Wednesday, July 16, 2008

Antibiotic Nazis

This was quite interesting. I operated on a little girl the other night for a perforated, gangrenous appendicitis. Laparoscopically, I removed the nasty little bugger and washed out her entire peritoneal cavity with liters and liters of irrigant fluid. [On a faintly related tangent, I still can't believe anyone is routinely doing open appendectomies anymore. Only laparoscopy allows you the capability to drain and lavage the peritoneal cavity for complicated appendicitis]. The next day, she looked remarkably better (normal WBC count, afebrile, etc) but I usually keep kids in the hospital for a few days for IV antibiotics, especially for perforated appendicitis. As I reviewed her chart, I noticed that her Zosyn had fallen off the med list. I asked the nurse and she replied that "pharmacy had called earlier notifying that they were terminating the IV antibiotics 24 hours post surgery."

At this point my jugular vein started throbbing in my neck and my face turned a deep shade of Buckeye scarlett. Why was pharmacy unilaterally cancelling my antibiotic orders and making crucial decisions on the care of my patient?

Here's the deal. My hospital has now implemented a policy of limiting unncecessary use of antibiotics by giving the pharmacy the power to cancel antibiotic orders that extend 24 hours past a patient's surgery date. On the surface, it seems like a reasonable policy. Unnecessary courses of antibiotics have certainly contributed to the preponderance of such modern dilemmas as widespread MRSA infections and toxic megacolon from C Diff colitis. And surgeons who lazily/carelessly forget to cancel prophylactic peri-operative antibiotics are certainly much to blame. But there's a difference between antibiotics for prophylaxis versus antibiotics for the treatment of an infectious process. For perforated appendicitis, I'm not giving Zosyn to reduce my rate of superficial surgical site infections, but rather to actually treat an established, complicated infectious disease.

I spoke with the lead ID pharmacist and he was cool and apologetic about the misunderstanding. But the policy remains unchanged. It is now the surgeon's obligation to write in the post op orders "antibiotic to be continued post operatively for X-disease process (appendicitis, diverticulitis, peritonitis, etc)"

36 comments:

Anonymous said...

Can't they read the chart and see the words "perforated appendicitis" and acknowledge the need for further antibiotics? why is it always the burden of the physician to have to explain to every Tom, Dick, and Harry in the hospital the reasons for one's actions?

tom said...

Let me get this straight- because some (not all) physicians fail to utilize antibiotics appropriately, a rule is passed that allows someone NOT responsible for the patient, to deem an antibiotic unwarranted and DC it without a conversation with the doc who prescribed the it? BTW if you have pharmacists (or nurses) who cannot (do not?) review the chart to try and understand why the ABX is being used-you need another rule-don't hire folks for clinical jobs if they are not going to do clinical assessment! Is Dilbert in the house??

The Happy Hospitalist said...

Buckeye, it seems to me that an adequate solution to your problem would be for perioperative antibiotics be written as a one time instead of an ongoing order and letting continuous antibiotics be ordered at per it's normal regimen. For example. Ancef 1 gram pre op times one dose. A one time order falls off the nursing orders the following day automatically. Having a pharmacist cancel the antibiotic as a default opens your hospital up to a ton of liablility and is frankly irrational thinking. I'm surprised the pharmacist wants to take on that responsibility.

Buckeye Surgeon said...

HH-
Good thought, but sometimes perioperative antibiotics are justified in being given over several doses. For instance, in colorectal surgery, there is good evidence to suggest that it is appropriate to give 24 hours of antibiotics after the procedure ends, ie Cefoxitin 2gm IV q 8hrs x 24 hrs.

I agree with you; it's strange that the pharmacists would be willing to involve themselves in sorting out when antibiotics are appropriate or not. Seems a better way would be to put the onus on surgeons; make it a QA issue to be evaluated quarterly....

Alice said...

They're going to get themselves in trouble like that. Maybe your young patient with appendicitis will do ok with missing a few doses, but the next elderly patient with fecal peritonitis won't take it so lightly. Then the pharmacists will be liable, and all the money saved will go down the drain.

Resident Anesthesiologist Guy (RAG) said...

And yet again we see another novel idea that clearly says: "You can't trust your doctor to do right by you". Sad.

Jonathan Dee said...

Perhaps a better solution would be for the policy to require the pharmacy to call the surgeon and ask if the antibiotics should be continued. A system that overrides a physician without notification is a broken system. Patient safety has to take priority over saving $$$.

Stalwart Hospitalist said...

I think Happy's on the right track here. Since the standard of care for prophylactic perioperative antibiotics is a 24-hour time frame post-operatively, the physician's order should reflect that (e.g., Ancef 1000 mg IV q8h x 3 doses).

This is made easier by more modern EMRs; our institution will be implementing post-operative order sets where the surgeon can select the antibiotic and indicate whether it is for prophylaxis (defaulting in a 24-hour limit) or therapy (defaulting in an open-ended order).

Anonymous said...

I'm a hospital pharmacist in the UK and we have similar policies in many NHS hospitals. In the hands of experienced pharmacists, I would argue that they're a good backstop for preventing unnecessary antibiotic use (we have C. diff, MRSA and VRE like you wouldn't believe in my region...). The problem comes when policies like this are applied by someone inexperienced, from the pharmacy department, without considering the individual patient's need. I would personally never have stopped this script without at least lookin in the patient's notes to check what was going on and would argue that any pharmacist that did so was negligent.

I'm not sure what the solution is though: Jonathan Dee's suggestion re the pharmacist requesting the change each time would in my hospital result in the surgeon being bleeped constantly: not great use of his/her time and not great for the surgeon/pharmacist relationship!

Frank Drackman said...

Responded to a Code in a hospital that had Pharmacy Residents in charge of the drug box(who knew there were Pharmacy residents?)Wasn't really a code, just a case of hypotension after C-section under spinal. I think the OBGYN asked for Ephedrine, patient got a milligram of Epinephrine IV, can you say ST elevation? We should call it "Adrenaline" like the limey's do.

Bongi said...

the only person who should have the right to change the prescription chart, or anything to do with the care of the patient, should be the person who looks after the patient. if i were you i'd demand to know which pharmacist had clinically assessed my patient. if they did not i would report them to their board for misconduct.

Teresa said...

Does a pharmacist have a license to practice medicine? If not, if he cancels a medical order by a real M.D., does that constitute practicing medicine without a license?

I would think that state law in every state would make this hospital policy patently illegal.

Anonymous said...

In my state, pharmacists can be given prescriptive authority based on the institutions policies. So, the guy could have had the 'power' to do so?

And would you freaking docs find a new cliche saying other than "do pharmacists have a license to practice medicine" or "stop playing doctor" -- They're both stupid and make you look like a pompous prick. You don't have a license to be a condescending jerk to everyone that doesn't have MD behind their name.

Buckeye Surgeon said...

Anon from 7/20:
The problem is, the order was not cancelled by an actual pharmacist; rather by some lackey pharmacist tech who was merely "following protocol". The pharmacist who rounds with the ID docs and was instrumental in intiaiting the policy was actually very cool about the whole thing and is actively looking in to ways to prevent this from happening again...

And if you're going to use perjorative words like "prick", at least have the cajones to do it with your real name, rather than anonymously....

Teresa said...

In my state, pharmacists can be given prescriptive authority based on the institutions policies. So, the guy could have had the 'power' to do so?

You mean that a pharmacist is empowered to prescribe medication? Are there limits to that authority that would not also apply to a medical doctor? That is interesting.

Does it makes sense to you, though, that a pharmacist could be changing medications based on someone else's notes rather than a clinical assessment of the patient?

How would you feel about the hospital assigning doctors on a rotating basis to wander through the wards reviewing patient medications and changing them based upon their own judgment? How would that be any different?

Is it conceivable that the surgeon might know something based on his full experience with the patient that the pharmacist doesn't know? This is actually not rhetorical; I'm wondering if that could be relevant.



And would you freaking docs find a new cliche saying other than "do pharmacists have a license to practice medicine" or "stop playing doctor" -- They're both stupid and make you look like a pompous prick. You don't have a license to be a condescending jerk to everyone that doesn't have MD behind their name.


Oops. I think you are referring to my previous comment. I meant to say license to prescribe medicine, not practice medicine.

But in any event, I'm not a medical doctor. Don't blame them. You seem to have some resentment towards those with an "MD" behind their names. I apologize to you for upsetting you and to all the real MD's out there who bore the brunt of your ire because of my comments. My bad.

Mark said...

Meh, it's just a mistake that probably some junior pharmacist made. Mistakes do happen and really there's no need to go hyper over it, people.

Can't we all just get along?

Pharmacy God said...

Rather than jump all over the pharmacy staff for d/cing the antibiotic order, why don't you see who implemented the policy? I'm pretty sure that the pharmacy department can't just adopt policies without some imput from the medical staff.

From my experience in a hospital setting, when the pharmacy wanted to do things a little bit different, we had a meeting that included the medical staff, nursing, respiratory, radiology, dietary, physical therapy, legal, and administration. Everybody had to be in agreement before new policies and procedures were implemented. So get off of pharmacy's back.

Pharmacy God said...

typing error......input


I don't want pharmacy to take the rap for my spelling error.

sickofstupidpeople said...

"You mean that a pharmacist is empowered to prescribe medication? Are there limits to that authority that would not also apply to a medical doctor? That is interesting."
I am a pharmacist in a state that allows pharmacists to have prescriptive authority. Most states that allow this allow it only nder very specific circumstances, such as collaborative agreements and protocols that the doctors have also agreed to. The state board of pharmacy is also involved Sometimes, the medical board will also have to sign off on the protocol. So, no, we are not "practicing medicine". We are practicing pharmacy.

Anonymous said...

I'm with Pharmacy God on this. No reason to get all hyper over anything. Investigate how the policy was implemented, then just write those simple little words on the post-op orders that will keep the desired antibiotics coming.

Anonymous said...

This is exactly why I am getting sick of almost every pharmacist I have to deal with. I had one completely change an order (I do experimental oncgological therapies) because he had "never seen them prescribed together before". He is now facing criminal charges, and I understand that he is an extreme example of the problem, but since when did pharmacists get the idea that they know more than physicians? I recently reemed out, probably somewhat unfairly, pharmacists in general on the angrypharmacist.com website and was called every name in the book for calling pharmacists on their arrogant bullshit. I am glad that this head pharmacist was cool about changing the order back, but as physicians we need to do something to reign in pharmacists and get them to stop practicing medicine. If they really want to, they should go to med school and go through the years of training we had to.
Sorry to expound, but I had to vent. Pharmacists are NOT M.D.s or D.O.s, and they need to realize it.

Murse 53 said...

Yeah, what do pharmacists know about medicine anyway? ......

No, j/k I see what you're saying. Where I work, I've seen MDs get all in a tizzy over clinical pharmacists ordering K riders adn they always say the same thing, "When did they ever go to medical school?". I see the point, but occasionally it seems borderline ad hom to me.

Anonymous said...

Sounds like you need to take this up with your med committee. There wa obviously a reason this was implemented.

You should probably write the indication as well so the order is not d/ced.

Hospital Pharmacist

Anonymous said...

Buckeye Surgeon, you said, 'It is now the surgeon's obligation to write in the post op orders "antibiotic to be continued post operatively for X-disease process (appendicitis, diverticulitis, peritonitis, etc)."' It is, in fact, the surgeon's responsibility- I am not placing a value judgement on that, I am simply speaking as someone who is well versed in regulatory policy.
Coming at this from both sides of the problem, first, let me say that there is a clear communication deficit in your institution. This policy was obviously put in place to mimic the national standards that every hospital has to abide by (which were put in place for good reason). However, the fact that it was adopted so stealthily that you were not aware is a problem.
For surgeons who were already doing the right thing, I can understand how the quality measures (and the process changes that result) can be infuriating. But there are a lot of caregivers who practice based on outdated evidence, or with less attention to their patients, and the measures were put in place to protect patients and hospitals from the sequelae of those doctors.

webhill said...

First of all, that totally sucks and would royally piss me off, too.

But I am curious about your comment that you can't lavage and drain the peritoneal cavity when doing an open appy. Why not? I'm a small animal vet. I have done ovariohysterectomy in emergent situations when a bitch has developed a pyometra which has ruptured prior to presentation, and you damn well better believe I irrigate the hell out of the peritoneal cavity before I close. Why can't you guys do the same thing?

JM said...

anonymous (MD) said"but as physicians we need to do something to reign in pharmacists and get them to stop practicing medicine. If they really want to, they should go to med school and go through the years of training we had to.
Sorry to expound, but I had to vent. Pharmacists are NOT M.D.s or D.O.s, and they need to realize it."

And MD need to realize that as clinical pharmacists, were looking out for the patients, too. And physicians are not PharmDs. They don't get every med order they write correct. As pharmacists we need to reign in physicians and get them to stop fucking up Pharmacy. I don't need to get reamed out by a general surgeon who prescribes Zosyn 4.5 g q6h for a 85 y.o. lady who's creatinine is 1.1 but is so tiny, her est CrCl is ~ 10mg/ml. She yells and say "her kidneys are fine" yeah, if she was 40 years younger and 140 pounds heavier, I'd agree.
I agree that the policy the Buckeye described is a little asinine, but someone from the medical staff committees, probably through P&T approved it. Pharmacy isn't taking the responsibility here, its the institution that put this policy into place.
the point really is, a sharp pharmacist is going to see that a ABX is for a post-op infection and call the surgeon to clarify, (if, he can actually reach him on the phone) and a sharp surgeon will appreciate a pharmacist who sees that the prescribed med may not be in the best interest of the patient and calls to follow up. The lackeys who graduate in the ass-end of pharmacy and medical school are the ones who have the problems with each other caring for their patients. And as pharmacists and physicians who are posting to this, we know who they are.

p.s. two jokes, equal opportunity
What do you call the guy/girl who graduates last in their class in medical school.........
Doctor
What question does the guy/girl who graduates first in their class in pharmacy school, get asked most often...............
so , what CVS do you work at?

Anonymous said...

I'm a pharmacist, and I worked in a hospital for a while. It is inconceivable to me that a pharmacist would change/cancel an order without at least discuss with the prescribing MD first. We have on occasion not entering a NEW order into the system pending the MD answering our page if the order does not conform to established hospital protocols (and yes these are set by MDs and in the case of my hospital, RNs).

In general, we do not page you guys to question if the use of Vanco is legit (although some will). We're just following protocols to cover our a**.

Anonymous said...

I'd like to put in my $0.02...
first of all, we have all run into really STUPID doctors... Medical Doctors, Doctors of Pharmacy etc..
In regards to this particular incident, well, I am sure it went through med exec and P&T to make a policy. Instead of everyone reaming pharmacists (and yes, not only are there pharmacy residents, but they ASHP is trying to mandate residencies, right now it is optional) how about pushing your hospital to get a proper, GOOD, clinical pharmacist who has the sole job of working on the floors and following up on things like "this pt had surgery, was it complicated? uncomplicated? really need abx?" Etc.
At my hosptial our clinical pharmacists go on rounds, review charts make suggestions and do really GOOD work and I would say a good 98% of the physicians appreciate them... if they call down to the basement to the staff pharmacists, I can't say they get as good quality of people, but there are still some damned good (And bad) pharmacists in the basement.

Everyone seems so hell bent on reaming everyone else instead of seeing how we can improve and change things for the good. My thought is that if your hospital had this policy go through, there had to have been many surgeons that forgot to d/c postop abx.

Our hospital? post surgery orders must have a duration.. uncomplicated? they write ancef 1gm IV q8h x24...48h etc... Usually if zosyn is ordered, we use our brains to realize it isn ot just a postop uncomplicated order... and don't d/c it but after 24-48h the clinical pharmacist does a followup and chart check or write a 'dear doctor' not that does not become part of medical chart.

Personally, I would never change an onc order, i wouldn't just d/c orders, and i have no idea how a pharm TECH could d/c an order. We would fire him/her in a split second, as they have NO right to do that.

Get off the 'all pharmacists suck' because i also yelled at the pharmacists with 'all those surgeons... doctors etc.. suck'

There is good and bad everywhere.

A paediatrician said...

Scary. Anyone who has seen how fast an infection in a kid can go systemic would find that frightening. As it happens, I think that a good experienced clinical phamacist is very useful. I have worked with a couple that were worth there weight in the diamond studded precious metal of your choice. I think pretty much all our drug charts are reviewed at some point by one of our paediatric pharmacists. In neonatal intesive care, we speak to them all the time about interactions, compatibilities and concentrations. If any of our pharmacists spot a possible problem, I am more than happy for them to phone/bleep/grab me on the ward. Sometimes there is a factor they are not aware of, sometimes there is a very specific reason to do things differently in that patient, and sometimes they have spotted a real problem. If there is a problem I want to know about it, to sort it out. If one of my juniors has made an error, I want to know that there is a training need to address. If I have made an error I definitely want to know about it. But none of these excellent pharmacists I have worked with would ever have dreamed of unilaterally changing the prescription for a patient they don't know. Because they have more sense. Communication and teamwork is invaluable, blind adherence to protocol without consideration of individual factors is dangerous. For instance...the 4 year old on sildenafil/viagra: that wasn't a drug error, he wasn't on it for impotence, but rather it was instigated by one of the top respiratory consultants in the country to treat his pulmonary hypertension. You can see why pharmacy queried it. You can also see why I'd have gone ape if they'd just crossed it off!

Anonymous said...
This comment has been removed by a blog administrator.
Anonymous said...

Well, the policy was probably implemented secondary to either a Medicare/Medicaid or a JCAHO requirement to stop all post-op antibiotics. I can't remember which organization it was that started the policy, but it was one of these. The policy will probably become standard at most institutions over the coming years.
As a clinical pharmacist, I have prescriptive authority in my state (with collaborative practice agreement with a physician) , and I am consulted on a daily basis by physicians to manage medication therapies. While I didn't go to medical school, I did spend a total of 7 years in graduate and post-graduate education to earn that right. I am ACLS certfied, PALS certified, and Board Certified as a Pharmacotherapy Specialist. Unlike the pharmacy residents mentioned earlier, I have actually run codes while the Intensivist was inserting a central line (and successfully I might add). I play a positive role in my patients' health.
While not all pharmacists are capable of this higher level of practice, I and many other clinical pharmacists are capable(at least a hell of a lot better than a NP or PA).
My suggestion: start paying attention to your institutions policies and quit complaining about a pharmacist that is just doing his job and following policy.
As I was told during my fellowship (yes we have those too!!!!), guns don't kill people....doctors do.

Anonymous said...

I am surprised by the ignorance of so many physicians on this blog. Do you really think that all they teach in pharmacy school and residency training is how to count pills? That is ignorant.
I have saved many lives by intervening when physicians write deadly orders....you don't bitch when we intervene on those do you?

Anonymous said...

sounds like the pharmacist was following hospital protocol.....maybe you should write a duration of therapy on your orders.

Buckeye Surgeon said...

Allright guys, let's all cool off. In no part of my post do I imply that "pharmacists are bad". Th problem is one of communication, comprehension of treatment goals, and policy implementation. Perioperative antibiotics versus antibiotics for treatment of established infections are two entirely different animals. The length of antibiotic use for diverticulitis/appendicitis/peritonitis ought to be left up to the discretion of the MD's involved in the case, not subject to the limits of an algorithm that doesn't even apply to the situation at hand. If you disagree with that, you're being asinine and a threat to patient safety. Pharmacists have saved my ass plenty of times in terms of dosages and cross reactions; but in this case the policy is simply wrong.

And the "pharmacist" wasn't following protocol; it was a lackey tech who was mindlessly following some arbitrary dogma.

As long as pharmacists clearly elucidate the prophylaxis/treatment distinction in these protocols, there should never be a reason for the surgeon to "specify duration of therapy".

Anonymous said...

As a clinical PharmD, I've been there. The infection control *nurse* and the medication use review subcommittee of the P&T established the protocol for post op abx orders. The two clinical PharmD's at our institution had nothing to do with it. It makes us cringe. The orders *automatically* fall off, with no alert upon order entry or alert to the clinical PharmD on duty. Even had I reviewed the chart of the patient you described, I would have had no way to tell that order was going to fall off unless I had remembered (like you should have since you know the policy), that the Zosyn will fall off without intervention. This entire process is oblivious to the nursing staff, who routinely report: "The pharmD killed that order", when the truth is, either the PharmD didn't review that chart because the patient hit the floor after our shift and we're not there on weekends to fix a flawed hospital policy, or the PharmD or physician forgot that orders like that automatically fall off. Truth likely is, this happened not because a PharmD was involved, but because there weren't enough PharmDs involved, and the clinical PharmDs have no voice at P&T. You're probably unaware of the significant number of interventions PharmDs make on your patients because your hospital doesn't record, track, and report them to you upon credentialing.

Anonymous said...

Good morning:)

Very Interesting Reading.

I practice both professions since 2002-so I can pay off my medical school loans. I see both points of view. Again, it is an institutional policy, discussed at the P&T and The Med Exec and at the Medical Staff meeting.

When it was discussed at my medical staff meeting-No one could response because of the 20 minute discussion on "why is it that the physicians who are oncall are not answering their calls?

My institution is going to CPOE next fall and this is to solve all the problems. Time is money with 2010 and the complete paperless system, COPE, and Joint Commissions mandates concerning safety and no "QD" just wait.
You can hire an LPN to sit at the CRT while you rush off to another sx-It will end up costing everyone Lots of Time and Money.

Perhaps if physicians would go to the source of the problem (the institution or Joint Commission) instead of always trashing, nurses, pharmacists, themselves (ortho saying cardiology not doing their job and cardiology blaming hospitalists for changing their orders)
The Tide of change is coming and we all have to pay attention.
Many years ago "Jako" wanted no standing orders-all individual orders-Now it is stream line protocol orders. Tides come in and they go out.
Oh to the physician who thinks pharmacists want and are practicing medicine-Go ahead and report them to the board for unlicense activity. Both my boards love it in Florida--Board costs are covered by either party regardless if you win or lose. Believe me you are going to lose with the board-especially if the institution made the pharmacists the watch dogs.

Thanks

(Pairadocs)