Making Sense of Rapid-Acting Insulin Patient Directions in the EMR

Abstract

Discharge prescription (Rx) instructions for rapid-acting insulin (RAI) are often missing information. Various barriers prevent complete RAI directions in the EMR, including a 140 character limit for e-prescribing which encourages use of abbreviations. Replacing "unit" with "U" has contributed to multiple dose mis-interpretations and unwanted glycemic excursions. Further, for insurance reimbursement, pharmacies must be able to estimate 30 day supplies for prescriptions, which is challenging when integrating a correctional scale into the directions. These barriers often lead prescribers to develop multiple workflows. The e-Rx may be ordered in terms of maxium daily dose (Take up to 60 units daily SQ as directed) while the patient may be provided separate medication instructions. At UCSF, every patient is provided a customized "after visit summary" (AVS) which includes a discharge Patient Medication List (PML), while the PCP is sent the PML and discharge summary electronically, and the PML also serves as a vehicle for prescribing to the pharmacy. A universal patient-centric standard for RAI instructions in the EMR medication list that can be both e-prescribed and used as the patient's instructions is not currently in place. Some medical centers recommend avoiding discharging patients with RAI correctional scales. A 2-month retrospective review of the PML, AVS and discharge provider summary for all adult inpatients discharged from UCSF to home revealed that 82% of patients were prescribed RAI with a correctional scale. (n=107) Of those, within the patient's PML or AVS medication instructions, 86% had range orders with incomplete scale directions, 22% had missing routes of administration, 12% contained unapproved abbreviations and 46% of nutritional RAI orders had missing units. Future efforts include identifying systematic approaches to ensure patients,their health care providers and their pharmacies are provided complete and accurate RAI instructions at discharge. Disclosure H.W. Macmaster: None. I. Fong: None. R.J. Rushakoff: None.