When working with residents who have chronic diseases, such as diabetes, it’s important for long-term care pharmacy providers to consider all facets of care, including vaccinations. So what’s the connection between vaccines and diabetes? There are two very important reasons why vaccines have a high level of importance for residents with diabetes—both Type 1 and Type 2. First, even if tightly controlled, diabetes has an effect on the immune system where it is harder for the body to fight infections. This increases the potential likelihood for infections including those that may be preventable with a vaccination. Secondly, residents with diabetes are at risk for more severe complications compared to residents who do not have diabetes. For example, some infections such as influenza can increase blood glucose levels to dangerously high levels. People with diabetes also have an increased risk of death from pneumonia and bacteremia. The CDC has identified five vaccinations that should be carefully considered for administration in residents with diabetes. They include the influenza, pneumococcal, hepatitis B, zoster, and Tdap vaccines. Let’s review some of the key reasons why these vaccines should receive special consideration from your post-acute care pharmacy team and the team at large for residents with diabetes.

Vaccines and Diabetes: Influenza (Flu)

The flu virus can complicate diabetes control by altering the body’s metabolism and by affecting the desire to eat, thus resulting in the potential for significant increases or decreases in blood sugar levels. In addition, the flu is the hardest on individuals age 65 and older, those who have underlying conditions, and those with weakened immune systems. Individuals who reside in Skilled Nursing Facilities and those with diabetes are two groups of people who are at high risk for developing flu-related complications such as pneumonia, bronchitis, and sinus or ear infections. While receiving the flu vaccine may not provide absolute protection against the flu, those who receive the vaccine and then get the flu are generally less sick and sick for a shorter duration of time. Annual flu vaccines are already recommended for all people over age 6 months, but should be considered even more so by residents with diabetes.

Vaccines and Diabetes: Pneumococcal (Pneumonia)

Individuals with diabetes have been shown to have a three times higher risk for contracting pneumonia compared to healthy adults the same age. This is coupled with the fact that a diabetic resident is also predisposed to severe complications from pneumonia. The guidelines for pneumococcal vaccination have recently changed with individuals over age 65 now being recommended to receive both the pneumococcal conjugate vaccine (Prevnar 13) and pneumococcal polysaccharide vaccine (Pneumovax). Due to the recent guideline changes coupled with the potential risks for diabetic residents, you may wish to review and update your current pneumonia vaccination protocol.

Vaccines and Diabetes: Zoster (Shingles)

Type 2 diabetes has been associated with an increased risk of developing herpes zoster (shingles), especially in those individuals over age 65. The CDC currently recommends the shingles vaccine for anyone age 60 and older. The vaccine is also recommended for those who have already had shingles in an effort to prevent recurrences. The shingles vaccine has been shown to successfully reduce the risk of developing shingles by 51 percent and postherpetic neuralgia by 67 percent. [Tweet “What’s the connection between vaccines and diabetes? We’ll tell you. #longtermcarepharmacy”]

Vaccines and Diabetes: Hepatitis B

The CDC reports that people with diabetes have been shown to have higher rates of hepatitis B than the rest of the population. Additionally, outbreaks of hepatitis B have been associated with improper blood glucose monitoring and insulin pen utilization and have occurred among residents with diabetes in long-term care settings. While some individuals may have already received the hepatitis B vaccination series, it is advisable to determine a resident’s vaccination history when assessing vaccination needs while in the facility.

Vaccines and Diabetes: Tdap

Vaccination has been identified as the best way to protect against pertussis (whooping cough); however, over time, our level of protection from this vaccine begins to fade. Consequently, over the past several years, the number of pertussis cases has been on the rise. At this time, the Tdap vaccination, which protects against tetanus, pertussis, and diphtheria, is recommended for adults every 10 years. Due to the recent changes in pertussis exposure and cases, it is a good time to review your current guidelines and processes for this vaccine. Grane Rx LTC pharmacy services encompass all aspects of a resident’s medication-related health, including vaccinations. Discover the Grane Rx difference today by calling (866) 824-MEDS (6337).]]>

Long-term care pharmacy services aren’t limited to the dispensing of oral medications—vaccines and insulin injectables are also among the items dispensed. Staying up-to-date on the latest findings related to injections is key for LTC pharmacy services providers. Blood glucose control can be a challenge in our geriatric resident population for a variety of reasons. As we age, a number of factors can affect blood glucose management, ranging from physiological changes and erratic nutritional intake to impaired renal or hepatic function to variable physical activity and even polypharmacy. Trying to pinpoint the culprit of blood glucose swings can be a daunting task. In addition to these common potential sources of blood glucose variability, there are several often-overlooked factors—a person’s skin, insulin injection technique, and injection site rotation practices. Let’s take a look at some important considerations and best practices associated with insulin injection technique and injection site rotation recommend by post-acute care pharmacy providers.

