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WRHA Pharmacy Program Direct Patient Care GuidelinesPharmacist Performance ExpectationsManitoba Renal ProgramMay 2013Links updated May 21, 2015 (Lori Wazny, Pharm.D.)DEVELOPMENT OF THE PHARMACIST PERFORMANCE EXPECTATIONSGUIDELINES FOR USEPharmacist Performance ExpectationsPurpose:The purpose of these Guidelines is to define performance expectations of pharmacy care that pharmacistswill provide to Manitoba Renal Program patient, at any acute care WRHA facility, or St BonifaceHospital under full-staffed [pharmacist] conditions. These performance expectations will establish the“norm” for pharmacist practice. Performance expectations will provide a tool for pharmacists to selfevaluate the quality of the service they provide for Manitoba Renal Program patients and identifyopportunities for personal and/or staff development. The performance expectations are viewed currentlyas the type of practice pharmacists will strive to attain. A phased-in approach for implementation issuggested.Pharmacists play a key role in medication safety. Prevention and resolution of drug related problems is anessential component for the provision of medications in a safe and effective manner. Prioritization ofpharmacist activities should take medication safety into consideration.In the near future, it is expected that the performance expectations will evolve to standards of practicewithin the WRHA Pharmacy Program. Standardization of practice activities will help support thepharmacy practice model, assist in the orientation/education of new staff, and assist in the evaluation ofstaff.Of note, different priorities exist across the MRP according to the clinical time allotted to the pharmacistswho have shared clinical and distribution functions.1

I. Expectations on a regular weekday (see appendix 1 for table for prioritization of activities,please refer to site specific standard operating procures for further detail):A. The pharmacist shall perform the following core activities of a fully staffed weekday in order ofpriority1. Attend Manitoba Renal Program clinics (peritoneal dialysis, local centres dialysis, homehemodialysis or renal health) as appropriate at site Organize patients and bloodwork processes as appropriate to site Review all clinic patients charts Review DPIN for all patients For patients seen by a pharmacist, generate best possible medication history, performmedication reconciliation and detailed medication review Document in health record any recommendations, suggestions or further patient informationrequired for patients not be seen by a pharmacist as appropriate to site Additional processes per site2. Attend multidisciplinary patient care rounds as appropriate (different models at different sites). Detailed discussion with team about patients covered on rounds Identify admitted patients for pharmacist medication reconciliation on discharge Identify patients for pharmacist medication review Additional processes per site (e.g. use rounds template)3. Discharge (or transfer) medication reconciliation for admitted hemodialysis, peritoneal dialysis,local centres dialysis, or home hemodialysis patients as appropriate or renal health clinic patientsas appropriate Reconcile inpatient medications with DPIN and Renal Medication flow sheet Write discharge prescription for medications including appropriate medications on the RenalMedication flow sheet and new medications started in hospital. Use professional judgmentand contact MD to clarify outstanding issues. Have prescription faxed to outpatient pharmacy and copy dialysis unit as appropriate Provide patient with medication card and patient counseling (if appropriate) Document discharge and any issues in the patient’s medical record if appropriate. Additional processes per site (e.g. some sites only do discharges for dialysis patients admittedunder nephrology, renal health clinic patients usually only for renal medications only and atthe request of the MRP team) Perform medication reconciliation during discharges, medication reviews, clinic visits, orbetween clinic visits as required in accordance with the MRP Medication ReconciliationPolicy loads/pdfs/P&P/P&P 60.40.09 guideline.pdf4. Review monthly bloodwork for hemodialysis patients as appropriate at site Organize patients and bloodwork processes as appropriate to site and according to siteprocessesII

