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Hospice Pharmacia is pleased to announce the release of the Pharmaceutical Care Tool Kit & MUGs Version 5. May 2003 Doug Weschules, PharmD, Director of Clinical Programs Jill McMath, PharmD, Director of Education Heather K. Omlor, PharmD, VP Client Development

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slide1

Hospice Pharmaciais pleased to announce the release of thePharmaceutical Care Tool Kit& MUGs Version 5

May 2003

Doug Weschules, PharmD, Director of Clinical Programs

Jill McMath, PharmD, Director of Education

Heather K. Omlor, PharmD, VP Client Development

Stephanie Zarus, PharmD, Chief Performance Officer

pharmaceutical care tool kit and mugs
Pharmaceutical Care Tool Kit and MUGs
  • First published in 1996
  • Limited distribution (<50 copies)
  • Less than a dozen guidelines
  • Designed in response to request by nurses in Samaritan Hospice, NJ
slide3

Pharmaceutical Care Tool Kit and MUGs

5th published release

15,000 copies & web posting

Evidence Based and Peer Reviewed

Systematic procedures for development, review and approval

21 external hospice expert reviewers

40 symptom management protocols

pharmaceutical care tool kit and mugs4
Pharmaceutical Care Tool Kit and MUGs

Thanks to All External Reviewers!

Jane Cornett, MD Hospice of Louisville

Karen Cross, MD, Nathan Adelson Hospice

Fran Davis, RN, CHPN, Hospice of Volusia Flagler

Mitzi Ellman-Pecorella, RN, Wuesthoff Brevard Hospice

Gwen Feather, RN, MS, Hope Hospice and Palliative Care

Claire Forsyth, RPh, FASCP Pikes Peak Hospice

Tara Friedman, MD, VITAS Helathcare, Philadelphia

Elizabeth Galfo, MD, FACP, Hospice of St. Francis

Paulette Hallihan, RN, BSN, Umass Memorial Hospice

Robert LeFevre, MD, Community Hospice Inc.

Debbie Luke, RN, BSN, Hospice of Coffee Regional Medical Center

Tim Moored, RPh, Hospice of Michigan

John Mulder, MD, alive Hospice

Valerie Pompey, RN, MS, The Center for Hospice and Palliative Care, Inc.

AJ Querciagrossa, RPh, OSF Hospice

Richard Sarkis, MD, Hospice of Southwest Florida

Diane Smith, MD, Hope Hospice and Palliative Care

David Taylor, MD, MetroplitanHispice of Greater NY

Alessandra Thompson, PharmD, The Hospices of the National Capital Region

Terri Walter, RN, MSN, Hospice & Palliative Care of Western CO

James Wright, MD, VITAS Healthcare, Dallas/FT. Worth

pharmaceutical care tool kit and mugs5
Pharmaceutical Care Tool Kit and MUGs

Designed to provide:

  • HP standard operating procedures
  • Clinical tools for hospice nurses and pharmacists
  • Symptom management decision making support
the hospice pharmacia pharmaceutical care tool kit version 5
The Hospice Pharmacia Pharmaceutical Care Tool KitVersion 5

Quick Guide to Services

Updates and Changes

the pharmaceutical care support center qgs 1
The Pharmaceutical Care Support Center (QGS-1)
  • The Pharmaceutical Care Assessment
  • Medication Care Plan Modification (detail)
  • Medication Distribution
  • Clinical Outcome Markers (new)
    • Endpoints
    • Outcomes
    • Documentation (Xeris/ARDS)

