Section 33.2: Foundational Sets: Admission & Transfer

33.2.1 The Admission Order Set: The Digital Handshake and First Blueprint

The Admission Order Set is arguably the most important single document in a patient’s entire hospital encounter. It is the initial, comprehensive blueprint that sets the trajectory for their entire course of treatment. Think of it as the digital handshake between the admitting provider—whether in the Emergency Department, an outpatient clinic, or another facility—and the inpatient clinical team. An incomplete, ambiguous, or hastily executed handshake can lead to immediate and severe consequences. A well-designed, thoughtfully completed Admission Order Set, by contrast, ensures a seamless, safe, and efficient transition into the complex inpatient environment.

Its primary purpose is to mitigate the immense risks inherent in this first major transition of care. When a patient is admitted, there is a massive transfer of data, responsibility, and clinical context. Without a structured tool, this transfer is fraught with peril. Critical home medications can be forgotten, necessary prophylactic care can be overlooked, allergies can be missed, and a patient’s baseline plan of care can be completely lost in translation. The Admission Order Set is the hospital’s primary defense mechanism against this information entropy. It functions as a forcing mechanism, a comprehensive checklist that compels the admitting provider to address every foundational domain of care, from diet and activity to code status and, most critically for us, the complete and accurate reconciliation of the patient’s home medications.

For the hospital pharmacist, the arrival of a completed Admission Order Set in your verification queue is a call to action. It is the starting gun for your most important professional responsibility: medication reconciliation. The order set is the provider’s first draft of the inpatient medication plan. Your job is to take that draft and, through your expert investigation and clinical judgment, transform it into a final, verified masterpiece that is safe, appropriate, and perfectly tailored to the patient. You are not merely checking for drug interactions or correct doses; you are validating the entire therapeutic story, ensuring the bridge from the patient’s home environment to the hospital bed is built on a foundation of accuracy and safety.

33.2.2 The Admission Order Set as the Catalyst for Medication Reconciliation: A Masterclass

Medication reconciliation (MedRec) is a formal process mandated by The Joint Commission and other regulatory bodies, but it is more than a bureaucratic requirement—it is the bedrock of inpatient medication safety. The process is designed to prevent medication errors by comparing the medications a patient was taking prior to admission with the medications the provider has ordered upon admission. Discrepancies are common, and identifying and resolving them is a core function of the hospital pharmacist. The Admission Order Set does not perform MedRec, but it is the instrument that formally triggers and demands it.

Deep Dive: Step 1 – The Forensic Art of the BPMH

A “Best Possible Medication History” is not what the patient was prescribed; it’s what the patient was actually taking. The gap between these two realities is where many errors occur. Your retail experience has given you a unique insight into this gap through the lens of adherence and fill history. In the hospital, you must become a forensic investigator, using multiple sources to piece together the truth. Never rely on a single source.

Information Source	Strengths	Critical Pitfalls & Your Investigative Questions
Patient or Family Interview	The gold standard for actual adherence, timing, and use of PRNs, supplements, and OTCs. The only source for the “real story.”	Pitfall: Subject to recall bias, health literacy limitations, and stress of illness. Questions: “The bottle says take this twice a day. How many times a day have you actually been taking it recently?” “Do you ever miss doses?” “What do you take for pain that you can buy without a prescription?”
Retail Pharmacy Fill History (e.g., Surescripts)	Excellent, objective data on what was dispensed, when, and by whom. Your retail expertise makes you a master at interpreting this data.	Pitfall: Confirms a prescription was filled, not that it was taken. Doesn’t capture samples, medications from other pharmacies (VA, mail order), or adherence. Questions: “I see you picked up your Eliquis 3 weeks ago. Are you still taking that every day?” “This data shows you haven’t filled your lisinopril in 3 months. Did you stop taking it?”
Patient’s Own Medication Bottles	Provides exact drug, strength, directions, and prescriber information. Can be used to perform a “pill count” to estimate adherence.	Pitfall: The patient may not bring all their bottles. The directions on the label may be outdated if the doctor verbally changed them. Questions: “This bottle says Dr. Smith told you to take one tablet, has he changed that dose for you recently?” “Are there any other prescription bottles at home that you didn’t bring with you?”
Transfer/Clinic Records	Provides a list of prescribed medications and often includes diagnoses, which gives clinical context.	Pitfall: This is often the LEAST reliable source. Lists are frequently outdated, inaccurate, and full of “copy-paste” errors from previous encounters. Questions: Treat this list with extreme skepticism. Use it as a starting point for your questions, not as a source of truth. “The list from the nursing home shows you’re on warfarin. Is that correct?”

