March 2024 |
New/Updated Pharmacy Directives:
- Therapeutic Directive CRRT and SLED Dosing Antimicrobials (Adult) (NEW) – new directive for dosing antimicrobial medications for patients requiring continuous renal replacement therapy (CRRT) and sustained low-efficiency dialysis (SLED). This directive provides medication dosing recommendations based on flow rates for those patients requiring CRRT or SLED.
- Therapeutic Directive Renal Dosing Antimicrobials (Adult) 2024 (UPDATED) - update includes a purpose statement that states, “To improve patient safety and optimize patient outcomes, pharmacists will adjust antimicrobials as deemed appropriate using the below protocol and guidance.”
- Therapeutic Directive – Diabetes (UPDATED) – update includes verbiage regarding pharmacists' ability to round weight-based insulin orders and home insulin dose conversions to formulary insulin agents to nearest units.
- Therapeutic Directive – Nutrition Support (UPDATED) – update included the removal of respiratory therapists on the nutrition services team as they no longer provide the services for indirect calorimetry.
- Therapeutic Directive IVIG Dose Rounding (UPDATED) – updates included clearer dosing guidance for obese and non-obese patients specifically regarding how to dose patients whose actual body weight is less than ideal body weight.
- Therapeutic IV to PO Step-down Anti-epileptics (UPDATED) – now includes valproate syrup.
- Therapeutic Directive Automatic Constipation Prevention (UPDATED) – pharmacists can add docusate, polyethylene glycol, and/or senna. Exclusion criteria now include patients undergoing gastrointestinal surgery or patients with a confirmed ileus.
- Therapeutic Directive IV-PO Step-down Diltiazem (UPDATED) – updates to the product cost section of the IV-PO Step-down Diltiazem Directive. These cost updates include price changes to the parenteral and enteral dosage forms.
- Therapeutic Directive 4 Factor PCC Dosing 2024 (NEW) – directive indicates the mechanism of action, indication, uses, dosing, pharmacokinetics, contraindications, and monitoring. Pharmacy is automatically consulted for all 4-Factor PCC orders; upon consultation, a pharmacist can provide dosing recommendations for anticoagulation reversal utilizing 4-factor PCC.
Renewal of Existing Pharmacy Directives:
- Therapeutic Directive IV-PO Step-down Dexamethasone
- Therapeutic Substitutions Automatic Calcium Chloride to Calcium Gluconate
- Therapeutic Directive Metronidazole
- Therapeutic Directive MRSA Nasal PCR
- Therapeutic Guideline CAP Treatment
- Therapeutic Guideline HAP-VAP Treatments
- Therapeutic Guidelines UTI Treatment
Policies and Procedures
A summary of the policies presented is below.
Policy Name
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Update/Delete
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New/Updated Policy Equivalent
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Resident Duty Hours – Management
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NEW
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Resident Moonlighting – Management
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NEW
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Resident Licensure – Management
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NEW
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Administration of Hypertonic Saline – Clinical
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UPDATED
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Allows for administration of 23.4% sodium chloride via peripheral line at the discretion of the physician during and emergency
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Medication Storage and Security
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RETIRE
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Replaced by Medication Procurement, Inventory Control, Storage, and Security
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Drug Procurement and Inventory Control
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RETIRE
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Replaced by Medication Procurement, Inventory Control, Storage, and Security
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Medication Procurement, Inventory, Storage, and Security
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NEW
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Medication Recalls
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NEW
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Tax-Free Alcohol
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RETIRE
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Pharmacy no longer storing for lab use
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JOINT COMMISSION REQUIREMENTS
- Antimicrobial Stewardship Report – presented the Standardized Antimicrobial Administration Ratio (SAAR) from 2022, 2023, and 2024. SAAR data shows antimicrobial usage at St. Dominic Hospital by benchmarking prescribing trends against risk-adjusted data from institutions of similar size and acuity provided by the Center for Disease Control and Prevention’s National Healthcare Safety Network (NHSN). Any SAAR value > 1.0 indicates more antimicrobial days observed than predicted whereas SAAR values < 1.0 indicate fewer days observed than predicted. Metrics include all antibacterials prescribed, broad-spectrum antibacterials used predominantly for hospital-onset infections (e.g., piperacillin/tazobactam, cefepime, meropenem), antibacterial agents predominantly covering gram-positive infections (e.g., daptomycin, vancomycin, linezolid), and broad-spectrum antibacterials predominantly used for community-onset infections (e.g., ceftriaxone, fluoroquinolones). Overall, our total antibacterial prescribing habits have held a SAAR of < 1.0 for all of 2022, 2023, and 2024. This trend was also reflected in SAARs for agents active against resistant gram-positive organisms, with SAARs mostly ≤ 1.0. However, broad-spectrum agents predominantly used for hospital-onset infections have largely held a SAAR > 1.0 in the ICU and wards. As for SAAR data for antibacterial agents often used for community-onset infections, the ICUs have mainly held a SAAR < 1.0 whereas the wards have mostly seen SAARs ≥ 1. It was also reported that the days of therapy for piperacillin-tazobactam were the highest in January 2024 compared to overall month-to-month use in 2022 and 2023. This has been largely attributed to the time of year and initiation of piperacillin-tazobactam before narrow spectrum gram-negative antimicrobial. De-escalating to narrower agents when possible and limiting antibiotic regimens to shorter, guideline-directed durations can help further improve our metrics and patient care.
