EIGHT STEP POSITIVITY PROCESS



Pharmacist’s Corner with Dr. Matt Pitlick | Part 2 of 2

Dino: Welcome back to IHC’s navigating within podcast. My name is Dino and I am your host. Providing high quality safe medical care is THE primary goal of health systems, so the public is alerted to quality failures such as preventable medication errors resulting in patient harm or death, concerns about the quality of healthcare arise. As experts in medication delivery, pharmacist played an integral role in preventing and managing medication errors, however, ensuring safety in the health system is a team effort. With me today is Matt Pitlick. For those who did not listen to our first podcast together, Dr. Pitlick is IHC’s medication management lead here at IHC. Just a little background on him; he is a 2008 graduate of the Drake University College of Pharmacy and Science. He has completed the PGY-1 residency with the VA St. Louis Healthcare System. He was an associate professor from about 2009 to 2017 and he completed his executive fellowship in association management with the Iowa Pharmacy Association. Welcome Matt, thanks for joining us for our second podcast together.

Matt: Thanks for having me back, Dino.

Dino: Great. Today’s topic is quality measures. We are going to dive into a few in quality measures that we’ve been recently getting some questions about. To start this off in your opinion, what role does a pharmacist play when it comes to quality measures in both the inpatient and the outpatient setting?

Matt: Sure, the pharmacist can be one of your biggest advocates in the ADE’s measures of course because we are talking about medications and bad things that happen with medications. We don’t want a bad thing to happen with medications but oftentimes they do and so a pharmacist can be that person to prevent ADE’s or if one does happen, we can kind you know go through the system root cause analysis and figure out why this ADE happened and put a system in place to prevent them happening again.

Dino: Right. Today, we are going to be looking at specifically to adverse drug event ADE measures. The first on that we are going to talk about is blood glucose below 50. So, this is a HINN measure that we’ve gotten some questions about. Can you just generally speak to this measure. How can a pharmacist engage specifically in this one?

Matt: Sure and I think this one in those time has passed. We see more and more patients with diabetes that are being admitted to the hospital for a variety of reasons and not just diabetes, so because of that, we are seeing maybe it will increase in this ADE measure. Because of that, specific patient population increase. You can utilize your pharmacist to improve this measure, of course one being following the ISMP recommendations for all the specific pharmacy labelling requirements and you know one unit per one patient, one dose per one patient, all that sort of stuff that gets drilled in a lot of people’s head, especially the pharmacist, because those are joint commission requirements that need to be handled if they had a visit. With that pharmacy, they will definitely look at all that stuff and make sure that those things are being followed. I think one of the more important things to do in addition to following all the ISMP recommendations is an appropriate medication reconciliation and with that, we know when patients are admitted to the hospital, there usually are discrepancies within that patient’s medication regimen and in the patients taking insulin you know how often is a dose of insulin being changed on the patient, especially when they’re you know trying to make changes themselves, improving diet and improving lifestyle. That patient might have a dose change of insulin that the hospital doesn’t know about and without doing a proper medication reconciliation, there is no way to know and that the pharmacist or nurses going to have to call the outpatient pharmacy to figure out exactly what’s going on to make sure that that dose that that patient is on the hospital is the same one that the patient is on when they are at home.

Dino: Is this something that a pharmacist can engage in specifically or how can that in a care team, how do you ensure that you are having appropriate med risk?

Matt: Yeah, I think this is a great question. Depends on the philosophy of the hospital, I think you know sometimes just pharmacy driven, sometimes just nursing driven and, however, you do it great, just make sure that you’re doing it the right way and not just going through the motions of outpatient check in-patient meds click over your good. You want to make sure that especially insulin doses that you’re using the appropriate dosage like I said because those doses changed so much and the prescription bottles don’t change, their doses along with some of the vials don't change their doses along with it.

Dino: Yeah, speaking about insulin in your experience, what do you think are some of the best practices for insulin in critical and noncritical settings?

