Interdisciplinary Collaboration for Problem Solving: the pathway to

better patient care

Molly Adams, Pharm.D., BCPSBrad Wright, Pharm.D., BCPS

Greg Rutecki, MD

Objectives Provide an example Define Collaboration Describe hypertensive crises Examine treatment options Explain Problem Solving via Quality Assurance Evaluate Stakeholder Perspectives

Our Example Identification of a problem

Hospital management of hypertensive crises Problem 1: Identifying patients experiencing

hypertensive urgencies/emergencies Problem 2: Choice of agent to treat the hypertensive

emergency/urgency appropriately

Team approach Put together a team to research the problem and

solution Pharmacist-physician collaboration

Diagnosis – Dr. Rutecki Treatment – Drs. Adams, Karwa, and Wright

Our Example Literature evaluation

Use evidence-based medicine to determine best diagnosis and treatment strategies

Pharmacy team Looked at guidelines, reviews, as well as trials

comparing drugs used in the treatment of hypertensive crises

Hypertensive Crises - Background Chronic hypertension is one of the most

common medical conditions in the United States Affects ~30% of the population Significant risk factor for cardiovascular,

cerebrovascular and renal problems Acute elevations in BP may result in acute

damage to organs and significant morbidity or mortality

Patients with acutely elevated blood pressure (BP) are considered to be experiencing a hypertensive crisis

Usually defined as a BP >179/109

End Organ Damage The Heart:

Acute myocardial infarction, acute coronary syndrome , acute heart failure.

During Pregnancy: Pre-eclampsia, eclampsia, or “HELLP” syndrome (Hemolytic Anemia,

Elevated Liver Enzymes & Low Platelets).

Blood vessels: Injury to the aorta - aortic dissection.

The Brain/Central Nervous System: Strokes, subarachnoid hemorrhage, and hypertensive encephalopathy

The kidneys: Acute renal failure

Emergency vs. Urgency Hypertensive crises can be further classified

into hypertensive emergencies or urgencies. Hypertensive emergency – severe elevation in

BP accompanied by end organ damage Damage to the brain, heart, eyes, or kidnes

Hypertensive urgency – severe elevation in BP not accompanied by end organ damage

Distinguishing between urgency and emergency is important Treatment differs for the two conditions and

therefore the most appropriate treatment plan is based on diagnosis

Emergency vs. Urgency treatment Urgency

Goal of treatment - reduce BP gradually over 24-48 hours

Significant morbidity is associated with too rapid a reduction in BP

Select oral combination medications to lower BP Most optimal agent should have:

A rapid onset Few adverse effects Absence of excessive hypotension Be able to be monitored

Emergency vs urgency treatment Emergency -

Goal of treatment – decrease BP immediately Slow and controlled decrease need to prevent organ

hypoperfusion, morbidity or mortality The patient should be admitted to the Intensive

Care Unit (ICU) Treat with an intravenous continuous infusion of

an antihypertensive agent that is titratable, short-acting and able to be monitored Drug of choice depends on the clinical scenario Avoid oral, sublingual, and intramuscular (IM) routes

Causes Majority of patients have been diagnosed with

chronic hypertension Many are poorly controlled on current therapy Many are non-adherent to current regimen

>50% of patients

Drug Use Prescription drugs

Drug interactions Clonidine withdrawal

OTC Herbal Illicit drugs

Other causes Endocrine disorders Kidney disorders CNS injury Unknown

Diagnosis Should be prompt to avoid end-organ damage Thorough medical and medication history Confirmation of BP in both arms Identify end-organ damage

Pulse in extremeties Auscultate lungs and hear Neurologic exam Fundoscopic exam Cardiac exam

Management - Hypertensive urgency Optimal agents should have a rapid onset, few

adverse effects, absence of excessive hypotension, and be able to be monitored

Oral drugs used to treat hypertensive urgencies Clonidine Captopril Patient’s home regimen

Oral drugs not used to treat hypertensive urgencies Nifedipine

Management – Hypertensive Emergency Same basic treatment principles as hypertensive urgency

Added goal is to prevent progression of end organ damage Intravenous medications for treatment of hypertensive

crisis Clevidipine Nicardipine Esmolol Labetolol fenoldapam Phentolamine Enalaprilat

Intravenous Medications that should be used with caution Nitroprusside Nitroglycerin Hydralazine

Quality Assurance Steps Identify the Problem Collect information for analysis Evaluate literature for comparison and

suggestions on improvement Select a method for improvement

Education Order sets and protocols System changes

Re-evaluate after a time to verify improvements effective

Problem Recognition Identify through anecdotal reports Care provider questions Case reports and series Barriers to optimal patient care

Ineffective results in patient outcomes Time management issues Adverse outcomes

Inpatient Improvement Methods Drug Utilization Evaluations (DUEs) Pharmacy and Therapeutics Committees

Protocols Order Sets

Teaching In-services Nursing Pharmacy Physician

Workflow adjustments

Collaboration Definition

To work, one with another; cooperate To work with another or others on a joint project

Collaboration occurs when no one profession or organization can achieve its goals without building upon its interdependence with others

Requires that all team members want to work together to accomplish a common goal Each team member brings a unique perspective or

expertise All work together to improve a problem

Collaboration – Our example A problem with was noted with the pharmaceutical

and medical management of sever hypertension A team was formed with each team member

focused on one goal Goal – Improve the management of hypertensive crises

Each team member brought unique expertise Physicians – Diagnosis of hypertensive crises Pharmacy – Medications used in the inpatient and

outpatient settings In the end each team member brought specific info

that when combined improved the treatment of hypertensive crises

Collaboration – Other examples Diabetes Management

University of Buffalo Hypertension Management

Inpatient - Midwest Veterans Affairs Medical Center

Outpatient – Iowa City, Iowa Heart Failure Management

PHARM Study