The epidemiology of nephrotoxicity associated with conventional amphotericin B therapy.

PURPOSE: We sought to quantify the incidence of, define risk factors for, and examine the relation between renal functional impairment and treatment with conventional amphotericin B. SUBJECTS AND METHODS: We performed a 9-year retrospective analysis of amphotericin B-associated nephrotoxicity in 494 adult inpatients who received > or = 2 doses of amphotericin B. Nephrotoxicity was classified according to two nonmutually exclusive severity categories (50% increase or doubling in the baseline creatinine level). RESULTS: The median cumulative dosage of amphotericin B was 240 mg (interquartile range, 113 to 500 mg), with the majority of patients (n = 361) receiving it for empiric treatment. Overall, 139 (28%) patients experienced renal toxicity, including 58 (12%) with moderate-to-severe nephrotoxicity. The rate of nephrotoxicity was relatively constant during amphotericin B treatment. For each 10-mg increase in the mean daily amphotericin B dose, the adjusted rate of renal toxicity increased by a factor of 1.13 (95% confidence interval: 1.02 to 1.25). We defined 5 categorical risk factors: mean daily amphotericin B dose > or = 35 mg, male sex, weight > or = 90 kg, chronic renal disease, and use of amikacin or cyclosporine. The incidence of moderate-to-severe nephrotoxicity was 4% (6 of 137) in patients with none of these risk factors, 8% (14 of 181) in those with 1 risk factor, 18% (21 of 117) in those with 2 risk factors, and 29% (17 of 59) in patients with > or = 3 risk factors. Nephrotoxicity rarely led to hemodialysis (n = 3); however, at the time of discharge or death, 70% of patients with moderate-to-severe nephrotoxicity had a serum creatinine level that was > or = 0.5 mg/dL above baseline. CONCLUSION: Amphotericin B-related nephrotoxicity is an important dose-dependent and duration-dependent toxicity that is accentuated by certain nephrotoxic drugs and patient characteristics. Patients with more than two risk factors for nephrotoxicity are potential candidates for alternative antifungal therapy.

Evaluation of a computer-assisted antibiotic-dose monitor.

OBJECTIVE: To examine the effect of a computer-assisted antibiotic-dose monitor used to reduce the number of days that patients receive excessive dosages of antibiotics and the number of adverse drug events (ADEs) secondary to antibiotics. DESIGN: Descriptive epidemiologic study of a two-year preintervention period and one-year intervention period. SETTING: The LDS Hospital, a tertiary care center in Salt Lake City, UT. PATIENTS: All patients aged > or = 18 years, admitted to LDS Hospital from April 1, 1993, to March 31, 1996, who received at least one of five targeted antibiotics (vancomycin, gentamicin, imipenem, cefazolin, cefuroxime), who had a serum creatinine or a urine creatinine clearance test result before antibiotic therapy, and who were never admitted or transferred to the shock/trauma/respiratory intensive care unit. METHODS: Each morning during the 12-month intervention period, the antibiotic-dose monitor checked the renal function of all patients who were receiving any of the five antibiotics. Pharmacists received a computer listing of patients who may have been receiving excessive dosages. The antibiotic-dose monitor suggested an alternate dosage and a pharmacist contacted the patient's physician if the suggested change in the dosage was appropriate. RESULTS: During the intervention period, 4483 patients received at least one of the five study antibiotics and 1974 (44%) were identified as receiving an excessive dosage, compared with 4494 (50%) of 8901 patients during the preintervention period (p < 0.001). The patients receiving excessive dosages received an excessive dosage for an average of 2.9 days during the intervention period, compared with 4.7 days (p < 0.001) during the preintervention period. In addition, these same patients during the intervention period received fewer doses of antibiotics (10.9 vs. 13.4; p < 0.001), fewer grams of antibiotics (10.4 vs. 12.0; p < 0.02), at less cost ($98 vs. $128; p < 0.004) than the patients during the preintervention period. Moreover, there were 14 ADEs (0.3%) secondary to the five study antibiotics during the intervention period, compared with 82 (0.9%; p < 0.001) for the two-year preintervention period. The study also found that significantly more patients identified as receiving excessive dosages had experienced decreases in renal function, compared with patients who were not identified as receiving excessive dosages (25% vs. 12% during preintervention period and 23% vs. 16% during intervention period; p < 0.001). CONCLUSIONS: Many patients experience decreases in renal function after antibiotics are ordered. The use of the computer-assisted antibiotic-dose monitor appears to be a promising method to help reduce the excessive use and cost of antibiotic therapy and reduce the number of ADEs secondary to antibiotics.

