Innovative projects improve glycemic control and decrease thrombosis risk
This success story was written in 2021.
Pharmacists across the country face numerous competing demands and priorities—from preventing adverse events to supporting cost-saving objectives to partnering with physicians to ensure high quality care. With so many critical tasks, it can be difficult to implement and pursue new initiatives.
That’s why the achievements of the pharmacy team at Holmes Regional Medical Center (HRMC), part of the four-hospital Health First network in Central Florida, are so impressive. The team continually pursues new and innovative projects, using technology to support their efforts.
“Our department thrives when novel patient care initiatives enable pharmacists to practice at the top of their license,” said Michael Sanchez, PharmD, BCCCP, Pharmacy Residency Coordinator. “We’re always looking for ways to optimize medication therapies, prevent adverse events, and contribute to antimicrobial stewardship.”
Three recent initiatives spearheaded by HRMC’s pharmacy team and supported by VigiLanz have significantly improved patient care while reducing costs.
Initiative #1: Medication optimization protocol reduces hyperglycemia in patients with acute COPD
In September 2019, HRMC pharmacists began collaborating with pulmonologists across the Health First network to identify opportunities to improve care for patients with acute exacerbation of COPD (AECOPD).
“We had seen some small studies describing the benefits of having pharmacists transition IV corticosteroids to PO, and we wanted to see how that could impact our hospital,” said Sanchez. “Oral and IV corticosteroid therapy have comparable outcomes, but oral therapy is associated with fewer adverse events and is less expensive.”
To test and evaluate the impact, HRMC implemented a protocol enabling pharmacists to independently change IV corticosteroids to oral prednisone, when appropriate. VigiLanz supports the initiative by sending an alert to pharmacists whenever a patient with AECOPD meets HRMC’s eligibility criteria.
“The VigiLanz alert is highly accurate in detecting patients who would benefit from streamlining to oral corticosteroids,” said Sanchez. “We wouldn’t have been able to implement this new protocol without it, due to the complexities of the eligibility criteria.” The criteria include current use of IV corticosteroids, respiratory rate, blood gas results, allergies, and history of asthma.
The workflow:
- VigiLanz alerts pharmacists of eligible patients, based on eligibility criteria
- Pharmacists review patients’ medical records to confirm eligibility
- Pharmacists switch eligible patients from IV corticosteroids to 40 mg of oral prednisone per day for five days
To assess the impact of the new protocol, HRMC pharmacists compared outcomes for 128 AECOPD patients admitted pre-protocol (November 1, 2018 to February 9, 2019), with outcomes for 134 AECOPD patients admitted post-protocol (November 1, 2019 to February 9, 2020).
“To our knowledge, this is the largest study examining the impact of a pharmacist-led IV to PO corticosteroid conversion protocol for AECOPD, and it’s the only study to examine safety endpoints, such as hyperglycemia,” said Sanchez.
While the study found no significant differences in average length of stay, 30-day readmissions, average blood glucose, or mean cost of corticosteroids per patient, it did find that the post-protocol group had a significantly lower rate of hyperglycemia (62% vs 37%).
“The odds were really stacked against that outcome because the intervention group had
more diabetic patients,” said Sanchez. “In the next few years, I hope we can gather more data to evaluate if there’s also a reduction in glucose related complications.”
The Health First network is considering incorporating the protocol into an AECOPD order set to guide physicians toward oral corticosteroid treatment. Based on feedback from providers, the new protocol would recommend moving from a single 40 mg daily dose of prednisone to two 20 mg doses to further reduce hyperglycemia.
Initiative #2: Kcentra initiative reduces thrombosis risks and cuts
In early 2020, Ted Heierman, PharmD, Clinical Pharmacy Specialist at HRMC, and Brianna Glenn, Pharmacy Resident at HRMC, noticed an increase in prescriptions for Kcentra, the only FDA-approved alternative to plasma for urgent warfarin reversal.
“We suspected that some of the increase in Kcentra utilization was inappropriate, and we confirmed that suspicion with a medication use evaluation,” said Heierman. “We began exploring how VigiLanz could help us address this problem.”
Heierman and Glenn worked with VigiLanz to create a Kcentra alert that is sent to the pharmacy team whenever the medication is prescribed.
The workflow:
- VigiLanz alerts pharmacists of Kcentra orders in real-time
- Pharmacists screen patients to ensure they meet Kcentra use criteria
- If patients don’t meet use criteria, pharmacists discuss medication alternatives with prescribers
“With this new approach, we found that Kcentra was being inappropriately prescribed about 15 percent of the time,” said Heierman, noting that the alert has been in place since September 2020. “This new approach has reduced inappropriate use to nearly zero.”
HRMC’s Kcentra use criteria:
- Life-threatening bleed
- Documented warfarin or direct-acting oral anticoagulant (DOAC) use
- For DOAC use, anti-factor Xa (AntiXa) above 0.5.
- For intracerebral hemorrhage-Glasgow coma scale(ICH-GCS) above 8 and neurosurgical evaluation and planned surgical intervention
“The initiative has significantly improved patient care and reduced costs,” said Heierman, noting that Kcentra comes with thrombotic risks, so ensuring appropriate use decreases the risk of thrombosis. “With a 15 percent reduction in use and 100 percent appropriate use, our HRMC can potentially save around $105,000 each year.”
Initiative #3: Pharmacist interventions reduce hypoglycemia and cut costs
In 2019, Health First identified that one of the top risk factors for severe hospital-acquired hypoglycemia in its health system was providers not adjusting insulin regimens after patients had episodes of hypoglycemia. HRMC pharmacists immediately began exploring how they could help prevent this problem.
The result was a new protocol, implemented in March 2019, that enables pharmacists to independently decrease rapid and long-acting insulin regimens if a hospitalized patient has had a severe hypoglycemic event after receiving insulin.
When the protocol was first implemented, nurses were tasked with notifying pharmacists of severe hypoglycemic events. However, the pharmacy team quickly recognized that real-time clinical surveillance could improve efficiency and reduce the risk of an error. “VigiLanz ensures we receive timely notifications and can adjust the patients’ insulin therapy sooner,” said Sanchez.
The workflow:
- VigiLanz alerts pharmacist when patients with hypoglycemic events have received insulin in the past 24 hours
- Pharmacists review patients’ information, and decrease insulin based on glucose value, as follows:
- 61 – 69 mg/dL = Reduce all meal insulin by 1 unit
- 51 – 69 mg/dL = Reduce basal insulin by 20 percent daily
- Less than or equal to 60 mg/dL = Reduce all meal insulin by 2 units
- Less than or equal to 50 mg/dL = Reduce basal insulin by 40 percent daily
HRMC had completed VigiLanz activations for 235 patients as of November 2020, and the protocol had decreased severe hypoglycemic events in patients with insulin from 7.14 percent to 5.45 percent.
The new protocol has also reduced costs, because the Centers for Medicare and Medicaid characterizes certain complications due to hypoglycemia as never events, said Sanchez. As a result, it does not reimburse hospitals for the extra costs associated with these events.
“On a personal level, my passion for supporting this initiative arose from helping the code response team identify severe hypoglycemia in a coding patient,” said Sanchez. “I’m confident this protocol has, and will continue to, prevent devastating outcomes for many patients.”
To learn more about how VigiLanz helps hospitals improve their patient safety and clinical surveillance, visit https://vigilanzcorp.com/ today.
