Minimizing Polypharmacy Addressing Therapeutic Duplications RISHP SHOWCASE 2015

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Minimizing Polypharmacy: Addressing Therapeutic Duplications RISHP SHOWCASE 2015 C. MAXWELL M. KELLEY

Minimizing Polypharmacy: Addressing Therapeutic Duplications RISHP SHOWCASE 2015 C. MAXWELL M. KELLEY

Objectives Technician Objectives: Understand when therapeutic duplications occur in the ordering of PRN medications.

Objectives Technician Objectives: Understand when therapeutic duplications occur in the ordering of PRN medications. Provide an example of a therapeutic duplication. Understand how guidelines can be developed to categorize severity of common psychiatric PRN indications for medications to avoid therapeutic duplications.

Objectives Pharmacist Objectives: Describe the process of guideline/order set development for PRN indications of

Objectives Pharmacist Objectives: Describe the process of guideline/order set development for PRN indications of anxiety, agitation, psychoses, nausea/vomiting and constipation in a specialized psychiatric hospital and community hospitals. Explain how use of PRN reasons defined by a guideline/order set facilitates compliance with Joint Commission standards and regulations. Choose the appropriate PRN reason for psychiatric symptoms utilizing the provided guideline.

Therapeutic Duplication occurs when: More than 1 med is ordered for a single indication

Therapeutic Duplication occurs when: More than 1 med is ordered for a single indication The level, degree, or the severity for the indication is not specified There is not hospital policy or guideline to guide nursing staff on when a med is to be administered

Corrective Action Steps Clarify some definitions of specific PRN Reasons in Power Plans Revise

Corrective Action Steps Clarify some definitions of specific PRN Reasons in Power Plans Revise the default PRN Reasons for some PRN orders in Power Plans Create Hospital Guidelines that define the Degree of Severity of some common psychiatric symptoms

Guidelines for Psychiatric PRN Reasons Guidelines are developed to categorize some common symptoms for

Guidelines for Psychiatric PRN Reasons Guidelines are developed to categorize some common symptoms for which PRN meds are indicated Anxiety and Severe Anxiety Agitation and Severe Agitation Psychosis and Severe Psychosis

PRN Guideline: Anxiety ANXIETY SEVERE ANXIETY Anxious, apprehensive, movements not aggressive Physical distress, or

PRN Guideline: Anxiety ANXIETY SEVERE ANXIETY Anxious, apprehensive, movements not aggressive Physical distress, or feelings of panic Nausea or abdominal distress Mild trembling or shaking Feeling tense or “wound up” Restlessness Physical distress leading to impairment of ADL Inability to sit still or sleep Marked trembling or shaking Fear of losing control Fear of dying Feelings of panic with somatic complaints (sweating, shortness of breath, hyperventilation, chest pain, palpitations, tachycardia, ) Paresthesia (numbness or tingling sensations) Feeling dizzy, unsteady, light-headed or faint Physical distress leading to impairment of ADL Inability to sit still or sleep Marked trembling or shaking Fear of losing control Fear of dying Feelings of panic with somatic complaints (sweating, shortness of breath, hyperventilation, chest pain, palpitations, tachycardia, )

PRN Guideline: Agitation AGITATION SEVERE AGITATION Impulsive, impatient, low Violent, combative and/ tolerance for

PRN Guideline: Agitation AGITATION SEVERE AGITATION Impulsive, impatient, low Violent, combative and/ tolerance for pain or frustration Uncooperative, resistant to care, demanding Rocking, rubbing, moaning or other self- stimulating behavior Restlessness, pacing, excessive movement Rapid, loud or excessive talking Sudden changes of mood or threatening violence toward people or property Explosive and/ or unpredictable anger Selfabusiveness, physical and/or verbal Immediate danger to self or others

PRN Guideline: Psychosis PSYCHOSIS SEVERE PSYCHOSIS Auditory or Visual Hallucinations Delusions Paranoid Thoughts Hallucinations

PRN Guideline: Psychosis PSYCHOSIS SEVERE PSYCHOSIS Auditory or Visual Hallucinations Delusions Paranoid Thoughts Hallucinations with threats of harm to self or others Delusions with threats of harm to self or others Paranoid Thoughts with threats of harm to self or others

Default PRN Reasons in Power Plans Oral IM Anxiety – Severe Anxiety – Benzodiazepines,

Default PRN Reasons in Power Plans Oral IM Anxiety – Severe Anxiety – Benzodiazepines, Antihistamines Agitation Antipsychotics Benzodiazepines, Antihistamines Severe Agitation Antipsychotics

PRN Guidelines: Nausea/Vomiting Order of use defined in the Power. Plans Ondansetron: Use first

PRN Guidelines: Nausea/Vomiting Order of use defined in the Power. Plans Ondansetron: Use first for N/V Promethazine: Use for N/V refractory to ondansetron Metoclopramide: Use for N/V refractory to ondansetron and promethazine

PRN Guidelines: Constipation Order of use defined in the Power. Plans Colace: PRN reason

PRN Guidelines: Constipation Order of use defined in the Power. Plans Colace: PRN reason for stool softening Senna: Use first for constipation MOM: Use if patient still constipated 24 hours after Senna Bisacodyl PO/PR: Use if patient still constipated 12 hours after MOM All laxatives below given with colace If both PO/PR ordered, use least invasive route first Miralax: Use if patient is still constipated after 48 hours from initial laxative dose

Therapeutic Duplications: Next Steps Therapeutic Duplication Policy Define order of preference for medications by

Therapeutic Duplications: Next Steps Therapeutic Duplication Policy Define order of preference for medications by indication Set criteria for IV or PO options Allow pharmacists to clarify orders per “policy/protocol” Pharmacist responsibility at time of verification Continual monitoring Regular audits of duplicates and corrective steps

Summary TJC and DOH are focused on Therapeutic Duplications Most commonly found duplicate orders:

Summary TJC and DOH are focused on Therapeutic Duplications Most commonly found duplicate orders: Pain Agitation/anxiety Nausea/vomiting Constipation Creation of Power. Orders and a policy Minimize prescribing of duplications Provide clarification when duplications exist Goal is to minimize patient harm, adverse drug events and unclear orders