The Canadian Society of Nephrology (CSN) CANN-NET Anemia Treatment Algorithm forHemodialysis Patients may be used as a guide to adjust ESA and IV iron ent-kt-projects#Project4 Additional processes per site (e.g. some sites, dieticians do MBD)Identify and resolve actual/potential drug elated problems (DRP’s) during discharges, medicationreviews, clinic visits, between clinic visits or on medication order review. This is accomplishedthrough review of patient's medication profile, medical record, and review of pertinent laboratoryresults, patient/caregiver/health professional dialogue, interdisciplinary interaction, andcommunication with the dispensary / community pharmacy staff, patient/caregiver/health professionalas appropriate. Patients may be prioritized according to their severity, at the discretion of thepharmacist.5. Perform detailed medication reviews for patients as appropriate at practice site. Medication reviewsare performed for new dialysis patients, on periodic review (q 6 months- 1 year), in preparation forMRP clinic visit (peritoneal dialysis, local centres dialysis, home hemodialysis or renal health) orat the discretion of the pharmacist or request of another health professional. (see list of renalspecific DRPs below). Generally, priority patients for dialysis units are new starts to PD/HD. Speak to patient, caregivers, family members and other healthcare professionals asappropriate to obtain the information required for the medication review. Review the most recent medication list (clinic list, Renal Medication flow sheet), DPIN andspeak to the patient and caregiver to determine the best possible medication history(medication list) including herbal and OTC Identify and resolve actual/ potential DRPs (see below) Review patient for medication coverage issues Ensure follow up bloodwork is ordered as appropriate based on recommendations andchanges Document any medication issues in the appropriate place: directly in the patient care recordor on the Pharmacist Medication Review Template or another place as appropriate to MRPsite in accordance with the WRHA Pharmacy policy for documentation. WRHA Documentation in the Health Record harmacistDocumentationinaHealthRecord 000.pdf Write out medications on a regular outpatient prescription as appropriate. Write refills as requested and as appropriate Provide continuity of care between facility and community pharmacy as appropriate. (e.g. tofacilitate prescription delivery, compliance aid, drug coverage or other issues as required) Liaise with patient, caregivers, family members and other healthcare professionals asappropriate to provide medication related information to or for patients Additional processes per siteTypes of DRP’s to assess include but are not limited to (some relevant nephrology referencesincluded for each DRP): Review medications to determine if any drugs require renal dose adjustments WRHA Pharmacypolicy for renal dosing, and standard resources such as Bennett’s or Dialysis of Drugs (labs:creatinine for CKD patients)III

oBailie GR, Mason NA.2014 Dialysis of Drugs. Saline (USA): Renal PharmacyConsultants. The app is available for 7.99 USD here: http://renalpharmacyconsultants.com/ An older 2011 online version is available free here: ogy-books/dialysisof-drugso Aronoff GR, Berns JS, Brier ME, Golper TA, Morrison G, Singer I, et al DrugPrescribing in Renal Failure Guidelines for Adults, 5th Ed. Portland (USA): Book News,Inc.; 2007 http://kdpnet.louisville.edu/renalbook/o WRHA Renal Dosing enalDrugDirectiveupdated 000.pdfo Matzke GR, Aronoff GR, Atkinson AJ, Bennett WM, Decker BS, Echardt KU. Drugdosing considerations in patients with acute and chronic kidney disease – a clinicalupdate from KDIGO. Kidney Int 2011;(80):1122-37 PMID 21918498 /pubmed/?term 21918498Review for any medications that are that are contraindicated in CKD and that should beminimized (e.g. NSAIDS in clinic patients, nitrofurantoin) (labs: creatinine for CKD patients)Review for any medications that are no longer required in dialysis (ie. potassium supplements,sodium bicarbonate, allopurinol etc) for dialysis patientsReview patient for medication allergies / intolerances in accordance with the WRHA Pharmacypolicy for documentationo WRHA Allergy Assessment dfReview patient for medication adherence using DPIN and interview with patient and or caregivero Raymond C, Wazny L, Sood A. Medication Adherence in patients with chronic kidneydisease. CANNT J, 2011;21(2):47-50 /pubmed/?term 21894841Review patient for drug drug interactions (resources include Micromedex, Lexcomp)Review patient for adverse drug reactions or side effects Review anemia management. Assess relevant labs, including trends (labs - hemoglobin,transferrin saturation, ferritin trends) and most recent EPO/iron therapy (dose, route,duration), and replavite (most recent fill and how/who administered for PD/clinic patients).Evaluate patient for possible EPO hyporesponsiveness, adverse effects. Recommend appropriateadjustments per protocol or pharmacist judgment.o Canadian Society of Nephrology commentary on the 2012 KDIGO Clinical PracticeGuideline for Anemia in CKD. (2013) a/pubmed/24054466o KDIGO Anemia guidelines (2012)http://www.kdigo.org/clinical practice guidelines/pdf/KDIGO-Anemia%20GL.pdfo KDIGO Guidelines for CKD Management (2012)http://www.kdigo.org/clinical practice guidelines/pdf/CKD/KDIGO 2012 CKD GL.pdfo TREAT Trial http://www.nejm.org/doi/full/10.1056/NEJMoa0907845 Review mineral and bone disease. Assess relevant lab values (labs - corrected calcium,phosphate, PTH trends, ALP, albumin) calcium bath concentration, parathyroidectomyIV

