Why your OR needs YOUStories from our journey with integrating clinical pharmacy into perioperative services

Sara Jordan, PharmD, BCPS

Brian Kramer, PharmD

Elise Weyrauch, PharmD, BCPS

Lauren Wood, PharmD

Adam Trimble, PharmD

Grant Medical Center, OhioHealthColumbus, OH – April 2016

The speakers have no actual or potential conflicts of interest in relation to this presentation.

Learning Objectives

• Pharmacists

– Identify potential roles for the pharmacist in the

perioperative arena

– Describe clinical pharmacist interventions to

optimize perioperative medications

• Technicians

– Describe ways the OR pharmacy technician can

support clinical pharmacist functions

Contents

• Introduction and beginning of service line

• Antimicrobial stewardship in the OR

• Role in massive transfusion protocol (MTP)

• Role in high risk therapies

• Role in other perioperative emergencies

• Service expansion and future directions

• Summary and recommendations

We need this

STAT!!

What are they

talking about?

This is

unacceptable!

Everything for

them is

“STAT”…

They can

never

meet our

needs…

Why are

they

always so

mean?

���� OR

Pharmacy ����

OR

Pharmacist

Hospital Continuum of Care

ED

OR?

ICU Floor Discharge

ASHP Guidelines

• Outdated

• Operations-focused

• What are our clinical roles?

Perioperative Pharmacotherapy

• Antimicrobial

stewardship

• High-risk therapies

– Anticoagulants

– Antifibrinolytics

– Vasoactive agents

– General and regional

anesthetics

– Chemotherapy

• Medical emergencies

– Trauma

– Malignant

hyperthermia

– Local anesthetic

systemic toxicity

• Medication safety

• Narcotic compliance

Grant Medical Center (GMC)

• OhioHealth hospital in downtown Columbus

– 640 licensed beds

– Not-for-profit, community teaching hospital

– Level 1 trauma center

• >85,000 ED admissions, ~5500 traumas, and >20,000 surgeries performed annually

• Inpatient and ambulatory surgery centers and numerous other procedural areas

Beginnings of Service Line

Resident vectorResident vector

Asking and

answering

questions

Asking and

answering

questions

Identifying

opportunities

Identifying

opportunities

Improving

small processes

Improving

small processes

Building

rapport

Building

rapport

Becoming a

point person

Becoming a

point person

Gaining alliesGaining alliesDemonstrating

Need

Demonstrating

Need

Garnering

Support

Garnering

Support

Financial

Justification

Med

Charge

Capture

Order

Volume

Narcotic

Compliance

ThroughputCore

Measures

Post-op

Compli-

cations

Physician

Satisfaction

Workflow

Emergency

Response

Drug Info

Order

process-

ing

Clinical

Bedside

Support

Pre-Op Abx

Review and

Continuity

Inpatient

Profile

ReviewNarcotic

Compli-

ance

Distribu-

tion

Process

Improve-

ment

Antimicrobial Stewardship

in the OR

Sara Jordan, PharmD, BCPS

Preoperative Antibiotics

�Started daily

prospective review

and optimization

�Coordinated order

set revision

http://www.jointcommission.org/surgical_care_improvement_project/

Surg Infect (Larchmt). 2013 Feb;14(1):73-156.

SCIP

Clinical Practice

Guidelines

Optimal

Pre-Op

Antibiotic

Local ASP

Story – Sitting at the Table

• Quality review of post-op infection

• “…patient developed fevers and elevated

WBC, started on ertapenem. Cultures finalized

with MRSA. …Patient discharged to SNF.

…Does anyone see any

opportunities for

improvement in

this case?”