Deep Dive: Step 2 – The Clinical Crucible of Reconciliation

Once you have your verified BPMH, you perform the core cognitive task of reconciliation. You will open the patient’s chart, place your BPMH list side-by-side with the provider’s admission orders, and make a clinical judgment on every single medication. This is one of the most intellectually challenging and highest-impact things you will do.

The following table provides a masterclass in the clinical decision-making required during this step for common drug classes. This is not a comprehensive list, but it illustrates the sophisticated thought process you must apply.

Masterclass Table: Reconciliation Decisions by Drug Class

Drug Class	Clinical Considerations & Common Scenarios	Pharmacist’s Reconciliation Scripts & Actions
Anticoagulants & Antiplatelets	EXTREMELY HIGH RISK. The most complex reconciliation. You must know the indication (A-fib? VTE? Mechanical valve? Post-stent?). An active bleed, a planned procedure, or acute kidney injury can all dramatically change the plan. Bridging with heparin or enoxaparin is a common but risky maneuver.	Action: If you see any discrepancy here, STOP. This is your top priority. Script: “Dr. Jones, this is the pharmacist. I’ve completed the med history on Mr. Smith. He takes apixaban 5mg BID at home for A-fib. I don’t see an order for it on admission, and his platelets and renal function look okay. Was the intention to hold it, and if so, for how long and why?”
Antihypertensives (ACEi, ARB, BB, CCB)	Is the patient being admitted with hypotension or AKI? If so, holding antihypertensives is appropriate. Is the specific home agent non-formulary? This is a prime opportunity for therapeutic interchange (e.g., home losartan to formulary valsartan).	Action: Assess BP and renal function. Script: “Hi Dr. Bell, I’m reconciling the meds for Mrs. Davis. I see you’ve ordered to continue her home amlodipine, but her admission BP is 95/60. I recommend we hold the amlodipine for now and re-evaluate if her pressure comes up. Do you agree?”
Statins	Due to their anti-inflammatory and pleiotropic effects, statins should be continued in almost all admitted patients, especially those with acute coronary syndrome, stroke, or sepsis. Valid reasons to hold include rhabdomyolysis or severe liver injury (transaminases > 3x ULN).	Action: If you see a statin on the BPMH that was not continued on admission, it is your duty to investigate why. Script: “Hi Dr. Chen, quick question about your new admission. The patient takes atorvastatin 80mg at home, but it wasn’t continued. Given his diagnosis of a NSTEMI, guidelines strongly recommend continuing high-intensity statin therapy. Would you like me to add that order?”
Diabetes Medications	Inpatient glycemic control is complex. Oral agents like metformin are almost always held due to risks in renal impairment and with IV contrast. Sulfonylureas are often held due to high risk of hypoglycemia. Most inpatients are managed with insulin. The key is to get a home insulin regimen correct.	Action: Verify all details of the home insulin regimen (type, dose, timing). This is often recorded incorrectly. Script: “Good morning Dr. Lee, I’m clarifying the insulin plan for Ms. Rodriguez. She takes 40 units of Lantus at home every night. The admission order set has a default sliding scale order only. To prevent severe hyperglycemia, I recommend we continue her basal Lantus at a reduced dose of 20 units and use the sliding scale for correctional coverage. Can I update the order?”
Psychiatric & Neurologic Meds	CRITICAL TO CONTINUE. Abruptly stopping SSRIs, SNRIs, benzodiazepines, or antipsychotics can cause severe withdrawal syndromes or relapse of the underlying psychiatric illness. Anti-epileptics must be continued at the precise dose and formulation to prevent breakthrough seizures.	Action: Ensure an exact match (or approved formulary equivalent) for these medications. Any omission is a critical error. Script: “Hi Dr. Patel, this is the pharmacist regarding your new admission in room 5. The patient’s home medication list includes escitalopram 20mg daily, but I don’t see it on the admission orders. To prevent discontinuation syndrome, this should be continued. Is it okay if I add the order?”
Pain Medications (Opioids)	You must determine if the patient is opioid-naive or opioid-tolerant. Giving standard opioid doses to a naive patient can cause oversedation. Giving them to a chronic pain patient on high doses at home will cause underdosing and withdrawal.	Action: Calculate the patient’s total home daily oral morphine equivalent (OME) dose. Use this to guide appropriate inpatient ordering. Script: “Hi Dr. Evans, I’ve calculated that your new patient takes about 120 OME at home daily. The PRN hydromorphone 0.5mg IV ordered on the admission set is likely insufficient and may put them into withdrawal. I recommend we add a scheduled long-acting agent, like morphine ER, and use the IV hydromorphone for breakthrough pain. I can help you with the dose conversion.”

