Over the course of 12 years as a pharmacist in clinical practice leading antimicrobial stewardship programs and taking care of patients on health system infectious diseases services, one of the things I realized was that I, personally, could do more than impact the patient in front of me. I also had the opportunity to impact patients throughout the entire health system if I could utilize clinical decision support tools to hardwire success for providers. As pharmacists, by using our knowledge to impact drug interactions, duplicate therapy alerts, and drug allergy alerts in the clinical space, we can help drive the decision-making that's needed at the right point in time.
Hospital pharmacy teams can help advise and shape the drug alerts from clinical decision support systems (CDSS) to benefit their organizational processes and help reduce alert fatigue, while enhancing overall patient outcomes.
The importance of evaluating current use of alerts in your system
CDSS aims to prevent adverse drug events and medication errors within healthcare settings by providing guidance and alerting for drug-related problems such as:
- Drug-drug interactions
- Drug allergies
- Duplicate therapy
- Drug dosing
- Precautions/warnings
Despite the benefits, alerts may not be clinically relevant in certain clinical situations or to certain patients, leading to a potential excess of alerts that are not actionable for providers. This contributes to the overwhelming information burden we’ve come to call alert fatigue. The combination of cognitive overload from too many alerts and desensitization from repeated exposure to unnecessary alerts can add to clinicians’ feelings of burnout and could potentially increase the risk that clinicians ignore a significant alert. Studies show that alert override rates range from 49%-96%.
While that’s a pretty wide range, it's also a really large and impactful number: It tells us, even though we know the value of these alerts, there's an opportunity to improve how meaningful they are.
Health systems need to deploy different strategies to make sure that important medication-related alerts get to the right clinician at the right time to help the right patient. They need to start by knowing how they currently use and evaluate their internal drug-related alerts. For example:
- Using out-of-the-box solutions with no alert customization.
- Reviewing current data on top overrides data to prompt customizations.
- Assigning teams to investigate common causes of overridden alerts.
Whatever an organization’s priorities or approach, pharmacists can and should be key contributors to helping hone a drug alerting strategy.
Taking steps toward more meaningful alerting
While speaking to pharmacy administrators at a recent pharmacy conference, I took an informal poll of audience members, asking how many of them were evaluating alerts for customization at their organizations, and over 70% said they were currently engaged in some form of alert management or customization. That means close to 30% were getting by or perhaps struggling with one-size-fits-all alerts not tailored to their practice environment.
Every health system approaches management of their alerting data differently. Many start using their drug data solution as it comes out of the box, waiting to dive into customization until they’ve gained some experience with the data and the alerts.
When they’re ready to explore their data, some possible places to start include:
- What are our top 50 overridden alerts?
- Who's overriding these alerts and why (are there any common themes)?
- What are the drug alerts that are populating the most, and which of those alerts are the most overridden?
Inputs into the process can come from various teams. Some organizations use their Medication Safety Committee, while others rely on their Pharmacy and Therapeutics (P&T) committee, and others depend on IT departments and informaticists to drive the process. While every organization’s path is different, partnering with the pharmacy department to come up with solutions is going to lead to the most success in understanding and taking advantage of some of these opportunities.
Opportunities to improve clinical screening: interactions and allergies
When I asked my conference audience in another informal poll where they saw the most opportunity for better alert management, they responded:
- Duplicate therapy: 25%
- Allergies: 23%
- Drug interactions: 21%
Drug interaction alerting is often a good place to start, as it can be a foundation for evaluating setting thresholds. It also represents a great opportunity for end users to work with pharmacists and for pharmacists to get involved in influencing system-wide standards for medication safety.
Pharmacists can help by evaluating current drug-drug interaction alerts and determining if the existing settings are producing notifications that match what they would ideally expect to see in key clinical situations. They can also work alongside care teams to recommend setting adjustments by provider type or location:
- Provider-type: For example, filters could allow hospital pharmacists to see all drug interaction alerts, but the prescribers would only receive notifications tied to a clinical action.