Impacting Outcomes

• 1-4 expert reviews monthly

• Average 78 interventions on antibiotics monthly

• Improved compliance with SCIP core measures

• Increased charge capture totaling >$1.9 million

annualized

Improved SCIP Compliance

0

1

2

3

4

5

FY13

579/582

FY14

543/544

66.7% Reduction in SCIP Misses

Emergency

Response

Drug Info

Order

process-

ing

Clinical

Bedside

Support

Pre-Op Abx

Review and

Continuity

Inpatient

Profile

ReviewNarcotic

Compli-

ance

Distribu-

tion

Process

Improve-

ment

Massive Transfusion Protocol

(MTP)

Adam Trimble, PharmD

Massive Transfusion Protocol• Purpose

– Ensure continuous and timely access to blood

components for use in the resuscitation of

patients with massive hemorrhage

• Grant Medical Center Definition

– Patient requires ≥6 units PRBCs within one hour

with continued hemorrhage

• Patient population

– Trauma – Most common

– Surgical

– Post-partum hemorrhage (PPH)

OR Pharmacy Role

• Pharmacist Role

– Emergency Response

– Ensures appropriate medications are ordered

– Facilitates timely medication administration

• Technician Role

– Prepare medications

– Replenish supply of critical medications

Tranexamic Acid• Ordering and Dosing

– Appropriate for patient?

– Trauma dose1

• Bolus - 1000 mg over 10 minutes

• Continuous infusion - 1000 mg over the next 8

hours

– PPH dose2

• 1000 mg bolus followed by second 1000 mg

bolus as needed

• Timely administration 1. Lancet. 2010 Jul 3;376(9734):23-

32

2. Trials. 2010; 11: 40

J. Anaesth. 2005;95:130-139

*

*Citrate binds

Ca2+

MTP Supportive Measures

• Acidosis

• Calcium replacement

• Antimicrobial prophylaxis

– Selection and initial dosing

– Intra-operative re-dosing when EBL>1500mL

Surg Infect (Larchmt). 2013 Feb;14(1):73-156.

Other Hemostatic Strategies

• Commonly considered coagulation factors

– Recombinant Factor VIIa (NovoSeven®)

– Prothrombin complex concentrate (Kcentra®)

• Recommend optimal selection and dosing

• Prevent inappropriate use and unnecessary

waste

• Facilitate safe and timely administration

Crit Care. 2013; 17(2): R76

MTP Story

• 48yom presented with injuries related to MVC

• My role

– Facilitated administration of tranexamic acid

– Recommended administration of sodium

bicarbonate and calcium chloride

– Reminded need to re-dose cefazolin

– Recommended optimal coagulation factor for

refractory bleeding

Role in High Risk Therapies

Elise Weyrauch, PharmD, BCPS

Additional Involvement

• Pharmacy participates in high risk situations to

improve safety

• Examples:

– Cardiothoracic surgery (CTS)

– Use of direct thrombin inhibitors

– Malignant hyperthermia

– PACU complications

– Chemo

Cardiothoracic Surgery (CTS)Pharmacy

Drug distribution and

safety

Surgeon

Needs support of others to

accomplish task

Perfusion

Cardiopulmonary bypass (CPB)

Anesthesia

Maintain stability of

patient

OR Pharmacist Roles in CTS

• Preparation/distribution

– Cardioplegia

– Anesthesia drips and antibiotics

• Safety evaluation

– IV pumps

• Clinical support

– Antibiotic evaluation

– Drug shortage management

Heparin Allergy or Intolerance

• Cardiac and vascular procedures often require

anticoagulation during operation

• Alternative therapy is required for patients who

cannot have the preferred therapy with heparin

• Options:

– Bivalirudin

– Argatroban

Open Heart

• Bivalirudin typically used

• Pharmacy provides drug products needed

– IV preparation for anesthesia

– CPB preparation

– Irrigation if needed for coronary artery bypass

graft (CABG)

• Coordinate care between providers

Perfusion. 2009 Jan;24(1):7-11.

Chest. 2012 Feb;141(2 Suppl):e495S-530S.

Vascular Bivalirudin

• Dosing – same as percutaneous coronary

intervention (PCI) dosing

– 0.75 mg/kg initial bolus

– 1.75 mg/kg/hr continuous infusion

• Monitoring

– Activated clotting time (ACT) measured 5 minutes

after initial dosing and dose changes

– Additional boluses provided if needed

Bivalirudin PI. The Medicines Company. 2016 Mar.

