July, 2000

We would like to devote this Special Pharmacy Key to welcoming you to the University of Kansas Hospital.  We would like to discuss the services provided by the Department of Pharmacy, institutional policies concerning drug use in the hospital and suggested guidelines for prescription writing.  The goal of this publication is to foster an understanding of pharmacy services and medication use policies so that safe, efficient and rational drug use or therapy may continue in this institution.

PHARMACY SERVICES AT THE

UNIVERSITY OF KANSAS HOSPITAL

The Department of Pharmacy provides comprehensive, 24-hour service to patients, physicians and staff as an integral part of the teaching, research and patient care programs at The University of Kansas Hospital.

CLINICAL PHARMACY SERVICES

Pharmacy Services for inpatients are provided by decentralized Clinical Pharmacists. The clinical pharmacist responsible for the medical service and/or nursing unit caring for your patients is a good person to know.  This pharmacist is an excellent resource and your best liaison with the central Department of Pharmacy when drug-related questions or problems and any special requests arise.

The Clinical Pharmacist is responsible for review of the patient medication regimen.  Pharmacists screen for potential problems with medication orders: dosing, drug allergies, drug interactions, intravenous incompatibility and more.  Physicians are informed of potential problems and possible drug therapy modification.  Pharmacists are actively involved in monitoring antibiotic therapy and provide pharmacokinetic dosing for selected antimicrobials.  Patient education during the hospital stay and/or upon discharge is provided by Clinical Pharmacists.  A Self-Medication Educational Program for patients and medication calendars is available for patients with multiple medications and compliance problems.

Pharmacy notes, located in the patient chart and/or the electronic medical record, contain information regarding patient education, compliance assessment, pharmacokinetic dosing or other information related to patient drug therapy decisions.

Nursing units at University Of Kansas Hospital are divided among six pharmacy teams.  Coverage during evening and weekend shifts varies slightly.  Clinical Pharmacists carry pagers for accessibility and nursing unit staff or central pharmacy can provide the pager number for designated pharmacists.

THE FORMULARY SYSTEM

The Formulary System is the accepted method approved by the Medical Staff whereby physicians select medications to be available for University Of Kansas Hospital patients. The Pharmacy and Therapeutics Committee evaluates, appraises and selects from the numerous medical agents commercially available and makes recommendations to the Executive Committee of the Medical Staff indicating medications which are the preferred medications for patient care at University Of Kansas Hospital.  These recommendations require approval by the Executive Committee of the Medical Staff prior to formulary inclusion.   The evaluation of drugs for admission into the Formulary System is comprehensive and considers efficacy, safety, and economic issues, all aimed at promoting rational, cost-effective drug therapy.  It also includes comparisons of therapeutic alternatives to minimize therapeutic duplication in the formulary.  The University Of Kansas Hospital Formulary is the published list of approved medications considered most useful in providing care for the vast majority of patients, both inpatient and outpatient, in the University Of Kansas Hospital Health System.  University of Kansas Hospital prescribers are expected to prescribe these approved formulary medications.  If medically necessary, non-formulary medications can be obtained upon request for specific patients during their hospital stay.

REQUEST FOR NON-FORMULARY DRUGS

When a non-formulary drug is requested, the pharmacist will inform the prescribing physician of therapeutically equivalent formulary alternatives and their proper dosage.  If an acceptable formulary medication is not identified, the Pharmacy will obtain a small supply of the drug for that a particular patient.  The entire quantity ordered and any delivery fee incurred will be billed to the patient.  A time delay of 24-48 hours should be anticipated since the drugs must be ordered from outside source.

The non-formulary drug may be sent home with the patient as a dismissal medication, if written for, but will be limited to only the remaining supply.  It is recommended that another prescription be sent with the patient for any additional quantity necessary.

If a physician intends to prescribe a non-formulary drug on a regular basis, it is recommended that a request for evaluation for Formulary admission be submitted.

FORMULARY ADDITIONS AND DELETIONS

Requests for additions to or deletions from the University Of Kansas Hospital Formulary should be submitted to the Director of Pharmacy on the Application for Formulary Admission Form to facilitate consideration by the Pharmacy and Therapeutics Committee.  Such requests must be approved by the Chairman of the Department desiring the drug.  Applications must be complete and must include sufficient supportive data to enable the committee to make a sound decision.  Application forms are available from the Department of Pharmacy or on the University Of Kansas Hospital Pulse at the following url: http://www2.kumc.edu/pharmacy/formrequest.html.  All drugs are admitted on a nonproprietary name (generic) basis.  No drug of unknown or secret composition will be admitted.

All drug additions and deletions to the formulary must be subsequently approved by the Executive Committee of the Medical Staff.  Drugs added or deleted from the formulary will be announced in the Pharmacy newsletter, the Pharmacy Key.  The effective date of the addition or deletion will be noted in the publication of the Pharmacy Key. The Pharmacy Key can be accessed via the Internet at the following: http://www2.kumc.edu/druginfo/pharmkey.html.   

