Interdisciplinary Collaboration for Problem Solving: the pathway to better patient care Molly Adams, Pharm.D., BCPS Brad Wright, Pharm.D., BCPS Greg Rutecki, MD

Objectives Provide an example Define Collaboration Describe hypertensive crises Examine treatment options Explain Problem Solving via Quality Assurance Evaluate Stakeholder Perspectives

Our Example Identification of a problem Team approach Hospital management of hypertensive crises Problem 1: Identifying patients experiencing hypertensive urgencies/emergencies Problem 2: Choice of agent to treat the hypertensive emergency/urgency appropriately Team approach Put together a team to research the problem and solution Pharmacist-physician collaboration Diagnosis – Dr. Rutecki Treatment – Drs. Adams, Karwa, and Wright

Our Example Literature evaluation Use evidence-based medicine to determine best diagnosis and treatment strategies Pharmacy team Looked at guidelines, reviews, as well as trials comparing drugs used in the treatment of hypertensive crises

Hypertensive Crises - Background Chronic hypertension is one of the most common medical conditions in the United States Affects ~30% of the population Significant risk factor for cardiovascular, cerebrovascular and renal problems Acute elevations in BP may result in acute damage to organs and significant morbidity or mortality Patients with acutely elevated blood pressure (BP) are considered to be experiencing a hypertensive crisis Usually defined as a BP >179/109

End Organ Damage The Heart: During Pregnancy: Blood vessels: Acute myocardial infarction, acute coronary syndrome , acute heart failure. During Pregnancy: Pre-eclampsia, eclampsia, or “HELLP” syndrome (Hemolytic Anemia, Elevated Liver Enzymes & Low Platelets). Blood vessels: Injury to the aorta - aortic dissection. The Brain/Central Nervous System: Strokes, subarachnoid hemorrhage, and hypertensive encephalopathy The kidneys: Acute renal failure

Emergency vs. Urgency Hypertensive crises can be further classified into hypertensive emergencies or urgencies. Hypertensive emergency – severe elevation in BP accompanied by end organ damage Damage to the brain, heart, eyes, or kidnes Hypertensive urgency – severe elevation in BP not accompanied by end organ damage Distinguishing between urgency and emergency is important Treatment differs for the two conditions and therefore the most appropriate treatment plan is based on diagnosis

Emergency vs. Urgency treatment Goal of treatment - reduce BP gradually over 24-48 hours Significant morbidity is associated with too rapid a reduction in BP Select oral combination medications to lower BP Most optimal agent should have: A rapid onset Few adverse effects Absence of excessive hypotension Be able to be monitored

Emergency vs urgency treatment Goal of treatment – decrease BP immediately Slow and controlled decrease need to prevent organ hypoperfusion, morbidity or mortality The patient should be admitted to the Intensive Care Unit (ICU) Treat with an intravenous continuous infusion of an antihypertensive agent that is titratable, short-acting and able to be monitored Drug of choice depends on the clinical scenario Avoid oral, sublingual, and intramuscular (IM) routes

Causes Majority of patients have been diagnosed with chronic hypertension Many are poorly controlled on current therapy Many are non-adherent to current regimen >50% of patients Drug Use Prescription drugs Drug interactions Clonidine withdrawal OTC Herbal Illicit drugs

Other causes Endocrine disorders Kidney disorders CNS injury Unknown

Diagnosis Should be prompt to avoid end-organ damage Thorough medical and medication history Confirmation of BP in both arms Identify end-organ damage Pulse in extremeties Auscultate lungs and hear Neurologic exam Fundoscopic exam Cardiac exam

Management - Hypertensive urgency Optimal agents should have a rapid onset, few adverse effects, absence of excessive hypotension, and be able to be monitored Oral drugs used to treat hypertensive urgencies Clonidine Captopril Patient’s home regimen Oral drugs not used to treat hypertensive urgencies Nifedipine

Management – Hypertensive Emergency Same basic treatment principles as hypertensive urgency Added goal is to prevent progression of end organ damage Intravenous medications for treatment of hypertensive crisis Clevidipine Nicardipine Esmolol Labetolol fenoldapam Phentolamine Enalaprilat Intravenous Medications that should be used with caution Nitroprusside Nitroglycerin Hydralazine

Quality Assurance Steps Identify the Problem Collect information for analysis Evaluate literature for comparison and suggestions on improvement Select a method for improvement Education Order sets and protocols System changes Re-evaluate after a time to verify improvements effective

Problem Recognition Identify through anecdotal reports Care provider questions Case reports and series Barriers to optimal patient care Ineffective results in patient outcomes Time management issues Adverse outcomes

Inpatient Improvement Methods Drug Utilization Evaluations (DUEs) Pharmacy and Therapeutics Committees Protocols Order Sets Teaching In-services Nursing Pharmacy Physician Workflow adjustments

Collaboration Definition To work, one with another; cooperate To work with another or others on a joint project Collaboration occurs when no one profession or organization can achieve its goals without building upon its interdependence with others Requires that all team members want to work together to accomplish a common goal Each team member brings a unique perspective or expertise All work together to improve a problem

Collaboration – Our example A problem with was noted with the pharmaceutical and medical management of sever hypertension A team was formed with each team member focused on one goal Goal – Improve the management of hypertensive crises Each team member brought unique expertise Physicians – Diagnosis of hypertensive crises Pharmacy – Medications used in the inpatient and outpatient settings In the end each team member brought specific info that when combined improved the treatment of hypertensive crises

Collaboration – Other examples Diabetes Management University of Buffalo Hypertension Management Inpatient - Midwest Veterans Affairs Medical Center Outpatient – Iowa City, Iowa Heart Failure Management PHARM Study