Partnering With Pharmacists—Season 1, Episode 6

Identify multiple roles of the pharmacist with opioid stewardship.


This material was prepared by Health Services Advisory Group (HSAG), a Quality Innovation Network-Quality Improvement Organization (QIN-QIO) under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication No. QN-12SOW-XC-02012023-01

Transcript

Speaker 1 (00:03):

So, now it's my absolute honor to introduce you, our subject matter expert today, pharmacy extraordinaire, Sarah Stevens. Dr. Stevens is the Network Medication Safety Officer for the Honor Health System in Scottsdale, Arizona. And in this role, she prioritize and prioritizes leads, initiatives to improve safety, uh, of the, of the medication use process. So, with that, I give you Dr. Sarah Stevens.

Speaker 2 (00:29):

I'll get right into the learning objectives that I hope to cover. Um, first is just identifying multiple roles of the pharmacist with opioid stewardship programs. There's lots of things we can do, so I'll try and outline some areas of opportunity, things you may, may not have thought of, um, and give some, some great ideas. Also, describing the pharmacist's role in safe pain care and opioid stewardship across care settings. So, my, my love and specialty is medication safety, but, we all know opioids are one of the top pilot medications in our health systems and in care generally. So there, there are specific ways pharmacists can help contribute to those, um, safe practices and best practices and reduce harm to patients. So, I'll try and cover that high level as well. So, what do pharmacists do? I think unless you're a pharmacist in the thick of our profession, you may or may not understand all the facets on that pharmacist contribute to.

Speaker 2 (01:24):

A lot of folks think of the operational comp component, and that's whether you're thinking of an acute care setting or maybe in an ambulatory clinic or retail. There is a large component of what pharmacists do for procurement of medications, but it gets complicated because we have to procure the right things. Think about how, um, that drug might look against other drugs that like, like look alike or sound alike. Sort of the safety of what we bring into our, our health systems is really important, how it's stored. Um, how they're ordered is also a large part of what pharmacists do. You think of the the pharmacist as verifying orders, so that's ensuring that what was ordered by a prescriber is safe, effective, optimized for patient care, makes sense what the other medications they're on, et cetera. And then there's a ton of systems design, and that might be one area that folks don't always think of, but we have all of these systems and devices that help manage the medication use process to make it as safe as possible.

Speaker 2 (02:26):

And pharmacists are integral in looking at the metrics around those designs, optimizing them and ensuring that they, they function well for, for the clinicians that are interacting with them. The leadership, piece is more what I'm doing. As I've advanced in my career now, I lead medication safety efforts and our opioid stewardship committee. But there's also drug diversion committees that pharmacists are often part of. And of course pharmacy and therapeutics committee. So, the groups that are making decisions about opioid use and safety, you of course want to ensure that you have your medication experts involved in those committees. So, those are the leadership activities. And then another really big bucket is clinical. So, I'll talk a little bit about an opioid consult service that I was able to interact with at my prior facility. There's also clinic settings.

Speaker 2 (03:18):

I've worked in a variety of institutions that have pharmacists in their ambulatory care clinics or directly managed chronic pain management, in addition to acute care services for acute care or palliative. And then, also just the general clinical responsibilities that pharmacists may have depending on the facility where they're out on units rounding, interviewing patients, med histories, all sorts of aspects of clinical care pharmacists can really contribute to. Getting that med history, such an integral part of where medication errors often occur, right? If we don't have an accurate list of what the patient's even doing with their medication management, it's really hard to best treat them. So, that's a huge component. And where pharmacists and pharmacy technicians are becoming more and more relied upon is to ensure those accurate med lists. There's quite a bit of evidence and data that supports pharmacists, team members doing a better job with regard to accuracy of medication lists when they're the people tasked with that.