LTC Pharmacy Services Best Practice: Why Injection Site Rotation Is important

Repeated injection into the same site can cause lipohypertrophy and lipodystrophy. Lipohypertrophy is the buildup of fat under the skin. Subsequent injection into areas of lipohypertrophy can lead to lipodystrophy, which is scarring of the fat. Subsequent injection into areas with lipohypertrophy or lipodystrophy can significantly slow the absorption of insulin. The altered insulin absorption may lead to elevated glucose levels, which may be attributed to insufficient disease management instead of poor insulin administration technique. [Tweet “DOs and DONT’s related to insulin injection in the #longtermcare setting”]

LTC Pharmacy Services Best Practice: Insulin Injection and Injection Site Rotation

Insulin is best absorbed from the abdomen, hips, upper buttocks, outer thighs, and the backs of the upper arms. Insulin is absorbed at different speeds depending on the injection site location. The abdomen is generally the fastest, followed by the upper arms, upper thighs, and buttocks. Because of the variability in absorption, it is suggested to use the same area of the body for different administration times to maintain as much consistency as possible. For example, if a resident has an order for insulin injections three times daily with meals and at bedtime, you may want to consider the following insulin administration plan:

For the breakfast and lunch doses, inject in different areas of the abdomen because of faster absorption from this area and the inherent need for insulin sooner because of carbohydrate intake during meals.
For the supper dose, inject in the upper arms, again because of the relative speed of absorption and the need of the insulin secondary to impending carbohydrate ingestion.
For the bedtime dose, inject in the upper legs or buttocks because these doses are normally longer-acting insulin that will be providing insulin coverage throughout the night.

For someone that is just getting meal doses, it is generally not recommended to give in the abdomen one day and the buttocks the following day due to the absorption variability and the need for these therapies to be faster-acting. To avoid lipohypertrophy and lipodystrophy, injections should be rotated within the general area of the body by switching sides, spacing injections by at least 2 inches from the previous injections, or by using the face-of-the-clock technique to keep track of injection location. Clear and consistent documentation on the medical administration record is important in the long-term care setting due to the variability in nurses who are providing the injections based on shifts or days of the week. The table below highlights some additional important considerations to administering insulin injections. Best practices related to insulin injection in LTC pharmacy services.

Best practices related to insulin injection in LTC pharmacy services.

While good insulin injection practices and injection site rotation are not the magic bullet for optimal blood glucose control in our resident population, it is a solid practice standard that should be utilized on a daily basis. If you have a resident that has poorly controlled blood sugars that cannot be attributed to other common areas of concern, injection techniques and site rotations may be areas of special consideration to try to find the root cause of the issue. Our Grane Rx team works with your team to help ensure optimal care for residents. Learn more about our long-term care pharmacy services and how we can partner by calling (866) 824-MEDS (6337).]]>

At the end of September, CMS finally approved and released the roll-out schedule for the long- awaited Final Rule, which includes some regulations related to LTC pharmacy services. Phase 1 was effective on Nov. 28, 2016, and Phase 2 will be effective on Nov. 28, 2017. The Final Rule encompasses the first major revisions to the Nursing Home Requirements for Participation since 1987, and it touches on essentially every aspect of our scope of practice, including long term care pharmacy. Grane Rx has been reviewing the new regulation changes and is prepared to accommodate all of the required changes and to support Skilled Nursing Facilities during this transition. Read on for a look at the upcoming changes as they relate to post acute care pharmacy.

Long term Care Pharmacy & Monthly Medication Regimen Reviews

With the new regulations, monthly medication regimen reviews must include a review of the resident’s medical chart. Grane Rx consultant pharmacists are already reviewing the resident’s medical chart and documenting the review accordingly in the chart on a monthly basis. There will not be changes to this practice. Any irregularities identified during the pharmacist’s monthly medication regimen review are to be reported in a separate report to the resident’s attending physician and the facility’s Medical Director and Director of Nursing. A new process and report was implemented by Grane Rx consultant pharmacists on Nov. 28, 2016, which will provide the aforementioned report to the identified parties. This change was in addition to our previous processes and methods of communication for recommendations and reports. As a reminder, all residents’ medication regimens must be free from unnecessary medications. An unnecessary medication is any medication that is being utilized in excessive dose (including duplicate therapies), for excessive duration, without adequate monitoring, without an adequate indication for use, or in the presence of adverse consequences—or any combination of these reasons. Additionally, when an irregularity has been identified by the consultant pharmacist, it is the responsibility of the resident’s attending physician to document that the irregularity has been reviewed and what action has been taken. Even if the attending physician disagrees with the recommendation and no action is taken, documentation must be provided for the rationale. This documentation should be part of the resident’s medical record. While changes to the Monthly Medication Regimen Review are not effective until Phase 2, Grane Rx is prepared to be in compliance at this time.

