“Unfortunately, we are seeing patients erroneously continued on this [medication] on the floor. Some are even discharged on this [med],” Clark said, adding that a specific order set can be developed that has a 72-hour automatic stop date for all orders for quetiapine when used specifically for delirium.
“[The order set] can help reduce the chance that it be continued unnecessarily when a patient transfers out of the ICU,” she explains.
Another class of medication that is often initiated in the ICU is proton pump inhibitors for stress ulcer prophylaxis. Continuing these on the floor or at discharge, Clark said, should be carefully considered to avoid unnecessary use and potential adverse effects.
5. Seek opportunities to change from intravenous to oral medications – it could mean big savings.
Intravenous medications usually are more expensive than oral formulations. They also increase the risk of infection. Those are two good reasons to switch patients from IV to oral (PO) as early as possible.
“We find that physicians often don’t know how much drugs cost,” said Marilyn Stebbins, PharmD, vice chair of clinical innovation at University of California, San Francisco.
A common example, she said, is IV acetaminophen, the cost of which skyrocketed in 2014. Institutions can save significant dollars by limiting use of IV acetaminophen outside the perioperative area to patients unable to tolerate oral medications. For patients who are candidates for IV acetaminophen, consider setting an automatic expiration of the order at 24 hours.
Hospitalists can help reduce the drug budget by supporting IV-to-PO programs, in which pharmacists can automatically change an IV medication to PO formulation after verifying a patient is able to tolerate orals.
6. Consider a patient’s health insurance coverage when prescribing a drug at discharge.
“Don’t start the fancy drug that the patient can’t continue at home,” said Ian Jenkins, MD, SFHM, a hospitalist and health sciences clinical professor at the University of California, San Diego, and member of the UCSD pharmacy and therapeutics committee. “New anticoagulants are a great example. We run outpatient claims against their insurance before starting anything, as a policy to avoid this.”
7. Tell the pharmacist what you’re thinking.
Dr. Jenkins uses a case of sepsis as an example:
“If you make it clear that’s what’s happening, you can get a stat loading-dose infused and meet [The Joint Commission] goals for management and improve care, rather than just routine antibiotic starts,” he said.
Dr. Ian Jenkins
Another example is anticoagulants:
“Why are you starting the anticoagulant? Recommendations could differ if it’s for acute PE (pulmonary embolism) versus just bridging, which pharmacists these days might catch as overtreatment,” he said. “Keep [the pharmacy] posted about upcoming changes, so they can do discharge planning and anticipate things like glucose management changes with steroid-dose fluctuations.”
8. Beware chronic medications that are not on the hospital formulary.
Your hospital likely has a formulary for chronic medications, such as ACE inhibitors, angiotensin receptor blockers, and statins, which might be different than what the patient was taking at home. So, changes might need to be made, Dr. Clark.
“Pharmacists can assist in this,” she said. “Often, a ‘therapeutic interchange program’ can be established whereby a pharmacist can automatically change the medication to a therapeutically equivalent one and ensure the appropriate dose conversion.”
At discharge, the reverse process is required.
“Be sure you are not discharging the patient on the hospital formulary drug [e.g., ramipril] … when they already have lisinopril in their medicine cabinet at home,” Clark said. “This can lead to confusion by the patient about which medication to take and result in unintended duplicate drug therapy or worse. A patient may not take either medication because they aren’t sure just what to take.”
9. Don’t hesitate to rely on pharmacists’ expertise.
“To ensure that patients enter and leave the hospital on the right medications and [that they are] taken at the right dose and time, do not forget to enlist your pharmacists to provide support during care transitions,” Dr. Stebbins said.
Dr. Humber said pharmacists are “uniquely qualified” to be medication experts in a facility, and that “kind of experience and that type of expertise to the care of the hospitalized patient is paramount.”
Dr. Thomas said that pharmacists can save hospitalists time.
“Check with your pharmacist on available decision-support tools, available infusion devices, institutional medication-related protocols, and medications within a drug class.”Additionally, encourage pharmacists to join you for rounds, if they’re not already doing so. Dr. Humber also said hospitalists should consider more one-on-one communications, noting that it’s always better to chat “face to face than it is over the phone or with a text message. Things can certainly get misinterpreted.”