No products in the cart.
MODULE 41: PHARMACY POLICIES, PROTOCOLS, & DOCUMENTATION
Section 1: Substitution & Conversions
Applying policies for automatic formulation, therapeutic, and IV-to-PO conversions: Moving from medication gatekeeper to medication governor.
SECTION 41.1
Substitution & Conversions
Harnessing protocol-driven autonomy to enhance safety, reduce costs, and optimize patient care.
41.1.1 The “Why”: From Gatekeeper to Governor
In the community pharmacy setting, your role is, by design and by law, that of a meticulous and highly-skilled gatekeeper. A prescription is a legal document, and your primary responsibility is to ensure the medication dispensed is precisely what the prescriber ordered, in the exact form and strength specified, unless a generic substitution is permitted. You are the final, critical checkpoint ensuring accuracy and safety before a medication reaches the patient. Your professional judgment is paramount, but it operates within the strict confines of the prescription order itself.
Upon entering the hospital, your role undergoes a profound evolution. While you remain a guardian of safety, you are now empowered to become a medication governor. A governor, in a mechanical sense, doesn’t just open or close a gate; it actively regulates a system to maintain optimal performance. As a hospital pharmacist, you are given a set of pre-approved, evidence-based protocols that allow you to make specific, autonomous changes to medication orders to optimize therapy for the patient and the healthcare system. This is one of the most significant and professionally satisfying shifts in practice you will experience.
These automatic substitution and conversion policies are not arbitrary permissions. They are the product of rigorous evaluation by the hospital’s Pharmacy & Therapeutics (P&T) Committee—a multidisciplinary body of physicians, pharmacists, nurses, and administrators. The P&T committee reviews clinical evidence, safety data, and pharmacoeconomic analyses to create protocols that standardize best practices. When you act on one of these policies, you are not making a unilateral decision; you are executing a carefully vetted institutional strategy. This protocol-driven autonomy is built on three foundational pillars:
Enhanced Patient Safety
Protocols are designed to transition patients to safer or more appropriate formulations as their clinical condition evolves. The classic example is the IV-to-PO conversion protocol, which aims to remove intravenous catheters as soon as possible, directly reducing the risk of Central Line-Associated Bloodstream Infections (CLABSIs)—a major source of hospital-acquired morbidity and mortality. Therapeutic interchanges can also replace higher-risk medications with safer alternatives for specific populations (e.g., swapping long-acting sulfonylureas for shorter-acting ones in the elderly to reduce hypoglycemia risk).
Improved Pharmacoeconomics
Intravenous medications are exponentially more expensive than their oral counterparts, not just in acquisition cost but also in the labor and supplies required for preparation and administration (IV tubing, pumps, nursing time). A robust IV-to-PO conversion program is a major driver of cost savings for the institution. Similarly, therapeutic interchange policies ensure the use of formulary medications that have been selected based on a balance of efficacy, safety, and cost, leveraging the hospital’s purchasing power to provide the best value-based care.
Optimized Clinical Outcomes
Getting patients onto oral medications facilitates their entire recovery process. It increases their mobility (no longer tethered to an IV pole), improves their comfort, and is often a key milestone for discharge planning. By proactively converting patients, you are not just saving money; you are actively contributing to a shorter length of stay. These protocols also ensure that patients receive a consistent standard of care based on the best available evidence, rather than on individual prescriber preference, which can vary widely.
Retail Pharmacist Analogy: The Evolution of Generic Substitution
Your existing expertise in substitution is the perfect foundation for these new responsibilities. Think about the rules you live by every day in the community pharmacy.
1. Formulation Conversion is like “Tablet vs. Capsule” Generic Substitution: A doctor writes for “Zoloft 50 mg tablets.” You receive the script, and your stock bottle is “sertraline 50 mg tablets.” You make the switch without a second thought. This is a P&T committee-approved, state-board-sanctioned automatic substitution. Now, imagine the doctor writes for “sertraline 50 mg tablets,” but the patient is a child or an adult with a new feeding tube who cannot swallow pills. The hospital’s Formulation Conversion Protocol empowers you to automatically switch to the therapeutically equivalent dose of sertraline oral solution. It’s the same drug, same intent, just a different, more appropriate dosage form for the patient’s current needs. You are applying the same core skill—ensuring therapeutic equivalence—to a new clinical scenario.
