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03/08/2017 MD -- UPDATES to the Multimodal Analgesia for Total Joint order set - Starts Friday, 3/10
From: Michele Durda
To: Pharmacists
Sent: Wednesday, March 8, 2017 12:57:55 PM
Subject: UPDATES to the Multimodal Analgesia for Total Joint order set - Starts Friday, 3/10
Pharmacists,
Thanks for all of the great feedback related to the multimodal analgesia protocol being used in total joint patients. Both nurses and physicians are reporting excellent pain management with the new process. The patients reportedly aren't sedated and are able to quickly participate in physical therapy. However, some issues have been identified that we are trying to correct with the updated order set (attached). Brian Boyett is currently collecting detailed data on these patients to evaluate the efficacy and safety of the order sets.
This order set will be posted on PULSE and released in iCare on Thursday afternoon. You will start seeing this order set on patients with Friday surgeries.
Changes:
- Title - Clarified that this is only currently in use on total knee, hip, and shoulder patients. Please let me know if you see it used on other patients.
- Past medical history screening - To identify potential contraindications to the medications on the protocol, the nurse will ask the patient the targeted questions and document the answers. Any "yes" responses will prompt the pharmacist to discontinue the offending medications (as instructed in the box at the top of the page) per protocol.
- Dose adjustments - Some patients have experienced transient SCr increases with the existing protocol. We believe that these changes are related to the aggressive NSAID dosing. The protocol has been adjusted to reduce the ketorolac to two 15 mg doses for all patients. The ibuprofen dosing has also been reduced. Gabapentin has been added to the regimen in an effort to offset a potential loss of efficacy. A daily BMP has also been added to allow for better monitoring.
- Dose scheduling - The current order set requires all medications to be re-scheduled "6 hours after anesthesia stop time". This has resulted in pharmacists re-timing a large number of orders. The new order set is designed to normalize all dosing to a TID schedule and default appropriate start times upon order entry. Unless the order set is entered after 2200, the default start times should NOT need to be rescheduled. If it is entered after 2200, a NOW dose for all scheduled medications should be entered (otherwise, the patient will not receive any doses until the next morning). The TID schedule will also be significantly more convenient for nurses and patients.
- Acetaminophen extended release - To allow for the convenience of TID dosing, the immediate release acetaminophen has been replaced with acetaminophen extended release 650 mg tablets. This is a new product for Huntsville Hospital and is already in stock.
Please let me know if you have any questions or concerns.
Michele
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Michele Durda, Pharm.D.
Medication Safety/Drug Utilization Pharmacist
Huntsville Hospital