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ADT and Medication Order Processing for Hospice Patients (19.1)

ADT and Medication Order Processing for Hospice Patients (19.1) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Outreach Services

19.1

POLICY & PROCEDURE





Effective Date:
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7Pharmacy Policy Manual
Chapter: Administration

Policy #: 19.1


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Title: ADT and Medication Order
Processing for Hospice Patients



I. PURPOSE
1) The purpose of this policy is to standardize the procedure for processing admission-
transfer-discharge (ADT) orders and medication orders by UWHC pharmacists and
Agrace Hospice Care staff.

II. POLICY
1) All ADT events and medication orders for hospice patients must follow the procedure
outlined in this policy.

III. DEFINITIONS
1) UWHC Pharmacist responsible for hospice orders
A. Agrace Hospice Care contact information
B. Charge nurse: 576-4575
C. Pod 1 fax: 276-7432
D. Hospice Pharmacist: 206-4422
E. Nurse Station
POD Room Numbers Phone Numbers
1 1-12 327-7174
2 14-19 327-7304
3 20-27 327-7184
4 28-35 327-7307
Monday-
Friday
Sat, Sun, &
Holiday
UWHC Pharmacist Fax Number Pager
Phone
Number
0700-2230 0700-1530 B6/6 Pharmacist
203-1024

262-2122
x7592
263-7230
2230-0700 1530-0700 Central Pharmacist n/a 263-0666

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5 36-43 327-7308
6 44-51 327-7309

2) UWHC: University of Wisconsin Hospital & Clinics
3) SPA: Sterile Products Area in the central pharmacy at the hospital
4) OnBase- Content management software program that will act as an electronic fax queue
for hospice orders faxed to UWHC
5) “Received” queue- OnBase queue to capture incoming documents waiting to be
processed by UWHC pharmacist
6) “Needs clarification” queue- OnBase queue used to index orders that need to be clarified
prior to pharmacist verification
7) “Active Patients” queue- OnBase queue used to index orders for patients currently
admitted to hospice
8) “Discharged Patient Hold” queue- OnBase queue used to hold discharged or deceased
patients’ orders for 72 hours prior to orders being archived
9) Emergency orders- Clinically urgent pharmaceuticals that are absolutely necessary to
maintain or improve a patient’s medical condition due to an unexpected change in the
condition of a patient

IV. PROCEDURE
1) Agrace Hospice Care processing of admission, transfer, discharge, and medication
orders
A. Hospice staff will be expected to fax all orders to UWHC pharmacist using fax
number provided above
B. Orders for multiple patients should always faxed separated by individual patient
2) UWHC Pharmacist processing of hospice orders
A. Designated UWHC pharmacist shall be responsible for processing hospice orders
using electronic fax queue according to timeframes listed above
B. UWHC pharmacist will access hospice faxed orders from electronic fax received
queue. Once orders have been processed UWHC pharmacist should link orders
using the patient’s Health Link MRN or UWHC ID and index orders in
appropriate queue (active patients queue or needs clarification queue) for record
keeping purposes
C. See Appendix A: OnBase Tutorial for details
3) Admitting, transferring, and discharging hospice patients

