UNIVERSITY OF MICHIGAN – DEPARTMENT OF PHARMACY SERVICES

 

ANNUAL REPORT FY2006

 

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CLINICAL PHARMACY SERVICES

 

Text Box: Paul C. Walker, Pharm.D. Clinical Pharmacy Manager The Department of Pharmacy Services provides pharmaceutical care to both inpatients and outpatients.  Clinical pharmacists function as integral members of health care teams at University Hospital, Women’s Hospital and C.S. Mott Children’s Hospital, working with physicians to achieve desired therapeutic outcomes, prevent or minimize drug-related problems, and improve medication use.  Currently, 30 clinical pharmacists, including 5 new positions added in FY2006 (in the areas of Ambulatory Care, Antimicrobial Management/Infectious Diseases, Hematology/Oncology, Pediatric Cardiothoracic Surgery, and Transplantation), practice full time providing direct patient care services.  In addition, a clinical practice model for staff pharmacists was implemented at Mott in 2006.  Similar to the model implemented at University Hospital in 2005, this model expands the role of the staff pharmacist beyond pharmacy operations, enabling them to participate in direct patient care activities.

 

Pharmacists actively participate in the development, implementation and enforcement of drug use guidelines, policies and procedures, help to ensure appropriate use of high-risk medications, and serve on quality improvement committees throughout the institution.  Specific departmental programs help assure cost-effective and appropriate use of high-risk or high-cost medications:

 

  • The High Impact Drug Monitoring Service.  The High Impact Drug Monitoring Service, implemented in 2005, continues to help manage the use of targeted biotech and high-cost drugs that significantly impact the costs of care and the institution’s margin.  Drugs managed by the service include: Recombinant Factor VIIa; Darbopoetin; Drotrecogin; Fenoldopam; Filgrastim; and Intravenous Immune Globulin. 
  • The Antimicrobial Restriction Program (ARP).  This program, implemented in 1997 to help manage rising antimicrobial expenses and escalating microbial resistance rates, evaluates the use of targeted antimicrobials on a case-by-case basis.  Four clinical pharmacists specifically monitor the use of restricted antimicrobial agents to ensure appropriate use and make interventions as necessary.  The ARP continues to help maintain pharmaceutical costs and attenuate or reduce microbial resistance rates at

 

Clinical Pharmacists led or participated in development, revision and implementation of numerous drug use guidelines, including:

 

  • Antifungal Guidelines
  • Antimicrobial Use Guidelines (revised existing guidelines)
  • Criteria for Use for IV Nafcillin
  • Febrile Neutropenia Treament Guidelines (revised existing guidelines)
  • Guidelines for Factor VII Use in Adults
  • Guidelines for Factor VII Use in Pediatric Patients
  • Guidelines for Inhaled Ribavarin
  • Guidelines for Octreotide Use in the Management of Bleeding Varices Admitted to Hepatology Service
  • Guidelines for Use of 3% Saline for Mott
  • IV Amiodarone Guidelines (revised existing guidelines)
  • IVIG Guidelines (revised existing guidelines)
  • Surgical Prophylaxis Guidelines

 

Other clinical initiatives, policies and procedures, and quality improvement projects undertaken by clinical pharmacists this year include the following:

 

