home since they are presenting with something acute that may have nothing to do with the herbals they take on the side.

The American Society of Health-System Pharmacists (ASHP) believes every hospital pharmacy department should provide its emergency department with the pharmacy services that are necessary for safe and effective patient care. The Joint Commission also has compliance requirements that can be met with a pharmacist in the emergency department (MM.4.10. which requires that all medication orders be evaluated by a pharmacist prior to administration of the first dose and MM 7.10 which identifies high-risk or high-alert medications and all the processes involved from procuring to monitoring and medication reconciliation). One of the National Patient Safety Goals is to accurately and completely reconcile medications across the continuum of care which would include the first stop in the emergency department.

One of the most common reasons most hospitals do not employ emergency room pharmacists is due to cost. Small hospital pharmacies are staffed at a bare minimum. Most hospitals do not realize that pharmacists working in the emergency room can reduce readmissions, medication errors and drug interactions to save money but more importantly increase patient safety while being treated for an acute illness.

1.       Impact of a prescription review program on the accuracy and safety of discharge prescriptions in a pediatric hospital setting. J Pediatr Pharmacol Ther. 2008 Oct;13(4):226-32. doi: 10.5863/1551-6776-13.4.226.

2.       Levy DB. Documentation of clinical and cost saving pharmacy interventions in the emergency room. Hosp Pharm. 1993;28:624-627,630-634,653.

3.       American Society of Health-System Pharmacists. ASHP statement on the role of health-system pharmacists in emergency preparedness. Am J Health Syst Pharm. 2003; 60:1993-5.

4.       Cohen V, et al. Effect of clinical pharmacists on care in the emergency department: a systematic review. – Am J Health-Syst Pharm. 2009;66;1353-1361

National Patient Safety Goals: The Joint Commission

The Patient that Made the Difference

Her initials were the same as mine, and we greeted one another after a few phone conversations with "Hi, BB, it's BB." 

We had this connection. Two grown women. Both single and young. The big difference was that I was her home health pharmacist in charge of her pain pump and she had terminal cancer.

When you are halfway through your life (and maybe your career) there comes a time when you look back and remember the patients that change your life and maybe even validate the half-ass "I want to be a pharmacist" decision made by a young twenty-something with no idea how profound the decision would have on every aspect of your life. 

B wanted to go to Florida and be in the ocean one more time.  Her boyfriend was in Florida and since she knew her time was short, the ocean was on her bucket list... with the dilemma of a pain pump. That's where I fit into the story, finding a creative way to make it happen along with a couple home health nurses and some supplies. She was a nurse, too, and was a big part of her own end-of-life care.

It has been eleven years ago. B was 33 years old. I had been a pharmacist for only four years; a baby in the working world with little idea of how that year would change my life.

I had these biweekly chats with her concerning supplies she might need, including the intravenous pain medication itself but we often left the rigid discussion of how we were connected through pharmacist and patient to human conversation of "please do monthly self breast exams," to "live a full life and travel Beth!" to "who cares what people think about you, you certainly won't care when you are at the end of your life" and "I wish I could have been a mother." It was almost as if I had been granted insight into the world of a life ending way too soon and maybe learning my own lesson along the way. I sure did.

I finally went to meet her the last few days of her life. I waited much too long to meet my friend and that is my only regret. There is a professional line you have to keep in place with your patients, but sometimes that looks a little different patient to patient.  She squeezed my hand and had a picture of her vibrant former self before cancer ravaged her body sitting on her nightstand. "You are beautiful," I had said although wishing I had arrived months before.

Pharmacists and nurses along with other healthcare providers can make a difference. 

I witnessed the same thing with my father-in-law's nurse at the VA in Nashville caring for a man that had no family at bedside because of a lack of a relationship with his family. His nurse was amazing and was not only his nurse but his friend.  

I saw it again in Memphis on a hospice rotation where I saw different patients in different stages of terminal illness along with their families in different stages of grief. 

