Today’s edition of Tales from the Counter is about pharmacist interventions. Interventions are not a new concept in pharmacy. Pharmacists have been interventionists for decades, and it doesn’t take a clinical pharmacist or a clinical environment to be an interventionist. Our main pharmacy documents several thousand interventions every month. When some pharmacists hear about the number of interventions our pharmacies document, they are often skeptical of either the quantity or the quality of the interventions. I thought that it would be interesting to give an overview of several categories of interventions that I completed during the last Monday morning I worked the counter. During this 5 hour shift I documented 186 interventions. I have picked a few key areas to discuss today as examples of our interventions and processes.
Compliance
Using a Percent of Days Covered (PCD) calculation looking at the last 6 months worth of refills, our PharmClin software alerts the pharmacist to any impending compliance issues (for all patient medications, not just the one being filled). Non-compliance is defined as a PDC below 75% or are above 125%. During my last Monday on the counter, 123 different medications were flagged as non-compliant. As we have stated in previous posts on this blog, compliance is one of the most common issues we see. It also represent the basis of three different EQUiPP pharmacy performance measures. We assess PDC on every medication, and many acute or as needed drugs will eventually fall into a “non-compliant” (or, in the case of a PRN medication, a hyper-compliant) state. Each one needs to be evaluated on a regular basis to ensure there are not any real problems underlying the issue. Of the 123 compliance issues evaluated:
- 91 were deemed non-issues because they represented acute drugs or were “as needed” medications. Each of these were flagged as “continue to monitor” and will be re-evaluated in 90 days (to prevent Alert Fatigue)
- 26 were explained by other evidence (recent dose changes)
- 9 were flagged for face-to-face questions with the patient. Illustrative examples included:
Propafenone compliance at 72%. The patient was asked if the dose or instructions have changed (and we were not alerted). Patient denied any change and denied any missed doses. The follow-up evaluation for this drug was moved up from 90 days to 30 days to re-assess.
Omeprazole compliance dropped to 63%. Patient asked if still using or if it was discontinued. Patient reported that the medication was discontinued and that they are using OTC ranitidine with good relief of occasional symptoms.
Omeprazole compliance at 70%. patient reports “as needed” use of this medication. Wanted the Rx to be available in case symptoms reappeared. Note sent to prescriber requesting a new Rx with “as needed” directions.
Sertraline compliance dropped to 63%. When approached, the patient admitted that she had this filled at another pharmacy to take advantage of a new patient program. The importance of a “pharmacy home” was discussed with the patient.
Metformin compliance at 73%. Patient reported that the doctor was doing a 90 day trial. The medication was discontinued
Screening for Adverse Drug Reactions (ADRs)
We routinely look for ADRs on several drug categories including all diabetic medications, opioid pain medications, and warfarin. PharmClin alerts the pharmacist of a new problem or that it time to re-assess an old one. Like other interventions, once an ADR potential has been investigated, the intervention is scheduled for re-assessment in 30 to 90 days (depending on the medication or the seriousness of the potential issues) to prevent Alert Fatigue. This built-in timing also prevents the patient from becoming overwhelmed with constant queries. The periodic nature of the ADR queries also allows us to assess problems that develop with time.
During my last Monday, almost 30 different potential ADRs were noted. Each of these resulted in a face-to-face with the patient. Some examples of these interventions:
- Patient on Novolog: Confirmed with the patient they understood the signs and symptoms of low blood sugar. Also documented blood glucose testing frequency and date of the last drawn Hemoglobin A1C.
- Warfarin patient: Asked about any unusual bruising or bleeding. Also documented patient reported goal INR, draw schedule, and last INR (patient reported value)
- Patient on Tramadol: Queried patient on possible constipation and confusion / drowsiness from the medication. Patient denies any problems at this time.
- Patient on Metformin: asked about diarrhea and other potential ADRs. Patient reports that this medication caused them to “fall” and that the prescriber discontinued the medication. Note sent to the prescriber to confirm discontinuation as no other therapy for blood sugar noted in patient profile.
Other Interventions
- During the 5 hour period, seventeen different new medications were flagged for counseling and patient education.
- Fourteen new “therapeutic duplications” were evaluated. None of these were deemed inappropriate.
- Five prescriptions were flagged as “product is the same but may look different” to alert the patient to a generic product change
- four different Lab values were recorded in the patient’s electronic chart. These included blood pressure, INR, TSH, and A1C
None of the above examples is above and beyond what an engaged pharmacist does on a daily basis. The primary difference, though, is the documentation done. By documenting what was done, and when it needs to be revisited, we can make every encounter with our patients count.