2. Therapeutic Interchange is like “Formulary-Driven” PBM Rejections: A patient brings you a new prescription for Crestor. You run it through their insurance, and it’s rejected with the message: “Not a preferred agent. Atorvastatin or simvastatin are covered.” You know the drill. You call the doctor’s office and say, “The patient’s insurance prefers atorvastatin. Would you like to switch to an equivalent dose, perhaps 40 mg?” This is a reactive, formulary-driven interchange. In the hospital, the P&T committee has already done this work for you. The Therapeutic Interchange Protocol is a pre-approved list of these switches. When an order for non-formulary Crestor comes in, the protocol empowers you to automatically change it to the equipotent dose of atorvastatin and simply notify the prescriber. You are moving from a reactive suggestion to a proactive, protocol-guided action.
3. IV-to-PO Conversion is like “Patient Counseling for Maximum Absorption”: A patient comes to you with a prescription for levothyroxine and another for cholestyramine. Your pharmacist brain immediately fires off a warning. You counsel the patient, “It is critical that you take your thyroid pill at least four hours before this cholesterol powder, otherwise it won’t be absorbed properly and won’t work.” You are using your clinical knowledge of drug absorption and bioavailability to ensure a therapeutic outcome. The IV-to-PO Conversion Protocol is the institutional version of this. You see an order for IV levofloxacin in a patient who is eating, drinking, and has a functioning gut. Knowing that oral levofloxacin has nearly 100% bioavailability, you use the protocol to switch the route of administration. You are applying your clinical knowledge of pharmacokinetics to select the most effective and safest route for the medication, just as you do when counseling at the pharmacy counter.
41.1.2 Masterclass on IV-to-PO Conversions
The automatic intravenous (IV) to oral (PO) conversion program is one of the most impactful, pharmacist-driven initiatives in any hospital. It is a daily opportunity for you to directly improve patient care and reduce healthcare costs. Your role is to be the primary driver of this process, constantly screening patients to identify candidates for conversion as early and safely as possible.
The Core Philosophy: The “De-escalation of Care”
Intravenous therapy is an invasive, high-intensity intervention. It is essential when patients are critically ill, cannot absorb medications through their gut, or require drugs that are only available in an IV formulation. However, every moment that an IV line remains in place when it is no longer necessary represents a moment of unnecessary risk and cost. The goal of an IV-to-PO program is to facilitate the “de-escalation of care” by transitioning patients to a less invasive, safer, and more cost-effective route of administration as soon as their clinical condition allows.
The “When”: The Clinical Criteria for a Safe Switch
The decision to switch a patient from IV to PO is not based on a single data point but on a holistic assessment of the patient’s clinical picture. Most hospital protocols codify this into a clear set of criteria. While specifics may vary, they almost always encompass the following domains. A useful mnemonic to remember the key criteria is SAFE.
| Criteria Domain | Description & Clinical Indicators | Pharmacist’s Investigative Questions |
|---|---|---|
| S Stable Clinical Picture |
The patient should be hemodynamically stable and showing signs of clinical improvement from their acute illness. The overall trend should be positive. |
|
| A Able to Absorb |
The gastrointestinal tract must be functioning and able to absorb oral medications reliably. This is the most critical pharmacokinetic consideration. |
|
| F Functional Indication |
The patient must be physically capable of taking medications by mouth. |
|
| E Effective Oral Agent |
A suitable oral equivalent of the IV medication must exist, and it should have adequate bioavailability to achieve therapeutic concentrations. |
|
Absolute Contraindications to IV-to-PO Conversion
Even if a patient meets the SAFE criteria, certain clinical syndromes require prolonged courses of IV therapy to ensure eradication of the infection from deep-seated or difficult-to-penetrate sites. Attempting an early switch in these cases can lead to treatment failure and relapse. Never convert the primary antibiotic therapy in patients with:
- Severe, Unstable Infections: Active septic shock, bacteremia with persistent positive blood cultures, or uncontrolled source of infection.
- Central Nervous System (CNS) Infections: Meningitis or encephalitis. Achieving adequate drug concentrations in the CNS is paramount and often requires high-dose IV therapy.
- Endovascular Infections: Endocarditis or infected vascular grafts. These require long courses of bactericidal IV therapy.
- Bone and Joint Infections: Osteomyelitis or septic arthritis often require weeks of IV antibiotics to achieve sufficient penetration.
- Deep-seated Abscesses: Unless the abscess has been fully drained and the patient is clinically stable, IV therapy is typically continued.
