Toolbox Talk – Pharmacy Session 3 Change Champion Breakout … · 2018. 7. 5. · Page 1Digital Hospital Program of 22 Mar 18 v0.1 Toolbox Talk – Pharmacy Session 3 Change Champion

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Digital Hospital Program Mar 18 v0.1

Toolbox Talk – Pharmacy Session 3 Change Champion Breakout Session Topic : Clinical Pharmacist Review of Complex Medications (Insulin, warfarin, tapering dose, and blood products)

Introduction This Toolbox Talk covers important information about:

• How a Pharmacist should review complex medications charted in PowerChart • How a Pharmacist would order appropriate non-medication orders to communicate important

high-risk-medication-related information • How a Pharmacist would review non-medication orders and modify as appropriate • Where ordered blood products appear in PowerChart

Key Points The following are the key points that need to be covered in this session:

1. How to review complex medications in ieMR as a Pharmacist 2. How to order, modify and cancel non-medication “dummy” orders as a Pharmacist 3. Where ordered blood products can be found in PowerChart and how to review these

Discussion Questions Subcutaneous Insulin Careset

1. How does a prescriber order regular subcutaneous insulin? Regular subcutaneous dosing is ordered using a Careset. To order an insulin Careset, the prescriber must search for the insulin using the brand name. The prescriber must ensure they carefully select the correct Careset (based on insulin-type and population (adult versus paediatric).

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The insulin orders within the Careset are specific for each day of the week only, therefore an individual order is required for each day. The daily insulin Careset orders have a stop date, which is 24 hours from day/time of order. If you wish to order additional/the same doses on different days of the week, then the order for each day must be selected in the Careset. This is referred to as Vertical Prescribing (we do not want a prescriber to prescribe horizontally)

Once a prescriber has selected the correct insulin for the correct days and has entered in the appropriate dose, the prescriber can select OK and sign the order(s).

2. How does a prescriber order sliding scale insulin? To order a sliding scale, a prescriber would need to order the Insulin Supplemental Subcutaneous PowerPlan. The PowerPlan is divided into Subphases. The phase to be used should be selected based on the patients level of insulin resistance. This is related to the patient’s body weight and usual daily insulin dose. It is important to select the correct phase, as the sliding scale dosage varies between the subphases.

Vertical Prescribing

Horizontal Prescribing

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The default dosing range (sliding scale) in Order Comments can be adjusted as required. Default administration times can be adjusted as required, by clicking the Frequency drop down arrow, and then clicking the ellipsis button.

3. How would a prescriber order a STAT dose of insulin?

In the system, a STAT dose is referred to as a ONCE ONLY dose with a NOW priority.

A prescriber would order the Insulin Subcutaneous (All Types) Once Only Careset for ordering once only NOW doses of insulin. There are separate options for Adults and Paediatrics.

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Within these Caresets, all insulin types are listed and categorised into Short Acting, Long Acting and Combination groups.

The prescriber must first select the insulin order, and then enter the dose for the selected insulin, ensuring the correct date and time have been entered.

4. What other orders are associated with Subcutaneous Insulin Caresets?

There are a number of additional orders within the insulin Caresets. Some of these will be pre-selected and some will not be. Additional orders include:

• Patient Care tasks – Blood Glucose Monitoring, Blood Ketone Monitoring, Urine Dipstick • Insulin Dose Check Order • Hypoglycaemia treatment • Consults to other specialists/health professionals

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5. What is the purpose of an Insulin Subcutaneous Dose Checker? All Adult Insulin Caresets include pre-selected Insulin Subcutaneous Dose Check orders. These are administration reminder tasks to prompt the Nursing Staff to confirm that there is an insulin dose prescribed at each specified time. Therefore, the timing of the Insulin Subcutaneous Dose Check orders should be consistent with planned regular and supplemental dosing times.

The subcutaneous dose check acts as a safe guard in case a dose is not charted. It is useful to place in the order comments for the dose check the brand name of the regular insulin used.