Long term Care Pharmacy & Psychotropic Medications

The definition of psychotropic medication has been changed and expanded to include any medication that affects brain activities associated with mental processes and behavior. This includes the following medication classes—antipsychotics, antidepressants, anxiolytics, and hypnotics. During medication regimen reviews and data reporting, Grane Rx consultant pharmacists are presently including and considering all of the above identified medication classes. Additionally, as regulated, consultant pharmacists monitor that psychotropic medications are being used to treat a specific condition that is diagnosed and documented in the resident’s clinical record. We also monitor and intervene to ensure residents who are receiving psychotropic medications receive gradual dose reductions and behavioral interventions, if appropriate, in an effort to discontinue these medications when possible. For Phase 2, specific focus and processes will be developed for PRN psychotropic medications. Beginning in Phase 2, the following conditions must be met for PRN psychotropic medications:

Residents do not receive a PRN psychotropic medication unless that medication is necessary to treat a diagnosis-specific condition that is documented in their clinical records.
PRN orders for psychotropic medications are limited to 14 days.
If an attending MD or prescriber feels it is appropriate for the medication to be used longer than 14 days, rationale must be documented in the resident’s medical record and the duration of the PRN order must be indicated.
PRN orders cannot be renewed unless the attending MD or prescriber evaluate the resident for appropriateness of the medication.

More information will be coming in the future on the PRN psychotropic regulation change. [Tweet “Making sense of the CMS Final Rule: 4 things to know. #longtermcarepharmacy”]

Long term Care Pharmacy & Medication Errors/Influenza and Pneumococcal Immunization

The requirements of the medication error and influenza and pneumococcal immunization tags are moving to the Pharmacy Services area. Skilled Nursing Facilities are still required to maintain a medication error rate below 5 percent and to ensure that residents are free from significant medication errors. The influenza and pneumococcal immunization tags also remain unchanged and continue to include proper education, vaccination, and documentation of immunizations of eligible residents.

Long term Care Pharmacy & Antibiotic Stewardship

As we progress into planning and implementation of Phase 2, attention will be given to the Antibiotic Stewardship Program. Your consultant pharmacist is already a required part of your facility’s Infection Control Committee but will also be an integral part of an Antibiotic Stewardship Program. Grane Rx consultant pharmacists are presently undergoing education and training to support you in this area. As we embark on this journey together, we look forward to continued partnership and collaboration to ensure on-going success. Grane Rx pharmacy providers partner with Skilled Nursing Facilities to understand and implement regulatory changes like the Final Rule. Get started working with our team today by calling (866) 824-MEDS (6337).]]>

In PACE pharmacy, medications are typically dispensed to participants in monthly increments that are either picked up at the PACE center or delivered to the home. But what happens when a participant’s medication regimen needs to change in the middle of a cycle? Because PACE participants usually take multiple medications for a variety of medical conditions, it isn’t uncommon for physicians to switch out a medication or change its dosing. It also isn’t a problem. We’ve created a seamless process designed to handle medication regimen changes when they occur—without compromising participant safety or health. Read on to learn more. Let’s first take a look at the “why” behind our packaging. Medication nonadherence is a significant problem among the senior population and is especially critical for PACE participants. With this in mind, Grane Rx uses innovative packaging called SimplePacks when dispensing PACE pharmacy medications. This packaging is just one part of the overall Grane Rx PACE Pharmacy Solution, which is designed specifically with seniors in mind—featuring clear, understandable information about medications to encourage adherence. Each month, participant’s medications are packaged together inside two color-coded boxes: one for everyday medications and one for medications that are taken as necessary. Within those boxes, medications are packaged in SimplePacks, which are easily opened perforated packs of medications taken at the same time of day, whether morning, noon, evening or at night. This unique PACE pharmacy solution offers a much better medication management system than the bingo cards typically used by long term care pharmacy and other PACE pharmacy providers. The very thing that makes our packaging unique and innovative—our SimplePacks perforated pill packs—can seem like it would be tricky when medication changes are needed. But actually, that isn’t the case. [Tweet “A simple #PACEpharmacy process can make medication changes seamless”]

“Immediate Change” Medications in PACE Pharmacy

The first step in managing medication changes is identifying medications that must be immediately changed. The vast majority of medication changes, including dosage changes, don’t need to be made immediately. Those changes can simply wait until a participant’s medications are dispensed again. Our PACE pharmacy worked with a team of physician and pharmacy experts to compile a list of medications that need to be changed immediately, along with medications that are more subjective in nature. When Grane Rx partners with a new PACE center, we review this list with the center’s medical staff to ensure it aligns with their practices. The center-specific list is adjusted as necessary at that time. Prescriptions identified as immediate change medications are placed in separate SimplePacks and not commingled with other medications. This typically includes certain classes of medications, such as anti-hypertensive drugs, that require periodic adjustments to dosage or to determine which medication works best for a participant. Because these medications are automatically packaged separately from the rest of a participant’s medication regimen, those pill packs can simply be removed and the replacement medication incorporated—at any time. In the case that a new, non-immediate change medication is prescribed for a participant, that medication is packaged as a one-off and then incorporated into the participant’s normal SimplePacks the following month. When it comes to PACE pharmacy services, Grane Rx thinks through all the possibilities and offers the solutions your PACE center needs. Get started today by calling (412) 449-0504 or emailing paceteam@granerx.com. ]]>

