Sunday, June 08, 2008

Polypharmacy Gone Wild

If you've ever wondered why doctors gone insane managing patients, take a look at this inpatient drug treatment list on a single patient. It came to my attention on call this weekend that many of the drugs that seem repetitious are actually computer-generated by the electronic medical record "management:"
Furosemide SOLN 40 mg (LASIX)
Enoxaparin SOLN 135 mg
Carvedilol TABS 6.25 mg (COREG)
Furosemide TABS 20 mg
Valsartan TABS 80 mg (DIOVAN)
LevoFLOXacin SOLN 750 mg (Levaquin)
Polyethylene Glycol PACK 1 Each (MIRALAX)
Ferrous sulfate TABS 300 mg (FEOSOL)
Pantoprazole TBEC 40 mg (PROTONIX)
Docusate CAPS 200 mg (COLACE)
Hydrocodone-Acetaminophen 10-325 MG TABS 1-2 Tab (NORCO)
Ezetimibe TABS 10 mg (ZETIA)
Ranolazine TB12 1,000 mg (RANEXA)
Clopidogrel TABS 75 mg (PLAVIX)
Pioglitazone TABS 15 mg (ACTOS)
Acetaminophen TABS 325-650 mg (TYLENOL)
Aspirin Enteric-Coated TBEC 325 mg (ASPIRIN)
Insulin (Aspart) Correction Table INJ (Novolog)
Bisacodyl SUPP 10 mg (DULCOLAX)
Milk of Magnesia SUSP 30 mL (MOM)
ProCHLORperazine SOLN 10 mg
Nitroglycerin SUBL 0.4 mg (NITROSTAT)
Glucose CHEW 16 g
Dextrose Gel GEL 15 g (GLUCOSE GEL)
Dextrose SOLN 12.5-25 g (DEXTROSE)
Glucagon SOLR 1 mg (GLUCAGEN)

Note the last several highlighted formulations of glucose and glucagon. If the patient has diabetes, a "hypoglycemic protocol" order set is automatically generated by the pharmacy. (No doctor order is required, but the treating physician's name is attached automatically to the orders, and these orders are typically reviewed by hospital physician "experts" endocrinologists before being deployed). It seems there are glucose blood sugar cut-offs that mandate a different form of glucose to be administered to the patient. Here's our example of cook-book medicine:
If Blood Glucose is <70mg/d (less than 60mg/d in the pregnant patient): 1. Give 15g of simple sugars: 4 Glucose Tablets (if unable to chew, give 4 oz of juice) 2 Recheck Blood Glucose in 15 minutes 3 Repeat 15g of Simple Sugars if glucose is not above 70mg/dl 4 Recheck Blood Glucose 5 Repeat 15g of Simple Sugars if glucose is not above 70mg/dl and notify physician

If patients' blood Glucose is <70mg/d (less than 60mg/d in the pregnant patient) and is conscious but NPO: - Dextrose 50% Half Amp IV - Recheck Blood Glucose in 15 minutes - Repeat Dextrose 50% if blood glucose is not >70mg/dl

If patient's Blood Glucose is <70mg/d (less than 60mg/d in the pregnant patient) and is unconscious: -1. Dextrose 50% 1 Amp IV and notify physician.- -2. If unable to administer D50 wihtin 5 minutes, give glucagon 1 mg IM and contact physicican. Monitor for nausea and vomiting.- - Recheck Blood Glucose in 15 minutes - Notify Physician, if blood glucose is not >70mg/dl
Imagine: these four orders for every patient admitted to the hospital with diabetes.

Does this save lives? Or does this cost patients for four different medications perhaps never needed? What is the cost of such automaticity when orders appear to manage patients without physician involvement? (That "little" order for glucagon, costs $104.82 retail at CostCo pharmacy. How much is it marked up for the hospital?)

Also, how many errors occur on the basis of misinterpretations of these automatic orders ("Oops, I forgot to ask if she was pregnant.")? Where are the evidence-based studies demonstrating the utility of this automated approach to patient care? Could this be why EMR's have not been found to save money to our health care system? Are we losing cost savings to our system by removing physician judgement?

In this era of cost overruns and exhorbitant Medicare expenditures, should we not be asking these tough questions?

No. That would be too difficult. Rather, it's far easier to cover your butt with automatically-generated orders that the patient has to pay for in the interest of assuring their own "safety."



Anonymous said...