Medication Use Evaluation:
- Assessing Compliance to Current Hospital Restriction Criteria – findings of her medication use evaluation (MUE) surrounding sugammadex utilization compliance compared to hospital restrictions. Her results indicated 100% adherence to hospital restrictions, but 0% to the 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade due to no documentation of train of four (TOF). It was recommended to update the hospital’s restriction criteria to provide more clear verbiage regarding the use of sugammadex and the current restriction criteria.
Pharmacy Reports
- Medication Reconciliation Statistics – Areas for improvement include reconciling medications at admission and transfer of care.
- FDA Safety Alerts – summary of the 2023-204 FDA Drug Safety Alert Communications. The alerts included discussion regarding serious drug reactions to antiseizure medicines levetiracetam and clobazam, the addition of a boxed warning for increased risk of severe hypocalcemia in patients with advanced chronic kidney disease taking osteoporosis medicine Prolia (denosumab), and an update on the FDA’s ongoing evaluation of reports of suicidal thoughts or action in patient taking glucagon-like peptide-1 receptor agonists (GLP-1 RAs) approved for type 2 diabetes and obesity.
- Adverse Drug Event Report – adverse drug event report from January and February 2024. Medication includes naloxone, flumazenil, D50W, and vitamin K. There were no concerning trends identified during the review.
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January 2024 |
New/Updated Pharmacy Directives:
- Therapeutic Directive Automatic Calcitonin (DELETE)
- Therapeutic Directive Metoprolol (DELETE)
- Therapeutic Directive Opioid Partial Agonists (DELETE)
- Therapeutic Directive Anticoagulation (UPDATED) – update to the Anticoagulation Directive including an editorial change labeling Kcentra as 4-PCC, the addition of more lab ordering abilities for pharmacists, and the inclusion of the most recent CHEST guidance for perioperative bleed risk.
- Therapeutic Substitutions Automatic Stadol and Nubain (UPDATED) – consolidation of the Therapeutic Directive Opioid Partial Agonists with this automatic substitution policy. The addition includes information regarding formulary status for butorphanol and nalbuphine.
- Medication Administration and Monitoring Guide (UPDATED) – new updates to the Medication Administration and Monitoring Guide which included the ICU Stepdown (6 Center)’s name change to the Progressive Care Unit (PCU), the authorization of dexmedetomidine (Precedex) use in the PCU, and mannitol being restricted to the emergency department and intensive care units.
Renewal of Existing Pharmacy Directives:
- Therapeutic Directive IV-PO Step-down Digoxin
- Therapeutic Directive Pharmacokinetic dosing IV-PO Step-down Phenytoin and Fosphenytoin
- Therapeutic Directive Epoetin alfa
Policies and Procedures
A summary of policies presented is below.
