Mar 2020
clinical initiatives, research and current updates in treatment
Interruptions and Distractions Justine Forbes, Epic Pharmacy Hollywood Elke Fischer, Epic Pharmacy Aged Care and Pharmacy Practice Unit Regardless of which healthcare profession, it is nearly impossible to work a single shift without being interrupted or distracted. Most healthcare professionals expect to be either distracted or interrupted and accept it as part of the job. These minor annoyances, however, can have a large impact on professional practice, patient care and safety. 1 Many studies and initiatives are employed in healthcare facilities worldwide to address these disturbances. A distraction is usually defined as ‘a stimulus from an external source where the worker responds to said stimulus, yet continues their task’. 1 A common example is writing patient notes whilst simultaneously answering a colleague’s question. Both tasks are completed, however, instead of completely focussing on one, attention is divided between the two. An interruption, however, is ‘a signal that distracts from the main task’. 1 The initial task is completely stopped in order to address the interruption. In this case, an example is going to see a patient in the middle of writing notes. The United States Institute of Medicine’s 2000 report, To Err is Human, identified interruptions as a likely contributing factor to medical
errors. 2 Some studies suggest healthcare practitioners are distracted and interrupted as often as once every 2 to 5 minutes. 1,3 Each interruption or distraction can increase mental fatigue, potentially leading to slips, lapses, omissions and mistakes. A 2010 Australian hospital study found that each interruption a healthcare worker experienced increased the risk of a medication error by 12.7%. 4 Telephone calls, pagers, face-to-face conversations, and the physical layout of a room are all common examples of external sources of interruptions and distractions which can potentially increase the risk of errors. 1 Another example of an interruption is when supplies and equipment are not available in the workspace, thereby causing a disruption in workflow. One United States hospital study found looking for items needed to complete day to day tasks accounted for 14% of interruptions. 5 Not only do interruptions and distractions increase the risk of medication errors, if a task is interrupted, the mean processing time of said task is greatly increased. 5 Interruptions and distractions are not always from external sources. An interruption can also be internal. There are two main types of internal interruptions, (1) a healthcare
professional may consciously decide to stop their task e.g. pharmacist stops dispensing to check their phone or (2) a thought may enter the working memory of the healthcare professional e.g. did I remember to sign the medication chart? These thoughts can have both positive and negative outcomes, the healthcare professional may remember a task they had forgotten, or the internal interruption may lead to failure to complete the primary task. 6 Identifying the cognitive implication of interruptions is essential in understanding their impact. 6 When an individual is interrupted, attention is switched from their primary task e.g. administering a medication, to the interrupting task e.g. responding to a question. Once this shift has occurred the memory of the primary task begins to fade allowing the brain to “make room” for the processes required to deal with the interrupting task. When the primary task is resumed, it is difficult to remember the current stage. This may result in steps in the process either being repeated or missed, or even failure to return to the original task. The impact of the interruption on the primary task is dependent on the individual characteristics of both the primary task and the interruption. Continued on page 2
Interruptions and Distractions Continued from page 1
In general, the most disruptive interruptions are those which; a) occur in the middle of the primary task, b) are similar to the primary task (i.e. require the same cognitive processes), c) are longer in duration or d) are complex to process. 6 Decreasing interruptions and distractions not only reduces the risk of errors and improves patient safety and care, but also increases worker productivity. Many healthcare facilities are beginning to implement various initiatives to reduce disrupting factors including: 3 ¬ Creating distraction free zones, such as ‘no interruption zones’ in areas where critical tasks are carried out ¬ Using ’Do not disturb’ signs for specific scenarios e.g. for nurses administering medication ¬ Implementing organisational phone
and social media policies aimed at mitigating internal interruptions ¬ Educating staff on the dangers of self-induced or internal interruptions ¬ Using checklists and protocols for long or difficult tasks, which can assist employees get back on track once distracted ¬ System wide strategies, such as the use of tall-man lettering on medication shelves to reduce drug selection errors, even if distracted ¬ Ensuring all the necessary resources are readily available ¬ Analysing noise alerts to identify any potentially insignificant or overly sensitive alerts, decreasing both alarm fatigue and the mere distraction these noises can create. To date, studies on interruptions in healthcare have largely focused on the impact of the person being interrupted and not the perspective of the interrupter. The benefits to
the interrupter and the healthcare organisation must also be considered. 1 Some interruptions are an important communication event, necessary and essential to the patient care process. A common example is when a nurse interrupts a medical practitioner advising of a patients declining clinical condition. 7 Though we see them as unavoidable, many interruptions and distractions can be lessened, and it is important every healthcare professional is aware of their potential impact. Further research into the impact, both positive and negative, interruptions and distractions have on healthcare safety is required. Healthcare professions will always experience interruptions and distractions, however it is vital that all necessary steps are taken to lessen their impact. References are available on request.