Vascular Bivalirudin continued

• Special considerations

– Adjust infusion for renal clearance

• CrCl<30 mL/min � 1 mg/kg/hr

• HD � 0.25 mg/kg/hr

– Post-op dosing

• If only running <4 hours, continue same infusion

rate

• If running ≥4 hours, decrease rate to 0.25 mg/kg/hr

Bivalirudin PI. The Medicines Company. 2016 Mar.

Vascular Argatroban

• Dosing – same as PCI

– 350 mcg/kg initial bolus

– 25 mcg/kg/min continuous infusion

• Monitoring

– ACT measured intraoperatively

– Additional boluses and changes in rate may be required

• Special considerations

– Hepatic metabolism

– Decrease dose to ≤2 mcg/kg/min post-op

Argatroban PI. GlaxoSmithKline. 2016 Jan.

Malignant Hyperthermia (MH)

Lauren Wood, PharmD

http://www.mhaus.org/

Malignant Hyperthermia (MH)• Rare side effect of inhaled anesthetics and

succinylcholine

• Malignant Hyperthermia Association of the United

States (MHAUS)

• Pharmacist’s role

– Called to bedside during every MH crisis

– Drug selection and preparation

– Drug procurement

– Updated allergy list

– Other supportive therapyMalignant Hyperthermia Association of the United States http://www.mhaus.org/

Process Improvement

• Formulary management

– Addition of Ryanodex®

• MH emergency box

– Locations

– Content

• Education

– Pharmacist

– Anesthesiologist

– Nursing http://www.ems1.com/ems-products/Ambulance-Disposable-

Supplies/articles/58734048-FDA-fast-tracks-RYANODEX-

development-for-treatment-of-exertional-heat-stroke/

http://www.outpatientsurgery.net/did

-you-see-this/2014/04/jhp-

pharmaceuticals-dantrium-iv-for-

malignant-hyperthermia

Dantrolene

• Dosing:

– 2.5 mg/kg IVP with repeat doses up to 10 mg/kg

– Followed by 1 mg/kg IVPB every 4-6 hours for at

least 24 hours

• Formulations:

• Revonto®/Dantrium®: dantrolene 20 mg per vial

• Reconstitute with 60 mL sterile water

• Ryanodex®: dantrolene 250 mg per vial

• Reconstitute with 5 mL sterile water

Malignant Hyerthermia Association of the United States http://www.mhaus.org/

Lexi-comp. Dantrolene drug monograph. Accessed 24 Mar 2016.

Drug Preparation and

Procurement

• Ryanodex®: mixed at bedside by pharmacist

• Ensure enough product present

• Revonto®/Dantrium®: prepared in IV room for

follow-up doses

• OR Pharmacist alerts the IV room MH crisis

• Ensure IV techs have adequate supply to provide

doses for follow-up period

MH Box Contents

Malignant Hyerthermia Association of the United States http://www.mhaus.org/

Description Par Level

Amiodarone 150mg/3mL vial 5

Dantrolene Sodium (Ryanodex) 250 mg vial 1*

Dextrose 50%, 50-mL syringe 2

Furosemide 10 mg/mL, 10-mL vial 2

Metoprolol 5mg/5mL vial 3

Sodium Bicarbonate 8.4%, 50-mL syringe 6

Calcium Gluconate 10%, 10-mL vial 2

Sterile Water for Injection PF, 20-mL vial 2

Syringes (10mL), needles, sterile gauze

Stock List

The Process of MH

MH crisis called

Pharmacist to

beside with MH

box

Ensure

discontinuation of

offending agents

Prepare

dantrolene dose

Advise on

supportive

therapy

Update allergy list

Facilitate follow

up dosing as

appropriate

Facilitate

restocking and

procurement

PACU Complications Example

– Local Anesthetic System

Toxicity (LAST)