Policy Name
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Update/Delete
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New/Updated Policy Equivalent
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Mission, Vision, and Goals – Management
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NEW
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Medications – Patient Supplied
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NEW
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Replacing the Administration and Storage of Patient Home Medications Policy
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Administration and Storage of Patient Home Medications
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DELETE
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Replaced with Medications – Patient Supplied
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Controlled Substance Diversion Prevention Program Policy
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NEW
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Controlled Substance Diversion Committee Charter
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NEW
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Code Carts
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UPDATED
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Automated Dispensing Cabinets – Requesting Additional Medications – Management
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DELETE
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Replaced with Automated Dispensing Cabinets – Requesting Additional Medications - Management
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Automated Dispensing Cabinets – Inventory – Management
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NEW
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Replacing the Automated Dispensing Cabinets – Requesting Additional Medications – Management
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USP 795 Pharmaceutical Compounding – Nonsterile Preparations – Clinical
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NEW
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USP 797 Pharmaceutical Compounding – Sterile Preparations – Clinical
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NEW
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USP 800 Hazardous Drugs – Handling in Healthcare Settings – Clinical
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NEW
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USP 797 Beyond Use Dating and In-Use Time – Compliance
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DELETE
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Replaced with Standard Operating Procedures
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USP 797 Competency Requirements – Compliance
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DELETE
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Replaced with Standard Operating Procedures
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USP 797 Competency Requirements - Form
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DELETE
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Replaced with Standard Operating Procedures
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USP 797 Garbing and Personal Hygiene - Compliance
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DELETE
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Replaced with Standard Operating Procedures
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USP 800 Deactivating, Decontaminating, Cleaning, and Disinfecting – Compliance
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DELETE
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Replaced with Standard Operating Procedures
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USP 800 Facilities and Engineering Controls – Management
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DELETE
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Replaced with Standard Operating Procedures
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USP 800 Hazard Communication – Guideline
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DELETE
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Replaced with Standard Operating Procedures
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USP 800 Hazardous Drug – Guideline
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DELETE
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Replaced with Standard Operating Procedures
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USP 800 Hazardous Drug Disposal – Compliance
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DELETE
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Replaced with Standard Operating Procedures
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USP 800 Hazardous Drug Order Entry – Management
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DELETE
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Replaced with Standard Operating Procedures
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USP 800 Hazardous Drug Transportation
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DELETE
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Replaced with Standard Operating Procedures
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USP 800 Receiving and Storage – Compliance
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DELETE
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Replaced with Standard Operating Procedures
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USP 800 Spill Control and Personnel Exposure – Management
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DELETE
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Replaced with Standard Operating Procedures
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IV and IVPB Discontinued Orders - Management
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DELETE
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IV and IVPB Stat Orders – Management
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DELETE
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IV Supply Replacement Procedures – Management
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DELETE
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IVPB Solution Preparation
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DELETE
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Look-alike Sound-alike Clinical
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UPDATED
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High Alert Medications – Clinical
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UPDATED
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Hypertonic Saline – Clinical
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UPDATED
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Scope of Pharmacy Services – Management
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UPDATED
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Anticoagulation Service – Clinical
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DELETE
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Combined into Scope of Service and/or directive
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Anticoagulation Bridging with LMWH Guide – Clinical
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DELETE
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Combined with Anticoagulation Directive
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Externship Program – Management
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DELETE
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Combined into Scope of Service and/or directive
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Patient Medication Education
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DELETE
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Combined into Scope of Service and/or directive
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Medical Record Documentation – Clinical
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DELETE
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Combined into Scope of Service and/or directive
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Pharmacokinetics Program – Clinical
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DELETE
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Combined into Scope of Service and/or directive
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Total Parenteral Nutrition
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DELETE
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Combined into Scope of Service and/or directive
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United Based Pharmacy Services – Clinical
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DELETE
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Combined into Scope of Service and/or directive
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Plan of Care – Management and Operations
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DELETE
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Combined into Scope of Service and/or directive
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Formulary Review: Additions, Revisions, and Removals:
- Balfaxar and Kcentra (4FPCC) – Proposal to add Balfaxar to formulary and remove Kcentra from formulary. Data shows both products are equivalent in reversal for both warfarin as well as other anticoagulants. The switch will occur on February 1, 2024 or soon thereafter. The decision was approved pending System P&T approval.
JOINT COMMISSION REQUIREMENTS
- Antimicrobial Stewardship Report – presented the Standardized Antimicrobial Administration Ratio (SAAR) from 2022 and 2023. SAAR data shows antimicrobial usage at St. Dominic Hospital by benchmarking prescribing trends against risk-adjusted data from institutions of similar size and acuity provided by the Center for Disease Control and Prevention’s National Healthcare Safety Network (NHSN). Any SAAR value > 1.0 indicates more antimicrobial days observed than predicted whereas SAAR values < 1.0 indicate fewer days observed than predicted. Metrics include all antibacterials prescribed, broad spectrum antibacterials used predominantly for hospital-onset infections (e.g., piperacillin/tazobactam, cefepime, meropenem), antibacterial agents predominantly covering gram-positive infections (e.g., daptomycin, vancomycin, linezolid), and broad spectrum antibacterials predominantly used for community-onset infections (e.g., ceftriaxone, fluoroquinolones). Overall, our total antibacterial prescribing habits have held a SAAR of < 1.0 for all of 2022 and 2023. This trend was also reflected in SAARs for agents active against resistant gram-positive organisms, with SAARs mostly ≤ 1.0. However, broad spectrum agents predominantly used for hospital-onset infections have largely held a SAAR > 1.0 in the ICU, wards, and oncology units. As for SAAR data for antibacterial agents often used for community-onset infections, the ICUs have mainly held a SAAR < 1.0 whereas the wards and oncology units have mostly seen SAARs ≥ 1. De-escalating to narrower agents when possible and limiting antibiotic regimens to shorter, guideline-directed durations can help further improve our metrics and patient care.