Clinical and financial impact of intravenous erythromycin therapy in hospitalized patients.

OBJECTIVE: To determine the economic consequences of intravenous erythromycin use in hospital patients in a variety of clinical circumstances. DESIGN: Retrospective cohort study of patients with specified primary diagnosis-related group discharge diagnoses treated from January 1, 1990, to December 31, 1994, who received erythromycin, and a matched cohort group from the same period who did not receive erythromycin. SETTING: LDS Hospital, Salt Lake City, UT, a 520-bed teaching hospital. PATIENTS: A long-term archive of clinical and financial data from a computerized hospital information system was searched for patients meeting a strict case definition. This archive contained information on erythromycin exposure as well as concurrent drug therapy and adverse drug events that had been prospectively evaluated during hospitalization throughout the study and cohort periods. Detailed costs were available for each patient. MAIN OUTCOME MEASURE: Attributable differences in lengths of stay and total costs determined using linear regression modeling. RESULTS: For 797 erythromycin patients and 2771 cohort patients, we found an attributable increased length of stay of 2.14 days and an increased cost of hospitalization of $6061 for erythromycin case patients. Case patients also had a significantly increased risk of adverse drug events. Linear regression modeling showed that erythromycin use was significantly related to increased length of stay and cost of hospitalization. CONCLUSIONS: Intravenous erythromycin use has been associated with significant increases in hospital length of stay and total hospital cost.

Antibiotic use and microbial resistance in intensive care units: impact of computer-assisted decision support.

As part of our integrated hospital information system (the HELP system), we developed computer-assisted decision support programs for antimicrobial prescribing that are available at bedside terminals throughout our 520-bed community hospital. Recently, options have been added to allow direct physician order entry of anti-infective agents in the shock-trauma intensive care unit (STRICU). Physicians prescribed the computer-suggested regimens for 46% but followed the suggested dose and interval for 93% of the orders during a 1-year study period. In comparison to a 2-year pre-intervention period, improved drug selection and reductions in adverse drug events and costs were seen. Antimicrobial resistance patterns for nosocomial gram-negative isolates remained stable or improved in the STRICU over an 11-year period of computer-assisted antibiotic management. We conclude that strategies for optimizing antimicrobial prescribing have the potential to stabilize resistance and reduce costs by encouraging heterogeneous prescribing patterns, use of local antimicrobial susceptibility patterns to inform empiric drug selection, and reduced "tonnage" of antibiotic use.

A computer-assisted management program for antibiotics and other antiinfective agents.