Care Center Hours Clarified

quick guide to services
Quick Guide to Services
  • Patient Enrollment (QGS-4)
    • Additional information requested by HP
    • Collaboration/Documentation by pharmacist
  • Medication Access (QGS-6)
    • Delivery from HP
      • Next Day PM is Standard; AM Delivery available upon request
      • 2nd Day Clarification—may arrive next day
      • Saturday—available in most service areas
    • Same Day Medications
      • Rejections at local pharmacies—include compounds/injectables
quick guide to services9
Quick Guide to Services
  • Planning for Emergencies (QGS-7)
    • Comfort Pak
      • ABHR names included
      • No refills on CPak meds
    • On Call
      • Pharmacist Cell Phone & New Admin On-Call number
  • Business Interruption/Disaster Planning (QGS-8)
  • Changes in Level of Care
    • Discharge responsibility (hospice) within 3 days
    • Definition of ‘discharge’
quick guide to services10
Quick Guide to Services
  • Infusion Therapy (QGS-11)
    • Not included for LTC under the per diem
  • ‘Authorization Required’ has been removed
mugs version 5 summary
MUGs Version 5: Summary
  • Review new medication additions and deletions.
  • Discuss existing protocols with added algorithms.
  • Introduce additional Endpoints and Outcomes markers.
  • Discuss additional protocol ideas and medications to be considered for Version 6.
mugs version 5 summary13
MUGs Version 5: Summary
  • Review new protocols with algorithms:
    • Nausea and vomiting
    • Dyspepsia
    • Secretions
    • Pruritis
    • Insomnia
    • Cachexia
    • Skin and skin structure infections
    • Genitourinary infections
    • Fever
mugs version 5 nausea and vomiting coverage code a
MUGs Version 5: Nausea and VomitingCoverage Code: A
  • Algorithm format based on suspected etiology
  • Clarification of compounded medications available (ABHR, ABR, ABD)
  • Erythromycin added for motility-related nausea
  • Hydroxyzine pamoate (Vistaril®) added for anxiety-related component

Common NMUG: Zofran®

Page 37

mugs version 5 dyspepsia coverage code a
MUGs Version 5: DyspepsiaCoverage Code: A
  • Algorithm format based on dyspepsia type
    • Ulcer-like
    • Reflux-like
    • Dysmotility-like
  • Twice daily dosing for H2blockers is now included under per-diem if once daily therapy fails
    • Must still assess appropriateness of dose based on age and renal impairment

Page 21

mugs version 5 dyspepsia coverage code a17
MUGs Version 5: DyspepsiaCoverage Code: A
  • Famotidine (Pepcid®) added as additional treatment option
    • 20mg po qd - bid
  • Metoclopramide and Erythromycin added for motility-related dyspepsia
mugs version 5 secretions coverage code a
MUGs Version 5: SecretionsCoverage Code: A
  • Algorithm format based on thickness of secretions
    • Is goal of therapy for patient to expectorate them or not?
  • Hyoscyamine ER added (Levbid®) as a treatment option
  • Atropine injection added to protocol as a treatment option

Page 55

mugs version 5 pruritus coverage code a
MUGs Version 5: PruritusCoverage Code: A
  • Algorithm format based on topical or systemic therapy
  • Cholestyramine powder added for pruritus due to hepatic disease/jaundice
  • Hydroxyzine pamoate (Vistaril®) added as alternate antihistamine choice
  • More detail on topical preparations and strengths

Page 53

mugs version 5 insomnia coverage code a
MUGs Version 5: InsomniaCoverage Code: A
  • Algorithm format based on presentation of insomnia
    • Is patient having difficulty falling asleep or staying asleep?
  • Chloral hydrate reserved as 3rd line therapy choice

Common NMUG: Ambien®

Page 32

mugs version 5 insomnia coverage code a25
MUGs Version 5: InsomniaCoverage Code: A
  • Alprazolam added as an alternate benzodiazepine choice
  • Hydroxyzine pamoate (Vistaril®) added as alternate antihistamine choice
mugs version 5 cachexia coverage code c
MUGs Version 5: CachexiaCoverage Code: C
  • Algorithm based on patient’s co-morbid conditions
    • If patient has a hx of GI bleed, immunosuppression, or osteoporosis, can use megestrol as 1st line
  • Cyproheptadine removed as treatment option due to lack of evidence demonstrating efficacy

Page 63

mugs version 5 skin skin structure infections coverage code a
MUGs Version 5: Skin & Skin Structure Infections Coverage Code: A
  • Algorithm recognizes treatment of fungating tumor separately
    • If metronidazole therapy for suspected fungating tumor fails, may go to either 1st or 2nd line antibiotic thereafter
  • Length of therapy is limited to 14 days
    • Therapy needs to be reassessed at this point
    • A new order for alternate antibiotic or extending current therapy needs to be procured

Page 58

mugs version 5 genitourinary infections coverage code a
MUGs Version 5: Genitourinary InfectionsCoverage Code: A
  • Algorithm is based on whether UTI is uncomplicated or complicated
    • Complicated UTIs may proceed right to 2nd line agents
    • RN will need to provide clinical info qualifying why UTI is complicated; document in Xeris