At Grane Rx, we’re committed to providing the highest-quality LTC pharmacy services. As part of that commitment, we share an ongoing series of pharmacy updates from our Chief Clinical Officer, designed to keep you in the know on clinical topics related to longterm care pharmacy and PACE pharmacy. At times, residents are ordered the combination of vitamin C and zinc for wound prevention and healing. The idea of using vitamin C as a supplement in wound healing has been discussed since 1937 when two Harvard medical school surgeons published an article concerning its use for this purpose. Since then, there have been some additional studies and opinion articles written on the topic, but there have been no well-powered, randomized, controlled trials (RCTs) evaluating whether the use of vitamin C (and also zinc) is efficient in helping wounds heal. This bears the question: is using this vitamin and mineral supplement combination for wound healing potentially beneficial?

Considerations for the Use of Vitamin C in LTC Pharmacy Services

When residents are experiencing vitamin C deficiency, they have impaired collagen cross-linking, reduced wound tensile strength and increased wound dehiscence (rupture along a surgical incision). The elderly are at the highest risk due to poor dietary intake and malnutrition. According to the Hospital of the University of Pennsylvania, a resident is indicated for vitamin C supplementation when there is a deficiency. However, the level of deficiency is difficult to determine—and thus, the appropriate dosing is also difficult to determine. Supplement dosing needs to also take into consideration whether a resident is taking a multivitamin, as this may already provide some vitamin C supplementation. While vitamin C is essential in wound healing, vitamin C supplements may interact with other medications, such as chemotherapy drugs and warfarin, which are both common among residents needing LTC pharmacy services. Vitamin C total intake should not exceed 2 grams per day, as there is no added benefit from higher doses. In fact, high doses of vitamin C have been associated with many serious adverse effects, such as blood clotting, kidney stones, digestive system problems and red blood cell destruction.

Considerations for the Use of Zinc in LTC Pharmacy Services

When residents are experiencing a zinc deficiency, they have reduced wound strength, decreased collagen synthesis and decreased immunity. Some risk factors for deficiency are wound vac drainage, diarrhea and malabsorption. According to the Hospital of the University of Pennsylvania, zinc supplementation is indicated when zinc is deficient; but, as with vitamin C, this is difficult to determine. In comparison to vitamin C, zinc is not essential to wound healing, it simply stimulates it. If zinc supplementation is used long term, it is possible that a copper supplement may also be needed. It has also been found that high doses of zinc can suppress the immune system and have even been linked to an increased risk of some cancers. [Tweet “In this #LTCpharmacyservices update, learn about how supplements affect wound healing”]

The Bottom Line: Vitamin C and Zinc in LTC Pharmacy Services

Taking into consideration all of the information available, the routine use of vitamin C and zinc supplementation for wound healing is not recommended. Vitamin C and zinc supplementation may be considered on a case-by-case basis, but it’s important to look at the whole picture of the resident to determine if supplementation is actually appropriate. When well-powered RCTs and more information on the topic become available, a re-evaluation of this recommendation will need to occur. Our post acute care pharmacy team stays up to date with the latest clinical information—and utilizes that information to the benefit of SNF residents. Get started today by calling (866) 824-MEDS (6337).]]>

At Grane Rx, we’re committed to providing the highest-quality long term care pharmacy services. As part of that commitment, we share an ongoing series of pharmacy updates from our Chief Clinical Officer, designed to keep you in the know on clinical topics related to LTC pharmacy services and PACE pharmacy. Antibiotics are some of the most commonly prescribed medications in Skilled Nursing Facilities. It has been shown that up to 70 percent of SNF residents will receive at least one antibiotic over the course of a year; however, approximately 25 to 75 percent of these antibiotics are prescribed incorrectly or are unnecessary. Overuse of antibiotics contributes to increased antibiotic-resistant bacteria, adverse drug events, drug interactions, colonization (where a resident has bacteria present in his or her system, but it is not causing an illness), secondary infection from resistant organisms and complications such as Clostridium difficile. Despite all of the risks associated with their use, antibiotics are still a necessary piece in the care of our elderly residents, especially those who reside in a long term care setting. These residents have a higher incidence of infections due to increased risk factors such as underlying disease states, age-related physiological changes, increased exposure to bacteria secondary to the environment of an SNF, and the use of invasive devices such as catheters or feeding tubes. A common ground needs to be achieved where a long term care facility is able to stop the misuse of antibiotics while still treating their residents appropriately—this is referred to as antibiotic stewardship.