What’s New Chemo Brain: Cognitive Changes Associated with Treating Cancer Helen Krupp, Epic Pharmacy Hobart
‘Chemo brain’ or ‘chemo fog’ is a term used to describe thinking and memory problems which may occur during or after chemotherapy treatment. ‘Chemo brain’ can lead to patients having difficulty concentrating, forgetfulness and problems multitasking. A broader clinical term is cancer-related-cognitive-impairment (CRCI) as, from the research conducted, it is clear that it is not just the cytotoxic medication causing this condition. Some of the contributing factors to this cognitive impairment also include the cancer itself, longterm stress, anxiety, depression and sleep disturbance. CRCI can affect the working memory, exhibited as forgetting names and having difficulty following directions, verbal memory, where patients feel that they are unable to keep up with a conversation, and processing speed, where patients report they have difficulty learning new skills and problem solving. 1,2 Whilst the incidence of this condition is not fully known, one review found that up to 30 percent of patients with cancer exhibit cognitive impairment prior to treatment, up to 75 percent report some form of measurable
cognitive impairment during treatment, and up to 35 percent of cancer survivors will continue to exhibit cognitive difficulties for months, even years, following treatment. 3 Several mechanisms have been proposed for the development of CRCI: ¬
Direct neurotoxicity of the cytotoxic agents, via damage to mitochondria, thereby impeding metabolic function and energy utilisation of brain cells. 2
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Chronic stress leading to the dysregulation of the hypothalamic-pituitary-adrenal axis. Whilst no direct link has been confirmed, it is known that this area plays an important role in learning and memory. It is also observed that many patients undertaking chemotherapy experience chronic stress. 2
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Inflammation potentially caused by the cytotoxic treatments or the malignancy itself. 2
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Genetic factors may play a role, given some genetic variations have been associated with a higher risk of CRCI. 1
There have been a number of investigations into the best management of cognitive symptoms in cancer patients, however no treatment has been established in mainstream practice. 1 A number of medications and herbs have been investigated in pilot studies, including erythropoietin, dexmethylphenidate, modafinil and Ginkgo biloba. 1 However, results have been disappointing so far and the data limited given that no randomised clinical trials have been performed to date. Non-pharmacological interventional strategies have also been investigated, as outlined in Table 1.
Table 1: Non-Pharmacological Interventions Studied in CRCI Strategy
Examples1,2
Outcomes1,2
Cognitive training
Brain games or exercises in a face-to-face or online format
Whilst the majority of trials were limited to the breast cancer population, this intervention was found to reduce cognitive symptoms in cancer survivors. It is unknown whether these results can be extrapolated to the wider cancer population.
Cognitive rehabilitation
Programs with skill training around memory and executive function e.g. incorporating memory aides such as checklists and making changes to home environments to decrease decision making requirements 4
Improvements were seen in some groups involved in the trial. There were a broader range of cancer populations studied, however small numbers limits the conclusions which can be made about this data.
Exercise
Such as aerobic exercise, yoga, tai chi
Yoga, either once daily or twice weekly, was seen to improve cognitive symptoms. Although studies in patients who have undergone chemotherapy are limited, a variety of other studies have shown an association between physical exercise and improved cognition.