My life changed with each of these moments and patients who touched my life and maybe that young twenty-something college student knew more than I thought about selecting a career?

Ativan Drips and Precipitation

If you happen to run short of the lorazepam 2 mg/mL vials to compound your ativan drips, be mindful of the possibility of precipitation when using the lorazepam 4 mg/mL vials.  AHFS Drug Info states:

Precipitation-- The choice of commercial lorazepam concentration to use in the preparation of dilutions is a critical factor in the physical stability of the dilutions. Both the 2- and 4-mg/mL concentrations utilize the same concentrations of solubilizing solvents. On admixture, the solvents that keep the aqueous insoluble lorazepam in solution are diluted twice as much using the 4-mg/mL concentration than if the 2- mg/mL were used, resulting in different precipitation potentials for the same concentration of lorazepam. Care should be taken to ensure that the compounding procedure that is to be used for lorazepam admixtures has been demonstrated to result in solutions in which the lorazepam remains soluble.

Lorazepam concentrations up to 0.08 mg/mL have been reported to be physically stable, while occasional precipitate formation in admixtures of lorazepam 0.1 to 0.2 mg/mL has been reported. The precipitate has been observed in both containers and in administration set tubing.

In one case, a visible precipitate formed in a lorazepam 0.5-mg/mL admixture in sodium chloride 0.9% in a glass bottle.  However, a 0.5-mg/mL concentration may remain in solution longer if prepared from the 2-mg/mL concentration, yielding a higher concentration of organic solvents in the final admixture.

Concentrations of 1 and 2 mg/mL have been reported to be physically stable for up to 24 hours as well as concentrations below 0.08 mg/mL.

Concentrations in the middle range of 0.8 to 1 mg/mL may be problematic.  In one report, use of lorazepam 2 mg/mL to prepare lorazepam 1-mg/mL admixtures in dextrose 5% or sodium chloride 0.9% was acceptable but use of the lorazepam 4-mg/mL concentration to prepare the same solutions resulted in almost immediate precipitation.

Lorazepam solubility in common infusion solutions has been reported. Its solubility in sodium chloride 0.9% is approximately half that found in the other tested solutions. This result was attributed to the pH of the sodium chloride 0.9% (pH 6.3) being essentially the same as the isoelectric point of lorazepam (pH 6.4), where aqueous solubility would be the lowest. Dextrose 5% was the best diluent for lorazepam.

If you are a hospital or facility that mixes the middle range of 0.8mg to 1 mg/mL you have to be more mindful of other factors.  This is the reason I had no idea of this problem since other facilities where I have worked we mixed a much less concentrated solution.  I found out the validity of this information and wasn't too pleased.

The bottom line is that it would be nearly impossible for a pharmacist to know every single intricacies of different hospitals and compounding practices.  If knowledge like this is indeed something we should all 100%  know, then someone somewhere dropped the ball on training and/or education.  I am mostly wondering, how does your facility compound ativan drips?  What scenarios caused precipitation?

For more about this issue read here.

Are You Kidding Me?

My mouth just dropped open.  It's obvious to me that physicians do NOT read medication reconciliation forms for home meds at all.  The ones that do, kudos, but the ones that don't make my job more interesting and at times really get to me. Case-in-point:  50-something presenting to the hospital with lower GI bleed.

The doctor signed off to CONTINUE HER HOME MED OF PHENTERMINE FOR WEIGHT LOSS.  Are you kidding me?

I guess the nurse could have written "Purina Dog Chow - take one cup by mouth daily" and the physician would have signed off on it.

Way to go Joint Commission on putting in a requirement with no means of adhering to any sort of THINKING for anyone involved.

Except for the pharmacist of course to wade through the BS and find what is really needed.

I really like the one where the physician wanted to continue the patient's viagra while in the hospital.  THAT should keep the nurses on the floor on their toes running from a man who is looking for some fun.  Not good.

Medication reconciliation forms.  The bane of my existence.