A Call to Action: Range Orders and Therapeutic Duplication

Abstract

Opportunity is missed by most people because it is dressed in overalls and looks like work. –Thomas Edison

The triad of physician, pharmacist, and nurse shares the common goal of providing the right medication in the right dose by the right route to the right patient at the right time. At times I perceive that each component of the triad also believes that their respective profession carries a disproportionate share of the burden of patient care. Range orders and therapeutic duplication are 2 topics that highlight this perception.

Range orders are defined by The Joint Commission (TJC) as orders in which the dose or dosing interval varies over a prescribed range, depending on the situation or patient's status. Range orders became the subject of some scrutiny after TJC began surveying to Pain Management Standards in January 2001. The subsequent development of National Patient Safety Goals and Medication Management standards emphasized safe use of potentially harmful medications and policies to describe the required elements of certain order types, including range orders.^1,2

Therapeutic duplication is specifically identified as a target of the pharmacist review process for all medication orders in both TJC standards and the Centers for Medicare & Medicaid Services (CMS) conditions of participation for hospitals.^2,3 TJC and CMS standards relevant to range orders and therapeutic duplication are listed in Table 1 .

Table 1.

The Joint Commission and Centers for Medicare & Medicaid Services (CMS) standards relevant to range orders and therapeutic duplication

Joint Commission Medication Management Standards:

MM 04.01.01 Medication orders are clear and accurate.

Element 01. The hospital has a written policy that identifies the specific types of medication orders that it deems acceptable for use.

MM 05.01.01 A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital. Element 08. All medication orders are reviewed for the following:

Therapeutic duplication.

CMS Conditions of Participation:

§482.25 Condition of Participation: Pharmaceutical Services

§482.25(b) Standard: Delivery of Service

In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law.

All medication orders (except in emergency situations) should be reviewed for appropriateness by a pharmacist before the first dose is dispensed.

Review of medication orders should include:

•

Therapeutic appropriateness of a patient's medication regimen;

•

Therapeutic duplication in the patient's medication regimen;

•

Appropriateness of the drug, dose, frequency, route and method of administration;

•

Real or potential medication-medication, medication-food, medication-laboratory test and medication-disease interactions;

•

Real or potential allergies or sensitivities;

•

Variation from organizational criteria for use;

•

Other contraindications

TJC recently updated a number of elements to better align its standards with CMS conditions of participation. The 1965 Medicare statute had originally established deeming authority for TJC. In 2008, the federal Medicare Improvements for Patients and Providers Act (MIPPA) dissolved TJC's statutory authority and instead outlined that the accrediting agency must apply for deeming authority for hospitals rather than being granted that authority by law. TJC now has to demonstrate that the organization's standards meet and exceed CMS conditions of participation in order to serve as a national accrediting agency for hospitals who participate in Medicare or Medicaid programs. Approval is currently effective for TJC from July 2010 until July 2014.^4–6 Refined adherence to CMS standards seems to have enhanced TJC scrutiny of range orders and therapeutic duplication.

Physician Accountability

Physicians should write clear and accurate medication orders. Institutions should hold medical staff accountable for writing clear orders. However, institutions also are challenged to maintain physician satisfaction and their interest as customers in order to maintain their services and avoid losing them to other practice sites, which may discourage strict enforcement of expectations. It's challenging to maintain physician satisfaction and accountability simultaneously. Medical staff resources are generally stretched to capacity as private practice physicians struggle to meet the demands of their private business interests as well as support institutional goals. Identifying opportunities to standardize practice or define workarounds and avoid contacting the prescriber seem to be a routine consideration at many institutions.

Nursing Scope of Practice

Nurses must have some flexibility to administer medication doses that correlate to fluctuating patient symptoms when authorized by the prescriber's order. Unless nursing staff approach symptom evaluation and dose determination with consistency, their actions may be construed as falling outside the scope of nursing practice. It is understandable that nurses are protective of the application of clinical judgment in patient assessment and medication administration determinations.⁷ The nursing profession may feel threatened when range orders are targeted by TJC and CMS.

