Whether from inpatient to outpatient, outpatient to inpatient, or between higher and lower-acuity settings within the hospital, transitions of care (TOCs) are a challenging time for the hospital pharmacy.
“You’re often coordinating between multiple providers in a variety of different settings, and need to coordinate a lot of different elements,” said Toby Trujillo, PharmD, a professor of clinical pharmacy at the University of Colorado Anschutz Medical Campus, in Aurora. “There is always the potential for medication errors and harm. It’s a relatively high-risk time for patients.”
During a session at the 2024 ACCP Annual Meeting, in Phoenix, Dr. Trujillo and other experts focused on three clinical situations that present particular TOC challenges: anticoagulation, opioids and diabetes.
Anticoagulants
Anticoagulants are a leading cause of adverse drug events (ADEs) occurring during emergency department (ED) visits, particularly for older adults. A 2021 review found that anticoagulant ADEs were implicated in 14.9% of ED visits for medication harms overall and in more visits involving therapeutic use of medications (21.5%) than any other class of medications (JAMA 2021;326[13]:1299-1309).
“Adverse events involving anticoagulants are common in all care settings, and direct oral anticoagulants [DOACs] pose unique challenges related to inappropriate prescribing and dosing, suboptimal management, and fewer touchpoints with patients,” said Dr. Trujillo, who is also a clinical pharmacy specialist in cardiovascular pharmacotherapy and anticoagulation at UCHealth University of Colorado Hospital.
Anticoagulation stewardship efforts typically are focused on a few common clinical situations, including admissions for acute medical illness or periprocedural management (for either emergent or planned surgery) of patients who are on chronic anticoagulation, typically with oral agents. Another common stewardship area involves hospital-to-home transitions for patients who received new-start anticoagulation in the hospital to treat or prevent thromboembolism.
Pharmacists need to be particularly invested in stewardship discussions about how to appropriately manage anticoagulation in the periprocedural setting, Dr. Trujillo stressed. He noted that different societies, such as the American Society of Regional Anesthesia and Pain Medicine and the American College of Chest Physicians, have guidelines on this issue, but these recommendations do not always line up exactly (Reg Anesth Pain Med 2018;43[3]:225-262; Chest 2022;162[5]:e207-e243).
“As you develop guidance for your institution, review the appropriate guidelines and get all pertinent stakeholders involved, and develop a consensus ahead of time so that you are not trying to scramble in real time to manage a specific patient,” Dr. Trujillo said. For example, he noted that UCHealth has developed decision support tools and operates a dedicated periprocedural management clinic that proactively identifies and communicates with all patients on chronic anticoagulation.
When patients on chronic anticoagulation are discharged home after an acute medical illness, it’s important for the care team to reassess the appropriateness of therapy for the patient, Dr. Trujillo noted. “Considerations include renal and hepatic function, new drug–drug interactions, dietary changes, and any bleeding or thromboembolic complications.”
Diabetes Challenges
More than 1 in 4 hospitalizations include a diagnosis code for diabetes, said Jennifer Clements, PharmD, a clinical professor of pharmacy and the director of pharmacy education at the University of South Carolina College of Pharmacy in Greenville. And these patients have 30-day readmission rates ranging between 17% and 26% (Clin Diabetes Endocrinol 2017;3:3).
“We need to not only recommend evidence-based therapy during a hospitalization but also ensure that these patients receive evidence-based recommendations when they leave the hospital,” she said. “For example, current standards from the American Diabetes Association now recommend that we can continue an SGLT-2 [sodium-glucose cotransporter-2] inhibitor in the hospital, whereas two or three years ago, we probably would have stopped it. And we can start these patients on one if they are not already receiving it, because the evidence shows that it’s beneficial for specific populations, such as people with type 2 diabetes and heart failure. Don’t be hesitant to make adjustments.”
Dr. Clements cited a number of common errors involving patients with diabetes at different TOC points, including:
- insufficient medication reconciliation;
- inappropriate use of an insulin order set;
- lack of attention to medication recommendations in the transition from hospital to home;
- oversight of the suggested discharge plan;
- lack of knowledge on newer glucose-lowering agents; and
- delayed consult for diabetes care and education during the transition from hospital to home.
