New Business

Pathway for Medical Management on Alcohol Withdrawal
APPROVED

The Committee was presented with the updated pathway for the medical management of alcohol withdrawal. The revised pathway addresses prophylaxis and treatment of the symptoms of alcohol withdrawal in patients with a history of alcohol abuse and/or a positive CAGE score. Scheduled administration of benzodiazepines to patients who have positive CAGE scores will replace "as needed dosing" of benzodiazepines. Nursing staff will routinely monitor vital signs around the clock, thus increasing physician involvement in dose adjustments. The multidisciplinary group involved in updating the pathway has prioritized a hospital-wide educational initiative to increase awareness for the medical staff to include new screen shots and algorithms in POE. The group has also agreed to monitor and oversee the pathway with regard to any needed changes. The pathway is being presented to the Nursing Practice Committee to determine the feasibility of routine monitoring on the general care floors. The policy will then be forwarded to the Medical Policy Committee for final approval.

The Committee approved the updated pathway for the medical management on alcohol withdrawal with the following provisions:

-Add conditions to prevent rapid dose escalation with co-morbid conditions -Include approximate times in which symptoms of withdrawal may be seen.
-Return in 6 months with a review and the outcomes of implementing the updated pathway

Appropriate Mixing Mediums for Gastrografin (Diatrizoate Sodium and DiatrizoateMeglumine)
APPROVED

The Committee was presented with appropriate mixing palatable oral liquids with Gastrografin (Diatrizoate Sodium and Diatrizoate Meglumine). The guidelines provide for:

MGH Mixing Guidelines for Oral Use*

The Committee approved the guidelines and suggests the mixing instructions be added in POE, Lexi-Comp Online Formulary and the PCOI website.

Herbal Product Policy Review
APPROVED

The Committee was presented with the Committee's previous discussion of herbal supplements, encouraging that they not be used in the institution due to the lack of evidence to their benefit and the risk of drug interactions. Currently, the nursing assessment form attempts to capture if a patient is taking any herbal products. The pharmacy department does not stock nor will they obtain any herbal products for patients. Due to the multiple herb/drug interactions, this is a concerning issue for patient safety. The Committee recommends that physicians include, as part of the admission process, any pertinent history of herbal supplement use. Online clinical resources, such as Complimentary & Alternative Medicine in MicroMedex and Lexi-Comp provide a broad overview of alternative medicines and potential drug interactions. Pharmacy staff should be able to consult on specific situations. The Committee suggests we revisit our policy and build off the nursing protocol to ensure any herbal products patients may be taking are documented and incorporated into their continuum of care.

Concentrated Potassium Infusions on Special Care Units Guidelines
APPROVED

The Committee was presented with the protocol restricting the use of concentrated potassium infusions on special care units. Currently, the policy for using concentrated potassium infusions is restricted to special care units only, using microinfusion syringe pumps. Patients receiving concentrated electrolyte infusions are closely monitored, have a central line, and labs are drawn to ensure appropriate blood levels. One of the primary reasons for using concentrated electrolytes is to reduce the risk of fluid overloading in already hemodynamically unstable patients. The infusion pumps are pre-programmed to avoid the risk of a patient receiving a bolus of IV potassium and to date we have had no adverse drug events due to infusion-related incidents. The Committee approved the policy for concentrated IV potassium on special care units.

Updated Free Care Program
APPROVED

The Committee was presented with the request to add alendronate (Fosamax) and several atypical antipsychotics that currently require prior authorization to the Free Care Formulary. There currently is not an oral bisphosphonate on the Free Care Formulary. These medications are indicated for the prophylaxis and treatment of osteoporosis in post-menopausal women. The Committee approved the addition of once-weekly alendronate 35 and 70 mg tablets to the Free Care Formulary.

Patients who were receiving certain psychotropic medications prior to the updated free care program now require a prior authorization to continue to receive their medications. Physicians are being encouraged to try and switch patients to the more cost-effective formulary drug. There have been situations were changing medications may be difficult if a current medication is controlling the symptoms. The Committee deferred decision on this item pending the review of all medications in this category by the Psychiatry Department at the June meeting.

Updated Food and Drug Interactions Policy for Cyclosporine (Neoral vs Sandimmune)
APPROVED

The Committee was presented with the updated food and drug interaction policy with revisions for Neoral and Sandimmune formulations as well as the revisions for fluoroquinolones and levothyroxine. Neoral and Sandimmune carry different compatibilities with respect to mixing with oral solutions. Fluoroquinolones are incompatible with polyvalent cations such as calcium and magnesium, which are present in a variety of dairy products and tube feedings. Levothyroxine and iron salts are incompatible as well. Please consult the Clinical Policy and Procedure Manual on line to see the complete update. The Committee granted administrative approval for the document with no further suggested revisions.