DRUG DISTRIBUTION

Unit floor stock is available from Pyxis units on all patient care units and many diagnostic units.  This automation allows a health care professional with a password to access medications that are on a patient profile and medications that are considered “PRN” for an individual unit.  Passwords are electronic signatures for which the health care professional is held ultimately accountable.

The medications available in each Pyxis unit are chosen by each nursing unit and its pharmacist.  The availability of each medication is based upon safety, usage and stability.  Prescribed medications that are not available in Pyxis units are delivered to patient care areas by the Department of Pharmacy in individual packages which identify each dose (unit dose packaging).  These doses are placed in a secure cassette drawer labeled for each patient on the nursing units

SAMPLES

Professional drug samples are not to be administered to inpatients.  Samples are not to be stored on the nursing units or hospital patient care areas.

PATIENT’S OWN MEDICATION POLICY

The hospital encourages the use of medications supplied and administered by the hospital at all times.  Patients may be permitted to use their own medications only under specific limited circumstances.  This limitation is based on patient safety with product integrity and potential self-administration of incorrect dosages being issues of concern.  In addition, the risk of medication error is increased by the use of medications outside of the normal medication use system. 

Handling of patient’s own medications is a time consuming process.  Order clarification, medication identification, documentation, special storage procedures and administration of these medications outside of the normal system consume valuable hospital resources.  It is prudent to consider the following procedures when making the decision to use patient’s own medications.

WHEN MAY AN ORDER FOR PATIENT’S OWN MEDICATION BE APPROPRIATE?

•        The medication is not on the hospital formulary and a reasonable therapeutic substitution is not available.  Consult with the nursing unit pharmacist if needed.

•        Rarely, a formulary medication may be used from the patient’s personal supply when the physician, pharmacist, and patient deem the use medically necessary to meet a specific health care need. 

•        The medication is an investigational or study medication provided under protocol as part of the patient’s participation in an investigational study. Medications that are not provided by the study shall be obtained through the pharmacy.

Patient’s own medication must be contained in the original prescription container that is properly labeled as required by state and federal laws, identifying the name, strength, dose, route, and directions for use of the medication.  Study medications may contain information as allowed by the study protocol and must be labeled with the patient name. If it is deemed necessary for a patient to use their medication from home, based on the guidelines above, specific written orders are required. An order stating only that “the patient may use his or her own medications” will not be accepted.  Medications to be supplied by the pharmacy must be ordered separately from the patient’s own medication order. 

HOW TO WRITE AN ORDER FOR A PATIENT’S OWN MEDICATION

•        A statement that the “patient may use their own supply” while in the hospital.

•        List only the medications that the patient is going to supply.

•        Name, dose, route, and directions for each medication

Accurate identification of patient’s own medication is vital to the health care outcomes and safety of the patient.  JCAHO standards require that the clinical pharmacist identify each medication the patient is to use from their own supply to ensure that they are receiving the appropriate medication. Identification needs to be completed prior to administration of medication to the patient.

STEPS FOR IDENTIFICATION OF PATIENT’S OWN MEDICATION

COMPLETED BY THE CLINICAL PHARMACIST

Verify the name, dose, route, and directions for use of each medication. Assess the patient’s understanding of how to take the medication correctly. Clarify with the physician any differences between the written order and communication with the patient. Document identification in the patient’s medical record.

STORAGE OF PATIENT’S OWN MEDICATION

Patients should be encouraged to send their own medications that are not being utilized at the University of Kansas Hospital home with a family member or friend.  Patient’s own medication that remains in the hospital shall be securely stored on the nursing unit. These medications will be stored either in the “Patients Own Medication” section of the Pyxis^® unit or in another locked cabinet on the unit.

ADMINISTRATION OF PATIENT’S OWN MEDICATION

Administration of patient’s own medication is similar to the administration of medication dispensed by the pharmacy.  A nurse shall obtain the appropriate medication at the appropriate time from the patient’s own supply in the Pyxis^® or other locked area.  This administration shall be documented on the medication administration record (MAR) indicating the medication, dose, and time given.  It is discouraged that a patient’s own medication be kept at their bedside, but if it is necessary to do so, the patient’s own medication order must also include the statement ”patient may keep their own medications at bedside”.  Controlled substances, however, may not be kept at the patient’s bedside.  The nurse shall observe the patient taking their bedside medication and document on the MAR the medication, dose, and time taken.

INTRAVENOUS ADMIXTURE SERVICE

The Department of Pharmacy prepares all intravenous drug admixtures.  The policy ensures that all solutions are prepared under aseptic conditions and are screened for drug interactions and incompatibilities.  Standard infusion concentrations have been established for several intravenous drugs.  Medication orders for these drugs should be written in the concentrations listed below.

Except for reasons of stability, compatibility, and/or volume problems, the standard diluent used in intravenous “piggyback” orders is D5W 50ml.

TOTAL PARENTERAL NUTRITION

·       The standard hang time for all adult and pediatric TPN solutions is 20:00.