“While in the hospital, patients may be continued on a medication that is not as efficacious as some others, and not adjusted, and they may be discharged on an older insulin dose rather than the prescribed hospital regimen,” Dr. Clements said. “We need to be sure that we are recommending evidence-based therapies, such as discharging them on SGLT-2 inhibitors or GLP-1 [glucagon-like peptide-1] receptor agonists.”
Steroids are also commonly given to hospitalized patients with diabetes. “While we may match the insulin to the steroid at the inpatient stage, we also need to ensure that there is education at the point of transition on decreasing the insulin as the steroid goes down, and that an endocrinology or primary care appointment is made before leaving the hospital so that we don’t put too much on the patient,” Dr. Clements said.
Dr. Clements added that technology in diabetes care also is frequently evolving. “It’s difficult to keep up with, and you have to have the right protocols and procedures in place to know when it is safe to continue with existing technology like an insulin pump during hospitalization and when you need to discontinue it,” she said. “If a patient comes in with a pump failure and you don’t see any prescriptions for backup insulin in case that happens again, you should be ensuring that is set up before they go home. It’s important to consult your diabetes care and education team at time of discharge, not just upon admission.”
Opportunities for Improved Opioid Care
Recent legislative changes around medications for opioid use disorder (MOUD), including buprenorphine and methadone, have given expanded access and flexibility to prescribers, explained Lyndsi Meyenburg, PharmD, a clinical pharmacy specialist at Ascension Seton Northwest Hospital, in Austin, Texas. “In 2023, the X-waiver requirement to prescribe buprenorphine was eliminated, and this year, some flexibilities in prescribing that were put in place around the COVID-19 Public Health Emergency (PHE) were also made permanent.”
New rules from the Substance Abuse and Mental Health Services Administration, effective as of April 2024, allow patients to receive up to 28 days of take-home methadone after one month in treatment. Before the federal PHE, that amount was available only after two years of in-person treatment. The updated rules also allow people to start treatment faster, without first demonstrating a one-year history of OUD.
On Jan. 12, 2023, the federal government officially announced the elimination of the X-waiver, which required that only doctors who received specialized training and federal permissions could prescribe buprenorphine to treat OUD. “That has been very beneficial, but there are still some challenges that we need to overcome,” Dr. Meyenburg said. “Although any prescriber can now prescribe[buprenorphine], it’s not something that’s been historically taught in medical school and residency, so it’s important to integrate addiction medicine training at various levels of health professional education so that doctors have more exposure, guidance and comfort with prescribing these medications.”
Getting in the MOUD
Hospitalization is a critical touchpoint for patients with OUD, presenting an important opportunity to initiate MOUD and link them to ongoing care—but all too often that opportunity is missed, Dr. Meyenburg said. In a study involving 6,654 patients who had a diagnosis of OUD during a general hospital admission in Oregon between April 2015 and December 2017, investigators found that 7.8% of patients died within 12 months post-discharge, with 58% of those deaths attributable to drug-related causes (J Addict Med 2022;16[4]:466-469). “There were clearly missed opportunities during those touchpoints,” she said. “More than half of the opioid overdose deaths were preceded by at least one touchpoint in the previous 12 months. With in-hospital initiation of buprenorphine versus detoxification alone, patients were more likely to engage in outpatient treatment, and illicit opioid use was reduced.”
When planning discharge for a patient on MOUD, it’s important to consider MOUD-related needs early. “If doses were split for pain, consolidate into daily doses,” Dr. Meyenburg advised. “Connect the patient with a peer recovery coach and offer harm reduction. It should be a top priority to distribute naloxone.”
To minimize the burden on patients with tailored care plans, “contact and arrange a next-day intake appointment with an opioid treatment program,” she advised. Additionally, “provide a buprenorphine follow-up appointment, and provide a discharge prescription or medication in hand, which is preferred.”
Dr. Clements reported financial relationships Eli Lilly, Embecta, Leapfrog Group, Novo Nordisk and Xeris Pharmaceuticals Inc. Drs. Meyenburg and Trujllo reported no relevant financial disclosures.
This article is from the March 2025 print issue.