Clinical pharmacy news (6/26/16)

26 Jun 2016

By: Matt Tanner, pharmacy residency program director & clinical coordinator

 

By Matt Tanner, pharmacy residency program director & clinical coordinator

Heparin

What is changing
The heparin per pharmacy protocol orders have been enhanced to make it easy for you to tell your pharmacist if you want to either delay the start of the heparin and/or start the infusion without a bolus. In addition, the “Indications” have been changed to buttons to make selection of the indication quicker.

Rationale
This simplifies communication between the provider and pharmacist by creating buttons to help you efficiently communicate common changes regarding heparin infusions.

Planned “Go-Live” date was June 20, 2016.

Additional helpful details
The buttons are:

• “Would you like to delay the start time?” If you click “yes”, you will be asked to enter a start time.
• “Keep bolus dose per protocol” If you click “No Bolus” the pharmacist will not order a bolus dose, even if the protocol would call for one.

Neither question has to be answered (leave them blank if you want the infusion to start now and give a bolus per protocol, if appropriate).

This idea was developed by the Medication Safety Subcommittee of P&T based on a recent Patient Safety Alert (where a pharmacist missed the method that the provider used to communicate that he wanted to delay the start of the heparin infusion by six hours).

If you have questions or concerns, please contact Matt Tanner in pharmacy at 503-814-2048 or by e-mail.

Insulin and warfarin changes

What is changing
The following directions will be added to the AVS for Levemir insulin, Novolog insulin, and Warfarin.

• For Levemir orders: Pharmacy may substitute Lantus (equal number of units) based on insurance or facility formulary.
• For Novolog orders: Pharmacy may substitute Humalog or Aprida insulin based on insurance or facility formulary.
• For warfarin orders: Warfarin should be taken at the same time daily based on clinic instructions or facility norms.

Rationale
Embedding these statements in the prescriptions/AVS will save pharmacies and skilled nursing facilities from having to call discharging providers to clarify orders.

Planned “Go-Live” date was June 21, 2016

Additional details
If a patient is started on Novolog or Levemir insulin while in the hospital (or their inpatient doses are continued on discharge), and the patient’s insurance (or SNF) uses a different rapid or long acting insulin, the patient’s pharmacy (or SNF) is required to either dispense the order as written or to call the provider to clarify/change the medication to match the insurance formulary.

If an inpatient warfarin order is continued as an outpatient, the order is often written “daily at 1400.” This order would force a SNF to give the warfarin at 1400, even if the facility normally gives warfarin later in the evening, unless a provider is called to “clarify.”

Adding extra text to each of these three orders has the potential to make providers happy (less “clarifying” phone calls) as well as patients, outpatient pharmacies and SNFs.

This idea was discussed and endorsed by the Physician Coalition during 6/2016 and developed in cooperation with Danita Green of the Care Managers.

For questions or concerns call 503-814-2048 or email Matt Tanner in Pharmacy.

Quinolone alternatives for UTI

Many of you have heard the FDA is advising against the use of floroquinolones for the treatment of UTIs whenever possible. Because ceftriaxone works well empirically, there is a temptation to change to an oral third-generation cephalosporin. Unfortunately, the third generation cephalosporins have a side effect that many patients find intolerable: an empty wallet. To remedy this, may I suggest the following as alternatives for our UTI patients?

Keflex – because cefazolin is active against 94 percent of the E. coli and about 81 percent of Proteus spp. isolated from our patients from September 2015 to February 2016, a first generation cephalosporin is a reasonable alternative.   

Augmentin – our antibiogram shows just short of 70 percent of E. coli are susceptible to ampicillim + sulbactam, but more than 85 percent of Proteus is susceptible.

Bactrim – In addition to covering 97 percent of our Staph aureus isolates from the urine, Bactrim covers 80 percent of E. coli, ~70 percent of Proteus and >90 percent of Klebsiella spp.

Nitrofurantoin – for the patients with cystitis, adequate renal function and no concerns about pulmonary or other toxicities, nitrofurantoin works for 97 percent of our E. coli and 92 percent of our Klebsiella oxytoca.

Ampcillin – E. faecalis isolates in the urine tend to respond well to ampicillin, and beta-lactams are preferred over quinolones for both Staph and enterococcal infections, if tolerated.

Fosfomycin – although it shares the “wallet-draining” side effect of cefpodoxime, it is a single dose option for both non-Acenitobacter gram negative or gram positive urine infections. It is not available as an inpatient, but it is a potential outpatient option to complete therapy.

Here is a link to the Salem Health antibiogram.

Here is a link to the algorithm that the Emergency Department pharmacists use to suggest alternative antibiotics for patients with cultures resistant to initial treatment.

If you have questions about any of this, please feel free to contact Matt Tanner in Pharmacy by email or at 503-814-2048.