Matt: Sure, a lots of different ways I think about insulin in the hospital one of the more dangerous medications like we talked about with the ADE measure. Let us start with the critical settings first because this tends to be a little bit more formalized in the way insulin is used. For the most part, insulin in the critical setting is going be administered via continuous IV infusion and so hopefully your hospital’s health systems had a protocol that you put in place that the P&T committee regularly reviews for those patients that get a continuous IV infusion of insulin while they’re in the critical care setting and so you’re adjusting the blood insulin based of blood sugar while that patient is in critical care. In such it tends to be a lift on the nurses part for monitoring blood sugars and in adjusting the infusion rate in all that stuff, so your hospital should have those things in place, if not I’m sure you can ask your friends, your colleagues at other hospitals and health systems for those if needed, ask at IHC for those things as well that we can get out here. Of course, always in those settings, you should have some reverse legends glucagon to get that blood sugar backup just in case anything does happen in terms of hypoglycemic events in those critical care patients.

A lot of times, we think nutrition in the critical care setting as well as the patient might be on enteral nutrition or parenteral nutrition in those critical care settings. In those patients still need some insulin and they can actually be utilizing a basal and prandial type of insulin regimen versus an IV infusion which is a little less intense from the nursing part, so they can if they are getting some sort of nutrition whether be enteral or parenteral can also use a more conventional type of insulin regimen versus an IV infusion. Now, if we move over towards the noncritical settings typically, we want to use a basal insulin such as glargine or detemir along with prandial insulin, so basal meaning is a slow acting insulin and longer acting insulin that covers that full day versus a prandial insulin such as Humalog and NovoLog which covers mealtime and typically that is we want to use during noncritical setting. Of course, what’s critical and what’s important to remember when reason is that the patient’s nutritional intake while they are in the hospital and because of that, the nutrition, the diet that the patient eats outside of the hospitals going to be very different from inside the hospital usually. So, we have to take a lot that into consideration, so that the patient’s diet might you know not be so good when they are at home right them that be there, that is why they are in the hospital, eat lot of salt, eat lot of chips, eating diet heavy in bread, and carbs and pastas and that’s why their blood sugars are 400-500 there in the hospital because they got DKA and other meal transitioning down and so we give them in the hospital there on you know they got their veggies and their fruits and their meats and eaten a nice full course meal and their blood sugars are changing and so you will have to be careful and very watchful in how the patients are responding to their food and their diet.

Dino: So, we know diet is important from your stressing. How can facilities manage these patients going from a weekly insulin to perhaps insulin pumps then?

Matt: Yeah, this one is a tough question because in the last five years, I would say the world of diabetes has had the most change in terms of technology, in terms of pharmaceutical advances with higher doses of insulin being made in smaller concentrations essentially, so there is a lot more instead of just U100 insulin which is typically what we think of in terms of you know the conventional insulin that we have. There is also U200 and U300 and U500 insulin, so we are getting super concentrated doses of insulin and kind of going back to the first question, you know you want to watch those concentrations of insulin to make sure you’re not giving the wrong dose of insulin to the patient. You don’t want to be giving you know two times, three times, five times the dose of insulin on a patient in those situations. So things we got to watch for their you know in tremendous advances in terms of continues glucose monitoring and insulin pump therapy that saved the majority of type I patients with diabetes are using insulin pump now and so it’s somewhat difficult to transfer that ones in to the hospital if they are in the hospital to something that the hospital staff can utilize and so I think the best scenario, if you have the availability, find an expert, find an endocrinologist, a clinical pharmacist who deals with the patients with diabetes on an exclusive basis, somebody who is board-certified and advanced diabetes management BC-ADM. I think it would be a great person to have helped you on this, so those types of patients that’s the type of person I think that should be managing. If you don’t of course that’s the bulk of you right? You don’t have access to that. Your pharmacist say there are patients on a fairly concentrated dose of insulin on a weekly dose. They can calculate doses for you based on the half-life of that medicine when they expected to be out of the patient’s system essentially and calculated dose for you so you can get that patient onto a daily dose of insulin while they are in the hospital if needed. So there are some ways that you can maneuver and clinically problem solve your way to a dose we can keep the patient safe but also make sure their blood sugar doesn’t skyrocket while trying to help that patient.

Dino: Absolutely, what you think are some factors that result in hypoglycemia and what can we do to prevent or limit those things?

Matt: The biggest of course is going to be medicine. The medicines you give the patient is going be the biggest cause. Typically, insulin is going to the number one cause. The other cause and especially this is for patients with type 2 diabetes who often come in with sulphonylurea areas such as glyburide or glipizide or glimepiride. Those often-caused hypoglycemia, especially in patients who come to the hospital, who may not have had a meal, or meal within 4,5, or 6 hours when they just took a dose of glipizide or glimepiride that caused them to be low that is going to perpetuate the hypoglycemia. So we see those. Other things to watch for to patients with diabetes, they don’t just have diabetes, they are going to have comorbid conditions often hypertension and heart disease those sorts of things. Patients who take beta blockers, their symptoms of hypoglycemia can often be masked, so you are not going to see the sweating and the shakiness all that sort of stuff. What you will see is just a different in their blood sugar and that’s it and you have to be careful with that. So patients especially on higher doses of beta blockers all those symptoms of hypoglycemia can be masked along with it. Other things to watch for to especially this is patients who may come in with acute kidney injury or have chronic kidney disease, insulin and many of the diabetes medicines are eliminated through the kidney and if their kidneys are damaged or being damaged, you're not removing the insulin, you are not removing the medicine, it’s hanging around longer which can cause hypoglycemic event so. Those are type of things that I typically think of and those are things you can watch for.

Dino: Thank you very much man. All the questions I've been asking and have been questions that have been coming in from our hospitals through our clinical quality consultants. So, these questions are directly from them. So, I think there are going to appreciate the input you have.

Matt: Kudos to you guys, hopefully it all is helping and if you have any questions, feel free to reach out anytime.

Dino: Yeah, for sure. I think I did a podcast with Cari Seddon here as well and we talked about diabetes and diabetes management. So, we have a lot of very highly skilled and highly educated people at IHC, Matt Pitlick and Cari Seddon are experts in these things, especially so if you have any questions about any measure in specific, please feel free to email us and let us know.

Matt: Can I have one thing to that?

Dino: Yeah, go ahead.

Matt: In this in terms of discharge planning for those patients oftentimes, there is going to be a change to diabetes medicine. Maybe you had to hold metformin for a couple days while that patient was getting ready for test and they got the test and then now they are ready to go home. Please, please make sure that that patient knows the discharge plans. Restart that metformin and not belabor the point, but really let the community pharmacists know in addition to their primary care provider what the discharge plans are, so that pharmacists can reach back out, make sure that patient is on metformin again or on the correct dose of insulin that would be from the hospital discharge to what is at home. Because oftentimes, we are going to have another vial of insulin at home that has another dose and a set of instructions on it and so if you want that community pharmacist to be that care coordinator to really help that out that would be a fantastic idea because oftentimes the patient is going end up seeing the pharmacist prior to primary care provider on a discharge. So if that is something that can be done in addition to some of those things that you do and that that could go a long way to help out maybe readmissions that happen in a variety of other things that could happen including adverse drug events.

Dino: I think that was back to our first podcast Matt, where we talked about the coordination, right. So I think making sure that if there are changes in medication that those are communicated with the community pharmacists and everyone that is involved in the care team, I think that is super important.

Matt: Absolutely.

Dino: We are going to go on to our next measure. This measure is INR greater than five. So we have some questions coming about this measure to that which we want to go over. Matt, what do you think the pharmacist role is in warfarin therapy?

Matt: Sure, this is a fantastic question. Can I go back to our first podcast 2 when we talked about you know clinical pharmacy in the advent of clinical pharmacy. Anticoagulation really was the first disease state that clinical pharmacist ended up owning that is because we also wanted to do it. It is really hard. Really hard stuff and you know, if we go back to warfarin and Coumadin really intended long time ago back in the 30s is when it was invented but they did not get it medical use until really the 50s and 60s and so that’s really when the clinical pharmacy movement started and they used anti-coag and specifically warfarin because there was nothing else around at that time right to be that advocate for and really be the clinical person to do that. So, I think clinical pharmacists and pharmacists should be an alternate every aspect of warfarin and so even in many academic medical centers, pharmacist managed full anticoagulation programs. When I was a clinical pharmacist at the VA, I managed a 500-person outpatient anti-coag clinic along with a few other clinical pharmacists, we just does so we had, once a patient got a diagnosis of whatever condition was AFib, VTE, valve replacement that was referred to the clinical pharmacist immediately for dosing, initial dosing, maintenance, follow-up INR, CBC, all laboratory stuff that needed, everything education along with it, so it was fully managed by clinical pharmacists. That be the ideal scenario.