surgical history and most recent phosphate binder/calcitriol /cinacalcet therapy. (Note, at someMRP sites, some aspects of this care are provided by dieticians)o KDIGO MBD (2009) http://kdigo.org/home/mineral-bone-disorder/o Raymond CB, Wazny LD, Sood A. Update on the new Kidney Disease: ImprovingGlobal Outcomes (KDIGO) guidelines for mineral and bone disorders (MBD)--a focuson medications. CANNT J, 2010;20(1):42-8 /pubmed/20426360o MRP Guidelines for use of cinacalcet (available by email)o Raymond CB, Wazny LD, Sood A. Sodium thiosulfate, bisphosphonates, and cinacalcetfor calciphylaxis . CANNT J, 2009; 19(4):25 /pubmed/20136032o CSN Guidelines for patients with CKD not receiving dialysis pdf html Determine if any medications are required or need to be adjusted for cardiac risk reduction afterevaluation of cardiac history and risk (presence of MI, CAD, angina, CHF, TIA, a fib, diabetes,smoking status, hypertension, PVD), relevant lab values (labs - lipid profile monitor MIBI,echo) and use of aspirin, clopidogrel, ACE/ARB, BB, CCB, NTG, statin, diuretic, andanticoagulants (labs INR warfarin, LMWH creatinine for clinic patients, platelets, allmonitor drug interactions).o Herzog CA, eta l. Cardiovascular disease in chronic kidney disease. A clinical updatefrom Kidney Disease: Improving Global Outcomes (KDIGO). oversy%20Rpt.pdfo Cheung AK, Henrich WL. Secondary prevention of cardiovascular disease in end-stagerenal disease (dialysis) UpToDate V disease-in-end-stage-renal-diseasedialysis?source search result&search cardiovascular disease and kidney disease&selectedTitle 12%7E150o Gibson CM, Henrich WL. Chronic kidney disease and coronary heart disease. UpToDateV 10.2. ease?source search result&search cardiovascular disease and kidney disease&selectedTitle 2%7E150o Bell et al The use of antiplatelet therapy in the outpatient setting: CanadianCardiovascular Society Guidelines Executive Summary. Can J Cardiol 2011 Mar-April27(2):208-21 a/pubmed/21459270o CSN Guidelines for patients with CKD not receiving dialysis pdf htmlo KDIGO Guidelines for CKD Management (2012)http://www.kdigo.org/clinical practice guidelines/pdf/CKD/KDIGO 2012 CKD GL.pdf Review blood pressure (and for clinic patients antiproteinuric therapies) including ACE/ARB,BB, CCB, diuretic and other antihypertensives (monitor – pre-dialysis, post dialysis,intradialytic, clinic, dry weight, home BP machine, recent change)o KDIGO Guidelines for Blood Pressure in CKD (2012)http://www.kdigo.org/clinical practice guidelines/pdf/KDIGO BP GL.pdfo KDIGO Guidelines for CKD Management (2012)http://www.kdigo.org/clinical practice guidelines/pdf/CKD/KDIGO 2012 CKD GL.pdfV

oooHenrich WL, Mailloux LU. Hypertension in dialysis patients. UpToDate V a/contents/hypertension-in-dialysispatients?source related linkKaplan NM, Rose BD. Hypertension in kidney disease. UpToDate V 10.2http://www.