I just realized i dropped a patient off at your facility yesterday... small world. i think the most annoying thing is that residents will be awoken from their call rooms with conversations like this:

Nurse: The patient was hypoglycemic and unconscious.
Resident: Did you give them an amp of D50?
Nurse: Yes.
Resident: And are they awake now?
Nurse: Yes.
Resident: And so why did you call me?
Nurse: The computer told me to.
Resident: (Click)

The Happy Hospitalist said...

You've just experienced life as a hospitalist.


Rogue Medic said...

There is no place for tailoring this to the individual patient.

What if some patients are known to respond dramatically to glucose? Does that information get figured in? Does the doctor have to override the automatic order? Is it possible to override the automatic order?

Or, more likely, a patient is known to require a lot more than the standard dose of glucose/D50 to raise the blood sugar. What happens with the individual tailoring of that order? Does the computer "correct" the physician's judgment based on the physician's individual knowledge of the patient?

ERMurse said...

The Devil is in the Details when designing EMR's. Imagine what a MAR or Nursing Cardex looks like with all these generalted what if orders spelled out. Its a mess and becomes so cluttered with stuff its hard to pick out the important stuff especially with aging eyes like many Nurses have. The sheer volume leads to scrolling to see whats below all the mess which leads to missed items. It would be much better if the order simply stated. "Initiate Glucose Protocal" with a electronic hyperlink to that protocol for reference and paper back-up of the protocal on the unit. It would also require Pharmacy to Stock some of those basic Emergency Meds like D50 and Glucagon (like they used to do) rather than order them up for each individual patient on the protocal. That way, the meds are available and only charged if used.

Anonymous said...

it's so interesting because in the locations i trained in, the endocrinologists were the most disdainful of sliding scales. they wanted to round each day and review the many accuchecks and customize on a daily basis the treatments for each patient.

Anonymous said...

Unless the "glucose" is actually given, I seriously doubt the patient is charged for this automatically generated order. Many meds are ordered "prn" and patients do not incur costs for a medication they never receive.

Anonymous said...


Order written for drug = patient charged for drug.

Don't know why, but that's the way it is.

Ed Renfro, PharmD said...

Charging for a drug that the patient did not receive would be a fraudulent charge and could get the hospital in serious legal trouble if it occurs regularly.

Two charging systems are common.

If the hospital uses automated dispensing cabinets (eg, Pyxis), then the patient is charged when the drug is removed by the nurse.

If the hospital uses a cart fill system, then the patient is charged when the cart is filled. If the drug is not used, it returns to the pharmacy when the cart is refilled, and the patient is credited.

José Luis Contreras said...

Muy buen blog
Saludos desde Chile

Anonymous said...

wealthandtaste - the orders say to call the MD if the blood sugar is not above 70 after those interventions. I do not interpret it to say that you should call the MD just to say what you'd done if what you did worked.

Yes, orders like that clutter up the order sets. But one gets used to seeing them and filtering them out after awhile.... but when my patient's blood sugar is 60 at 7am on Sunday morning? Damn right I look for those orders right away. Who wants to call a doc at 7am on a Sunday for something so stupid and so easily remedied?

I love those orders. To me, they are clear and concise. I have followed them successfully several times and simply notified the MD on rounds a few hours later.

They have not worked only a handful of times.. and wouldn't you want to know if your patient's glucose was still 55 after an amp of D50???

Those orders (and others like them) are very common sense and eliminate the need for the nurse to wait 15 minutes for the MD to call back.

They eliminate the need for the doctor to be called at all.

Unless you've seriously pissed us off for some reason, nurses do not usually relish the idea of calling MD's (especially at night, etc) for stupid crap.

Mike Craycraft said...

I would find it hard to believe that any system automatically charges patients for PRN medications used for the treatment of hypoglycemia. Any revenue integrity department and all insurance auditors would have a fit with this.
I also find it hard to believe that such treatment protocols are "cookbook medicine." They are simply a way to quickly treat a patients condition, based on the medical executive committees approval, without the need to consult the individual physician. As a physician how else would you treat the patient? Would you like to be paged every 15 minutes with the blood sugar readings? If so, then you are to be commended because that is great individualized care. However, in the real world, orders such as "resume home meds" or start levophed or dopamine for sbp<90 still prevail and are much less safe and deserve more attention that a treatment scale for hypoglycemia. As a patient I'd much rather have my nurse be able to treat my hypoglycemia quickly than have to rely on a call back from my physician.