Page 61

mugs version 5 genitourinary infections coverage code a32
MUGs Version 5: Genitourinary Infections Coverage Code: A
  • Length of therapy is limited to 14 days
    • Therapy needs to be reassessed at this point
    • A new request for alternate antibiotic or extending current therapy needs to be procured
mugs version 5 fever coverage code a
MUGs Version 5: FeverCoverage Code: A
  • Algorithm based on response to previous therapy
  • Clinical information for quick reference
    • Types of fever patterns
    • Temperature conversion formulas
    • Common cancers associated with fever
    • Common medications associated with fever

Page 25

mugs version 5 pain protocol updates coverage code a
MUGs Version 5: Pain Protocol UpdatesCoverage Code: A
  • Add Misoprostol as a therapeutic option for prevention of NSAID/steroid related GI symptoms
  • Clarify long acting-opioid policy to reflect that two different concurrent long-acting opioids are outside per-diem (Methadone is exception)
  • Clarify maximum daily dose of Gabapentin=3600mg in divided doses
  • Algorithm added for all pain protocols

Common NMUGs: Ultram®, Celebrex®, Vioxx®

mugs version 5 constipation coverage code a
MUGs Version 5: Constipation Coverage Code: A
  • Remove Docusate sodium/Casanthranol
  • Insert various types of enemas as therapeutic options
    • Some enemas may need 1-2 days to order into stock

Common NMUG: Miralax®

Page 12

mugs version 5 gastrointestinal symptoms coverage code c
MUGs Version 5: Gastrointestinal Symptoms Coverage Code:C
  • Rabeprazole (Aciphex®) added as an alternate PPI choice, 20-40mg daily
  • Statement removed that suggests PPIs are 2nd line therapy for this patient population (gastric, esophageal, pancreatic cancer)

Common NMUG: Prevacid®, Protonix®, Nexium®

Page 64

mugs version 5 genitourinary symptoms
MUGs Version 5: Genitourinary Symptoms
  • Anorectal agents: Coverage Code: A
    • Hydrocortisone cream and supps clarified to be included
  • Spasm Coverage Code: A
    • B+O preparations include strengths
    • Frequency of administration increased to q6-8h prn
  • Related to malignancy Coverage Code: C
    • Doxazosin (Cardura®) added for prostate cancer patients only to treat dysuria, urethritis, urgency

Common NMUG: Flomax®

Page 28

mugs version 5 delirium dementia coverage code a
MUGs Version 5: Delirium & DementiaCoverage Code: A
  • Add Risperidone (Risperdal®) as 2nd line agent for treatment of delirium
    • Patient must try and fail Haloperidol or Chlorpromazine, or relative contraindication must exist
    • Maximum dose of Risperidone =2mg/day under per-diem
  • Add subprotocol for sundowning
    • Risperidone is 1st line therapy for this subtype

Common NMUGs: Zyprexa® and Aricept®

Page 15

mugs version 5 diarrhea coverage code a
MUGs Version 5: DiarrheaCoverage Code: A
  • Remove Tincture of Opium as therapeutic option due to confusion with dosage form and availability issues
  • Paregoric clarified with generic name of Morphine, camphorated (0.4mg/ml)

Page 20

mugs version 5 parkinson s disease coverage code o
MUGs Version 5: Parkinson’s DiseaseCoverage Code: O
  • Quetiapine fumarate (Seroquel®) is now included under per-diem for management of psychoses for Parkinson’s patients only
    • Initial dose: 25mg bid
    • Usual dose: 300-400mg/day
    • Maximum dose: 750mg/day

Page 83

mugs version 5 congestive heart failure coverage code h
MUGs Version 5: Congestive Heart FailureCoverage Code: H
  • Add Lisinopril (Prinivil®, Zestril®) as ACEI choice
  • Add statement to promote ARB (Valsartan) if patient cannot tolerate ACE inhibitor
  • Add Isosorbide mononitrate (Ismo®) 20mg bid (doses 7 hours apart) as alternate nitrate option

Common NMUG: Coreg®

Page 69

mugs version 5 primary cardiac diagnoses coverage code h
MUGs Version 5: Primary Cardiac DiagnosesCoverage Code: H
  • Add Lisinopril (Prinivil®, Zestril®) as ACEI choice
  • Clarify that Diltiazem ER and Verapamil SR are included in MUGs
  • Add Isosorbide mononitrate (Ismo®) as alternate nitrate option