Dino: You see that as a positive? As in of course yeah but I think as in terms of do you see that is something that maybe you have not seen in 15-20 years ago.

Matt: I would say in places that were not academic medical centers where students run and around, medical residents run and around you know full teams I would say that would be outside the norm and noted to be nurses and nurse practitioners that managed a lot of patients and as much as you can do a team-based approach, I think that is an ideal scenario as well, beneficially.

Dino: Absolutely. We have a ton of questions about lab draws. What your recommendations on the frequency of lab draws, one an INR is identified as greater then 5.

Matt: Sure, this is the great it depends questions. It always depends. An INR above 5, that is your cut off for your core measure in this instance. In ideal scenarios, you know if that patient maintained very well INR between 2 and 3 for greater than six months, you could go over every 12 weeks with an INR draw. That is the most, you can go and see recommended the last majority times, you will see recommending every four weeks but this last study now showing every 12 weeks for those who are well controlled. For those who were uncontrolled may be between 3 and 5, every 2-4 weeks. But above 5, it’s a little bit different scenario. In the outpatient setting, if the patient is not bleeding, no risk for bleeding, I would recommend maybe checking in 3-4 days and this goes back to the pharmacology of warfarin, very complicated pharmacology. So, we think of warfarin. It is technically we think it is a blood thinner, but is not really how it works.

Dino: High risk or no?

Matt: Very high risk. Warfarin is a very high-risk medication. We will talk about that all through this pharmacology review.

Dino: Great, I am excited.

Matt: So, warfarin is a vitamin K antagonist which gets into a lot of different things. People talk about the food and vitamin K but what it does and inhibits an enzyme of vitamin K dependent enzyme in the clotting cascade. So, once it irreversibly inhibits this enzyme you stop making clotting factors, since you don’t clot as really, clot as fast, etc. I might say this irreversibly inhibits. These clotting factors lets go back here. You think of usually how long a medicine goes through the body as the half-life of the medicine, how that and how long it will work for , when warfarin that is not how it works because everything is dependent on the clotting factors and so the clotting factors in their halftime decides how long that the medicine works and the clotting factors at half-life really depends on the clotting factors and a few other things on the patient but it can vary between really 20 and 80 hours as the half-life and so you are looking no three, four, or five days before medicines gone out the body by 50% and so that is why, I would not recommend another check as the patient is at a high risk of bleeding from the 3-4 days while on the outpatient side. On the inpatient side, it’s a little different. One, because you can’t check, right. That is nice thing. You have the availability check but also if they are in the hospital, there is probably higher chance of bleeding for a variety of reasons and I would check again depending on situation maybe that patient needs to go surgery for some reason. You want to check a little quicker, right so that you get that patient in the surgery or if that patient was at high risk of bleeding and so he gave them a reversal agent, you gave them vitamin K, you gave them fresh frozen plasma, or prothrombin complex concentrate you do want to check sooner than later, so every 4-6-12 hours those variation points of by the that you gave that medicine when you're waiting for that patient to go to surgery for illustrating condition etc. Now, if the patient just in there for you know whatever reason not life-threatening, if that INR is about 5 you could get away with you know check in the next day.

Dino: Absolutely, great. It is the ultimate a depend question. Does it depend when we are looking at trying to prevent errors in dosing or is that cannot a general guideline to prevent errors. Can you elaborate on that?

