Computerized pharmacokinetics on an institutional clinical information system.

Computer-based hospital information systems (HISs) are an integral part of the current hospital environment. Traditionally, the HIS hospital information system has performed drug distribution-related activities for the pharmacy. Clinical applications have been limited to monitoring for drug interactions, duplication of therapy, drug allergies, and dosage range checking. Personal computers have been used for more clinical applications and individualized dosing. At Hamot Medical Center, the integration of the pharmacokinetics consultation service with the HIS has been accomplished. The pharmacokinetic equations were programmed into the HIS. Data needed for the equations were extracted from information in the database, thereby eliminating the need to enter the majority of the data. The program was designed to print the pharmacokinetic consultation for the chart. The integration of the pharmacokinetic consultation service with the HIS has saved time and increased efficiency.

Strategic planning for residency training programs.

Residency training is practice-based learning that is reflective of the practice environment. As practice changes, changes in residency training are needed. Strategic planning is a process that considers internal and external factors that will impact the future. The planning process includes gathering input, focusing on important issues, developing a consensus, and writing clearly defined goals. The strategic planning process was applied to residency training at Hamot Medical Center. A retreat was held, consensus was developed, and a plan was written. The planning process prepared us to make changes in the types of residency programs we offered. This article describes strategic planning for our residency and progress on our goals.

Target drug monitoring: a cost-effective service provided by staff pharmacists.

A concurrent drug use evaluation program that improves patient care while meeting JCAHO requirements was designed and implemented. Integration of staff pharmacists into the program has been an important component. The net annual savings of the program for H2 antagonists and cephalosporins was $16,756. The net annual cost of the program if all drugs were studied throughout each quarter would be $1,336. The program essentially pays for itself, meets medication use standards for JCAHO, and may save significant healthcare costs if potential drug misadventures are avoided.

Theophylline-mexiletine interaction: a case report.

Theophylline and mexiletine can be prescribed in patients with chronic obstructive pulmonary disease with coexistent arrhythmias. The drugs have common metabolic pathways that may result in an interaction. A patient who was taking theophylline became toxic after the initiation of mexiletine. Discontinuation of mexiletine led to an improvement in theophylline clearance.

Clinical career ladders: Hamot Medical Center.

The clinical career ladder program for pharmacists at Hamot Medical Center (HMC), a 500-bed not-for-profit community teaching hospital, is described. Between 1980 and 1989 a career ladder at HMC evolved from an idea to an established program with parallel administrative, business, and clinical tracks. The development of the career ladder mirrored the growth of clinical programs and the diversification of pharmaceutical services. A formal plan for a clinical ladder was developed when the first satellite pharmacy opened in 1984. An entry-level pharmacist at HMC starts with a six-month period during which he or she learns the drug distribution system and prepares for several certification tests. The employee is then promoted to staff pharmacist. Staff pharmacists are promoted to clinical pharmacist II (CP II) upon meeting requirements for competence in a broad range of clinical skills and knowledge. Candidates for the position of clinical pharmacist specialist (CP I) must have either a minimum of three years of experience as a CP II or a Pharm.D. degree and have established an area of clinical expertise. A CP I can progress to assistant and associate director positions as vacancies occur. The clinical ladder has enhanced job satisfaction and encouraged the development of clinical practitioners who provide improved care. Problems have included time constraints, competition for positions, and management of incentives. A parallel career ladder program with a clinical track has enhanced the growth of pharmacy practice at HMC and improved the quality of pharmaceutical care.

Clinical considerations and costs associated with formulary conversion from tobramycin to gentamicin.

