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

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

3. 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

4. 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

5. 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

6. 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

7. 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

8. Emergency vs. Urgency treatment
Goal of treatment - reduce BP gradually over 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

9. 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

10. 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

11. Other causes
Endocrine disorders
Kidney disorders
CNS injury
Unknown

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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

19. 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

20. 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