The “How”: A Deep Dive into Bioavailability and Dosing
Your pharmacology knowledge is the engine of the IV-to-PO conversion process. The central concept you will use every day is bioavailability (F), which represents the fraction of an administered dose of unchanged drug that reaches the systemic circulation. By definition, the bioavailability of an IV drug is 100% (F = 1).
The fundamental equation for dose conversion is based on achieving the same systemic exposure (Area Under the Curve or AUC):
$$Dose_{PO} \times F_{PO} = Dose_{IV} \times F_{IV}$$Since we know $F_{IV} = 1$, the formula simplifies to the practical equation you will use for calculations:
$$Dose_{PO} = \frac{Dose_{IV}}{F_{PO}}$$The 1:1 Conversion: Your Bread and Butter
Many of the most commonly used IV medications have excellent to outstanding oral bioavailability (F > 90%). For these agents, the oral dose is simply the same as the intravenous dose. This is known as a 1:1 conversion. Identifying these opportunities is the fastest and easiest way to make a significant impact. Your daily goal should be to screen for any patient receiving one of these drugs intravenously and ask the question: “Does this patient meet the SAFE criteria?”
Masterclass IV-to-PO Conversion Table
This table is not just a list; it is a clinical tool. It details common conversions, bioavailability, standard dosing, and the critical clinical pearls you need to make safe and effective decisions.
| Drug Class | IV Drug & Dose | Oral Bioavailability (F) | Standard Converted PO Dose | Clinical Pearls, Warnings, and Nuances |
|---|---|---|---|---|
| Fluoroquinolones | Levofloxacin 750 mg IV Q24H | ~99% | Levofloxacin 750 mg PO Q24H (1:1) | The quintessential 1:1 switch. A prime target. Be mindful of QTc prolongation risk and interactions with polyvalent cations (calcium, iron, antacids). Ensure a 2-hour separation. |
| Moxifloxacin 400 mg IV Q24H | ~90% | Moxifloxacin 400 mg PO Q24H (1:1) | Excellent bioavailability. Highest risk of QTc prolongation among fluoroquinolones. Provides anaerobic coverage, unlike other FQs. | |
| Ciprofloxacin 400 mg IV Q8-12H | ~70% | Ciprofloxacin 500-750 mg PO Q12H | Not a 1:1 conversion. The oral dose must be increased to account for lower bioavailability. A common conversion is 400 mg IV Q12H to 500 mg PO Q12H. Subject to significant cation interactions. | |
| Antifungals (Azoles) | Fluconazole 200 mg IV Q24H | >90% | Fluconazole 200 mg PO Q24H (1:1) | Excellent 1:1 conversion. Oral suspension is also available. A very common and easy switch. Check for drug interactions (CYP3A4/2C9 inhibitor). |
| Voriconazole 4 mg/kg IV Q12H | ~96% | Voriconazole 200-300 mg PO Q12H (Dose based on indication/levels) | Excellent bioavailability, but exhibits non-linear kinetics. Therapeutic drug monitoring (TDM) is often required. The IV formulation contains a cyclodextrin vehicle that can accumulate in renal impairment (CrCl < 50 mL/min), making the PO switch highly desirable. | |
| Posaconazole 300 mg IV Q24H | ~55% (solution) ~90% (tablet) |
Posaconazole DR 300 mg PO Q24H (1:1 with tablet) | The delayed-release (DR) tablet has excellent bioavailability and is a 1:1 switch from IV. Crucially, the oral suspension has very poor and erratic absorption and is NOT equivalent. Must be taken with a full meal. | |
| Macrolides | Azithromycin 500 mg IV Q24H | ~38% | Azithromycin 500 mg PO Q24H | This is a notable exception. Despite poor bioavailability, the standard of practice and clinical data support a 1:1 dose conversion. This is due to the drug’s extremely high tissue penetration and long half-life. The total body exposure, not just serum concentration, is key. |
| Oxazolidinones | Linezolid 600 mg IV Q12H | ~100% | Linezolid 600 mg PO Q12H (1:1) | Perfect 1:1 bioavailability. A very high-cost IV drug, making this an extremely high-impact conversion. Monitor for thrombocytopenia with prolonged use. Risk of serotonin syndrome with other serotonergic agents. |