33.2.3 The Transfer Order Set: Navigating the Perilous Journey Between Care Levels

If admission is the first major transition of care, a transfer between units is the second. Whether a patient is improving and moving from the ICU to the medical floor (a de-escalation) or deteriorating and moving from the floor to the ICU (an escalation), the transition is a moment of high risk. Orders appropriate for an ICU patient—like continuous sedative infusions, hourly neurologic checks, and potent vasopressors—would be catastrophic on a general medical floor that lacks the necessary monitoring and nurse-to-patient ratios. Conversely, floor-level orders are wholly inadequate for a patient crashing and needing intensive care.

The Transfer Order Set is the essential tool designed to manage this handoff safely. Its single most important function, its entire reason for being, is to force a complete, systematic re-evaluation of the patient’s entire plan of care. It prevents the inertia of inappropriate orders from carrying over from one level of care to another.

Masterclass: Deconstructing the ICU-to-Floor De-escalation

The most common and complex transfer is the de-escalation of a patient who has stabilized in the ICU and is now well enough for the medical floor. The Transfer Order Set guides a fundamental shift in the intensity of care across every domain. This triggers a “Medication Reconciliation 2.0″—an internal reconciliation where you, the pharmacist, must compare the patient’s active ICU medication administration record (MAR) to the newly proposed orders for the floor.

Masterclass Table: The ICU-to-Floor Medication Transition

Transition Type	ICU Reality	Floor Goal & Transfer Orders	Pharmacist’s Role & Clinical Focus
IV-to-PO Conversion	The patient was NPO or had an NG tube and was receiving IV push pantoprazole, IV levofloxacin, and IV metoprolol.	The patient is now eating. The transfer order set defaults to oral equivalents: [X] Pantoprazole 40mg PO daily, [X] Levofloxacin 750mg PO daily, [X] Metoprolol tartrate 25mg PO BID.	Your job is to ensure these conversions are appropriate. Does the oral form have good bioavailability? (Yes, for these three). Is the dose equivalent? Is the frequency correct? You are the gatekeeper of safe IV-to-PO switches, a key driver of cost savings and reduced line infection risk.
De-escalating Infusions (Insulin)	The patient was on a continuous IV insulin infusion for stress hyperglycemia, with hourly blood glucose checks.	The infusion must be stopped. The order set prompts a transition to a scheduled subcutaneous regimen: [X] Start Basal/Bolus Insulin Protocol. [ ] Insulin Glargine (Lantus) [__] units SubQ daily. [ ] Insulin Aspart (Novolog) sliding scale AC/HS.	CRITICAL TIMING. This is a high-risk transition. You must ensure there is an overlap between the IV drip and the first subcutaneous injection. The standard of practice is to give the first dose of basal insulin (e.g., Lantus) 1-2 hours *before* the IV infusion is discontinued to prevent rebound hyperglycemia. You will need to coordinate this timing with the nurse. You also must help the provider calculate a safe starting basal dose, often based on the patient’s insulin requirements over the last 6-12 hours of the infusion.
De-escalating Infusions (Analgesia/Sedation)	The patient was intubated on continuous infusions of Propofol and Fentanyl.	These infusions are now off. The patient needs an oral/IV push pain plan. The order set prompts: [ ] Oxycodone 5-10mg PO q4h PRN. [ ] Morphine 2-4mg IV q3h PRN.	You must review the patient’s sedation and analgesia needs over the past 24 hours to ensure the new PRN plan is adequate. Was the patient requiring high doses of fentanyl? If so, they may be opioid-tolerant, and the standard PRN doses will be insufficient. This requires a conversation about potentially adding a scheduled long-acting agent.
Re-evaluating Prophylaxis (SUP)	In the ICU on a ventilator, the patient was appropriately on IV pantoprazole for Stress Ulcer Prophylaxis (SUP).	The patient is now off the ventilator. The transfer order set may have an order for oral pantoprazole.	This is a key antimicrobial stewardship and de-prescribing moment. The patient likely no longer has an indication for SUP. The risk of C. difficile and pneumonia from unnecessary acid suppression now outweighs the benefit. Your role is to recommend discontinuation. Script: “Dr. Smith, I see the transfer order for oral pantoprazole. Now that the patient is off the ventilator and stable, he no longer meets indications for stress ulcer prophylaxis. I recommend we discontinue it. Do you agree?”