Multiple medication orders with the same indication offer nurses an opportunity to exercise clinical judgment in determining which available agent is the most appropriate depending on the severity of symptoms or available routes of administration. Unless the prescriber outlines selection criteria, however, this judgment may also be considered outside the scope of nursing practice.

Like medical staff resources, nursing resources are stretched to capacity. This can discourage appropriate documentation of patient symptoms to justify the drug or dose selected and affect the accuracy of documentation related to monitoring of effect of the drug and dose administered. Monitoring is needed to assess practice patterns and determine whether consistency in practice or adherence to policy is achieved at each facility.

Pharmacist Responsibility and Opportunity

Pharmacists are likewise challenged by generally having finite resources to devote to abundant patient care demands, but they are well-poised to reinforce clear, accurate order writing. It is the pharmacy profession's responsibility to provide this service.

How can your pharmacy service best meet your institution's needs for compliance with range order and therapeutic duplication standards? Involve your department in policy development. Offer your expertise in computerized prescriber order entry (CPOE) and preprinted order design to support clear and accurate order writing. Communicate with prescribers to educate them and seek order changes. Monitor your practices and educate the organization about your analysis of order writing clarity and administration patterns. Evaluate administration habits for agents utilized for range orders or that may be subject to therapeutic duplication. Become involved in adverse event monitoring and root cause analyses. Develop process improvements to reduce undesirable ordering and enhance sound drug administration practices. Invite physicians and nurses to be partners in developing solutions instead of developing workarounds to compensate for inadequate order writing. Innovate.

We often complain of being asked to do more than we have the resources to accomplish, but this is one of countless examples of opportunity cloaked in hard work. Rather than avoiding or denying these challenges, we must seek out these opportunities to meet a critical need and enhance our value to our partners in patient care.

My pharmacy director teaches me about how much pharmacy practice has changed and consistently challenges me to innovate and develop professional strategies that support the need of a dynamic patient care environment. Active involvement is the key to the evolution and security of the pharmacy profession. As enhanced technologies supplant our traditional duties, we can continue doing what we're doing and eventually wonder why we've become obsolete, or we can step up to the challenge and take ownership in deciding our profession's fate. An editorial by one of our profession's visionary leaders has called the current pharmacist practice model into question and challenges us to seize control of our profession's destiny.⁸

Let's roll up our sleeves and meet the challenge.

References

Gordon

D.B.

Dahl

Phillips

; American Society for Pain Management Nursing, American Pain Society. The use of “as-needed” range orders for opioid analgesics in the management of acute pain: a consensus statement of the American Society for Pain Management Nursing and the American Pain Society. Pain Manag Kurs. 2004; 5(2): 53–58.

2011 Comprehensive Accreditation Manual for Hospitals (CAMH): The Official Handbook. Oakbrook, IL: The Joint Commission; 2011.

State Operations Manual. Appendix A - survey protocol, regulations and interpretive guidelines for hospitals. Centers for Medicare and Medicaid Services. http://www.cms.gov/manuals/downloads/som107ap_a_hospitals.pdf.

Facts about federal deemed status and state recognition. The Joint Commission. www.jointcommission.org/…/Federal_Deemed_Status_1_25_11.pdf.

UPDATE: The Joint Commission's hospital deeming authority application. The Joint Commission. www.jcrinc.com/common/PDFs/fpdfs/pubs/pdfs/…/JCP-12-08-S1.pdf.

Medicare and Medicaid Programs. Approval of the application by the Joint Commission for Continued Deeming Authority for Hospitals. Federal Register. 74: 227(November 27, 2009): 62333.

Manworren

R.C.

Pain control. A call to action to protect range orders. A consensus statement supports this important nursing responsibility. Am J Nurs. 2006; 106(7): 65–68.

Zellmer

W.A.

Seeking “better ways” in hospital pharmacy. Am J Health Syst Pharm. 2009; 66(8): 713. ■