TOC

Question 1

Cost associated with AE?

Answer 1

A single ADE can increase length of stay by as much as 4.6 days and increase cost up to $4685.

Question 2

Hospital admission

Answer 2

36% of paitents had errrs in admission meds

Question 3

Hospital discharge

Answer 3

30% of patients have at least one medication discrpancy at discharge

Question 4

Readmissions

Answer 4

20% readmission rate within 30days (~25% medicare)

Question 5

System Clinical Council

Answer 5

approved recommendation for pharmacy involvement in review of PTA meds and at discharge

Question 6

TOC documented by pharmacy

Answer 6

PPMC 46%

PSVMC 38%

Question 7

Impact of TOC

Answer 7

fewer readmissions in patients receiving Pharmacy TOC services

Question 8

TOC Focus

Answer 8

1. Provide patient education on oral anticagulants
2. Review CHF patients for pharmacist TOC activities-HF patients are at highest riks for readmission of all CMS core measure diseases

Question 9

TOC clinical worflow

Answer 9

1. Complete clinical ivents, dosing, and AMS review
2. Identify high risk patients
   - patients new oral antiC
   2b. ensure education i-vent is open and provide patient education
   2c. HF emphasize adherence compare discharge and admission list to hospital meds

Question 10

How to identify new start oral anticoagulaiton patients

Answer 10

At order verification of ALL warfarin and DOAC orders open ivent

Question 11

Patient Education Handouts

Answer 11

• add pertinent info for patient i.e dose they are taking and indication
• review each section with patient, check for understanding and questions
• Continue to provide coumadin booklet for warfarin patients.

Question 12

Patient Education Documentation

Answer 12

Complete i-vent education documentation

Complete Patient Education documentaiton in EPIC

Question 13

PVI Tool

Answer 13

Providence Vulnerability Index- method to idenitfy the highest risk to readmit CHF patients

Question 14

PVI

Answer 14

30 day readmit risk Score 
very low =1
low=2
Med=3 
Med High=4
High=5
Very High=6

Question 15

How do I document TOC activites for CHF patients?

Answer 15

add (CHF patient) to pharmacist documentaiton in the i-vent for admission med hx, education, and discharge med rec.

Question 16

Readmission Problem

CHF exacerbation

Answer 16

diuretics omitted or unclear directions on discharge med list. Educate patient on medication compliance

Question 17

Readmission Problem

hypokalemia

Answer 17

K ordered with diuretics? is patient tolerating K? Alternative product?

Question 18

Readmission Problem

AKI

Answer 18

ACE-I along with ibuprofen and aspirin. Pt Education

Question 19

Readmission Problem

Constipation

Answer 19

New start opioids without stool softener/laxative

Question 20

Readmission Problem

N/V/D

Answer 20

New start colchicine. Pt education on SE and when to contact physician

Question 21

Common CHF Meds

Answer 21

Beta Blocker
ACE or ARB
Nitrates or hydralazine 
Aldosterone Antagonist 
Diuretics

Question 22

Negative Inotropic effect

Answer 22

CCB (verapamil diltiazem, nifedipine) except: amlodipine

• Sotalol, Flecainide, dronedarone
• itraconazole, amphetamines, anagrelide, cilostazole, etanercept, infliximab
• natural products: Ephedra, Ma huang

Question 23

Sodium or water retention

Answer 23

NSAID’s, Celecoxib, systmeic corticosteroids, TZD (glitazones), minoxidil (direct arterial vasodilator)