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A. UWHC Pharmacist is responsible for processing all the ADT events for hospice
inpatients
B. Admitting a patient to inpatient hospice
1. Hospice staff will fax admission documents for all patients being admitted to the
hospice inpatient unit to the UWHC OnBase fax number
2. Patients who do not already exist in Health Link need to be created then
admitted.
3. If the patient already exists in Health Link then the patient can be selected and
admitted.
4. See Appendix B: Admitting, Transferring, and Discharging Hospice Patients in
Health
C. Transferring a patient within the inpatient hospice
1. Hospice staff will fax the appropriate information when patients are transferred
within Hospice
2. The pharmacist will manually transfer the patient to the designated bed within
the hospice unit
3. Patients can only be transferred within the hospice unit and not between any
other units
4. If a patient is transferred to UWHC, the patient will have to be manually
discharged from the hospice unit
a. Hospice staff will call or page to notify the pharmacist of a patient transfer to
UWHC
b. The patient will be admitted to UWHC by the standard ADT process not by
the pharmacist
c. A patient can have only one inpatient admission open at a time (i.e. if a
patient is still admitted to hospice they can NOT be admitted to the UWHC
ED or inpatient units)
D. Discharging a patient from the inpatient hospice
1. Hospice staff will fax discharge information including patient name, hospice
identification number, date, and time of discharge to the UWHC OnBase fax
number
2. The pharmacist will then manually discharge patients from Health Link and
move patient’s orders within OnBase to the Discharged Patient hold queue
3. When a patient passes away, the patient is discharged the same as above but
the reason for discharge should be “deceased” rather than one of the other
required reasons
4) Medication order processing

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A. Hospice staff will fax all medication orders to the UWHC fax number
1. All medication orders must be signed by an authorized prescriber
2. Orders faxed from Hospice shall indicate whether medications are “related or
unrelated.”
3. All orders faxed from Hospice will be processed as “UW to provide” unless
indicated on order as “patients’ own”
B. The UWHC pharmacist will determine if the patient is inpatient or residential
1. Indicated on a form faxed from Hospice when a new admission
2. Indicated in the orders when the patient is transferred from the
inpatient to residential
C. For inpatient Hospice patients, the UWHC pharmacist will process orders based
on the following chart:
Related (R) Unrelated (U)
UW
Enter and process order as per standard
procedure
Enter and process order as per standard
procedure
Pts
Own
Enter order as patient's own Enter order as patient's own
1. Per Hospice policy, an unrelated multidose medication must be filled by a family
member and brought in for the patient to use while inpatient
a. If the patient’s own supply is not present, nursing staff will contact the
patient’s family or representative and request that the patient’s own supply be
obtained
b. The nurse may hold the medication while the supply is being obtained
c. If after 3 days the patient’s own supply is still unavailable, the nurse will
contact the prescriber and the prescriber will then decide to either discontinue
the medication or will request that the item be obtained from UWHC if the
item is deemed to be clinically necessary
d. A physician order stating medical necessity and request for the item will be
written in the patient’s chart BEFORE the pharmacist will dispense the item
from UWHC
D. For residential Hospice patients, the UWHC pharmacist will process orders based on
the following chart:

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Policy #: 19.1


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Related (R) Unrelated (U)
UW
Enter and process order as per standard
procedure

Pts
Own
Enter order as patient's own
Enter order as patient's
own
1. Any medication that is classified as “unrelated” must be filled as an outpatient
script
a. Billing information form and patient information form will be completed by
the charge nurse
b. Prescriptions will be written for all medications (prescriptions, over-the-
counters, herbals) by the prescriber/nurse at Hospice (30 day supply unless
lower day supply is more appropriate)
c. Forms and prescriptions will be faxed to a pharmacy of the patient’s choice
d. If the patient brings in their own supply, the prescriptions should be faxed
when the medication supply is depleted
e. The pharmacy will fill the prescriptions and charge the patient by their
preferred method of payment
f. Hospice must contact the pharmacy to refill prescriptions
2. Hospice patient may choose to have a retail prescription filled at a UW outpatient
pharmacy
a. UW 1 S. Park Pharmacy offers delivery to Hospice if patients choose to
get scripts filled at their pharmacy
i. The pharmacy’s delivery driver will deliver the prescriptions to Agrace
HospiceCare
ii. If the driver is unable to deliver the prescription, the pharmacy will
contact the UW technician delivering medications from the central
pharmacy (228-4059) and ask the technician to deliver the prescription
E. Medication orders will be treated as routine priority except those orders deemed by
hospice staff as stat orders using criteria for emergency orders
1. Handling of stat orders dispensed from the AcuDose cabinet
a. Hospice staff will page/call the pharmacist to notify them that stat orders
have been faxed