·       Neonatal TPNs are hung between 1500 - 1700

·       All TPN orders for adults and pediatric patients are due in Pharmacy by 14:00.  This includes new and changed orders. Changes in neonatal orders are due in the Pharmacy by 1300

·       For adult and pediatric patients, the pharmacy will compound the 24 hr supply of TPN for a patient based on the orders in the Pharmacy at 14:00 and these solutions will be delivered to the nursing unit by 19:30. Neonatal TPNs will be delivered by 1500.

·       When a new TPN order is received after 14:00 for an adult or pediatric TPN, the pharmacist will contact the prescribing physician to determine when the order will need to be processed and if it can be scheduled for delivery the next day at 20:00.

MEDICATION ORDER TURN AROUND TIME

To prioritize the processing of new medication orders and to establish an appropriate turnaround time for these orders. The following turnaround times have been established:

1.     STAT:  Stat orders are defined as emergency medications (medications that are needed only in life threatening situations) and so written by the prescribing physician.  The physician should call a STAT order to the attention of the nurse so it can be taken off the chart immediately.  Pharmacy can fill these orders in five (5) minutes if the order is called down and someone from the unit picks up the order.

2.     ASAP/NOW:  ASAP or NOW orders will be written as such by the prescribing physician.  These orders will be delivered to the nursing unit within 30 minutes from the time pharmacy receives the written order. Exception:  Chemotherapy will be delivered within 2 hours from the time pharmacy receives the written order.

3.     ROUTINE ORDERS: Routine orders are all orders not written as STAT, ASAP or NOW.  Routine orders will be delivered within two (2) hours from the time pharmacy receives them.

SCHEDULED TIMES FOR MEDICATIONS

Standard schedules for medication orders have been established when a specific schedule is not indicated on the medication order or pharmacy requisition.

PROCEDURE:

1.     It is the responsibility of the physician, nurse and/or clinical pharmacist to indicate the appropriate time schedule for the drug on the order or pharmacy requisition.

2.     If a time schedule is not indicated on the order, the following schedules will be used:

*These schedules are to be determined by when the order is received in the pharmacy and what the turn around time for the order needs to be.

Special Schedules:

Unit specific schedules will be limited to the following:

QID verses Q6H schedules are not interchangeable and will be interpreted strictly as indicated above unless the clinical pharmacist suggests a different time schedule is more appropriate and indicates that schedule on the pharmacy requisition.  If the prescribing physician does not want the standard time schedule he/she must indicate on the drug order the exact times the doses are to be administered.

OUTPATIENT SERVICES AND PRESCRIPTIONS

Outpatients cared for by the University of Kansas Hospital are covered by a variety of health insurance programs. Reimbursement practices/requirements, preferred medications and formularies of various programs differ greatly. To provide comprehensive pharmacy services to all outpatients, the Outpatient Pharmacy maintains a drug inventory, which not only includes the University of Kansas Hospital formulary medications but additional medications as well. While  the University of Kansas Hospital prescribers are encouraged to utilize our preferred medications, other medications are also available.

Prescriptions filled in the Outpatient Pharmacy must be written only on a University of Kansas Hospital prescription blank by the University of Kansas Hospital Medical Staff and the patient must be a patient of the University of Kansas Hospital.  Prescriptions for University of Kansas Hospital employees and their dependants, however, verifiable prescriptions from local physicians may be filled for employees.    Prescriptions written by medical students must be countersigned by a staff physician.  The Physician’s name must be legibly printed or stamped on the prescription in addition to the signature. The outpatient pharmacy is open 8:00 - 19:00 Monday through Friday and 9:00 - 15:00 Saturday and Sunday and most holidays.

CONTROLLED SUBSTANCES: Schedule II prescriptions must be written on green blanks. All other prescriptions, including Schedule III, IV and V are to be written on University of Kansas Hospital colored prescription blanks labeled "Not Valid for Schedule II Prescriptions". All prescriptions written for controlled Substances (Schedule II - Schedule V) MUST be written by a physician possessing a Drug Enforcement Administration (DEA) registration number.   All new staff must sign a signature card to be maintained in the outpatient pharmacy.  All prescriptions written for Controlled Substances must bear the name and address of the patient, the current date and the DEA number. Refills on Schedule II prescriptions are not permitted.

DISMISSAL PRESCRIPTIONS:  Prescriptions for dismissal medications should be written on the Take Home Medication Form. Keep in mind that the patient may already have sufficient quantities of maintenance medications at home and additional quantities will not be reimbursed by prescription plans.  The physician must print the patient information, diagnosis, and physician’s name.  A signature is required for each prescription and the DEA number must be included on any prescriptions for controlled substances.  As a convenience,  patients may have take home medications filled in the University of Kansas Hospital Outpatient Pharmacy by faxing the order form to ext. 82385. Patients will be expected to provide any prescription insurance information, co-payments required by their prescription plan or the full prescription amount at the time of service.  The second copy of the form will stay in the patient's chart and the original copy is exchanged for the medications at the University of Kansas Hospital Outpatient Pharmacy or taken by the patient to the pharmacy of their choice.  Writing prescriptions 24 hours prior to discharge prevents a long wait for patients ready to go home and allows time to resolve financial issues that may arise.