The Role of Long term Care Pharmacy in Antibiotic Stewardship

The Centers for Disease Control and Prevention has stated that antibiotic stewardship is “a set of commitments and activities designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.” Following President Obama’s executive order for a national action plan to combat antibiotic resistance, the Centers for Medicare and Medicaid Services proposed expanded requirements in the conditions of participation beyond the ones already in place to review and monitor the use of antibiotic drugs. On Sept. 29, 2016, CMS released these new regulations—the requirements revolve around facilities having an infection prevention and control program (IPCP). This IPCP must include protocols for controlling infections and communicable diseases as well as using antibiotics and monitoring their use, incorporate education and training sessions for facility staff, and be reviewed and updated annually. The IPCP must have been created by Nov. 28, 2016, with the antibiotic stewardship program being implemented by November 28, 2017. The IPCP must also have a designated infection prevention/control officer who is a clinician with specialized training in infection prevention and control in place by Nov. 28, 2019. The consultant pharmacist is one of the people who are qualified to fill the role of an infection prevention/control officer. The American Society of Health-System Pharmacists (ASHP) believes that pharmacists have a responsibility to take prominent roles in antibiotic stewardship by 1.) promoting the optimal use of antibiotics, 2.) reducing the transmission of infections and 3.) providing education to health professionals, patients and the public. These roles are all needed in an infection prevention/control officer. [Tweet “Learn about the role of consultant pharmacists in this #longtermcarepharmacy update”]

How Can Your Long term Care Pharmacy Consultant Help You Beyond the Monthly Medication Regimen Review?

Promoting the Optimal Use of Antibiotics. Consultant pharmacists (as infection prevention/control officers and in general) have the responsibility to ensure the optimal use of antibiotics throughout the facility. One way this can be done is by encouraging interprofessional collaboration within the facility to ensure the best team is put together to maximize resident outcomes. This team would focus on optimizing resident antibiotic care by establishing restricted antibiotic-use procedures, therapeutic interchanges and treatment guidelines to aide in the appropriate selection, dosing, monitoring and de-escalation of antibiotic therapy. Additionally, consultant pharmacists can generate and analyze quantitative data on antibiotic use through working with the lab to ensure appropriate microbial susceptibility tests are reported on residents in a timely manner. Finally, long term care pharmacy consultant pharmacists can also use information technology to enhance stewardship through surveillance, utilization and outcome reporting, and use efficient and effective systems to reduce potential errors and adverse drug events.
Reducing the Transmission of Infections. Reducing the transmission of infections is just one of the many roles a consultant pharmacist would have as a part of antibiotic stewardship. Different ways this could be accomplished would be by encouraging routine immunization of facility staff and promoting screening for transmissible diseases, promoting adherence to standard precautions, striving for zero tolerance of health care-associated infections, and collaborating as a member of the interprofessional team in the development of guidelines for risk assessment, treatment and monitoring of patients and healthcare workers, who have been in contact with a person with a transmissible disease.
Providing Education. A consultant pharmacist has the ability to educate all stakeholders in the antibiotic stewardship process including fellow health professionals, residents, family members and the public about antibiotic stewardship and infection prevention and control. This can be completed many different ways, but some examples of this are as follows:

Consultant pharmacists for long term care pharmacies have the potential to be the leader of the IPCP—their extensive knowledge of antibiotics and how to reduce the transmission of infections allows them to educate the interprofessional team to have the best antibiotic stewardship possible. Antibiotic stewardship is a huge undertaking and is best tackled in a stepwise approach. Consultant pharmacist are able to guide what activities the facility is ready to undertake and work toward the end goal of an IPCP and antibiotic stewardship, focusing on one or two key topics to start and then expanding outwards. Pharmacists are an essential resource to ensuring appropriate antibiotic stewardship with the end goal of optimal resident care always in sight. When you partner with Grane Rx, our consultant pharmacists serve as true partners with your team, passing their knowledge on to you. Learn how your center can benefit by filling out this quick form or calling (866) 824-MEDS (6337).]]>

The Centers for Medicare & Medicaid Services have placed increased emphasis on avoiding hospital readmissions over the past few years—for good reason. According to the Center for Health Information and Analysis, hospital readmissions cost Medicare $26 million annually, of which $17 million is considered avoidable. What role does nursing home pharmacy services play in avoiding readmissions? First, let’s consider the consequences of a high readmission rate. Three of the six new measures added to the Five-Star Quality Ratings System in July specifically relate to hospital readmissions—and beginning in 2018, Skilled Nursing Facilities will have their Medicare reimbursement rate partially based on those measures. The senior population as a whole is more likely to be admitted to the hospital. In fact, adults 65 years and older make up more than 40 percent of annual hospital admissions. Because of this, a multidisciplinary team effort is required to help long term care residents avoid rehospitalization. Long term care pharmacy providers play a significant role. Pneumonia, asthma, congestive heart failure, pressure ulcers, dehydration and urinary tract infections represent the leading causes of hospital readmission for the elderly population. Among hospital readmissions for those causes, the CMS reports that up to 80 percent of cases could have been avoided if managed proactively. Here’s how LTC pharmacy services can help.