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b. Medication orders will be processed and verified by UWHC pharmacist
within 30 minutes of receiving the fax
2. Handling of stat orders that must be prepared and delivered by UWHC
a. Hospice staff will page/call the pharmacist to notify them that stat orders
have been faxed
b. The hospice nurse and UWHC pharmacist will coordinate to facilitate
acceptable delivery time frame.
c. Emergency orders should contain a “STAT” notation on the label and the
central pharmacy should be notified to facilitate prompt order processing
3. Handling of routine priority orders
a. Medication orders will be processed and verified by UWHC pharmacist
within two hours of receiving medication order via fax.
b. The hospice staff will indicate on the order if the medications are needed
prior to the next scheduled delivery for medications prepared and delivered
by UWHC.
F. Pharmacists will enter all medication orders (new, discontinued, and modified
orders) into Health Link using a hospice order set
1. All orders will be reviewed for appropriateness prior verification by the
pharmacist
2. Upon verification by the pharmacist, orders will be linked to patient using Health
Link MRN or UWHC ID and filed under the active patients queue in OnBase
3. Pharmacists will intervene as necessary to correct any identified problems at the
time of order entry
4. If additional information is needed to verify the order, hospice will be
contacted to provide the necessary information and medication order will be
linked to the patient and filed under the “Needs clarification” queue within
OnBase
a. The hospice inpatient desk should be contacted initially for questions
b. The inpatient desk can assist with finding the appropriate nurse or physician
c. Upon order clarification, the medication order can be moved from the “Needs
clarification” queue to the “Active patients” queue in OnBase
5. Process for pharmacist modification of the medication order
a. The pharmacist will place a note on the order in OnBase
b. The modified order will be printed with the note
c. The pharmacist will indicate the authorizing prescriber, sign and date the
modified order and fax the printed copy to hospice for their records
d. The pharmacist will update the patient’s chart in Health Link if necessary

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G. Medications should be scheduled according to the following administration times
Frequency Administration Times
QD or QAM 0900
BID 0900,2100
TID 0900,1400,2100
QID 0900,1200,1600,2100
QHS 2100
H. Medication dispensing
1. Medications will be automatically routed through hospice floor stock, AcuDose,
the Robot/MedCarousel, or Central Pharmacy (sterile products or oral
compounds)
2. Medication dispensing from AcuDose
a. Medication orders must first be entered into the UWHC pharmacy order
entry system to be accessed from AcuDose-Rx unless the medication is
selected using override (See OVERRIDE FUNCTION below). When a
specific patient is selected, that patient’s medication profile will be displayed.
b. Medications on the patient’s profile displayed with a “white background”
indicate the medications stocked and available in AcuDose-Rx for that
particular patient.
c. Medications on the patient’s profile displayed with a “gray background”
indicate those medications that are not available via AcuDose-Rx. Please
contact UW pharmacy regarding dispensing of these medications if
questions.
d. Please note that the medications listed in AcuDose-Rx do not represent the
patient’s medication administration record (MAR). The MAR (or
practitioner’s order) must be consulted prior to accessing the medication.
e. If the medication is not listed in the AcuDose-Rx profile, the following may
apply:
i. The order has not been entered into Heath-Link or has not yet been
verified by a pharmacist.
ii. The medication is not in the AcuDose-Rx formulary or inventory