Brain Kramer, PharmD

PACU Complications

• My story

• Local Anesthetic Systemic Toxicity (LAST)

• Treatment

Local Anesthetic System

Toxicity (LAST)

• 67 yof s/p orthopedic procedure and recipient of

peripheral nerve block

• Heart rate and blood pressure declining in PACU

• Anesthesiologist thinks LAST, wants to administer

IV lipids � calls OR Pharmacist

Symptoms

• CNS Signs (may be absent or subtle)

– Excitation

– Depression

– Nonspecific

• Cardiovascular Signs

– Hypertensive

– Progressive hypotension

– Conduction block, bradycardia

– Ventricular arrhythmiasAnesthesiology. 2012 Jul;117(1):180-7

Treatment

• Airway management

• Seizure suppression

• Alert the nearest cardiopulmonary bypass center

• Arrhythmia management (ACLS)

– Avoid CCBs & BBs

– Reduce epinephrine doses to < 1mcg/kg

Reg Anesth Pain Med. 2012 Jan-Feb;37(1):16-8

Treatment

• Lipid (20%) Emulsion

– Bolus 1.5 mL/kg (lean body mass) IV over 1 min

• ~100 mL (2 x 50 mL syringes) in 70 kg patient

– Continuous infusion 0.25 mL/kg/min (can be

doubled)

– Bolus can be repeated once or twice

– Continue infusion for at least 10 minutes after

patient stable

Reg Anesth Pain Med. 2012 Jan-Feb;37(1):16-8

PACU Complications

• PACU complications can be life threatening

• OR pharmacists need to be prepared

• OR pharmacists fill a vital role in the management

of complications such as LAST

Service Expansion and

Future Directions

Sara Jordan, PharmD, BCPS

Service Expansion• Increasingly valued by anesthesia, surgery, and

nursing

0

10

20

30

40

Yes- Strongly

agree

Yes - Agree No - Disagree No - Strongly

Disagree

Do you think the implementation of the Clinical OR

Pharmacist position has improved perioperative care of

our patients at Grant Medical Center?

Service Expansion

Where are we now?

• 2 Pharmacist FTEs: Mon-Fri 0700-1700

• 2 CPhT FTEs: Mon-Fri 0600-2200

• Direct report to operations manager

• OR Pharmacy

Team Manager Team Lead

CPhTs Pharmacists

Committee and Project Work

• Operational process changes

– Distribution, narcotic compliance

– CPOE, Pyxis® Anesthesia

• Clinical quality improvement

– Post-op infection reviews, workgroups

– Formulary advisory

– Prescribing guidelines, order sets, MUEs

• Representation at all committee levels

• Research, education, precepting

Future Directions

• Piloting new role at orthopedic surgery center

– Focus on reducing post-op complications

• Increasing precepting and educational roles

– PGY1, PGY2 pharmacy residents

– APPEs, IPPEs

– Other disciplines

• Presenting and publishing work

Summary and Recommendations

• The pharmacist’s clinical role in perioperative

areas is valuable to patients and providers

• Pharmacy technicians play an important

supporting role

• Financial justification can be achieved through a

variety of means

• Assess your perioperative medication use and

get involved in improving both daily patient care

and institutional processes

Special Thanks to Our Team

• Additional OR Pharmacists:

– Desta Borland, PharmD

– Brent Mulholland, RPh, BCPS

• Leadership:

– Brad Petersen, PharmD, MS

– Jeff Cook, PharmD,

MSPharm, MBA

– Curt Passafume, MBA, RPh

– Chanda Drake, CPhT

– Derek Mills, CPhT

• OR Pharmacy Technicians:

– Marsha Lott, CPhT

– Roxie Nelson, CPhT

– Jackie Steele, CPhT

– Jennifer Wilson, CPhT

– Ashley Morris, CPhT

– Stephen Sharp, CPhT

– Ben Holesapple, CPhT

– Miland Jenkins, CPhT

– Vonna Bailey, CPhT

Questions and Discussion