| Anaerobic Coverage | Metronidazole 500 mg IV Q8H | ~100% | Metronidazole 500 mg PO Q8H (1:1) | Another perfect 1:1 switch. Inexpensive and effective. A very frequent and easy target for conversion. Counsel on alcohol avoidance (disulfiram-like reaction). |
| Beta-Blockers | Metoprolol 5 mg IV Q6H | ~50% (highly variable) | Metoprolol Tartrate 25-50 mg PO Q6H | Highly complex conversion due to extensive first-pass metabolism. A common conversion ratio is 1 mg IV to 2.5 mg PO (e.g., 5 mg IV -> 12.5 mg PO), but this is not standardized. The best practice is to start with a conservative PO dose (e.g., 25 mg Q6H) and titrate to heart rate and blood pressure response. Never convert IV Metoprolol to long-acting Metoprolol Succinate (Toprol XL). |
| Labetalol 20 mg IV push | ~25% (highly variable) | Labetalol 100-200 mg PO BID | IV labetalol is typically used for acute hypertensive crises. Conversion to a scheduled oral agent is not a direct dose conversion but a transition in therapy. A common starting dose is 100 mg PO BID, titrated to effect. | |
| Acid Suppressants | Pantoprazole 40 mg IV Q24H | ~77% | Pantoprazole 40 mg PO Q24H (1:1) | Standard practice is a 1:1 conversion. All PPIs have good bioavailability. This is a key target for cost-savings. If a patient is on IV PPI for stress ulcer prophylaxis but now tolerating a diet, question if it’s still needed at all. |
| Famotidine 20 mg IV Q12H | ~40-45% | Famotidine 20 mg PO Q12H or 40 mg PO Q12H | Some institutions use a 1:1 conversion (20 mg IV -> 20 mg PO). Others double the dose (20 mg IV -> 40 mg PO) to account for lower bioavailability. Check your hospital’s specific protocol. For most indications, 1:1 is acceptable. | |
| Miscellaneous | Doxycycline 100 mg IV Q12H | ~100% | Doxycycline 100 mg PO Q12H (1:1) | Perfect bioavailability. An easy switch. Subject to cation interactions. Counsel patient to take with a full glass of water and remain upright to avoid esophageal ulceration. |
41.1.3 Masterclass on Therapeutic Interchange
Therapeutic Interchange is a P&T Committee-approved policy that grants pharmacists the authority to automatically substitute a non-formulary medication with a preferred, formulary agent from the same therapeutic class. This is not generic substitution; you are substituting a different chemical entity that is deemed to be therapeutically equivalent (i.e., produces the same or similar therapeutic outcome and has a similar safety profile).
This practice is the backbone of hospital formulary management. It allows the institution to streamline its medication inventory, reduce costs through bulk purchasing contracts, and standardize treatment protocols, which can reduce medication errors. Your role is to execute these interchanges accurately, ensure dosing is equipotent, and communicate the change clearly to the medical team.
Key Principles of Therapeutic Interchange
- Equipotency is Paramount: Your first responsibility is to ensure the dose of the formulary agent is therapeutically equivalent to the dose of the prescribed non-formulary agent. This requires you to know the standard dose conversions for major drug classes.
- Communication is Key: While the protocol gives you the authority to make the switch automatically, the standard of practice is to notify the prescriber of the change. This can be done via a note in the electronic health record (EHR), a secure message, or a verbal conversation. Clear communication prevents confusion and ensures continuity of care.
- Patient-Specific Factors Matter: The protocol is a guideline, not a blind command. There may be rare clinical reasons why a patient needs a specific non-formulary agent (e.g., a documented allergy to all formulary options, or treatment failure on formulary agents in the past). If you suspect this, you must contact the prescriber before making a switch.
Masterclass Therapeutic Interchange Table
This table outlines some of the most common therapeutic interchanges you will perform. Mastering these conversions is essential for efficient and safe practice.