Nursing Home Pharmacy Services Key 1: Clinical Consulting

There are a number of factors that contribute to hospital readmissions, and many are particularly prevalent among seniors. Clinical factors that can contribute to readmission include:

Certain conditions, such as COPD, diabetes or heart failure
Having more than six chronic conditions
Polypharmacy
The use of certain medications, such as anticoagulants, antipsychotics and opioids

Other factors pertinent to SNF residents may include how often a resident has previously been admitted to the hospital (with particular emphasis on hospitalizations within the last year) and low health literacy. Because medications are often a contributing factor when seniors are readmitted to the hospital, Grane Rx utilizes regular clinical consultations in long term care pharmacy. As part of these consultations, our team of PharmDs performs comprehensive medication regimen reviews at admission and at regular intervals thereafter. In addition, pharmacists also conduct clinical change of status reviews, targeted medication class and disease state management reviews, and medication utilization optimization reviews, which are specifically designed to reduce polypharmacy. These thorough and regular reviews are designed to keep a keen eye on issues that could contribute to rehospitalization.

Nursing Home Pharmacy Services Key 2: Emphasis on Certain Contributing Factors

In addition to conducting general medication reviews, long term care pharmacy providers pay particular attention to medications that could contribute to the leading causes of rehospitalization. For example, certain classes of medications, including antihistamines, antihypertensives, diuretics and chemotherapy agents, cause increased urination, which can lead to dehydration. When residents are prescribed medications in these classes, pharmacists work with the rest of the multidisciplinary team to regularly observe them and ensure they remain properly hydrated. In addition, pharmacists may suggest alternative medications and recommend that residents be prescribed only the lowest possible dose for the shortest possible duration needed. [Tweet “Medication reviews play a role in limiting hospital admissions among #skillednursing residents”]

Nursing Home Pharmacy Services Key 3: Observation & Communication

In many cases, signs of medical conditions present themselves early enough that a condition can be stopped in its tracks. In fact, symptoms of pneumonia, asthma, congestive heart failure, pressure ulcers, dehydration and urinary tract infections can be treated effectively with early intervention. How can you ensure early intervention in these cases? It requires a multidisciplinary team approach. In regular interactions with residents, medical providers can carefully observe residents for emerging symptoms, such as shortness of breath and unusual fatigue in the case of pneumonia and fever or chills and reports of pain or pressure in the abdomen in the case of urinary tract infections. After meeting with residents, nursing home pharmacy services providers can communicate and corroborate their observations with other members of the medical team. This approach makes prompt intervention and treatment more likely. When you partner with Grane Rx for LTC pharmacy services, we work alongside your Skilled Nursing Facility’s team. Discover the Grane Rx difference today.]]>

At Grane Rx, we’re committed to providing the highest-quality post acute care pharmacy services. As part of that commitment, we share an ongoing series of pharmacy updates from our Chief Clinical Officer, designed to keep you in the know on clinical topics related to long term care pharmacy and PACE pharmacy. Antibiotics are some of the most frequently used medications in inpatient and outpatient settings. Due to their amount of use and tolerability, the major side effects that these medications can cause are not always recognized—the biggest of these would be the toxic side effects on the central nervous system (CNS). The most common CNS side effects are seizures, delirium, confusion, personality changes and ototoxicity. If CNS effects occur and are due to antibiotic therapy, they will typically occur within days of starting treatment.

Common CNS Offenders Used in Post acute Care Pharmacy

The antibiotics that are the biggest offenders in post acute care pharmacy are fluoroquinolones such as ciprofloxacin or levofloxacin; penicillins such as piperacillin and ampicillin; cephalosporins such as cefazolin, ceftazidime and cefepime; carbapenems such as imipenem and meropenem; and macrolides such as clarithromycin and erythromycin. It’s important to determine whether the CNS effects are occurring due to the medication or due to other causes such as neurological conditions, electrolyte imbalances or the infection itself. [Tweet “Learn which antibiotics can negatively affect the central nervous system. #longtermcarepharmacy”]

Steps Post acute Care Pharmacy Providers Can Take to Prevent and Treat CNS Effects

Before dispensing a medication that has the potential to be neurotoxic, it’s important for long term care pharmacy providers to evaluate residents for the risk factors associated with neurotoxicity. These include extremes of age (young children and the elderly), impaired renal function, history of CNS disease and damage to the blood-brain barrier. Avoiding the use of potentially neurotoxic agents in these residents may not be possible, so post acute care pharmacy providers should be aware of which medications have these side effects in order to suggest appropriate dosage adjustments and to develop monitoring plans for these residents. If a resident does develop any CNS effects while on a potentially neurotoxic antibiotic such as ciprofloxacin, it is important to immediately discontinue the offending medication and replace it with an appropriate non-neurotoxic antibiotic. CNS effects due to antibiotics normally resolve within five days of stopping the medication. If a resident continues to experience neurotoxicity effects such as seizures despite stopping the offending medication, anticonvulsants may be needed temporarily. If a resident continues to experience neurotoxicity effects due to impaired renal function, hemodialysis or hemofiltration may be required for sufficient clearance of the medication. Because of the potentially higher incidence of CNS adverse effects in the geriatric population, it is important to be vigilant of this potential both when a therapy is started and when evaluating the potential cause of symptoms. Fortunately, most CNS adverse effects are rare and reversible. When it comes to post acute care pharmacy, discover the Grane Rx difference. Get started today by filling out this quick form or calling (866) 824-MEDS (6337).]]>

