85 Herrick Street 978.922.3000 P Beverly, MA 01915 beverlyhospital.org

Physician Orientation to Beverly Department

Hours of Operation Hours: 24/7

Medication Ordering Physician order management (computerized order entry) Electronic MAR Include indication for use on prn orders Select indication for antibiotic order entry MRSA screen order for Vancomycin orders. Automatic stop orders/ renewal policy IV fluids (24 hours), TNA (24hours), narcotics (7 days except meperidine which is 48 hours), ketorolac (5 days). Rewrite orders post-op, in/out of ICU/CCU and telemetry Pharmacy and Therapeutics Committee approved Therapeutic interchange program e.g. extended Zosyn 4 hour infusion TPN ordered before 1:00 p.m.

Clinical Services Unit-based stations on J2, J4, J6 and CCU (Mon – Fri) Drug information x2610 Adverse Drug Reaction hot line x 6677 Pharmacist rounds in CCU, multi-disciplinary rounds on Johnson units Antimicrobial Stewardship Program medication discharge counseling

NIC- Pharmacy Intranet Access Forms Formulary addition request form, TPN order sheet/guidelines News/References Pharmacy newsletter, ISMP newsletter, antibiogram (pocket size available)

Medication Safety Prohibited abbreviations- acceptable abbreviations as per ISMP guidelines Restricted ID approved antimicrobials Standard high alert IV infusion mix

Others Non-formulary meds/ preferred drug list Request for formulary additions

Daniel F. Newberg, MS, RPh Director of Pharmacy 85 Herrick Street Beverly, MA 01915 TEL: 978 922 3000 ext 2612 FAX: 978 921 7006 E-MAIL: [email protected]

Reviewed: Dec 2013

Approved Hold Acknowledges Insulin Types and Actions

Administration time change on antibiotics when more Rapid Acting than one antibiotic is to be given at the same time. Brand / Generic Name Onset Peak Duration Adjust start times of SCIP protocol antibiotics Humalog / Insulin <15 1-2 3-4 hr Lispro min hr Adjust start times of Post-Op Ketorolac and Apidra / Insulin Glulisine <15 min 1-2 hr 3-4 hr Acetaminophen IV orders. Hold acknowledge to Novolog / Insulin Aspart <15 min 1-2 hr 3-4 hr Pharmacy should include time of first dose given. CIWA and DETOX Protocols. Hold acknowledge to Pharmacy should include time of first dose given. Short Acting Adjust times of to reflect patient’s regular Brand / Generic Name Onset Peak Duration medication schedule from home if necessary. Department of Pharmacy Novolin R ½ - 1 2-3 3-6 hr Insulin Regular hr hr Adjust times on Maternity Ketorolac orders.

Intermediate Acting General Medication Use Brand / Generic Name Onset Peak Duration Approved Oral Solid to Liquid Dosage Guidelines Novolin N 2-4 hr 4-10 10-16 hr Conversion for Nursing

Insulin NPH hr (Nursing can interchange the following oral solid and liquid medications as dictated by patient needs via POM) Hours of Operation Long Acting Medication Strength Note 24 hours a day Acetaminophen 160 mg/ 5 ml 10ml (320mg) = 1 Tablet Brand / Generic Name Onset Peak Duration (325mg) 7 days a week Levemir / Insulin ¾ - 2 Mini- Up To 24 Ibuprofen 200 mg/ 10 ml x2610 Detemir hr mal hr Peak Amantadine 100 mg/ 10 ml Lantus / Insulin Glargine 2-4 hr No 20-24 hr Diphenhydramine 12.5 mg/ 5 ml Peak Docusate 100 mg/10 ml For POM related issues, please Ferrous Sulfate 300 mg/5 ml 5ml (300mg) = 1 Tablet call IS at x2600 Concentrated Insulin – High Alert (325mg) Fluoxetine 20 mg/5 ml Contains 500 units/ml. Usually dosed BID or TID and is used as a basal insulin due to prolonged duration of action. Not Haloperidol 10 mg/5 ml interchangeable with U-100 insulin. See Policy. Megestrol Acetate 400 mg/10 ml Brand / Generic Name Onset Peak Duration Metoclopramide 5 mg/5 ml Discharge Medication Counseling Humulin R U-500 / 30 min 1-3 8-24 hr Multivitamins 5 ml 5ml = 1 Tablet Performed By Floor Pharmacist Regular U-500 hr Ondansetron 4 mg/5 ml

