Survey among Hospitals on Strategies to Ensure Appropriate Use of Intravenous Acetaminophen

*Assistant Professor, Institute for Healthcare Delivery Science, Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York; †Drug Information Clinical Pharmacy Coordinator, Department of Pharmacy, The Mount Sinai Hospital, New York; ‡Professor of Biostatistics and Director, Institute for Healthcare Delivery Science, Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York; §Chief Pharmacy Officer, Department of Pharmacy, The Mount Sinai Hospital, New York. *Corresponding author: Jashvant Poeran, MD, PhD, Institute for Healthcare Delivery Science, Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue (Box 1077), New York, NY 10029; phone: 212-659-9650; fax: 212-423-2998; e-mail: jashvant.poeran@ mountsinai.org To the Editor: In November 2010, the US Food and Drug Administration (FDA) approved the intravenous formulation of acetaminophen (IV APAP). Its use appeared particularly promising in the postoperative setting as a means to reduce opioid consumption. However, the utility of IV APAP relative to the rectal and oral formulation has been the subject of discussion and ongoing study.1 After a price increase in May 2014, many institutions have been evaluating IV APAP to ensure its appropriate use and role in multimodal pain management. To get a better understanding of the different approaches utilized in institutions throughout the country, a 5-question electronic memberinitiated survey was distributed through the University HealthSystem Consortium (UHC) Pharmacy Council listserver on January 28, 2015 and closed on February 18, 2015. UHC comprises 117 academic medical centers as well as more than 328 of their affiliated hospitals. We received a reply from 65 recipients, with the majority of hospitals (n = 25; 38%) located in the nor theast United States and with a bed size of more than 500 beds (n = 37; 57%) (Table 1). In 54 (83%) hospitals, IV APAP was on formulary before May 2014; 16 (30%) of these indicated that it was removed from formulary, whereas 22 (41%) reported new restrictions to ensure proper utilization. Respondents were asked to describe the specific IV APAP restrictions at their institution that were put in place after May 2014. The majority described a restriction to nothing-by-mouth (NPO) or nothing-per-rectum (NPR) patients (n = 31; 70%) and restrictions related to the duration of an IV APAP order, most often 24 or 48 hours (n = 29; 66%). We believe the results of this survey would be beneficial to institutions looking for strategies to ensure the appropriate use of IV APAP. In addition to the nature of the restrictions imposed in other hospitals, the survey also yielded some interesting insights into the strategies used. Several hospitals mentioned the verification of NPO status through the existence of active orders for other oral drugs, in which case the IV APAP order was converted into oral. Other useful measures that were mentioned pertained to the sharing of pricing information with prescribing physicians or the adaptation of computerized physician order entry systems to restrict IV APAP orders to a predefined limit of order duration or number of doses. Given the ongoing discussion, more evidence on the utility of IV APAP in clinical practice in the United States is needed.