| Drug Class | Common Non-Formulary Agent(s) | Typical Formulary Agent | Equipotent Dose Conversion & Action Plan | Clinical & Safety Pearls |
|---|---|---|---|---|
| HMG-CoA Reductase Inhibitors (Statins) | Rosuvastatin (Crestor) | Atorvastatin (Lipitor) | Rosuvastatin 10 mg ≈ Atorvastatin 20 mg. Rosuvastatin 20 mg ≈ Atorvastatin 40 mg. Action: Convert to the equipotent daily dose of atorvastatin. Document the change in the EHR. |
This is a very common interchange. Remember the relative potencies: “R pharmacists Are Proud to Save Lives” (Rosuva 2, Atorva 4, Pitava 1, Simva 20, Lova 40, Prava 40, Fluva 80). Atorvastatin and Rosuvastatin are considered high-intensity at higher doses. |
| Simvastatin (Zocor), Pravastatin (Pravachol) | Atorvastatin (Lipitor) | Simvastatin 40 mg ≈ Atorvastatin 20 mg. Pravastatin 40 mg ≈ Atorvastatin 10 mg. Action: Convert to the equipotent daily dose of atorvastatin. |
Be aware of the 80 mg simvastatin restriction due to myopathy risk. Interchanging to atorvastatin often simplifies management and avoids drug-drug interaction concerns (simvastatin is a major CYP3A4 substrate). | |
| Proton Pump Inhibitors (PPIs) | Esomeprazole (Nexium), Omeprazole (Prilosec), Lansoprazole (Prevacid) | Pantoprazole (Protonix) | For most indications, all PPIs are considered equipotent at standard doses. Esomeprazole 40 mg ≈ Pantoprazole 40 mg. Omeprazole 20-40 mg ≈ Pantoprazole 40 mg. Action: Convert any IV/PO PPI to Pantoprazole 40 mg IV/PO daily. |
Pantoprazole is a hospital workhorse due to its availability in IV form and perceived lower risk of CYP2C19 interactions compared to omeprazole. This is one of the most frequent interchanges you will perform. |
| H2-Receptor Antagonists (H2RAs) | Cimetidine, Nizatidine | Famotidine (Pepcid) | Cimetidine 800 mg ≈ Famotidine 40 mg. Action: Convert to an equivalent dose of Famotidine (typically 20 mg BID or 40 mg daily). |
Cimetidine is notorious for its numerous drug interactions (CYP inhibitor) and side effect profile (e.g., gynecomastia, confusion in elderly). Switching to famotidine is a significant safety improvement. |
| ACE Inhibitors | Any ACE-I (e.g., Ramipril, Quinapril) | Lisinopril | Convert to the equivalent daily dose based on a standard chart. Ramipril 5 mg ≈ Lisinopril 10 mg. Enalapril 10 mg ≈ Lisinopril 10 mg. Action: Consult your institution’s conversion chart and switch to the equipotent lisinopril dose. |
Hospitals often select one or two ACE-I and ARBs for their formulary to simplify inventory. Lisinopril is a common choice. Always double-check your conversion chart. |
| Angiotensin II Receptor Blockers (ARBs) | Any ARB (e.g., Irbesartan, Candesartan) | Losartan | Convert to the equivalent daily dose. Irbesartan 150 mg ≈ Losartan 50 mg. Olmesartan 20 mg ≈ Losartan 50 mg. Action: Consult your institution’s conversion chart and switch to the equipotent losartan dose. |
Similar to ACE inhibitors, losartan is a very common formulary ARB. Be aware that some ARBs have specific indications (e.g., valsartan in heart failure) that may require a discussion with the prescriber before switching. |
| Non-Dihydropyridine Calcium Channel Blockers | Diltiazem (Cardizem) | Verapamil (and vice versa) | Generally NOT interchanged. | While in the same class, diltiazem and verapamil have different effects on heart rate and contractility, and different side effect profiles. Most hospitals carry both and do not have an automatic interchange policy. This is an example of where class-based substitution is not appropriate. |
41.1.4 Masterclass on Formulation Conversions
Formulation conversion protocols allow the pharmacist to change the dosage form of a medication to one that is more appropriate for the patient’s current clinical condition, as long as the active ingredient and dose are equivalent. This is most commonly applied when a patient’s ability to take oral medications changes, such as being made NPO (nothing by mouth) or having a new enteral feeding tube placed.
From Solid to Liquid: The Most Common Switch
When a patient can no longer swallow tablets or capsules, you are responsible for identifying a suitable liquid alternative. This is more complex than simply finding a product with the same name. You must consider:
- Different Salt Forms: Does the liquid formulation use a different salt than the tablet? This can affect the equivalent dose. For example, phenytoin sodium capsules contain 92% phenytoin, while the suspension is phenytoin base (100%). Doses must be adjusted accordingly.
- Concentration and Volume: Always double-check the concentration of the liquid product. A large volume may be required to achieve the correct dose, which could be problematic for fluid-restricted patients or for administration via feeding tube.