Matt: Sure. So, errors in dosing occur commonly with warfarin because you could under dose or you could overdose that patient for a variety of reasons. Oftentimes initially that patient will get the wrong dose of warfarin because you can’t make a guess on the dose that patient needs. So, most initiation you know protocols for warfarin will either tell you to use 5 mg or 10 mg of warfarin. Checking INR you know two days and then see what happens from there and then you figure out the dose maybe it's too high or may be too low, you bump the dose up by 15-20% or decrease it by 15-20% based on how that patient responded and kind a go from there. So, you are playing this guessing game constantly at the beginning of dosing warfarin and so you really have to be careful with it and pay close attention to what's going, follow-up with the patient making sure the patient educated on things that they need to that can increase or decrease the patient's INR level which are a variety of different things, maybe one of the questions but we can get into it now in terms of you know the education that patient needs for warfarin one being other medications. Warfarin is a known drug interactor. When I was teaching my students and residents at that the VA, always assume that a drug interactor is warfarin if you don't know, just assume it and educate and look it up and figure out if it does not because more often the not, it's going to. So the warfarin works through liver, metabolized through the liver, so many different enzymes that it wants to with the metabolism in the liver that always other medications are competing or going through as well that things get changed quite a bit when the patient is on you know four, five, or six different meds which is often the case when they are taking warfarin because this is not the only health problem they are going to have by and large. So, always you educating about drug interactions the other big piece that we talk about to with warfarin is diet like we talked about vitamin K. Vitamin K containing food will work against you or will decrease the INR level, so it's hard to anticoagulate that patient and get to a consistent INR level or anticoagulation level and so you want to call that patient is to be consistent with her vitamin K intake and foods that do contain vitamin K are green leaf vegetables, red meats often contain it. Those are the kinds of things we typically think of often, tends to be healthier type of food, so I always said it is terrible tell a patient who you know just came in for a heart condition or AFib or something stop eating all the healthy food you know and go back to eat junk food because they does not have any vitamin K consistent food. You eat a salad a day, if you are eating three third of vitamin K containing food, keep it that way, that is the easiest way to do it and whoever is managing the warfarin can adjust the dose around that.

Dino: Interesting.

Matt: Yeah and so we often see because of that, the seasonal flares in INR. So you might see a patient you once their greens coming in the garden, INR dips down but when in the winter, they come you know, they goes back up. So, you got to be careful, things to watch. Alcohol intake is another big and of course we want to recommend no alcohol intact with warfarin that can cause increase in INR, significant increases in INR, especially binge drinking episodes putting that all the toxins in the liver can be very harmful. So keeping that to a minimum if possible is always recommended. The other big thing smoking and when we think of smoking, of course we want that patient to quit smoking, right. When we quit smoking, we encouraged that patient to quit smoking and they do, the INR will go down. So you get to really watch out for that patient after quitting smoking doing a great job doing that, with adjust the dose of warfarin backup because that patient quit smoking and so it happens with tobacco mostly because of the impurities in tobacco. It is nothing that the nicotine is still doing it but the other impurities and things there in tobacco that are causing it.

Dino: My clinical background is not as strong as anyone that I've interviewed and had on this podcast but from what you're saying and I think a good relationship with your patient. There is a long way especially with that.

Matt: Absolutely, in a very holistic you know relationship with the patient talking about diet, food, social determines of health, not in addition to medicine and all the you of the necessary things when managing a patient with warfarin with lab draws and all that stuff because the patient can't travel to get to a lab draw. Warfarin is not going to be very good option for that patient. So, it's a very holistic approach to healthcare.

Dino: Yeah, for sure. Do you have a garden, that is good, good to know.

Matt: That is right, absolutely.

Dino: So, when we are talking about an inpatient versus outpatient setting, why is an INR greater than 5 just is important in inpatient as it in an outpatient?

Matt: Sure, an INR at the same level you know above no matter where the patient is at, so, at the same risk of bleeding, no matter where the patient at is important. Same level of risk of bleeding and so I think this question might stem maybe that patient you know got admitted with an INR of 6 or 7 and that you know yet to report that because of the core measurements and it is an INR above 5 but was nothing you did. So, I get miffed with that too, but I think now we are going back to the patient and taking care of the patient is the most important thing versus anything else and so we take care of that patient appropriately making sure that INR does come down and depending on you know maybe it's a life-threatening type and the INR above 10 and we really need to make sure that were reversed in that one maybe between 5 and 8 and the patient is not a high risk of bleeding, then we can watch that one. We can get an INR the next day or we can you know give them great education and great instructions on what to do and you know figure out why that patient’s INR went above 5. Give them that education, so that situation does not happen again.

Dino: Great, Matt thanks to be on the podcast today. I bout think we've covered pretty much everything that we were supposed to cover today.

Matt: That was more technical than the last one. If you guys have any questions, feel free to reach out any time.

Dino: Yeah, we will be happy to answer any questions and if you have any topics that you'd like Matt and I to discuss, please let us know and we will be happy to discuss those. It is always nice to have Matt, on the Podcast on the podcast. This is one of many for sure, so Matt thanks for being here and until next time.

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