Only one dose check is required for each administration time for insulin no matter if different insulins are administered at the same time. This means that each time a Careset is ordered, you will need to assess if a dose check order is required

6. What should a pharmacist do if the Insulin Subcutaneous Dose Checker is absent, has a

mismatched frequency/time (compared to the insulin doses) or if there are multiple dose check orders? If the Insulin Subcutaneous Dose Checker is absent, a pharmacist can order this via the orders page. From the orders page, select Add and search for “insulin dose”, select the following order with an associated order sentence “Insulin subcutaneous dose check” (ensuring you are selecting the correct age group).

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The pharmacist should ensure the frequency is appropriate for the patient’s insulin regimen and should also ensure that the times of the dose check align with the due times of the insulin dose(s).

Once the pharmacist has clinically reviewed the order for appropriatness, the pharmacist can sign the order which will immediately send the order to the MAR. If the Insulin Subcutaneous Dose Checker has a mismatched frequency/time compared to the subcutaneous insulin doses, a pharmacist can modify the current Insulin Subcutaneous Dose Checker found in the orders screen. This will open the scratch pad where the pharmacist can modify the frequency and/or times of the dose check to match the patient’s insulin order(s). If there are multiple Insulin Subcutaneous Dose Checkers, the pharmacist can Cancel/Discontinue the additional, unnecessary dose checkers via the orders screen. Only one dose check is required for each administration time for insulin no matter if different insulins are administered at the same time.

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7. The Doctor says they have ordered this morning’s insulin however I can’t see any insulin due for today. Why would that be? This may be because the prescriber placed the order after the due time of the morning insulin. The regular Insulin Careset default time for morning doses is at 7.00am. If a prescriber orders the morning insulin dose via an Insulin Careset (rather than the once only Insulin PowerPlan) after 7.00am and does not modify the due time of the morning dose, it will automatically default to 7.00am the following week, for the same day (e.g. It is Wednesday morning at 7.05am. The prescriber prescribes a Novorapid dose using the Novorapid Insulin Careset which they want to be given this morning. Because the prescriber forgot to change the time of the morning Novorapid dose, the complete Novorapid order they thought they were prescribing for today has now appeared on the MAR for administration NEXT Wednesday). This is why it is very important for prescribers to always review their ordered medications on the MAR, once they have signed their order, to ensure it is appearing for administration as intended.

8. The patient has an insulin pump. How does a prescriber document this? Yes. These can be ordered by the prescriber using the Insulin Patient’s Own Pump PowerPlan.

9. The patient self-titrates and self-administers their regular insulin. How would a prescriber document this?

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This can be prescribed using the Insulin Subcutaneous Self-Titration Adult PowerPlan

10. Are there any other important subcutaneous insulin orders I should be aware of? Yes. Below are a list of additional insulin PowerPlans available in ieMR:

11. What ways can a pharmacist or intern pharmacist review insulin orders? There are several ways that insulin dosing can be reviewed. The information can be viewed as a table, as a graph or at the point of ordering. Best practice is to review all previous insulin orders and modifications using MAR Summary You can filter by endocrine agents – and view over a 24 hour period. Finally, don’t forget to expand your medication order details cell to be able to see the order in its entirety.

If your preference is to review the patient’s results in a table format, this can be done from the Diabetes – Endocrine band in Interactive View. Results display insulin dosing, ketones and BGLs in one place.

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If your preference is to review the patient’s results in a graphical format, this can be done from the Advanced Graphing band in Interactive View. If the Advanced Graphing band does not appear by default, this can be added to your profile (please refer to QRGs). The Advanced graphing band allows a view of insulin dosing, ketones and BGLs. You can view graphs/results while reviewing the MAR/MAR summary by using the Tear Off function.

The BGL trends can also be reviewed graphed on Results page. The BGL data populates on the Assessments tab.