- Opioid Stewardship Report – preliminary information regarding the newly created Opioid Stewardship Committee. The report highlighted data from the fourth quarter of 2023 analyzing different specialties’ opioid ordering trends. Of note, some data excluded fentanyl orders to help adjust for analgosedation needs in the ICUs. Moreover, the information only pertained to the order placed, not the number of administrations per patient. The top specialties by morphine milligram equivalents (MME) were determined by average daily MME prescribed. When excluding fentanyl, hospice and palliative care, internal medicine, and hematology and oncology were the top prescribers; when including fentanyl orders, nephrology, pulmonary medicine, and emergency medicine were the top prescribers. Nephrology’s place as top prescriber for this group can likely be attributed to a fentanyl infusion that was incorrectly ordered under a nephrologist’s name. Average days of opioid therapy were used to determine the top specialties by duration of therapy. For the fentanyl excluded group, internal medicine, thoracic and cardiovascular surgery, and neurosurgery were the top three prescribers. For the fentanyl included group, pulmonary medicine, internal medicine, and thoracic and cardiovascular surgery held the top three spots. Other than nephrology’s unexpected jump to top specialty for average daily MME when including fentanyl, the data appropriately reflects current practice.
Pharmacy Reports
- Automated Dispensing Cabinet Medications on Override (Annual Review) - list of Pyxis medications on override by device and explained the differences between override groups as well as that each Pyxis device is individually set with specific override settings. The committee approved the override medications with no requested changes.
- Medication Reconciliation Statistics - medication reconciliation data for admissions, transfers, and discharges. Discharge medication reconciliation saw a compliance of 97.3% at FYTD, but admission and transfer medication reconciliations saw a much lower rate of compliance with 37.4% and 37.2% at FYTD, respectively. These findings can potentially be attributed to discharge medication reconciliation having a hard stop in Epic, while admission and transfer medication reconciliations do not.
- Adverse Drug Event Report – November/December 2023 and Q3/Q4 Summary - adverse drug event report as well as a third and fourth quarter summary. The reports highlight the usage of naloxone (excluding OR and procedural areas), flumazenil, D50W, and vitamin K. In total between November and December, no orders were pulled on override and there was a total of 7 naloxone administrations, 1 flumazenil administration, 510 administrations of D50W, and 29 administrations of vitamin K. Of note, naloxone’s administrations were slightly inflated for November as one patient received three doses. D50W was predominantly administered in the emergency department with 14.9% of the 510 administrations given there. This was likely due to hypoglycemia on admission. A similar trend for vitamin K was also observed, with 24.1% of all administrations occurring in the emergency department. It should also be noted that two patients outside of the emergency department and not on any anticoagulation accounted for 31% of all vitamin K doses for November and December. For the Q3/Q4 summary, there were a total of 32 naloxone administrations, 17 flumazenil administrations, 1,784 administrations of D50W, and 106 administrations of vitamin K. Naloxone was utilized on average 5.3 times per month with usage peaking in August with 10 administrations. Flumazenil saw an average of 2.5 administrations per month with a peak in August with 7 administrations. D50W was used approximately 297 times per month, with October seeing the most administrations at 354. Finally, vitamin K’s usage peaked at 26 administrations in October but ultimately averaged 17.7 administrations per month. Overall, usage trends remained relatively similar for Quarters 3 and 4 with each agent having one month fall outside of one standard deviation from the average.
- Adverse Drug Reaction Report – December 2023 - adverse drug reactions (ADR) from December 2023. This report includes data on adverse drug reaction reporting which classifies adverse effects and reactions based on degree of harm to the patient. Historically, the majority of ADRs occur before admission to the hospital or are self-limiting or benign and are associated with anticoagulants, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARB), and potassium-containing products. There were 29 total ADRs with 21 occurring before admission to the hospital, 5 which were self-limiting or benign, and 3 which were deemed to not be a drug reaction. There were no instances of ADR leading to permanent disability, increased length of stay, or death. Potassium, apixaban, and spironolactone were the most reported medications. In comparison to previous 2023 ADR reports, there were less ADR overall in December 2023.
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