Potassium Chloride 20 mEq/15 ml Conversion Not To Exceed Monday – Friday 7:30-3:30 Mixed Insulins 40 mEq Mixed Insulins are usually dosed BID and provide meal Sennosides 8.8 mg/5 ml 5ml (8.8mg) = 1 Tablet coverage for breakfast and dinner (8.6mg) Sucralfate 1 g/10 ml Brand / Generic Name Onset Peak Duration Parenteral Nutrition Humulin 70/30 30 min 2-12 18-24 hr NPH/Regular hr TPNs must be ordered prior to Humalog 75/25 15-30 1-6.5 14-24 hr 1 p.m. in order to be infused that Lispro Protamine / min hr Herbal Policy Lispro All herbal medications / dietary supplements are not permitted same day Novolog 70/30 15 min 1-4 hr 18-24 hr for patient use during hospitalization per P&T committee TPNs are out sourced to Central Aspart Protamine / Aspart approval. These medications may be resumed at the time of Admixtures Pharmacy Services

discharge under the physician’s discretion.

Highlighted / Bold Insulin = Formulary

10/13

KCl IV Administration Policy Lovenox / Arixtra Prescribing Restrictions

Medication Safety Issues ***Never administer IV push*** Enoxaparin (Lovenox) Fondaparinux (Arixtra) Must dilute in D5W or NS as IV infusion Hypersensitivity to Hypersensitivity to enoxaparin, heparin, pork fondaparinux CENTRAL LINE ADMINISTRATION Look Alike / Sound Alike Meds Active major bleeding Active major bleeding Cardiac monitored Examples Maximum rate 40 mEq/hr Thrombocytopenia Thrombocytopenia Mucomyst vs Mucinex Maximum concentration 40 mEq/100 ml Bacterial endocarditis Clonidine vs Klonopin Unmonitored patients Contraindicated for Novolin 70/30 vs Novolog mix 70/30 Maximum rate 20 mEq/hr prophylaxis in patients Cerebyx vs Celebrex Maximum concentration 20 mEq/250 ml weighing <50 kg Risperidone vs Ropinirole Renal Dose Adjust- Contraindicated with ment recommended CrCl<30 ml/min PERIPHERAL LINE ADMINISTRATION with CrCl <30 ml/min Maximum infusion rate 10 mEq/hr Maximum concentration 80 mEq/1000 ml Targeted High-Alert Medications (20 mEq/250 ml, 40 mEq/500 ml) Opiates/Narcotics New Oral Anticoagulant Comparison Chart Oral Anticoagulants Medication Pharmacotherapy Pearls Parenteral Anticoagulants Opioid Equianalgesic Conversion Table (Adults) Dabigatran •Renal dose adjustment required Insulin Drug Oral (mg) Parenteral (mg) (Pradaxa) •Use not recommended in CrCl<15 ml/min Morphine 30 10 Oncologic Agents •Caution >80 years old Hydromorphone 7.5 1.5 Injectable Potassium Concentrate Rivaroxaban •Doses ≥15 mg/day must be Oxycodone 20 N/A (Xarelto) administered with food Sodium Chloride Solutions >0.9% •Renal dose adjustment required in Fentanyl N/A 0.1 nonvalvular atrial fibrillation Lexicomp 2013 •Avoid use in CrCl<30 ml/min for DVT, PE, reduction of the risk of recurrent

DVT/PE, postoperative Glucocorticoid Equivalencies, Potencies, and Half-Life thromboprophylaxis •Avoid use in CrCl <15 ml/min for non- Glucocorticoid Equivalent Anti- Sodium Half-Life valvular atrial fibrillation Potency Inflammatory Retaining Plasma Apixiban •Nonvalvular atrial fibrillation dose is Restricted Antibiotics Dose (mg) Potency Potency (min) (Eliquis) 2.5mg twice daily if serum ceatinine (Require ID Approval) Short Acting ≥1.5 mg/dL and either age ≥80 years or body weight ≤60 kg Ceftaroline (Teflaro) Cortisone 25 0.8 2 30 Concomitant therapy with Warfarin, Heparin, Lovenox, and Clindamycin (Cleocin) Hydrocortisone 20 1 2 80-118 Arixtra is contraindicated. Daptomycin (Cubicin) Intermediate Acting These oral anticoagulants are not interchangeable amongst each other. Ertapenem (Invanz) Linezolid (Zyvox) Prednisone 5 4 1 60 Meropenem (Merrem) Prednisolone 5 4 1 115-212 Preferred Formulary List Micafungin (Mycamine) Triamcinolone 4 5 0 200+ Piperacillin/Tazobactam (Zosyn) Methylprednisolone 4 5 0 78-188 Proton Pump Inhibitor – Omeprazole Telavancin (Vibativ) Tigecycline (Tygacil) Long Acting H2-Antagonist – Famotidine

Voriconazole (Vfend) Dexamethasone 0.75 20-30 0 110-210 Statins – Atorvastatin, Simvastatin Betamethasone 0.6-0.75 20-30 0 300+