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12. On discharge, how does a prescriber reconcile insulin and indicate the discharge dose?

For patients who were prescribed the same insulin prior to admission:

Within the discharge reconciliation screen, the prescriber will stop ( ) all insulin orders charted

during the encounter (these can be identified by this symbol ). The prescriber must not select

any of the radio buttons ( ) for the documented home medication insulin

(identified by this symbol ), instead the prescriber will right click on the documented home medication and select Modify, entering information about the dose for discharge into Special

Instructions. If the patient requires more supply on discharge, the button may be selected for the documented home medication insulin and the Special instructions updated at this point.

For patient’s prescribed new insulin (started in hospital):

Within the discharge reconciliation screen, the prescriber will select the prescription button for only one insulin order for each type of insulin that they would like to write a prescription for/continue on discharge. Within the prescription scratch pad, the prescriber will enter information about the dose for discharge into Special Instructions. If there is more than one insulin dose for

that type of insulin, the prescriber must stop ( ) all other doses.

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Warfarin PowerPlan

13. How does a prescriber order regular warfarin? How do they ensure they select the right brand? The prescriber will order warfarin through a PowerPlan. From the orders screen, the prescriber is encouraged to search for warfarin using the correct brand name to ensure the correct warfarin PowerPlan is selected.

Within the PowerPlan, the prescriber can then order warfarin dose(s).

14. What is the difference between ordering a NOW once only warfarin dose versus a dose ordered

for next 1600? The first warfarin dose option (which appears underneath the yellow heading “Default order time is 1600. If dose for today is overdue, please use the NOW order”) is to be used when the prescriber is ordering a warfarin dose for today and the time they are placing this order is after 1600. By selecting this warfarin option, the order will be placed onto the MAR for nursing staff to administer today (with a due time of NOW).

The second warfarin dose option (which appears underneath the yellow heading “Dose ordered for next 1600”) is to be used when the prescriber is ordering a warfarin dose for today and the time

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they are placing this order is before 1600. By selecting this warfarin option, the order will be placed onto the MAR for nursing staff to administer today at 1600.

15. Can a prescriber order multiple days of warfarin doses at once?

Yes. Within the PowerPlan, a prescriber can order more than one dose of warfarin. When a prescriber is initially prescribing warfarin: If the prescriber is prescribing the warfarin before 1600, the prescriber will select today’s dose and any additional doses by selecting the future doses they wish to prescribe. The offset indicates when that dose will be due for administration (e.g. +1 day indicates that the dose will be available for administration tomorrow at 1600)

If the prescriber is prescribing the warfarin after 1600 (i.e. they are utilising the NOW once only warfarin dose within the PowerPlan), the prescriber will need to be mindful that they select the NOW once only dose, the dose with no offset (which will be available for administration at the next 1600 (i.e. tomorrow)), and any future doses (keeping in mind that the offset will be from the next 1600 e.g. It is 1700 on a Monday and a prescriber is ordering a NOW once only warfarin dose for today, another warfarin dose for Tuesday, and a third warfarin dose for Wednesday. The warfarin dose which will appear on the MAR for administration tomorrow (Tuesday) will be the dose prescribed which does not have an offset. The warfarin dose which will appear for administration on Wednesday will be the dose prescribed with an offset of +1 day)

When a warfarin PowerPlan has already been initiated and signed by a prescriber and another dose of warfarin needs to be prescribed: The prescriber will navigate to the initiated warfarin PowerPlan within the orders screen and Add to Phase (Add Order).

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Within this screen, the prescriber must search by the correct warfarin brand name and select the order which has an associated order sentence.

This will open up the scratchpad where the prescriber has to enter in all mandatory fields (which are highlighted yellow). It is important that the prescriber reviews the offset details to ensure the dose will be due for administration on the correct day/date.