Speaker 2 (04:21):

And then just monitoring good steward stewardship and use of different medications. And that's the drug use evaluation. So, pharmacists are typically tagged with evaluating use. So, say in your health system, you want to know how often fentanyl patches are prescribed, and are we, are we adhering to the black box warning criteria for fentanyl patches for safe use? How often are we prescribing long-acting opioids in patients and are we doing so in appropriate patients that would be a drug use evaluation and, and something typically pharmacy teams are tasked with doing in organizations. And then the administration management, often people think of nursing as the medication administration experts, which they are, but there are other folks involved with monitoring drug therapy and documentation and education of patients. Pharmacists can especially be beneficial in doing patient education on discharge from acute care sites in managing patients that come to clinic and in retail settings on their opioid therapy and especially the multimodal and non-opioid treatment therapy, and therapies that are available to patients to help optimize their care.

Speaker 2 (05:34):

This is the, the study I alluded to earlier about clinical management of patients being treated for pain in an acute care setting. The prior facility I worked at, Kuya Health, actually won a best practice award from ASHP, which is a national pharmacy organization for their work in improving safety of pain management. What this team did, we created a pain pharmacy, pain management service. The hospital that this was done in was 581 beds. Three FTE were dedicated pharmacist FTEs for this service line. And what they implemented was a consultation service as well as opioid stewardship activities. So, what that looked like is prescribers could consult the pharmacy pain team to see any patient that they felt could benefit from their optimization of their pain treatment during the hospital stay. Usually, these were patients that were more difficult to manage, but over time it kind of ended up being a lot more right?

Speaker 2 (06:32):

'Cause they, they saw the value of those services. The opioid stewardship activity piece were, that was identifying patients who were high-risk for opioid over sedation. So, they used a risk-stratification criteria for patients. Patients that qualified at a certain number of what they, what they utilized for their risk criteria. They would get a report for those patients and then they would proactively go look at their medication management and make recommendations to the prescriber onpotential ways to optimize therapy to prevent an adverse drug event. One of the most important outcomes that they realized from this work is they looked at every rapid response and code blue that occurred due to opioid over sedation before and after the service line was implemented. And you can see on this graph here that in 2013 before the service, there were 65 of those events and just 2014, the year after the service was implemented, you can see that that was cut in half and maintained, and actually decreased even further in 2016.

Speaker 2 (07:38):

So, really great outcome for our patients where this service was implemented. And then, there were also, they also were measuring total opioid exposure, oral morphine equivalence of patients that were admitted and all of those numbers decreased and the multimodal therapy increased. So, it really was a beneficial service, service line to implement. It's not cheap. It is pharmacists, but if you look at the cost of avoidance of just these rapid responses, right? You, you easily pay for the pharmacist personnel to do this work. So, really great, great outcomes there. So, now I'm at Honor Health, and what we have for our opioid stewardship committee. I wanted to outline how we're set up as a potential option as well. I think we have a pretty effective strategy in utilizing a chair/co-chair of our committee that involves both a physician chair, anesthesiologist by training, and myself as a co-chair.

Speaker 2 (08:40):

So, I have the, the medication-use process expertise, but also have my medication safety hat on. So, I think that can be really effective, but if you don't have a med safety officer to tap into, you could certainly, I think co-chair a committee like this with a pharmacist, and hopefully a specialist in pain management if you have that luxury at your facility. But that partnership has been really helpful for us in looking at, at things in different perspectives that are very cohesive. We report directly up through our quality committee of the board and we have a dashboard. We have dashboard metrics that specifically look at adverse drug events related to opioids. So, it's pretty high. We're highly visible, I guess, in the organization is what I would say. So, our work is, is considered very important to Honor Health.

Speaker 2 (09:31):

So, it helps hold us accountable and I think it also helps us move initiatives forward because our facility, our network is very committed to moving the mark in this area. We meet monthly. We have a task force subgroup kind of biweekly meetings set up so that, so as we're working through specific tasks, like right now, we're, we're getting ready to review all our order sets. We can utilize that time for people to get in on a WebEx and just knock out the work. So, that's been effective in us moving the needle on some of the more onerous projects. And then, this committee, of course approves all our metrics and monitoring, which we're trying to flesh out still. But essentially, we we're looking at the best practices that are already published in opioid management and prioritizing our initiatives based on where our gaps are and where we think we have, you know, the highest leverage items to fix.