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Policy #: 19.1


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3. OVERRIDE FUNCTION - FOR PROFILE DISPENSING
a. Override criteria are based on the risk of poor patient outcomes from not
receiving a medication before a pharmacist reviews the order. This risk must
outweigh the risk of a nurse administering an incorrect or inappropriate
medication. Nurses may not dispense a medication via override simply
because that medication is on the override list. Rather, specific criteria for
when nurses may dispense a drug via override before a pharmacist reviews
the medication order against the patient's medication profile (and other
relevant patient information) are as follows:
i. For an emergency or STAT situation when time does not permit such a
review by a pharmacist, and the resulting delay to do so would result in
clinical harm to the patient (emergency orders)
ii. For a 1st dose in an urgent situation where the clinical need of the patient
demands immediate administration (morphine for acute pain, diazepam
for DTs, or Nitroglycerin for angina). In such cases, the pharmacist still
reviews the order in a timely manner following administration.
iii. When administering a medication via the override function the nurse is
responsible for determining appropriateness based on the above criteria.
The nurse must verify selection of the correct patient; review the
patient’s profile, allergies, and all other pertinent clinical criteria before
administering the medication.
iv. If the above information has been verified and the override medication is
needed, proceed by dispensing the medication via the “OVERRIDE”
button.
v. Hospice staff must ensure that all medications dispensed on override
have a corresponding physician order.
vi. If the override drug is not available the nurse should contact UW
pharmacy to expedite the order entry procedure to facilitate availability
of the drug.
vii. See Appendix C: Agrace Hospice AcuDose Override List for approved
medication list. Medications will be available via the Override function
only if they have been approved for Override Status following review
from the Agrace Pharmacy Advisory Board.
viii. See Appendix C: Agrace Hospice AcuDose Override List
b. Pharmacy will monitor/analyze medications dispensed via an “override”
and determine the appropriateness. Pharmacy will forward
concerns/issues to the appropriate hospice manager as needed.

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c. Entering patient information into cabinet for override dispense
i. Patient information for all hospice patients is entered into AcuDose-Rx
by an interface with the UW Hospital’s Admission/Discharge/Transfer
(ADT) patient registration system. The patient’s name should appear on
the AcuDose-Rx census list.
ii. If patients are not listed on the AcuDose-Rx census list at the time a
medication is needed, the nurse shall enter the patient into AcuDose-Rx
manually into a phantom bed called WILD 01.
iii. Duplicate patient entries will populate the AcuDose census once the
UWHC pharmacist processes the patient’s orders. Future dispenses
should be done under the AcuDose patient entry with active medication
orders. Duplicate patient entries will be reconciled every twenty four
hours by UWHC pharmacy staff.
iv. Only medications on the approved override list will be available to
remove from the cabinet under manually admitted patients.
4. Scheduled unit dose medications not stocked in the hospice AcuDose will be
filled daily by the robot and MedCarousel through a central cartfill process.
5. Scheduled extemporaneous medications will be prepared on a daily basis through
a central fill process.
5) Controlled substances
A. All controlled substances stocked in AcuDose will be entered into Health Link and
dispensed from AcuDose according to a patient specific medication order
B. Schedule II controlled substances not stocked in the AcuDose will be dispensed on a
patient specific basis
1. The original order in the patient’s chart will be re-written on a “Non-Stock
Schedule II Prescription” form (see Appendix D)
2. The form MUST be signed by the ordering provider and have that provider’s
DEA number on it
3. This form is faxed to BOTH the UWHC OnBase fax number and the UW
Outpatient Pharmacy
a. UW Outpatient Pharmacy hours are M-F: 0730-2000, Sat & Sun: 0800-1900
4. UW Outpatient Pharmacy fax number 265-8878The UWHC Pharmacist will
verify the order is appropriate (as outlined above) and then enter it into Health
Link
a. The pharmacist should indicate on the label when the order is needed by (i.e.
should central send via taxi because it’s needed ASAP or if it should be sent
on the next delivery run to hospice)