16. How can you offset a warfarin dose?

Within the warfarin scratchpad, the prescriber can navigate to the offset details tab where they can indicate what offset (if any) they would like for that dose of warfarin. Once an offset is entered, the actual start date/time will appear below the manually entered offset so the prescriber can review this and ensure it matches their intention.

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17. Is it mandatory for the prescriber to enter the indication and target INR range? Yes. The warfarin dose, indication, and target INR fields are mandatory.

18. How would a prescriber with-hold a dose? For a dose which is currently ordered: The prescriber would navigate to the warfarin PowerPlan within the orders screen and locate the dose of ordered warfarin they would like to with-hold, right-click this order and select modify. The scratchpad will open below. Within the dose field, the prescriber will type WITHHOLD. This will prompt a warning within the system saying that the dose (WITHHOLD) has been entered as a freetext value (which means that dose range checking will not be possible). The prescriber is to select ‘Yes’ when presented with this warning

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For a dose which has not yet been ordered: When a prescriber would like to withhold a future dose which has not yet been ordered, the prescriber would either freetext WITHHOLD for the future dose if prescribing the initial warfarin PowerPlan or they would locate the current warfarin PowerPlan, add to phase a warfarin dose and type WITHHOLD within the dose field of this order.

19. What other orders are associated with the Warfarin PowerPlan? Within the warfarin PowerPlan, there are warfarin medication orders as well as:

• A warfarin/INR dose check – this is pre-selected within the PowerPlan to remind nursing

staff to check if a warfarin dose is present for that day and/or review the relevant INR results, escalating to a prescriber where necessary

• Laboratory orders – FBC, INR, CHEM20, platelet count • Consult to Pharmacy (for warfarin education) – this is pre-selected within the PowerPlan

and functions similarly to the red warfarin education record located in the centre of the NIMC.

20. How does a Pharmacist know if warfarin counselling is required?

As mentioned above, the Consult to Pharmacy (for warfarin education) is pre-selected within the PowerPlan. This will send a message to the pharmacist’s Multi Patient Task List, under the Pharmacy Consults tab where the pharmacist can review the consult and action this as appropriate.

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• If warfarin counselling is provided, the pharmacist will sign of the pharmacy consult and document what counselling was provided (e.g. verbal, written materials etc).

• If warfarin counselling is not required, the pharmacist will right click on the consult task and select “Chart Not Done” and enter counselling not required in the reason field.

21. On discharge, how does a prescriber reconcile warfarin and indicate the discharge dose? If the patient has warfarin documented as a home medication:

Within the discharge reconciliation screen, the prescriber will stop ( ) all warfarin orders

charted during the encounter (these can be identified by this symbol ). The prescriber must not

select any of the radio buttons ( ) for the documented home medication

warfarin (identified by this symbol ), instead the prescriber will right click on the documented home medication and select Modify, entering information about the dose for discharge into

Special Instructions. If the patient requires more supply on discharge, the button may be selected for the documented home medication warfarin and the Special instructions updated at this point.

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If the patient was started on warfarin during the admission (therefore scripts are necessary):

Within the discharge reconciliation screen , the prescriber must stop ( ) all warfarin doses

charted during the encounter (these can be identified by this symbol ). The prescriber will then Add warfarin as discharge prescriptions, utilising Special Instructions to convey information about the warfarin discharge dose. The prescriber must remember to prescribe all three warfarin strengths, searching by the correct brand name.

Tapering Dose 22. When would a prescriber use the tapering dose function?

The tapering dose function can be used when a prescriber is wanting to increase or reduce the dose of a medication at a specified rate. The tapering dose function is only available for specific medication orders. You will know if a tapering dose function can be performed if you notice the symbol highlighted below is green.

23. What are the benefits of using the tapering dose function?

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The tapering dose function saves prescriber time and risk of dose input error as the function will automatically calculate the tapered doses and order each dose (rather than a prescriber having to manually calculate this and order each change in dose as a separate order).