  • Piloted an order from for DVT prophylaxis on the general medicine units to improve DVT prophylaxis
  • Collaborated with Phlebotomy to optimize blood draw time frames to improve work flow to allow for better laboratory information for clinical decision making
  • Implemented the sepsis bundle in MICU to improve patient care with respect to laboratory ordering and antimicrobial prescribing.
  • Helped develop and implement the hyperglycemia management protocol in the TICU.  Currently evaluating the impact of the protocol in TICU.
  • Participated in the Diabetes Mellitus Quality Improvement Initiative
  • Implemented a Pill Splitting Program that has resulted in significant financial savings to the institution
  • Text Box: Pharmacists as integral members of health care teams, actively participate in the development, implementation and enforcement of drug use guidelines, policies and procedures, help to ensure appropriate use of high-risk medications, and serve on quality improvement committees throughout the institution. Establishing billing for pharmacist-provided clinical services in the ambulatory environment
  • Developed and implemented a Diabetes Medication Algorithm for use at East Ann Arbor
  • Developed and implemented a Hypertension Medication Algorithm for use at East Ann Arbor
  • Developed and implemented a Hypertension Management Protocol.
  • Developing an Insulin Titration Protocol for clinical pharmacists at the other health centers
  • Developed and implemented of a protocol for adding cysteine in neonatal TPN’s
  • Developed protocol for using ethanol locks in patients with occluded central venous catheters (CVCs), and a protocol to measure the length of CVCs.
  • Developed and implemented a process for the safe administration of inhaled ribavirin
  • Participated in practice drills pertaining to pandemic influenza
  • Assisted with formulary management of HIV-related medications
  • Conducted a systematic review of the Antimicrobial Management Program
  • Helped to develop and review OMP order sets
  • Investigated/recommended process changes to address errors associated with obtaining of aminoglycoside and vancomycin levels
  • Worked with the microbiology lab to select an automated antimicrobial susceptibility system (Vitek II).
  • Developed and implemented a nicotine replacement therapy order form
  • Standardized an alcohol withdrawal treatment protocol
  • Developed a protocol for daily interruption of sedative infusions in the TBICU
  • Updated the maximum dose list for continuous IV infusions in the adult ICU
  • Implemented and assessed the impact of an insulin infusion protocol for patients undergoing cardiac surgery
  • Reviewed and revised the CMV prophylaxis protocol for kidney transplant patients
  • Assisted with review and revision of lung transplant protocols
  • Assisted with review and revision of lung transplant patient education materials, staff education, and new transplant patient education
  • Revised standardized drip charts and created new chart for the Holden NICU to facilitate elimination of Rule-of-Six
  • Implemented standardized concentrations in the Holden NICU to eliminate the Rule-of-Six
  • Revised the pediatric electrolyte protocol
  • Developed a CIN protocol
  • Built and implemented of drug libraries for new smart pump syringe pumps
  • Built and implemented new PCA/epidural pediatric pain libraries for new PCA smart pumps
  • Converted OB anesthesia to a commercial labor epidural solution
  • Implemented new epidural pumps in OB anesthesia
  • Trained staff on use of new epidural pumps
  • Standardized infusions in the Mott OR for consistency with the Holden NICU and Pediatric ICU
  • Developed and implemented a radio contrast media policy for OR areas
  • Developed an intrathecal drug administration policy for OR areas
  • Standardized emergency drug supplies for the ICU's
  • Developed a process to transfer topical hemostatic agents from the pharmacy inventory to Materiels and Central Supply
  • Developed new pediatric and adult postoperative nausea and vomiting algorithms
  • Implemented pre-hospital care pain management protocols
  • Developed nursing information sheets for intrathecal baclofen pumps
  • Updated OR anesthesia drug trays
  • Converted anesthesia to generic propofol and cisatracurium
  • Implemented pharmacist documentation in the electronic medical record (Careweb)
  • Developed a health-system Medication Administration Policy that governs who is authorized to administer medications
  • Implemented a pilot project to evaluate the impact of a pharmacist in the discharge process
  • Implemented an on-call clinical pharmacist process to support staff pharmacists
  • Implemented an on-call clinical pharmacist to support the new palliative care teams

 

 

DUE Projects Completed In the Last Year

 

The following DUE projects were undertaken in FY 2006:

 

  • Evaluation of Factor VII Use in Adults
  • Evaluation of IVIG Use
  • Outcome of a Multidisciplinary Intervention Aimed at Preventing the Concomitant Oral Administration of Fluoroquinolone or Tetracycline Antibiotics with Supplements Containing Polyvalent Cations
  • Post-Operative Vancomycin Prophylaxis in Patients Undergoing Cardiothoracic Surgery
  • Use of Antifungal Agents in Transplant Patients

 

 

Committee Participation

 

Clinical pharmacists served on the following hospital committees, work groups and task forces:

 

§         Accreditation and Regulatory Readiness Council

§         Anesthesia Quality Assurance Committee

§         Anesthesia Technical Support Committee

§         Antimicrobial Subcommittee (Secretary)

§         Body Substance Exposure Task Force

§         Cancer Pharmacy Committee

§         Chemotherapy Content and Knowledge Subgroup (for Orders Management Project)

§         Chemotherapy Content and Knowledge Subgroup Committee

§         Committee of Pain and Sedation

§         Contrast Media Reaction Committee

§         CPR committee

§         Critical Care Steering Committee

§         Drug Diversion Committee

§         DVT Risk Assessment and Prophylaxis Workgroup

§         Emergency Medicine Bio-terrorism/Disaster Committee

§         Falls Committee

§         Geriatrics Center Clinical Advisory Committee

§         Hematology Standard of Care group

§         Heparin Orders Management Project

§         Immunization Committee

§         Inpatient Cardiology Quality Assurance Committee

§         Inpatient Diabetes and Insulin Workgroup Committee

§         Joint Practice for Critical Care

§         Joint Practice for Critical Care/Surgery

§         Kidney/Pancreas Transplant Operations Committee

§         Lipid Therapy Guideline Committee

§         Liver Transplant Policy Committee

§         Medical ICU Multidisciplinary Committee

§         Medication Administration Policy Development Committee (Chair)

§         Medication Reconciliation Committee

§         Medication Reconciliation Committee (Co-Chair)

§         Medication Safety Committee

§         Pain and Analgesia Sedation Committee

§         Pediatric Anesthesiology Research Committee

§         Pediatric Anesthesiology Technical Support Committee

§         Pediatric Medication Safety Committee (Interim Co-Chair)

§         Pediatric Nurse Network

§         Pharmacy and Therapeutics Committee

§         Pharmacy Intervention Team, Medication Reconciliation Project

§         Product and Vendor Selection Committee

§         Smoking Cessation Policy Committee

§         Surgical ICU Multidisciplinary Clinical and Administrative Team

§         Timed Blood Draws Lean Team

§         Vincristine Sentinel Alert #37 Response Committee (Chair)

§         Pharmacy also participated in the planning committee for the new pediatric hospital.