At Grane Rx, we’re committed to providing the highest-quality senior care pharmacy services. As part of that commitment, we share an ongoing series of pharmacy updates from our Chief Clinical Officer, designed to keep you in the know on clinical topics related to long term care pharmacy and PACE pharmacy. Antibiotics account for 20 percent of all drug-related emergency department visits in the United States. This is a major cause of concern because while these are some of the commonly prescribed medications, they are not always necessary and/or appropriate. As antibiotic stewardship continues to gain momentum and become implemented at Skilled Nursing Facilities, the overprescribing of antibiotics should decrease. Until this happens, it’s important for LTC pharmacy services providers to be aware of what’s happening to/with your residents and the different risks associated with unnecessary antibiotic use. The most consequential risk from unnecessary antibiotic use is an increase in antibiotic resistance. As defined by the Centers for Disease Control and Prevention (CDC), antibiotic resistance is the ability of microbes to resist the effects of medications. The microbes are not killed, and thus their growth is not stopped. Simply using antibiotics creates resistance. When antibiotics are prescribed, they kill the bacteria causing the illness and the good bacteria protecting the body from infection but leave the few drug-resistant bacteria behind. The drug-resistant bacteria then grow and take over. They even have the ability to give their drug resistance to other bacteria, which worsens the issue. These drug-resistant bacteria can then be spread from person to person or from nonhuman sources in the environment such as animals to humans.

Drug-resistant Threats to Be Aware of in Senior Care Pharmacy Services

The CDC identified the Top 18 Drug-Resistant Threats to the United States and categorized them as either being urgent, serious or concerning. Urgent Threats. Urgent threats are high-consequence antibiotic-resistant threats. These may not be currently widespread, but they have the potential to become so and require urgent public health attention to identify infections and to limit transmission.

Clostridium difficle (C. Diff)
Carbapenem-resistant Enterobacteriaceae (CRE)
Drug-resistant Neisseria gonorrhoeae (cephalosporin resistance)

Serious Threats. Serious threats are significant antibiotic-resistant threats. These have the potential to worsen and may become urgent without ongoing public health monitoring and prevention activities.

Multi-drug resistant Acinetobacter
Drug-resistant Campylobacter
Fluconazole-resistant Candida (a fungus)
Extended spectrum beta-lactamase producing Enterobacteriaceae (ESBLs)
Vancomycin-resistant Enterococcus (VRE)
Multidrug-resistant Pseudomonas aeruginosa
Drug-resistant Non-typhoidal Salmonella
Drug-resistant Salmonella Typhi
Drug-resistant Shigella
Methicillin-resistant Staphylococcus aureus (MRSA)
Drug-resistant Streptococcus pneumonia
Drug-resistant tuberculosis (Mycobacterium tuberculosis and extensively drug-resistant tuberculosis)

Concerning Threats. Concerning threats have a low threat of antibiotic resistance and/or multiple therapeutic options for resistant infections. These bacterial pathogens cause severe illness—these threats require monitoring and, in some cases, rapid incident or outbreak response.

Vancomycin-resistant Staphylococcus aureus (VRSA)
Erythromycin-resistant Streptococcus Group A
Clindamycin-resistant Streptococcus Group B

These resistant organisms have become more common as a result of unnecessary antibiotic use and are increasingly difficult to treat. A resident infected with antibiotic-resistant bacteria could experience more severe illness, increased mortality rates and an increased risk of complications, including admission to the hospital. If the amount of unnecessary antibiotics prescribed does not decrease, the World Health Organization predicts a post-antibiotic world where healthcare advances over the past 100 years would be null and simple infections would become unmanageable and potentially fatal—in part from unnecessary antibiotic use and the continued growth of antibiotic-resistant organisms. [Tweet “Learn the latest on antibiotic misuse in this #seniorcarepharmacyservices update”]

Adverse Effects Caused by Unnecessary Antibiotic Use in Senior Care Pharmacy Services

Another risk associated with the increased use of unnecessary antibiotics is the increased potential for adverse effects. Some of these are more closely related to certain classes of antibiotics, while others are broad and go across the board.

Nausea. Nausea is one of the most common adverse effects associated with antibiotics. This is especially problematic for long term care pharmacy providers when working with elderly residents who don’t have an appetite to eat or may be experiencing weight loss.
Renal Toxicity. Renal toxicity is another issue more commonly associated with our elderly residents. It occurs when a resident has declining renal function. Many antibiotics are renally eliminated, so unnecessary use has the potential to add to the renal toxicity and declining renal function a resident may already be experiencing.
Clostridium difficile (C. diff). The development of C. diff is another very serious complication that can occur from antibiotic use and, especially, unnecessary antibiotic use. This is a very debilitating disease that is also incredibly contagious. The antibiotics that are most commonly associated with C. diff are clindamycin, fluoroquinolones such as ciprofloxacin and levofloxacin and broad-spectrum (3rd and 4th generation) cephalosporins such as ceftriaxone and cefepime.
Cardiotoxicity. Cardiotoxicity is more commonly seen with quinolones and macrolides and occurs via QT interval prolongation.
Musculoskeletal toxicity. Musculoskeletal toxicity such as tendon rupture is commonly seen with quinolones.
Others. Other adverse effects seen with antibiotics are anaphylaxis and other allergic reactions, blood disorders such as anemia, leukopenia and thrombocytopenia, and dermatological reactions such as rash and Stevens-Johnson Syndrome.