Mind-body
Mindfulness, meditation, acupuncture
Pilot trials in mindfulness-based stress reduction demonstrated an improvement in cognitive symptoms.
Continued from page 3
As yet, we are not able to identify which patients are at most risk of developing persistent cognitive symptoms. Therefore, providing support and education to all patients about ‘chemo brain’ is very important. This support may include counselling patients, their families and carers on this condition, ensuring they are
aware of what symptoms to be aware of and any coping strategies. Useful patient resources include Cancer Council Australia’s “Understanding Changes in Thinking and Memory” 5 and eviQ’s “Memory Changes and Chemotherapy”. 6 To date there has not been any pharmacological agents which have proven effective for assisting with
cancer-related cognitive impairment. By implementing strategies which encourage cognition such as the training programs described above, or by increasing mind-body awareness and exercise, we can assist patients who may be reporting trouble with cognition since their diagnosis with cancer. References are available on request.
¬¬Ryzodeg® 70/30 Flextouch® and Penfill® Gaby Ang, Epic Pharmacy Ryzodeg® 70/30 is the first combination insulin consisting of an ultra long-acting basal insulin (insulin degludec 70%) and a rapid acting mealtime insulin (insulin aspart 30%). 1,2 It is indicated for both insulin naïve and insulin experienced adults with either type 1 or type 2 diabetes mellitus (T1DM, T2DM). 1 The long flat basal glucose lowering action of insulin degludec and the peak prandial (mealtime) glucoselowering effect of insulin aspart remain separate in co-formulation (figure 1). This co-formulation eliminates the ‘shoulder effect’, which is the interaction between the two insulin components, prolonging the action of the short-acting insulin and
increasing the risk of hypoglycemia often seen with other premix insulins. This results in sustained glycemic control with less hypoglycaemia. 1,2 Ryzodeg® 70/30 is administered subcutaneously once or twice daily with the main carbohydrate containing meal. 1 If taken once daily, the administration time can be changed, as long as it is dosed with the largest carbohydrate meal of the day. 1,3 Due to the ultra-long action of the insulin degludec component, any dose adjustments will require two to three days to take effect. 1 In patients with T2DM, Ryzodeg® 70/30 can be used singularly, in combination with oral antidiabetic
medicines approved for use with insulin, or in combination with bolus insulin. 1 In T1DM a short or rapidacting insulin is required at the remaining meals. 1 The most commonly observed adverse effect of Ryzodeg® 70/30 is hypoglycaemia. 1 The prolonged effect of Ryzodeg® 70/30 may delay recovery from hypoglycaemia. 1 Ryzodeg® 70/30 is available in two presentations, the FlexTouch® pen and the Penfill® cartridge. The cartridge is compatible with Novo Nordisk insulin delivery systems. Both products are listed on the Pharmaceutical Benefits Scheme. 5 References are available on request.
Figure 1: Steady state glucose infusion rate (GIR) profile of Ryzodeg® 70/30 after single dose administration of 0.8 U/kg in type 1 diabetes mellitus 1,4
Research from our staff
In 2019 our pharmacy staff conducted a number of research projects. Of these, 10 were presented in various forms at the annual Society of Hospital Pharmacists (SHPA) and the Clinical Oncology Society of Australia (COSA) conferences. We don’t often share this work so we have included 2 of these projects to give you some understating of our innovations.
Pushing Back the Tide of Opioid Prescribing Ellie Chan (BPharm) and Kristen Thessman (GradDipClinPharm BPharm) - Epic Pharmacy, Wesley Hospital, Auchenflower QLD
Background Opioids are an important treatment option for acute postoperative pain. 1 However, mounting literature suggests the overprescribing of opioids post-surgery place patients at risk of chronic use. 2,3 Opioid dependence increases the likelihood for severe adverse events 4 and are the leading drug group associated with fatal accidental overdoses in Australia. 5 The Australian and New Zealand College of Anaesthetists recommend against the use of slow-release (SR) opioids for acute pain due to the risk of respiratory depression. 6 Previous research found that 70% of medications prescribed for postoperative pain were unused, 7 opening avenues of potential diversion. 4,8
Aim To gain an understanding of opioids prescribed and quantities required at discharge for postoperative pain relief.
