RISHP SHOWCASE 2015C. MAXWELLM. KELLEY

Minimizing Polypharmacy: Addressing Therapeutic

Duplications

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 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

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 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 which PRN meds are indicated

Anxiety and Severe AnxietyAgitation and Severe AgitationPsychosis and Severe Psychosis

ANXIETY SEVERE ANXIETY

Anxious, apprehensive, movements not aggressive

Physical distress, or feelings of panic

Nausea or abdominal distress

Mild trembling or shakingFeeling 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: Anxiety

AGITATION SEVERE AGITATION

Impulsive, impatient, low 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

Violent, combative and/ or threatening violence toward people or property

Explosive and/ or unpredictable anger Self- abusiveness, physical and/or verbal

Immediate danger to self or others

PRN Guideline: Agitation

PSYCHOSIS SEVERE PSYCHOSIS

Auditory or Visual Hallucinations

Delusions Paranoid Thoughts

Auditory or Visual 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

PRN Guideline: Psychosis

Oral IM

Anxiety – Benzodiazepines, Antihistamines

Agitation - Antipsychotics

Severe Anxiety – Benzodiazepines, Antihistamines

Severe Agitation - Antipsychotics

Default PRN Reasons in Power Plans

PRN Guidelines: Nausea/Vomiting

Order of use defined in the PowerPlans 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 PowerPlans Colace: PRN reason for stool softening

All laxatives below given with colace 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 If both PO/PR ordered, use least invasive route first

Miralax: Use if patient is still constipated after 48hours from initial laxative dose

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: Pain Agitation/anxiety Nausea/vomiting Constipation

Creation of PowerOrders and a policy Minimize prescribing of duplications Provide clarification when duplications exist

Goal is to minimize patient harm, adverse drug events and unclear orders