Category: Professional Posters
Purpose: Therapeutic interchange programs authorize pharmacists to exchange medications with therapeutic alternatives in accordance with a guideline, protocol or policy. The process is employed by healthcare systems as a mechanism to maintain a sound formulary while providing cost-efficient care. It is a practice supported by ASHP and ACCP. Monitoring the impact these programs have on outcomes of care is important. Concerns were recently expressed regarding the potential impact therapeutic interchange has on discharge medication reconciliation in terms of discharging the patient home on incorrect medications. We theorized that safeguards are in place within our CPOE system that minimize this risk.
Methods: An assessment of the therapeutic interchange workflow in the COPE system was planned. Orders for medications with a therapeutic interchange should trigger an alternative alert to display that directs the provider to order the therapeutic interchange medication. This in turn should allow the discharge medication reconciliation process to show that a home medication has been interchanged to a different inpatient medication thereby allowing the provider to clearly see the interchange and make appropriate discharge decisions. A review of medications ordered via an alternative alert was planned in order to identify the original home medication ordered and the corresponding therapeutic interchange medication ordered. The patients’ after-visit summary was reviewed to identify if the patient was discharged home on the original home medication or the therapeutic interchange medication.
Results: The CPOE system workflow assessment confirmed that functionality was present to support a successful therapeutic interchange program. Alternative alerts were working as expected for the commonly utilized therapeutic interchanges and identified gaps were submitted for corrective action. The CPOE discharge medication reconciliation process displays the home medication list and the current inpatient medication list. Home medications therapeutically interchanged via an alternative alert are displayed side by side with the therapeutic interchange medication such that the interchange is visible to the provider. Ordering the home medication for continuation at discharge results in discontinuation of the therapeutic interchange medication. A total of 103 therapeutic interchanges that occurred within the system were reviewed. Ninety seven percent of the time the patient was discharged home on their original home medication. Of the 3% that were not discharged on their original home medication 66% had a valid reason: one patient had their home medication discontinued at the time of discharge and one patient had their home medication purposefully changed due to a change in medical status. Only one patient ( < 1%) was discharged on the therapeutically interchanged medication with no documented reason for the change resulting in a conclusion that this was done inadvertently.
Conclusion: Therapeutic interchange programs can be successfully implemented without negatively impacting clinical care during discharge medication reconciliation when safeguards are in place within the CPOE system to avoid inadvertently discharging patients on the therapeutically interchanged medication.