24. How does a prescriber order a tapering dose? From the orders screen, the prescriber will add an order, searching by generic drug (or brand name for high-risk or brand-specific medications) and select the order which has the most appropriate order sentence. From the scratchpad, the prescriber will enter in the indication, the initial dose, and modify the frequency if necessary. The prescriber will then select the tapering dose function which will bring them to the following screen:

The prescriber must complete all mandatory fields, ensuring the correct tapering details are entered correctly. Once this is done, the prescriber will then select Calculate Steps. The Planned Regimen box should now be populated with the planned doses. The prescriber will then select OK and review the orders in the next screen. If any orders are inappropriate, the prescriber can remove or modify these. The prescriber would then sign their orders as per their usual process and these tapering dose will be will be in an ordered status.

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25. On discharge, how does a prescriber reconcile the tapering medication and indicate the discharge dose?

Within the discharge reconciliation screen, the prescriber will select the prescription button for only one tapering dose medication order. The prescriber should select the prescription button for the order(s) which most closely matches what will be required on discharge (e.g. if the patient is tapering prednisolone (currently on 50mg with the plan to reduce by 10mg every three days), the prescriber should select the prescription button for both the 50mg and the 10mg prednisolone orders. This will then produce a prescription for both the prednisolone 25mg tablets as well as the prednisolone 5mg tablets, respectively). Within the prescription scratch pad, the prescriber will enter information about the dose for discharge into Special Instructions. All other tapering dose

orders must be stopped ( ) by the prescribers.

Blood Products 26. Why don’t Blood Products appear on the MAR?

Blood products do not appear on the MAR as they are not flagged as a medication within the system. The prescriber orders the administration of a blood product within ieMR which falls under the category of Laboratory.

27. How do I know if my patient has been ordered for blood products? There are a two ways you can check if your patient has been ordered for blood products: From the orders screen, if you ensure your display is set to All Orders (All Statuses), any ordered administration of blood product(s) would appear under the laboratory category (depending on what view you have customised)

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Another way to see if blood products have been administered is through Interactive View. There is a Navigator Band titled Blood Product Administration which is where nursing staff would document administration of blood products. If this band is not viewable to you, you can customize your Navigator Bands to ensure the Blood Product Administration band is viewable.

28. Where do nursing staff document relevant observations and batch information about blood products? As illustrated above, nursing staff document this information within Interactive View.

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29. How do pathology know what blood products to supply?

Processes for generating an order with blood bank and obtaining blood products from blood bank will remain unchanged.

Practice Activity As a Doctor

1. Log into PowerChart and order the following: • Novorapid once only, due now, 8 units • Novorapid and Lantus Careset for today and tomorrow (please consider the once only

Novorapid dose you have prescribed to ensure the time between the next dose is appropriate) – The patient only takes Novorapid in the morning (8 units) and at night (10 units), Lantus is 10 units at night

• Marevan 2mg for tonight, 3mg for tomorrow, and with-hold after this as the patient is having a procedure

• A tapering dose of prednisolone (starting at 50mg, tapering by 5mg every 3 days, final dose is 5mg and patient will stop final dose after 3 days) indication: exacerbation of COPD

As a nurse

1. Administer Novorapid (entering a BSL of 12 mmol/L), prednisolone and Marevan (need to give early as patient is attending an appointment)

2. Mark off the morning insulin dose checker 3. Enter another two BSL readings – 14mmol/L and 16mmol/L

As a pharmacist

1. Log into PowerChart and review the patient’s insulin (utilising the MAR summary, advanced graphing, and results page)

2. Review the insulin dose checker. The insulin dose checker will not align with the insulin doses. Modify the dose checker to ensure this aligns.

3. Review the warfarin doses 4. Review the tapering doses

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Toolbox Talk – Pharmacy Session 3 Change Champion Breakout … · 2018. 7. 5. · Page 1Digital Hospital Program of 22 Mar 18 v0.1 Toolbox Talk – Pharmacy Session 3 Change Champion