Methods Four prospective audits were undertaken over three week periods (2018-2019) across three private metropolitan/regional hospitals.
1. Consent Obtained for patients >18 years who were prescribed an opioid for discharge post-surgery.
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2. Medical Records were used to identify type of surgery, length of stay, adverse drug reactions and opioids used prior to admission.
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3. Follow Up occured 7-14 days after discharge to ascertain pain scores seven days after discharge, opioid usage, education/disposal and side effects.
Scan QR code for survey questions
Results A total of 199 patients were included in the study and 93% of patients were opioid naïve on admission. Orthopaedic surgery accounted for the most common surgery performed (see figure 1). Pain scores improved seven days post-discharge where 82% of patients reported absent to minor pain (see figure 2). A combination of opioids including SR formulations were received by 38% of patients on discharge. The most common analgesic prescribed for postoperative pain was oxycodone immediaterelease (IR) with 164 out of 199 patients receiving supply. The average quantity prescribed exceeded the average quantity of tablets taken for all opioids (see figure 3). Awareness of correct disposal of opioids was only known to 37 patients. Putting into perspective for 199 patients: 93% of patients were opioid naïve on admission.
3% 3%
Orthopaedics
8%
38% of patients were prescribed SR opioids.
Head and Neck
7%
Gastrointestinal
8%
Other Surgery
65% 6%
Urology Gynaecology
82% of patients were prescribed oxycodone IR.
Average oxycodone IR use was 8 out of 20 tablets.
Figure 1. Types of surgery.
180
163
160
Number of patients
140
Discussion This study demonstrated opioid over-prescribing in postoperative pain relief. These results are consistent with both local and international findings. 3,9 There are limited studies in Australia comparing the quantity of opioid tablets supplied with the quantity taken in the post-discharge setting. Recommendations for optimal opioid supply on discharge for postsurgical pain relief are scarce. Available guidelines recommend a multimodal treatment approach where opioids are only prescribed if required for a maximum duration of three to five days and advocate IR over SR preparations. 1,9
120 100 80 60 40
0
Absent to Mild (0-4)
14 Severe (8-10)
Figure 2. Pain score seven days post-discharge.
Conclusion Number of Tablets
25
A powerful picture is presented of opioids supplied in excess of quantities required. Strategies which provide prescriber and governance support are necessary for safe opioid prescribing. Innovations currently being implemented across the organisations include:
23 Moderate (5-7)
20
21
20
20
19
20
10
12
14
15
8
10 5
14 n= nt ad
ol
SR
n= Ta pe
ol IR nt ad Ta pe
ne / do Ox yc o
17
Na lo xo n
n= 16 IR ne do
Patient-centered pain management plans
yc o
Awareness among health professionals
Ox
Prescriber feedback
e
4
n=
51
0
Average number of tablets prescribed Average number of tablets used
Pain management stewardship programs
Patient specific counselling highlighting correct disposal and risks of opioids
Pharmacist-led intervention to reduce opioid quantities on discharge
Figure 3. Average number of opioid prescribed vs used.
Epic Pharmacy is part of Icon Group – Australia’s largest dedicated private provider of cancer care.
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Review of a pharmacist medication management plan referral program for a small private regional hospital
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Alyssa Pidgeon1, Eve Finn1, Danielle Queale1, Chris Giles2 1. Epic Pharmacy, St Vincent’s Hospital, Lismore, NSW 2. Pharmacy Practice Unit, Icon Group Pharmacy Services, Brisbane, QLD
Background A small regional private hospital, with 86 overnight beds, introduced the Medication Management Plan (MMP) to improve medicines management. Recognising the value of pharmacist involvement, resources were allocated to implement a limited clinical pharmacy service focused on medicines reconciliation on admission, prioritised for high risk patients.