Speaker 2 (10:27):

And we've done that in a variety of ways. We started with ISMP recommendations and that it's probably largely due to my influence of med safety officer, as co-chair of the committee. But if, if you're kind of unclear where to kind of begin, aside from all of the excellent resources that HSAG is providing you all, ISMP is also a really great resource to tap into for where's the most high-risk area for medication use with opioids. So, their targeted med safety best practice 15 is... I just a screenshot here, but it's largely around long-acting opioid therapy. So, ensuring you're prescribing fentanyl patches, Oxycontin, MS-contin appropriately is really what this is targeting, but specific, specifically fentanyl is really addressed here. So, that would be a great place to start. And this is a perfect way to leverage pharmacy as the gatekeeper of safe fentanyl prescribing.

Speaker 2 (11:26):

So, you can easily, well, I shouldn't say easily, but I would recommend implementing a hard stop or pharmacists are forced to review these orders before they're active in your system if you're in an acute care facility. So, opioid status must be monitored, must be assessed, and documented before we give a fentanyl patch to anyone in the facility, and you shouldn't stock them anywhere, right? So, those are easy fixes, and just understanding where you're at is an excellent place to start and you'll improve safety immediately. So, remembering that pharmacy is your best friend is a take home. Medication history collection. Absolutely. I think leveraging pharmacist services is key to get an accurate list and ensure we don't perpetuate errors through an acute care stay and on discharge and then into the clinic setting. Stewarding of criteria for use, like I mentioned for fentanyl patches, absolutely key.

Speaker 2 (12:21):

You can consider things like methadone, which are very high-risk. We could talk about MAT therapy, all sorts of things that pharmacists can be your expert guide and help save prescriber time and nursing time trying to do a lot of these assessments. Identifying at-risk patient populations that warrant pharmacist review, right? So that we're utilizing limited resource resources as effectively as possible is an important strategy. Pharmacists are trained typically to attend rounds, be multidisciplinary team members, and collaborative collaboratively manage patients. Collaborative practice agreements are an option to give full autonomy or just considering the consult methodology. Patient education on discharge. We're trained to do this work and speak with patients on their medications. So, leveraging that, bringing up nursing time for certain high-risk meds could be a really effective strategy in an organization and in clinics.

Speaker 2 (13:21):

And then chronic pain management clinics and ambulatory care pharmacy, this is a huge area of growth, and opportunity for pharmacists. So, utilizing those folks to work alongside prescribers in clinic settings has been really beneficial in optimizing pain therapy. And, you know, helping quite complicated patients best manage their medications. And then, I cannot forget emergency department pharmacy services. So, more and more facilities are hiring full-time emergency department pharmacists that help with trauma, all sorts of stuff. They're integral for MAT therapy, dealing with those kinds of patient issues, especially when you're trying to discharge from the ED. So, do you have a pharmacist in the ED and can you leverage them? Be sure you know that. And then, just a quick note on specialized pharmacist training. Pharmacists have the opportunity to do a second year of residency, specialized PGY2 training and pain management and palliative care.

Speaker 2 (14:27):

So, finding those folks is, is great and if you have them in your organization, utilizing them is, is essential. And then same with a certificate program through ASHP. So, the key takeaways are that pharmacists are available to assist with all aspects of the med use process. So, hopefully you have a better understanding of where they might fit and where where you can leverage, leverage pharmacists. Improving pain management can with pharmacist services, can reduce opioid use, improve utilization of multimodal therapy, and reduce adverse drug events, which is the goal of every opioid stewardship program, right? Leadership positions can be helpful and help move the mark on various initiatives as well as identify where we need to focus. And then, of course, the team approach, including pharmacists, is just an outstanding, effective strategy that hopefully everyone is already doing. And if not, I hope that you have the opportunity to consider.