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b. The pharmacist will call the UW Outpatient Pharmacy (263-1277)
c. Verify they have received the faxed “Non-Stock Schedule II Prescription”
form; if not the pharmacist will fax it to them
d. Ask them to generate a prescription label and tube the label to the central
pharmacy (tube station 210) with a note to give to the SPA
5. The UW Outpatient Pharmacists are ONLY generating prescription labels and
are not responsible for verifying the order or the integrity of the product
dispensed from the central pharmacy
a. The outpatient pharmacy will fill and maintain a hard copy of the
prescription order in their records
6. The SPA technician will prepare the product and the central pharmacist will
verify the product is prepared appropriately
7. SPA staff will adhere the prescription label (in addition to the Health Link label)
to the product, record the prescription number on the SPA controlled substance
log, and arrange for deliver to hospice as specified by the pharmacist entering the
order
a. The SPA pharmacist is responsible for verifying that the prescription label is
adhered to the product before it is delivered to hospice
8. If the UWHC pharmacist is processing a partial dispense of a controlled II
substance (legally allowed in the hospice population), the pharmacist dispensing
the label MUST contact the UW Outpatient Pharmacy to print a prescription
label and debit the quantity dispensed from the original prescription
a. The UWHC pharmacist is responsible for verifying that the original
prescriptions for the partial dispense is appropriately debited.
b. The label from UW Outpatient Pharmacy should be tubed to the central
pharmacy (tube station 210) with a note to give to the SPA
6) Medication delivery (schedule below)
A. Non-emergency orders will be sent on the next scheduled delivery
When Who
Daily (including Holidays) AM UWHC Technician
Daily (including Holidays) PM UW to arrange Taxi
Emergency PRN UW to arrange Taxi

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B. If the UWHC pharmacist determines that the medication needs to arrive earlier than
the next scheduled delivery the pharmacist will communicate this to the central staff
who will arrange delivery via taxi
C. Upon receipt of patient specific medications from a delivery other than a UWHC
technician, the hospice nurse will place them in the labeled patient specific drawers
7) Therapeutic substitution
A. For medications with approved therapeutic substitutions, the pharmacist entering the
order will record the medication order change with an order note in OnBase
B. The pharmacist will print the medication order from OnBase (with note), sign and
date the order, and fax the printed order to hospice to be placed in the patient’s chart
C. Hospice maintains the same therapeutic list as UWHC
8) Patient’s own medications
A. Patient’s own medications as indicated on the order will be entered into Health Link
per standard procedure
B. Hospice nurses will verify the identity and integrity of the patient’s own medication
before administering
9) Medications not stocked by UWHC pharmacy (non-formulary medications)
A. If a medication is ordered that is unrelated to the patient hospice diagnosis and is
non-formulary, the pharmacist will make a therapeutic interchange whenever
possible
1. If an interchange cannot be made for an inpatient, the non-formulary item may be
dispensed from UWHC following the same procedure outlined in below
2. If an interchange cannot be made for a residential patient, the pharmacist must
not dispense the medication from UWHC and require the family to supply the
patient’s own medication
B. If a medication is ordered that is related to the patient’s hospice diagnosis and non-
formulary, the pharmacist processing the order will make a therapeutic interchange
whenever possible
1. If no alternate item is acceptable, the pharmacist processing the order will
determine the urgency of the order (after discussing with hospice staff) and
contact the stockroom staff about purchasing the product
2. If the medication is urgently needed the pharmacist processing the order and the
stockroom staff will determine how quickly the product can be obtained (i.e.
loan/borrow or emergency acquisition from the wholesaler)
3. If the medication is not urgently needed, the stockroom staff will have the
medication delivered to hospice via the normal daily delivery when the product is
received