MMP referral criteria, illustrated in Figure 1, were created incorporating elements from the SHPA Fact Sheet: Risk factors for medication-related problems1 and National Prescribing Centre: A Guide to Medication Review 20082 to identify higher risk patients on admission and prioritise pharmacist time for these patients. Admission medication history, medicines reconciliation, and ongoing clinical review outcomes (e.g. interventions) are documented on the MMP by the pharmacist for use by the multidisciplinary team.
Figure 1. Sample MMP Referral Form
Average time for the pharmacist to perform the service
An average of 1.2 clinical interventions per MMP were completed. Clinical interventions were recorded using the D.O.C.U.M.E.N.T classification system for medication related problems, in line with SHPA Clinical Pharmacy Standards (See Table 1).3
31 MINS
Table 1. Clinical Interventions 80
Number of clinical interventions
Description
High risk patients referred for an MMP represented 20% of total hospital admissions with 90% of referred MMPs completed. Pharmacist referrals not completed were largely due to insufficient timeframe between receiving the referral and discharge, or referrals to end-of-life pathway.
The initial pilot program resulted in the allocation of 30 minutes of pharmacist time to complete each MMP for high risk patients.
70 60 50 40 30 20 10 0 Condition untreated
An audit found that MMP’s were not being completed by nursing staff for non-referred patients, prompting consideration of extending the scope of referral to pharmacists.
Actions The pharmacist referral program was evaluated two years after implementation to determine the percentage of total overnight patients referred, pharmacist time required to perform admission medication reconciliation and medication review, and the number and significance of clinical interventions reported, with consideration of future expansion of the program.
Evaluation A retrospective analysis of patients admitted over a 3 month period was conducted to calculate the average time taken per MMP and resulting interventions. The results were compared to resource estimates based on the initial pilot program and also extrapolated to the total number of overnight admissions during the 3 months to build a business case model for expansion of the service. The referral criteria was previously validated with reasonable confidence to confirm the 80% of non-referred patients were of a lower risk cohort.
Condition undertreated
Prescribed dose Prescribed dose Incorrect or unclear Other clinical too low too high dosing instructions interventions
Evaluation of the clinical interventions revealed a significant number of untreated and undertreated conditions; not an unexpected finding when performing admission medication reconciliation. Examples of clinically significant interventions involving high risk medicines included under-dosing apixaban, dabigitran not restarted post-operatively, enoxaparin charted for the wrong patient, and underdosing of gliclazide with subsequent high blood glucose levels. Other examples included disposal and replacement of expired patient medicines and correcting poor inhaler technique.
Implications The results validate the initial allowance for 30 minutes of pharmacist time per high risk patient’s MMP. By quantifying the pharmacist time required for 18% of overnight admissions, the approximate pharmacist hours required for expansion of this program is one full-time pharmacist. As the 18% of patients receiving pharmacist MMP services were high risk and thus more complex, it is forecast that expanding the program would encapsulate a cohort of lower risk patients requiring less time per case, allowing pharmacists to complete other clinical activities such as medication counselling and medication review. Support for extending the clinical pharmacy service to all admissions will require a business case proposal quantifying the benefits achieved through increased pharmacist interventions reducing medication misadventure: increased treatment costs, extended length of stay and avoidable readmissions.
Figure 2. MMP Activity for all Overnight Admissions
Forecasting Resources for Expanding this Service
2% 18%
Referred MMP not completed Referred MMP completed
80%
MMP not eligible for higher risk referral
31 minutes per MMP (high risk patients)
37.5 hours per week to complete all overnight admissions
Employment of one full time pharmacist
If you have any queries regarding Circuit content and authors please contact the Epic Pharmacy Practice Unit by email: circuit.editor@epicpharmacy.com.au Every effort has been made to ensure this newsletter is free from error or omission.
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