Identifying opportunities to advance practice at a large academic medical center using the ASHP Ambulatory Care Self-Assessment Tool.

PURPOSE: The use of the ASHP Ambulatory Care Self-Assessment Tool to advance pharmacy practice at 8 ambulatory care clinics of a large academic medical center is described. SUMMARY: The ASHP Ambulatory Care Self-Assessment Tool was developed to help ambulatory care pharmacists assess how their current practices align with the ASHP Practice Advancement Initiative. The Henry Ford Hospital Ambulatory Care Advisory Group (ACAG) opted to use the "Practitioner Track" sections of the tool to assess pharmacy practices within each of 8 ambulatory care clinics individually. The responses to self-assessment items were then compiled and discussed by ACAG members. The group identified best practices and ways to implement action items to advance ambulatory care practice throughout the institution. Three recommended action items were common to most clinics: (1) identify and evaluate solutions to deliver financially viable services, (2) develop technology to improve patient care, and (3) optimize the role of pharmacy technicians and support personnel. The ACAG leadership met with pharmacy administrators to discuss how action items that were both feasible and deemed likely to have a medium-to-high impact aligned with departmental goals and used this information to develop an ambulatory care strategic plan. This process informed and enabled initiatives to advance ambulatory care pharmacy practice within the system. CONCLUSION: The ASHP Ambulatory Care Self-Assessment Tool was useful in identifying opportunities for practice advancement in a large academic medical center.

Chimerism in Myeloid Malignancies following Stem Cell Transplantation Using FluBu4 with and without Busulfan Pharmacokinetics versus BuCy.

In the era of precision medicine, the impact of personalized dosing of busulfan is not clear. We undertook a retrospective analysis of 78 patients with myeloid malignancies who received fludarabine and busulfan (FluBu4) with or without measuring Bu pharmacokinetics (Bu PK) and those who received busulfan with cyclophosphamide (BuCy). Fifty-five patients received FluBu4, of whom 21 had Bu PK measured, and 23 patients received BuCy. Total donor cell chimerism showed that the percentage of patients maintaining 100% donor chimerism on day 100 was 66.7%, 38.2%, and 73.9% in the FluBu4 with PK, FluBu4 with no PK, and BuCy, respectively (P = .001). Patients who had decreasing donor chimerism by day 100 were 23.8%, 52.9%, and 26.1% in the FluBu4 with PK, FluBu4 with no PK, and BuCy, respectively (P = .04). Bu PK group had fewer patients with less than 95% donor chimerism on day 30, which was not statistically significant, 5% (FluBu4 PK), 31% (FluBu4 with no PK), and 21% (BuCy) (P = .18). Survival distributions were not statistically significant (P = .11). Thus, personalized drug dosing can impact donor chimerism in myeloid malignancies. This will need to be examined in larger retrospective multicenter studies and prospective clinical trials.

Fatal hypersensitivity reaction to gemtuzumab ozogamicin associated with platelet transfusion.

PURPOSE: A case of a fatal hypersensitivity reaction to gemtuzumab ozogamicin in a patient who received a platelet transfusion on the same day is presented. SUMMARY: A 75-year-old man went to a hematology clinic in April 2005 because of anemia and thrombocytopenia. He was diagnosed with acute myelogenous leukemia (AML). In May 2005, the patient was started on induction chemotherapy with cytarabine and idarubicin. During the induction phase, the patient received platelet transfusions on multiple occasions without any evidence of transfusion reactions. He went into partial remission and received two cycles of cytarabine and idarubicin followed by one cycle of high-dose cytarabine. In March 2006, the patient relapsed, and he received dose number one of the first cycle of gemtuzumab ozogamicin at a dose of 9 mg/m2 on March 28, 2006. He tolerated the infusion. He had received multiple platelet transfusions during the week before gemtuzumab infusion without reaction but received no transfusions on the same day as the gemtuzumab infusion. On April 4, 2006, the patient received an infusion of gemtuzumab at 11 a.m., and he received 6 units of leukocyte-depleted, irradiated platelets at 6:40 p.m. At 1 a.m. the next morning, the patient developed fever and shortness of breath and went into severe distress. Despite treatment, the patient died shortly after. CONCLUSION: A patient with AML developed severe respiratory distress and died after receiving gemtuzumab and 6 units of platelets on the same day. The fact that he had previously received gemtuzumab and platelets safely on separate days suggests that the gemtuzumab-platelet combination contributed to a fatal hypersensitivity reaction.