2025 Southeastern Residency Conference

Title: Impact of a Pharmacist Daily Medication Review on the Rates of Intravenous to Oral Conversions and Renal Dose Adjustments 
 
Authors: Johny Nguyen and Lisa Gibbs  


Objective/Self Assessment: Will be included in the presentation 
 
Background/Purpose: A hospitalized patient’s clinical status may fluctuate during their admission, requiring monitoring of medications for potential renal dose adjustments or transitions from intravenous (IV) to oral (PO) routes of administration. Pharmacist led IV to PO and renal dose adjustment protocols have been created at our institution but are not utilized on a consistent basis. Our pharmacy practice model consists of pharmacists following service lines within our institution (e.g., cardiology, psychiatry, internal medicine). However, patients who are covered by hospitalists do not have a dedicated pharmacist.
Preliminary data was collected in September and October of 2024 to assess the number of eligible IV orders for conversion using our existing protocol as well as the need for an expanded renal dose adjustment protocol beyond antimicrobials. This data showed an opportunity for improvement in the utilization of our protocols as well as cost-savings for our institution. Additionally, an adjustment was made to the renal adjustment protocol to include famotidine and gabapentin based on preliminary data. This project aims to evaluate the impact of utilizing our institution’s renal dose and IV to PO protocols within a newly implemented decentralized floor-based pharmacist model.

Methodology: This study is a prospective analysis that was conducted during a 4-week span in February and March 2025. All adult patients admitted to medical or telemetry monitored floors at Self Regional Healthcare were included. A pharmacist was stationed on each floor for daily monitoring of patients' medication therapy, including renal dose adjustments and IV to PO opportunities. Patients receiving medications included in our protocols were flagged for potential adjustment using our institution's electronic health record software functionality. Patients were also assessed for medication adjustments outside of pharmacy approved protocols. The primary outcome of this study was the number of IV to PO or renal adjustment interventions made per protocol. Secondary outcomes include number of IV to PO or renal dose adjustment interventions made outside of protocol via recommendation to provider, provider acceptance rates, and IV to PO cost savings.
Results:

Between February 24th, 2025 – March 26th, 2025, 1046 patients were admitted to medical and telemetry-monitored floors. During this period, 37 IV to PO transitions occurred and 68 medications were renally dosed adjusted. Of the 68 medications that were renally dose adjusted, 62 were adjusted per protocol and 6 outside of protocol. Similarly, 34 medications were transitioned to PO per protocol while 3 were outside of protocol. Provider acceptance was 100% for enoxaparin, sitagliptin, and rosuvastatin renal dose adjustment recommendations but 0% for pravastatin. Both folic acid and thiamine transition to PO therapy achieved a 100% provider acceptance rate. Total cost savings from IV to PO transitions was $1,135.44, with the greatest savings seen with levothyroxine, at $737.

Conclusion: Ultimately, having a pharmacist located on the floors to perform renal dose adjustments and IV to PO transitions improved patient care and reduced healthcare-associated costs.