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10) Charging and crediting of medications
A. All patient-specific medications will be charged when the medications are dispensed
and will be credited upon return
1. Exception: Medications dispensed in the future are auto-credited based on the
time a patient is discharged from hospice
B. Patient-specific medications not located in AcuDose and not used by the patient may
be returned for credit
1. Hospice will be responsible for returning the unused and unadulterated
medications to UWHC for credit
2. The medications will be placed in a plastic zip lock bag with the patient’s name
3. The UWHC technician will return the medications to UWHC and credit the
proper account
C. UWHC technicians will audit UWHC provided Hospice stock medications
1. All medications missing and not charged to a patient will be billed to hospice
11) AcuDose downtime procedure
A. If technical problems develop the hospice nurse or pharmacy staff will call the
McKesson Help Desk at 1-800-700-8737. The Help Desk will resolve most issues.
B. If the McKesson Help Desk is unable to resolve the issue, the hospice nurse or
pharmacy staff will contact the central pharmacy by calling 263-1272 to inform them
of the issue.
1. The AcuDose technician or Central Pharmacy staff will contact the McKesson
Help Desk to determine how long the cabinet(s) will be down.
2. If after 60 minutes, an acceptable timeframe cannot be provided as to when
cabinet activity will be restored, the AcuDose technician or Central Pharmacy
staff will request that an AcuDose service representative be paged and sent on-
site
C. AcuDose cabinet loss of connectivity to the Hospital Network
1. Cabinet will remain operational, but will not be receiving new orders and patient
information. If this occurs the cabinet will display "NOT RECEIVING
ORDERS". Nursing staff can continue to dispense medications that were
available on the patient profile before the loss of connectivity occurred. If a new
medication order is needed, the nursing staff will inform the UWHC pharmacist
to help facilitate medication delivery
2. In certain circumstances, the cabinet may need to be switched to inventory
dispensing mode whereas nurses will have access to all medications available in
the cabinet until issue is resolved.
12) OnBase downtime procedure

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A. If hospice staff experiences issues transmitting orders via fax to UWHC, the hospice
staff should contact the UWHC pharmacist (see numbers listed below) to determine
if OnBase is the cause of the issue.
B. If technical problems arise with OnBase, the UWHC pharmacist will call the UWHC
Help Desk at 265-7777. The UWHC Help Desk should be able to resolve OnBase
issues. Until the OnBase issues have been resolved, hospice staff will fax medication
orders to designated UWHC pharmacist according to chart listed below for
processing.
Monday-
Friday
Sat, Sun, &
Holiday
UWHC
Pharmacist
Fax
Number
Pager
Phone
Number
0700-2230 0700-1530 B6/6 Pharmacist 263-4028
262-
2122
x7592
263-7230
2230-0700 1530-0700
Central
Pharmacist
262-2584 n/a 263-0666
C. Designated UWHC pharmacist shall process admissions, transfers, and discharges in
Health Link as listed above
D. Designated UWHC pharmacist shall enter all medication orders from fax as outlined
above making sure to retain paper fax for record keeping purposes until OnBase
issues have resolved.
E. All other processes as outlined above shall remain unchanged
13) Scheduled OnBase downtime
A. A brief maintenance downtime will occur the first Thursday of each month from
0200-0300. Service is typically interrupted for approximately one hour during this
time.
B. Faxes sent during the downtime will be maintained in the OnBase queue and will
transmit once the service is resumed
C. Hospice staff is expected to call UWHC pharmacist in the event of an urgent order
than cannot wait until service has been resumed.
D. The hospice staff and UWHC pharmacist shall coordinate transmission of paper fax
and order preparation during this time.
V. REFERENCES, RELATED POLICIES & PROCEDURES
1) Appendix A: OnBase Tutorial (pdf)

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2) Appendix B: Admitting, Transferring, and Discharging Hospice Patients in Health Link
(pdf)
3) Appendix C: Agrace Hospicecare AcuDose Override List
4) Appendix D: Prescription Facsimile Form (pdf)
5) UWPAS (REV. 06/22/11): Commercial Taxi Authorization duplicate form
VI. COORDINATION
1) Authored by: Kimberly Sherman, PharmD
2) Reviewed by: B6/6 Pharmacist, Hospice Pharmacist, Brad Ludwig, MS, RPh
3) Committee Approval: Pharmacy Operations Committee

Approved By:___________________________
Director of Pharmacy Services
Date:_________________