Incidences of all of these adverse effects would be decreased with the elimination of unnecessary antibiotic use.

How Unnecessary Antibiotic Use Increases the Risk of Drug Interactions in Senior Care Pharmacy Services

A final risk associated with unnecessary antibiotic use is the increased occurrence of drug-drug interactions. Many common medications elderly residents take on a daily basis (such as warfarin) interact with antibiotics. Continuing to use antibiotics without a proper indication has the potential to add adverse interactions. If a resident has been placed on an antibiotic and then a maintenance medication is changed as a result, this places unneeded burden on the resident and nursing staff. There is also the potential for the changed maintenance medication to not be changed back to its appropriate dosing upon completion of the antibiotic. Avoiding unnecessary antibiotic use would eliminate the increased drug-drug interaction risk. It is important for senior care pharmacy services providers and other long term care staff to be aware of the risks associated with unnecessary antibiotic use and to become advocates for decreasing the amount of unnecessary antibiotics prescribed by really knowing what is happening to your residents, following appropriate prescribing guidelines and becoming advocates for appropriate antibiotic stewardship. At Grane Rx, we treat your residents with the utmost care. Our team of PharmDs specializes in caring for the unique needs of the geriatric population. Sign up here for a free consultation to learn how we can put our care to work for your Skilled Nursing Facility.]]>

At Grane Rx, we’re committed to providing the highest-quality LTC pharmacy services. As part of that commitment, we share an ongoing series of pharmacy updates from our Chief Clinical Officer, designed to keep you in the know on clinical topics related to long term care pharmacy and PACE pharmacy. Antibiotic resistance has become a growing threat to the healthcare industry. Antibiotic-resistant infections can lead to more toxic treatments, higher healthcare costs and poorer health outcomes. Approximately 30 to 50 percent of all inpatient antibiotic use is considered to be inappropriate or unnecessary. Each year throughout the United States of America, more than 2 million illnesses and at least 23,000 deaths occur due to antibiotic-resistant bacteria. In order to combat this growing problem, the CDC launched the Get Smart program, which focuses on common illnesses throughout America for which most of the antibiotic prescriptions are written. From November 14 to 20, the CDC will promote its annual antibiotic awareness week.

Long term Care Pharmacy Facts About Antibiotics

Overuse of antibiotics can cause Clostridium difficile and possibly deadly diarrhea.
Some bacterial infections are now completely resistant to all available antibiotics.
Millions of antibiotic medications are prescribed each year for viral infections.
Seventy percent of residents in a nursing home receive one or more courses of systemic antibiotics per year.

Antibiotic Use: What Could Go Wrong?

Increased adverse drug events
Drug interactions
Colonization/infection with antibiotic-resistant bacteria
Risk of serious diarrheal infections from Clostridium difficile
Increased resistance to important antibiotic medications

[Tweet “Learn the latest on #antibioticresistance in this #longtermcarepharmacy update”]

Get Smart Goals

Decrease antibiotic-resistant bacteria
Improve infection control and prevention
Improve antibiotic utilization throughout communities
Improve resident’s quality of life
Save lives

How Long Term Care Pharmacy and Other Providers Can Combat Antibiotic Resistance

Set goals to decrease antibiotic use
Collaborate and develop relationships with other healthcare professionals (doctors, nurses, pharmacists, etc.)
Test for specific bacteria and reevaluate regimen after results
Avoid treating viral infections with antibiotics
Use patient and provider resources
Educate and engage family members

Why Is This Important?

Long term care facilities and nursing homes house a culture where close contact is imminent, whether it is resident-resident, resident-staff or staff-staff. Infections are prone to being spread throughout; it is how healthcare providers respond that will make a difference. Throughout the week of November 14 to 20, the CDC will once again be promoting its Get Smart annual antibiotic awareness week. Awareness and education are a fundamental necessity for improvements to occur in the healthcare environment that Grane Rx hopes to continue. We encourage you to join the crusade to reduce inappropriate antibiotic use and increase awareness of the unfortunate consequences of antibiotic overutilization. The CDC website is an excellent source of resources to help you prepare and create awareness about this important cause. Looking for a long term care pharmacy provider that’s a true partner for your team? Learn about the Grane Rx difference today by calling (866) 824-MEDS (6337).]]>

SERVICES

Technology

RESOURCES

About

ADDRESS

105 Gamma Drive, Suite 100
Pittsburgh, PA 15238

CALL

Phone: 866-824-MEDS
Fax: 412-968-5800