Improving Safety in the Geriatric Patient By Reducing Potential Harm from High-Risk Medication Use A NICHE Initiative Kristin Miller, Pharm. D., Erin Kohler, Pharm. D., BCPS, Marketa Friel, MS, RN-BC, CEN, Dr. Steve Montamat, Rob Wills, Pharm. D., BCPS, St. Luke’s Health System – Boise, Idaho Preparing for the Silver Sunami o 28% of all hospitalizations in the elderly are from adverse drug reactions (ADR’s) o By 2020, on average, an elderly patient will require $25,000 worth of health care costs per year. o The average elderly patient takes 14 different medications NICHE Medication Team o Consists of 1 geriatric physician, 2 pharmacists, 2 geriatric resource nurses, and 2 nurse educators. Input was also received by other internal medicine physicians, pharmacists, educators, and nurses. o GOALS consisted of: o Developing ways to decrease the usage of PIM’s, as defined by the Beers list oImproving patient safety o Educating other health care members on the potential harm medications can cause to elderly patients Importance of Staff Education o The biggest impact of the study was involving other disciplines during the education component. o Physicians became aware of the dangers of PIM and of the amount they were prescribing o Change of practice was noted before the study was started based on physician feedback o Nurses gave smaller doses of PIM’s when ordered as a dosage range in hopes of decreasing the risk of ADR’s. Results NURSES IMPROVING CARE FOR HEALTHSYSTEM ELDERS o National organization designed to help hospitals improve the care of older adults, greater than 65 years if age. o NICHE is unlike other programs in that it does not prescribe how institutions should modify geriatric care; rather, it provides the materials and services necessary to stimulate and support the planning and implementation process. o St. Luke’s participated in the NICHE Leadership Program and has applied to become a certified provider in 2012. o Originally designed as a nursing program, the local NICHE committee has input from physicians, pharmacists, nurses, nurse educators, and clinical administrators. Objectives Retrospective • Identify which PIM are being used most frequently by collecting data on administered medications • Develop a system to decrease usage of those medications identified by data collection Prospective • Determine effectiveness of a pharmacists-driven communication system that would notify a physician when they prescribe a PIM to an elderly patient • Identify barriers to implementing a system-wide communication tool and ways in which pharmacists can intervene on behalf of the elderly patient that may be at risk of developing an ADR Implementation • Take the results of the retrospective and prospective study and implement a process change on all medical units • Provide necessary staff education to other health-care providers • Develop measurable endpoints to determine if patient safety is improving PIMS & Safer Alternatives Diphenhydramine • Itching: cetirizine • Sleep: behavioral modification or low-dose doxepin • Anti-emetic: ondansetron Promethazine • Anti-emetic: Ondansetron Hydroxyzine • Itching: cetirizine • Sleep: behavioral modification or low-dose doxepin • Anti-emetic: ondansetron Benzodiazepines • Anxiety: Lorazepam is preferred • Any other indication: Not recommended Citalopram • Doses > 20 mg no longer recommended by the FDA. Use alternative agent or decrease dose Escitalopram • Doses > 10 mg no longer recommended by the FDA. Use alternative agent or decrease dose Next Steps o St. Luke’s has now taken the steps to roll out NICHE Medication Review o Throughout Treasure Valley o Eventually System Wide o Initial rollout includes a Boise Pilot o Targeting Critical Care and Cardioloty/Telemetry Units o Interventions include o Daily trigger report of patients > 64 years of age o Patient Profile Review of Potentially Inappropriate Medications o Pharmacy to Physician Communication Forms specific to the NICHE initiative with areas for prescriber feedback o Expected System Wide Rollout - 2015