- Location: Filters could, for example, remove inpatient drug-alcohol interaction alerts as they are not typically pertinent to an inpatient setting where a patient would not be consuming alcohol, but could reinstate those alerts in outpatient or retail settings when they could again be relevant to the patient.
Pharmacists are valuable in getting patient engagement in the allergy reconciliation process as well. This is something antimicrobial stewardship programs have focused on a lot in recent years, emphasizing the importance of educating the patient as to why they’re being asked detailed questions about their reactions to medications and how it will influence the options we have to most appropriately treat them.
Recording reaction severity and any other contextual information alongside hospital policies and guidelines about the allergy can go a long way in improving the sensitivity of the alerting mechanism and supporting treatment options for patients that have certain allergies. I think for a long time we've been fearful to explore use of certain drugs because the patient might have an allergy. But as medicine advances, literature has uncovered that in certain scenarios there may be some options available that we previously thought weren't necessarily appropriate. Having hospital policies and alerts in place to support providers in appropriately using those drugs that might have traditionally been considered an allergy risk – for example, prescribing beta-lactams for patients with penicillin allergies – can be helpful and make providers feel more comfortable making decisions related to these therapies.
Evidence-based data and expert services drive precision alerting
While pharmacists and informaticists working within their organization can do a lot to evaluate and filter alerts, it is essential to utilize a CDSS database that is evidence-based, supported by expert teams maintaining the content, and implementing mechanisms to enhance clinical alerting by improving relevancy to certain clinical situations or particular patients.
For drug interactions, CDSS solutions like Medi-Span® help improve precision alerting by applying mechanisms that help target the most actionable alerts toward clinically relevant scenarios by:
- Incorporating patient profile data in alerting: This mechanism applies additional context to specific alerts, such as patient age or medical conditions. An example of applying age to an alert would be for a drug interaction between ceftriaxone and calcium. This is a clinically important alert for neonates (28 days of age or younger), but would not be applicable to patients older than 28 days.
- Applying advanced logic: This strategy uses more complex rules to make the most use of all available data to deliver more precise and actionable insights. For example, a specific drug interaction alert may notify a prescriber that serum potassium monitoring is required. If a serum potassium is already ordered on the patient’s profile, a drug interaction alert may be unnecessary.
Expert services from CDSS can also help organizations hone the precision of allergy screening by providing insight into the concepts used to perform allergy screening. An organization may be well-intentioned in thinking they can achieve greater alerting sensitivity by filtering allergies to specific drug products or NDCs. While, theoretically, this sounds like a thorough plan, having expert services to offer guidance and implementation support can uncover that this will also trigger alerts for inactive ingredients also contained in drug products or NDCs for which organizations are posting allergies. Ultimately, this will lead to more – not fewer – alerts, that could cause confusion to clinicians burdened with irrelevant alerts for every drug product that contains the same inactive ingredient (for example, corn starch) as the flagged medication allergy. Experts can advise and help implement a more efficient system that favors posting a patient’s allergy to the active ingredient.
‘Hardwiring success’ with systemic approaches to medication safety
The biggest call to action to pharmacists is get involved, at the system or individual institution level, to evaluate your alerts, whether it's drug allergy, drug interactions, or drug dosing, as all these same considerations should be evaluated. Understanding what alerts are most likely to be overridden on your team or at your hospital will give you the opportunity to home in on those specific drug-prescribing scenarios to identify your best path forward.
I'm a huge advocate of “hardwiring” success through establishing sound processes. Using a systematic approach to review your top 50 or even top 20 overridden alerts and addressing how to customize them can have a far-reaching effect in minimizing some of the noise and positively impacting patient safety.
To learn more about how pharmacy and nursing leaders can help align care and reduce harmful variability, download our eBook, “Bring clarity to drug decisions to improve care.”