The clinical and financial effects of replacing tobramycin with gentamicin on the formulary of a 550-bed teaching hospital were studied. On the recommendation of the pharmacy and therapeutics committee, the formulary aminoglycoside was changed from tobramycin to gentamicin in June 1985; the nonformulary status of amikacin was unchanged. Five weeks later, physician compliance was assessed and the reasons for prescribing nonformulary aminoglycosides were determined. Two four-month-long evaluations were done at 6 and 18 months after implementation to assess patterns of use of nonformulary aminoglycosides. The impact on costs was determined after one and two years by considering use patterns of formulary and nonformulary aminoglycosides, as well as those of third-generation cephalosporins and mezlocillin. Resistance patterns of two gram-negative organisms, Pseudomonas aeruginosa and Serratia marcescens, were assessed for 1982-1987. Finally, the rate of nephrotoxicity in gentamicin-treated patients was determined. During the first five weeks after the formulary conversion, 80.3% (106 of 132) of the aminoglycoside orders received were for gentamicin. After telephone follow-up by the pharmacy department, that figure rose to 93.9%. During the four-month reviews beginning at 6 and 18 months, nonformulary orders accounted for 10.9% and 7.4%, respectively, of the total number of courses of aminoglycosides prescribed. In the majority of these cases, tobramycin and amikacin were used to treat infections caused by organisms with documented resistance to gentamicin or to gentamicin and tobramycin, respectively. No clear-cut changes in resistance patterns for Ps. aeruginosa or S. marcescens could be associated with the formulary conversion.(ABSTRACT TRUNCATED AT 250 WORDS)

Delivery of gentamicin by a controlled-release infusion system versus a minibag system.

Delivery of gentamicin via a new controlled-release intravenous infusion system was compared with conventional delivery via small-volume injections in minibags by measuring serum drug concentrations in 10 healthy men. Each volunteer received gentamicin (as the sulfate salt) 2 mg/kg. In phase 1, subjects randomly received the drug either as a 50-mL admixture in 5% dextrose injection (D5W) or from the controlled-release system (CRIS, IVAC Corporation), in which drug was diluted in a vial with 10 mL of sterile water for injection (density of drug solution, approximately 1.5% w/v) and was delivered when the primary solution (D5W; density, 5% w/v) displaced drug from the vial and infused it into the subject over 30 min; subjects were then crossed over. In phase 2, nine of the subjects received the drug via CRIS with the diluent changed to 10 mL of 5% dextrose and 0.9% sodium chloride injection (D5NS; density of drug solution, approximately 5.9% w/v). In phase 3, 10 men (seven of the original subjects) received the gentamicin dose via CRIS with 20 mL of D5NS as the diluent or via minibags in a crossover design. The amount of drug remaining in each vial used with the CRIS system was determined. Drug administration via CRIS with 10 mL of sterile water diluent resulted in serum concentrations approximately 35% of those obtained with the minibag system, and a substantial portion (71 +/- 8%) of the dose to be administered remained in the vials.(ABSTRACT TRUNCATED AT 250 WORDS)

Creatinine clearance predictions in acutely ill patients.

In acutely ill patients, predicted creatinine clearance (Clcr) values [obtained using the Siersbaek-Nielsen nomogram (SNN) and ideal body weight (IBW)] were compared with actual Clcr based on measured urine creatinine concentrations. Timed urine collections were obtained from 118 patients (423 collections from 68 men, 400 collections from 50 women) before, during, and after aminoglycoside therapy. Patients were in intensive care units for management of acute exacerbations of sepsis, pneumonia, or abscess; most had other complicating conditions and were chronically ill. Urine was collected for 8 to 24 hours (70% for 24 hours) from Foley-catheterized patients. Patients were divided into low (less than 15 mg/kg/day), normal (15-25 mg/kg/day), and elevated (greater than 25 mg/kg/day) urinary creatinine excretion groups. Actual body weight (ABW) was used in some patient subgroups to explore differences between using IBW and ABW. SNN most accurately predicted Clcr in the 20% of the urine collections characterized by normal urinary creatinine excretion (Ucr). Most study patients excreted significantly less creatinine than the age-matched population tested in developing the SNN. In acutely ill patients with low Ucr, SNN overpredicted Clcr by 10-20 ml/min. SNN also overpredicted Clcr values in obese patients, but use of IBW rather than ABW improved the correlation between measured and predicted values in this subgroup. The SNN nomogram is applicable to critically ill patients if adjustments are made in predicted values. The characteristics of patients with low Ucr and the mechanism responsible for the decreased Ucr deserve further study.