The impact of pain management changes to an inpatient general admission electronic order-set.

BACKGROUND: Opioids pose many risks, and standardized ordering processes need to be created. In May 2020, our institution implemented pain management changes to the inpatient general admission electronic order-set and increased provider education on pain management prescribing. OBJECTIVES: This study aimed to investigate the impact of pain management changes to the inpatient general admission electronic order-set on opioid prescribing. METHODS: Data were collected by retrospective chart review of 376 patients who were admitted using the inpatient general admission electronic order-set at 8 hospital locations within an integrated health system. Two cohorts were identified for comparison: patients admitted pre-electronic order-set change (n = 183; August 2019) and patients admitted post-electronic order-set change (n = 193; August 2020). The primary end points were the amount of intravenous (IV) opioids received measured in morphine milligram equivalents (MME), the quantification of opioids received for pain management, and the oral MME prescribed on discharge. RESULTS: There was no statistically significant difference in the use of IV opioids. There was, however, a statistically significant difference between the IV MME 24 to 48 hours with median 0 (interquartile range [IQR] 0, 6) and 0 (IQR 0, 0) for pre- and post-electronic order-set implementation, respectively (P = 0.003). Oxycodone was more frequently prescribed in the postimplementation cohort-55 patients (29%) compared with the 31 (17%) in the preimplementation cohort (P = 0.008). Tramadol was prescribed less frequently in the postimplementation cohort (n = 12 [6%]) than in preimplementation cohort (n = 28 [15%]) (P = 0.004). There was no statistically significant difference in the oral MME prescribed on discharge (P = 0.833). CONCLUSION: Changes to the inpatient general admission electronic order-set had relatively little impact on the prescribing of opioids. Further electronic order-set changes or other methodologies should be explored to affect inpatient opioid use.

Improved pharmacy department workflow with new method of order entry for single-agent, high-dose methotrexate.

PURPOSE: To determine whether a process change impacted the proportion of orders for single-agent, high-dose methotrexate entered by chemotherapy pharmacists instead of general pharmacy staff. Coordination of antiemetic premedication and leucovorin rescue with the new method of order entry was evaluated. METHODS: Adults treated with single-agent, high-dose methotrexate were identified retrospectively. Order entry of methotrexate and ancillary medications was examined to determine whether the old or new method was used and whether it was performed by a chemotherapy pharmacist. The fundamental difference between the old and new methods for order entry is use of the "unscheduled" frequency of medication administration to replace the administration frequency of "once" with a specified date and time. Timing of antiemetic premedication and leucovorin rescue relative to methotrexate administration were tallied for the new method. Chi-square analysis was performed for the primary objective. Observational statistics were performed otherwise. RESULTS: The number of evaluable encounters identified was 158. A chemotherapy pharmacist entered a greater proportion of orders when the new method was utilized (P < .0001). The proportion of orders entered by a chemotherapy pharmacist increased during the hours of 0700 and 2259 with the new method. Appropriate coordination of antiemetic and leucovorin administration was documented for 96% and 100% of cases with the new method of order entry. CONCLUSION: The proportion of orders for single-agent, high-dose methotrexate entered by a chemotherapy pharmacist was significantly greater with the use of the new method. Administration of antiemetic premedication and leucovorin rescue were appropriately coordinated with the use of the new method for order entry of single-agent, high-dose methotrexate.

Medication reconciliation effect on prolonged inpatient stress ulcer prophylaxis.

BACKGROUND: While medication reconciliation (MR) has been shown to reduce medication errors by limiting errors of transcription, omission, and duplicate therapy, its impact on the provision of unnecessary prophylaxis is largely unknown. OBJECTIVE: To determine the effect of MR on the incidence of prolonged stress ulcer prophylaxis (SUP) across the continuum of care from hospital admission to discharge as well as evaluate clinical conditions associated with prolonged SUP. METHODS: This retrospective study assessed patients who were admitted to the intensive care unit (ICU) and had SUP initiated. Patients were excluded if they were receiving gastroprotective therapy prior to ICU admission, were being treated for an acute gastrointestinal hemorrhage, or died. The need for SUP was determined using risk factors adapted from evidence-based guidelines developed by the American Society of Health-System Pharmacists. The use of SUP was assessed upon transfer from the ICU to a non-ICU setting and at hospital discharge. Results were compared between pre-MR and post-MR groups. RESULTS: Data from 114 (pre-MR, n = 53; post-MR, n = 61) medical and surgical ICU patients were evaluated. There was no significant difference in the use of prolonged SUP upon transfer from the ICU to a non-ICU setting in the pre-MR and post-MR groups, respectively (85% [45/53] vs 79% [48/61], p = 0.393). Similarly, there was no significant difference in the use of prolonged SUP upon hospital discharge in the pre-MR and post-MR groups, respectively (14% [6/44] vs 23% [10/43], p = 0.247). There were no clinical conditions for which prolonged SUP use was predominant. CONCLUSIONS: The strategy of MR alone will not decrease the incidence of prolonged SUP in hospitalized patients. Other techniques should be evaluated to encourage appropriate use of acid-suppressive agents.