Demographics: Average Age 66 years SD +/ Gender: Female Gender: Male

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1 Organization: Sinai Hospital of Baltimore Solution Title: Pharmacy Renal Dosing Service Program/Project Description, including Goals: The Department of Pharmacy at Sinai Hospital takes a proactive approach in identifying opportunities to support medical care and promote the safe use of medications within the organization. As such, the department undertook a retrospective review to determine if an opportunity existed to develop a Pharmacy Renal Dosing Service. The objective of the review was to quantify and describe the extent to which renally eliminated medications were adjusted with changing renal function. Process: Using the Plan-Study-Do-Act framework, the Department of Pharmacy conducted a retrospective chart review was conducted for a consecutive thirty-one day period (July 8, 2015 to August 7, 2015). Patients with a 0.2 or 20% change in serum creatinine from the previous day AND an active order for a renally eliminated medication were included in the scope of the review. Data collected included demographics, service, location, and medication order history details. Data was analyzed by comparing the current estimated creatinine clearance to the current medication dose and frequency. Missed renal dosing opportunities were quantified and described. Timeframe: July 8, 2015 to August 7, 2015 Number of Patients: 74 Number of Renal Dosing Opportunities: 121 Demographics: Average Age 66 years SD +/ Gender: Female Gender: Male 48% 52% 58/121 63/121 Average Weight 78 SD +/ Hemodialysis: Yes Hemodialysis: No 86% 17/ /121 Unit: ICU Unit: 3 rd Floor Unit: IMC Unit: 6E/6W Unit: B6: Unit Other 22% 18% 17% 15% 13% 27/121 22/121 21/121 18/121 16/121 17/121 Service: Medicine Service: Surgery Service: Emergency Service: Psychiatry Service: Other 73% 9% 5% 4% 9% 88/121 11/121 6/121 5/121 11/121 1

2 Change in Renal Function Chart 1 Declined 33% Improved 67% Improved Declined Dose vs. Frequency Change Chart Dose Frequency 2

3 Opportunites by Medication Cefazolin Chart 3 Other 19% Cefazolin 7% Ciprofloxacin 7% Enoxaparin 6% Ciprofloxacin Enoxaparin Famotidine Meropenam Piperacillin Tazobactam 29% Famotidine 18% Piperacillin Tazobactam Other Meropenam Dose/Frequency Changed? Medication D/C 16% Chart 4 Yes 7% No Yes No 77% Medication Discontinued Solution: Medications identified for the review included: Cefazolin (7%), Ciprofloxacin (7%), Enoxaparin (6%), Famotidine (18%), Meropenam (), Piperacillin-Tazobactam (29%), and a category of other (19%) (Chart 3). Analysis of the data revealed 33% of the patients included in the review experienced a decline in renal function (Chart 1) during the identified timeframe. The most frequent intervention required based on renal function was a change in medication frequency 3

4 (Chart 2). Upon further review, opportunities to intervene by changing the medication frequency or dose were missed 77% of the time (Chart 4). As a result of the retrospective review, the Department of Pharmacy recommended the implementation of an automatic renal dosing service in order to ensure patient safety, improved medication outcomes, avoid adverse drug events, and reduce the number of missed dose opportunities. After approval by the Pharmacy and Therapeutics Committee and Medical Executive Committee, development of the Pharmacy Renal Dosing Service was commenced by establishing the goals of the program. The goals of the program are to reduce the number of medication dosing errors for patients with renal dysfunction, to improve quality outcomes for patients by avoiding adverse drug events or subtherapeutic drug concentrations and to realize the financial savings for the hospital by avoiding costs associated with iatrogenic toxicity or under dosing of critical medications. In addition, a policy was developed to ensure the proper adjustment of renally-eliminated medications for patients with changes in renal function. Medications approved for Pharmacist doing in renal impairment include Acyclovir, Apixiban, Ciprofloxacin, Dabigatran, Daptomycin, Edoxaban, Enoxaparin, Famotidine, Fondaparinux, Ketoralac, Levofloxacin, Meropenem, Pipercillin/Tazobactam, and Rivaroxaban. Pharmacist education of this new process and policy will begin in early December with an anticipated start date of December 15, Measurable Outcomes: Once the program begins in December, the Department of Pharmacy will continue measure the number of missed opportunities with an established goal of zero. Sustainability: In order to sustain momentum with the Pharmacy Renal Dosing Service, data collection will focus on missed opportunities instead of number of pharmacist interventions. The data will be reported regularly at the hospital-wide Performance Management Council, Pharmacy and Therapeutics Committee, Antimicrobial Stewardship Committee, and newly formed Anticoagulant Stewardship Committee. Role of Collaboration and Leadership: The development of the project was multidisciplinary including members of the Pharmacy and Therapeutics Committee and Medical Executive Committee. Representatives of the Pharmacy and Therapeutics Committee include members of the medical staff, executive team, Pharmacy, Quality/Medication Safety, Patient Care Services, Infection Prevention and Control, Nutrition Services, and the Education Resource Center. Innovation: Currently, the Pharmacy does not have a clinical surveillance system in place. This requires reports to be home grown written and tested - by the Clinical Pharmacy Manager. In 4

5 addition, the dosing service will measure the effectiveness of the program throughout the patient s hospitalization. Data collection will focus on missed opportunities instead of the more traditional focus of pharmacist interventions. Related Tools and Resources Policy: Pharmacy Dosing Service Renal Dosing Literature available upon request Contact Person: Kathleen Friedel, RN Title: Medication Safety Officer kfreidel@lifebridgehealth.org Phone: