CHPPC Module 15, Section 2: Inpatient Therapy Continuity
MODULE 15: TRANSITIONS OF CARE & DISCHARGE MED REC

Section 2: Inpatient Therapy Continuity

You have mastered the foundational act of the admission medication reconciliation. Now, we turn our focus inward to the complex journey a patient takes *within* the hospital walls. A hospital stay is not a static event; it is a dynamic series of transitions between different levels of care, different teams, and different therapeutic goals. This section will teach you the art of ensuring medication therapy continuity throughout this journey. You will learn to be the vigilant guardian who ensures home medications are appropriately managed, who scrutinizes orders during high-risk internal transfers, and who prevents the silent propagation of errors that can occur when a patient’s clinical status changes.

2.1 The Propagation of Error: Active Orders and Clinical Inertia

Why an unreviewed order is a latent threat.

A fundamental difference between outpatient and inpatient practice is the nature of a medication order. An outpatient prescription is a static, one-time authorization. An inpatient order, however, is often a continuous, active command that will be carried out indefinitely until a provider actively discontinues it. This creates a powerful phenomenon known as “clinical inertia,” where a medication regimen, once started, tends to stay in motion. This inertia is a significant source of error. An incorrect dose ordered on admission can be administered for days. A therapy started for an acute problem can be continued long after that problem has resolved. Your role as a pharmacist is to be the force that counteracts this inertia through daily, proactive medication profile review.

Retail Pharmacist Analogy: The “Auto-Refill” Without Re-evaluation

Imagine your pharmacy has a robust “auto-refill” program. A patient is started on amlodipine 5mg, and you enroll them. The system automatically refills and sends the medication every 90 days. A year later, the patient’s blood pressure is still high, so their doctor increases the dose to 10mg and sends in a new script. However, no one remembers to turn off the original 5mg auto-refill. Now, the patient is receiving both the 5mg and 10mg prescriptions, a dangerous therapeutic duplication caused by an “active order” that was never re-evaluated.

Inpatient orders are like a high-speed auto-refill system that runs every single day. The order for “Vancomycin 1.5g IV Q12H” will continue to be prepared and administered automatically until someone intervenes. If the patient’s renal function declines on day 3, but no one re-evaluates that active order, the “auto-refill” will continue to deliver a now-toxic dose. Your daily profile review is the manual process of re-evaluating every single auto-refill, every single day, to ensure it is still appropriate.

2.2 The Internal Transfer Touchpoint: Bridging the Gaps in Care

Ensuring a safe handoff as a patient’s level of care changes.

While admission and discharge are the most recognized transition points, internal transfers are a hidden source of significant medication errors. When a patient moves from a general medical floor to the ICU, or vice versa, their entire clinical picture changes. The medications appropriate for a critically ill patient on a ventilator are often dangerous for a stable patient on the floor. This handoff between medical teams and nurses is a critical moment where a pharmacist’s review of the medication orders is essential to ensure they are still appropriate for the patient’s new clinical status and location.

2.2.1 A Masterclass on Common Errors at Internal Transfer

Your proactive profile review should be laser-focused on identifying these common pitfalls. The direction of transfer dictates the most likely errors.

High-Risk Transfer: ICU ⟶ Medical Floor

This is the most dangerous internal transfer. The patient is moving from a 1:1 or 1:2 nurse-to-patient ratio with continuous monitoring to a 1:5 or 1:6 ratio with intermittent monitoring.

Error Type Example & Rationale Pharmacist Intervention
Continuation of ICU Drips An order for a continuous insulin or sedation (propofol, dexmedetomidine) drip remains active. General floors are not staffed or equipped to manage the frequent monitoring and titration these drips require. This is a “never event.” You must ensure all ICU-specific continuous infusions are discontinued *before* the patient physically leaves the ICU. Proactively contact the provider: “Dr. Smith, I see the transfer order for Mr. Jones. We need to discontinue the insulin drip and transition him to a subcutaneous insulin regimen before he moves to the floor.”
Failure to De-escalate Therapy A patient who is now stable and eating continues to receive IV antibiotics instead of being switched to PO. A patient on two vasopressors is transferred with both still active. This is a prime opportunity for antimicrobial stewardship and regimen simplification. “Now that the patient is transferring, they meet criteria for an IV to PO switch for their levofloxacin. I recommend we make that change.”
Failure to Resume Home Medications A patient’s home atorvastatin and sertraline were held during their acute critical illness. Now that they are stable, the transfer orders forget to resume them. This requires a systematic comparison of the transfer orders to the original BPMH. “I noticed the patient’s home atorvastatin is not on the transfer order set. Now that their LFTs have stabilized, I recommend we resume it.”

Moderate-Risk Transfer: Medical Floor ⟶ ICU

Error Type Example & Rationale Pharmacist Intervention
Failure to Hold Inappropriate Meds A patient who is now intubated and NPO has active orders for their home oral diabetes medications (e.g., metformin) or complex oral antihypertensives. When a patient becomes critically ill, many home medications become inappropriate. Your role is to ensure these are placed on hold to prevent hypoglycemia or hypotension. “The patient is now NPO in the ICU. We need to hold their home metformin and glyburide and manage their blood glucose with an insulin protocol.”
Delayed Initiation of Critical Therapies The patient is intubated, but no order for stress ulcer prophylaxis (SUP) is placed. The patient is immobile, but no order for VTE prophylaxis is placed. Your role is to be a protocol expert. “The patient now meets criteria for SUP due to mechanical ventilation. I recommend we start pantoprazole 40mg IV daily.”
Failure to Adjust Doses for Organ Failure A patient develops acute kidney injury (AKI) during their decline. Their active order for renally-cleared cefepime is not adjusted. This is a classic pharmacist intervention. “Given the patient’s new AKI, their current cefepime dose needs to be renally adjusted to prevent neurotoxicity. I recommend we decrease the dose to…”

The Pharmacist’s Transfer Reconciliation Workflow

As soon as you are notified that one of your patients is transferring, you should initiate this proactive safety review. Time is of the essence.

  1. Review the Current MAR vs. the Admission BPMH: Pull up two lists side-by-side. What is the patient currently on? What were they on at home? Identify all the home medications that are currently on hold or were modified.
  2. Review All Continuous Infusions & High-Risk Meds: Are there any active drips that are inappropriate for the receiving unit? Are the doses of anticoagulants or antibiotics still appropriate given the patient’s new clinical status?
  3. Create a “To-Do” List for the Provider: Based on your review, create a clear, concise list of recommendations. Structure it by “STOP,” “START,” and “CHANGE.”
    • STOP: Insulin Drip, Propofol Drip.
    • START: Resume home atorvastatin 40mg daily. Start SUP with pantoprazole.
    • CHANGE: Convert levofloxacin from IV to PO.
  4. Communicate Proactively: Don’t wait for the provider to make a mistake. Contact them before they write the transfer orders. “Dr. Smith, I see you are planning to transfer Mr. Jones to the floor. I’ve performed a medication reconciliation to ensure a safe transfer. We’ll need to discontinue the insulin drip and I recommend we resume his home atorvastatin. Would you like me to pend those orders for you to co-sign?”
  5. The Bedside Handoff: When the patient arrives on the new unit, your rounding process is crucial. You can physically go to the room, introduce yourself to the new nurse, review the new MAR with them, and verify that the pump for any new infusions is programmed correctly.

2.3 Adjudicating “Continue Home Meds” Orders: A Masterclass

Your systematic process for translating the BPMH into safe inpatient orders.

One of the most common and most dangerous practices in CPOE is the use of a blanket order to “Continue all home medications.” This is often done by a busy admitting provider who may not have time to review each of the 20 medications on a patient’s home list. This order essentially delegates the entire reconciliation process to the pharmacist and the nurse. It is your job to intercept this order and systematically adjudicate every single home medication, deciding if it should be continued, modified, or held. Simply verifying this blanket order without a thorough review is a major medication error.

Retail Pharmacist Analogy: The “Refill All” Request

A patient comes to your counter and says, “I’m out of everything, can you just refill all my medications?” Do you blindly go to their profile and hit “refill all”? Never. You pull up their profile and go through it with them, one drug at a time. “Okay, let’s see. The lisinopril for blood pressure, you still need that one? Yes. The metformin for diabetes? Yes. The tramadol from your surgery six months ago, do you still need that one? No. Okay, I’ll inactivate that one.” You are performing a manual adjudication of their entire profile.

The “Continue Home Meds” order is the inpatient version of the “Refill All” request. Your job is to perform that same, systematic, line-by-line review, applying your clinical judgment to decide the appropriate fate of every single medication on the BPMH.

2.3.1 The Four Fates of a Home Medication: A Systematic Framework

For every single drug on the BPMH, you must assign it one of four fates. This should be a formal, documented process in your pharmacy intervention software or in a clinical note.

The Fate The Clinical Question Example & Rationale
CONTINUE AS IS Is this medication safe and clinically necessary for the patient’s chronic condition during their acute hospital stay? Levothyroxine: Essential for metabolic function. Must be continued.
Levetiracetam: Essential for seizure prevention. Must be continued.
Atorvastatin: Important for long-term CV risk, safe to continue in most acute illnesses.
CONTINUE WITH MODIFICATION Is the medication necessary, but is the home dose, route, or frequency inappropriate for the inpatient setting? Long-acting Insulin: “Patient takes Lantus 40 units QHS at home. We will continue this basal insulin, but we must also add a correctional sliding scale to manage potential hospital-related hyperglycemia.”
Furosemide: “Patient takes furosemide 40mg PO daily at home. They are admitted with acute heart failure and are fluid overloaded. We will convert this to the IV equivalent (20mg IV) and increase the frequency to BID.”
HOLD TEMPORARILY Is this medication unsafe or unnecessary during the acute phase of the patient’s illness, but should be resumed once they are stable? Lisinopril in AKI: “Patient admitted with AKI (SCr 3.0). We must hold their home lisinopril to avoid worsening renal injury. This should be re-evaluated daily.”
Metformin with IV Contrast: “Patient is going for a CT scan with IV contrast. We must hold their metformin for 48 hours post-procedure to mitigate the risk of lactic acidosis if they develop contrast-induced nephropathy.”
DISCONTINUE Is this medication inappropriate, unnecessary, or potentially harmful, and should likely be stopped permanently? Herbal Supplements: “Patient takes Ginkgo Biloba at home. This can increase bleeding risk and has no proven benefit. It should be discontinued.”
Chronic NSAID Use in HF: “Patient with heart failure takes ibuprofen daily for arthritis. This is known to cause sodium/water retention and can exacerbate HF. It should be discontinued and replaced with acetaminophen.”