Page 67

mugs version 5 hyperglycemia coverage code c o
MUGs Version 5: HyperglycemiaCoverage Code: C,O
  • Criteria include:
    • End-stage diabetes is the admitting diagnosis to hospice
    • Pancreatic cancer/metastases as admitting diagnosis
    • Hyperglycemia is medication-induced and hyperglycemia symptoms affect QOL
  • Add Humulin®/Novolin® 70/30 as alternate insulin choice

Page 65

mugs version 5 thyroid dysfunction coverage code c
MUGs Version 5: Thyroid DysfunctionCoverage Code: C
  • Coverage Code changed from “O” to “C”
  • Criteria include:
    • Patient has primary thyroid cancer
    • Irradiation induced thyroid dysfunction for patients with head and neck cancer

Page 66

mugs version 5 ascites coverage code a
MUGs Version 5: Ascites Coverage Code: A
  • Coverage Code changed from “C” to “A”

Common NMUG: Demadex®

Page 9

mugs version 5 seizures coverage code a
MUGs Version 5: Seizures Coverage Code: A
  • Coverage Code changed from “C” to “A”

Page 57

mugs version 5 copd pulmonary malignancy coverage code c l
MUGs Version 5: COPD, Pulmonary Malignancy Coverage Code: C,L
  • Remove “Authorization Required” statement for Combivent®
  • Add Salmeterol (Serevent®) as long-acting ß2 agonist with maximum dose =2 puffs bid
  • Remove Vanceril®, Beclovent®
    • Replace with Qvar® (Beclomethasone dipropionate, CFC free)

Common NMUG: Singulair®, Flovent®

Page 73

mugs version 5 copd pulmonary malignancy coverage code c l59
MUGs Version 5: COPD, Pulmonary Malignancy Coverage Code: C,L
  • Add Albuterol oral tablets and solution if unable to use MDI, nebulizer
  • A spacer is available for patients using an MDI (one per patient)
mugs version 5 microbial infections respiratory tract coverage code c l
MUGs Version 5: Microbial Infections – Respiratory TractCoverage Code: C,L
  • Coverage Code changed from “A” to “C, L”
  • For antibiotics to be included under the per-diem:
    • Patient must have admitting diagnosis of either COPD or pulmonary malignancy AND
    • Patient must meet Winnipeg Criteria Stage 2 or 3

Page 76

mugs version 5 palliative sedation coverage code a
MUGs Version 5: Palliative SedationCoverage Code: A
  • Remove Lorazepam continuous infusion due to inability to provide via national courier service
    • May continue to use lorazepam injection intermittently/PRN if unable to use po/sl/pr

Page 51

mugs version 5 injectable medications
MUGs Version 5: Injectable Medications
  • Injections listed on this page can be procured same day at the local pharmacy using the MIM card
    • same-day access for infusions or products compounded/provided by a local infusion company are not included under the per-diem
  • All orders for morphine infusion bags/cassettes need to be received by excelleRx by 6PM local time for overnight delivery
  • Insulin syringes will be included under the per-diem for patients receiving insulin
  • Flushes for parenteral lines are also included under per-diem

Page 31

mugs version 5 additional algorithms
MUGs Version 5: Additional Algorithms
  • Algorithms have been added to the following symptom protocols
    • Pain
    • Anxiety/agitation
    • Cough
    • Dyspnea
    • Oral conditions
    • Hiccups
    • Depression
mugs version 5 endpoints and outcomes
MUGs Version 5: Endpoints and Outcomes
  • In the last 72 hours, how would the patient rate his/her :
    • Worst pain
    • Constipation
    • Nausea
    • Anxiety
    • Shortness of breath
    • Fatigue
    • Appetite
    • Ability to sleep
    • Ability to interact with family and friends
    • Quality of life
mugs version 5 timeline
MUGs Version 5: Timeline
  • Version 4 and 5
    • Effective May 14 to June 30, 2003
  • Version 5 only
    • Effective July 1, 2003
mugs version 6 planning
MUGs Version 6: Planning
  • Version 5 feedback
  • Symptom protocol ideas for Version 6
  • Medication additions to be considered for Version 6
  • E-mail MUGs@excellerx.com
questions

Questions????

Thank you for your participation!