- Enteral Tube Compatibility: Is the liquid formulation suitable for administration via an NG or PEG tube? Some viscous syrups or suspensions can clog tubes. Sorbitol, a common excipient in liquid medications, can cause significant diarrhea when given repeatedly via feeding tube.
The “Do Not Crush” List: A Core Safety Function
This is a skill you have honed in community practice that becomes even more critical in the hospital. When a liquid formulation is not available, the default option is often to crush the tablet and administer it via feeding tube or in a soft food like applesauce. You are the safety net that prevents a catastrophic error from crushing a modified-release dosage form. Crushing these medications can lead to “dose dumping,” where the entire day’s dose is released at once, causing acute toxicity.
“Do Not Crush” Master List: Common Examples
| Drug/Class | Suffix/Reason | Consequence of Crushing | Pharmacist’s Action |
|---|---|---|---|
| Metoprolol Succinate | XL, ER (Extended-Release) | Loss of 24-hour coverage, potential for acute bradycardia/hypotension. | Switch to an equivalent total daily dose of immediate-release metoprolol tartrate, divided into a Q6H or Q8H schedule. |
| Nifedipine ER | XL, CC (Extended-Release) | Rapid, profound vasodilation leading to severe hypotension and reflex tachycardia. | Switch to an alternative agent like amlodipine, which is immediate-release by nature and has a long half-life. |
| Diltiazem ER | CD, LA, XR (Extended-Release) | Loss of extended duration, potential for acute bradycardia/hypotension. | Switch to an equivalent total daily dose of immediate-release diltiazem, divided QID. |
| Potassium Chloride | ER, K-Dur, Klor-Con (Wax Matrix) | Loss of protective matrix, causing severe, localized GI irritation and ulceration. | Switch to potassium chloride oral solution or powder packets. Be aware of the high concentration and need for dilution. |
| Enteric Coated (EC) Products (e.g., Aspirin EC, Dulcolax) |
EC (Enteric-Coated) | Destruction of the drug by stomach acid (if acid-labile) or release in the stomach causing irritation. | For Aspirin, use chewable or immediate-release tablets. For bisacodyl, consider a rectal suppository if appropriate. |
41.1.5 Workflow, Documentation, and Communication
Successfully implementing substitution and conversion protocols requires a systematic approach that combines clinical assessment, accurate execution, and clear documentation.
The Pharmacist’s Conversion Workflow
- Review and Identify: Proactively screen patient medication profiles. Does the order meet the criteria for a protocol-driven change? Is it a non-formulary statin? Is it an IV antibiotic with a great oral equivalent?
- Assess the Patient: Apply the clinical criteria. For an IV-to-PO switch, go through the “SAFE” checklist. For a therapeutic interchange, confirm there are no patient-specific contraindications.
- Confirm the Conversion: Double-check your dose conversion. For IV-to-PO, what is the bioavailability? For therapeutic interchange, what is the equipotent dose? Consult your institution’s approved charts.
- Execute the Change: Modify the order in the EHR as allowed by the protocol. This may involve discontinuing the old order and entering a new one.
- Communicate Clearly: Notify the prescriber of the change. The method depends on the urgency and institutional policy. For routine interchanges, a note in the EHR is often sufficient. For a more complex conversion, a direct message or call may be better.
- Document Thoroughly: Your documentation is your legal and professional record. A clear note demonstrates your value and thought process.
The Art of the Intervention Note
A good documentation note is clear, concise, and defensible. It should follow a standard format, such as a SOAP note, even in a shortened form.
Example: IV-to-PO Conversion Note
S (Subjective): Patient eating, no N/V/D reported by nursing.
O (Objective): Tmax 37.5 C, WBC trending down to 10.5. Tolerating oral diet. Currently on Levofloxacin 750 mg IV daily for CAP.
A (Assessment): Patient meets institutional criteria for IV-to-PO conversion. Oral levofloxacin has ~99% bioavailability, allowing for 1:1 conversion.
P (Plan): Per IV-to-PO protocol, discontinued IV levofloxacin and ordered PO levofloxacin 750 mg daily. Notified primary team via EHR message.
Example: Therapeutic Interchange Note
A/P: Patient ordered non-formulary Rosuvastatin 20 mg daily. Per P&T-approved therapeutic interchange protocol, this has been converted to an equipotent dose of formulary Atorvastatin 40 mg daily to begin this evening. Primary team notified.