BACKGROUND AND METHODS: Optimal decisions about the use of antibiotics and other antiinfective agents in critically ill patients require access to a large amount of complex information. We have developed a computerized decision-support program linked to computer-based patient records that can assist physicians in the use of antiinfective agents and improve the quality of care. This program presents epidemiologic information, along with detailed recommendations and warnings. The program recommends antiinfective regimens and courses of therapy for particular patients and provides immediate feedback. We prospectively studied the use of the computerized antiinfectives-management program for one year in a 12-bed intensive care unit. RESULTS: During the intervention period, all 545 patients admitted were cared for with the aid of the antiinfectives-management program. Measures of processes and outcomes were compared with those for the 1136 patients admitted to the same unit during the two years before the intervention period. The use of the program led to significant reductions in orders for drugs to which the patients had reported allergies (35, vs. 146 during the preintervention period; P<0.01), excess drug dosages (87 vs. 405, P<0.01), and antibiotic-susceptibility mismatches (12 vs. 206, P<0.01). There were also marked reductions in the mean number of days of excessive drug dosage (2.7 vs. 5.9, P<0.002) and in adverse events caused by antiinfective agents (4 vs. 28, P<0.02). In analyses of patients who received antiinfective agents, those treated during the intervention period who always received the regimens recommended by the computer program (n=203) had significant reductions, as compared with those who did not always receive the recommended regimens (n= 195) and those in the preintervention cohort (n = 766), in the cost of antiinfective agents (adjusted mean, $102 vs. $427 and $340, respectively; P<0.001), in total hospital costs (adjusted mean, $26,315 vs. $44,865 and $35,283; P<0.001), and in the length of the hospital stay days (adjusted mean, 10.0 vs. 16.7 and 12.9; P<0.001). CONCLUSIONS; A computerized antiinfectives-management program can improve the quality of patient care and reduce costs.

Reengineering a surgical service line: focusing on core process improvement.

Integrating principles from a variety of theory has led to the development of a conceptual framework for reengineering in a clinical care delivery setting to improve the value of services provided to the customer. A conceptual framework involving the identification of three high level core processes to reengineer can provide clarity and focus for clinicians to begin directing reengineering efforts. Those core processes are: clinical management of the patient's medical needs, patient operational processes to support the clinical processes, and administrative decision-making processes to support the implementation of the clinical and operational processes. Improvement in any one of these areas has the potential to increase value, but the concurrent targeting of these core processes for reengineering has provided a synergy that has accelerated the achievement of the desired outcomes in the area of surgical services.

Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality.

OBJECTIVE: To determine the excess length of stay, extra costs, and mortality attributable to adverse drug events (ADEs) in hospitalized patients. DESIGN: Matched case-control study. SETTING: The LDS Hospital, a tertiary care health care institution. PATIENTS: All patients admitted to LDS Hospital from January 1, 1990, to December 31, 1993, were eligible. Cases were defined as patients with ADEs that occurred during hospitalization; controls were selected according to matching variables in a stepwise fashion. METHODS: Controls were matched to cases on primary discharge diagnosis related group (DRG), age, sex, acuity, and year of admission; varying numbers of controls were matched to each case. Matching was successful for 71% of the cases, leading to 1580 cases and 20,197 controls. MAIN OUTCOME MEASURES: Crude and attributable mortality, crude and attributable length of stay, and cost of hospitalization. RESULTS: ADEs complicated 2.43 per 100 admissions to the LDS Hospital during the study period. The crude mortality rates for the cases and matched controls were 3.5% and 1.05%, respectively (P<.001). The mean length of hospital stay significantly differed between the cases and matched controls (7.69 vs 4.46 days; P<.001) as did the mean cost of hospitalization ($10,010 vs $5355; P<.001). The extra length of hospital stay attributable to an ADE was 1.74 days (P<.001). The excess cost of hospitalization attributable to an ADE was $2013 (P<.001). A linear regression analysis for length of stay and cost controlling for all matching variables revealed that the occurrence of an ADE was associated with increased length of stay of 1.91 days and an increased cost of $2262 (P<.001). In a similar logistic regression analysis for mortality, the increased risk of death among patients experiencing an ADE was 1.88 (95% confidence interval, 1.54-2.22; P<.001). CONCLUSION: The attributable lengths of stay and costs of hospitalization for ADEs are substantial. An ADE is associated with a significantly prolonged length of stay, increased economic burden, and an almost 2-fold increased risk of death.

Integrating pharmacokinetics into point-of-care information systems.

Computer-based patient care information systems (PCIS) have emerged as an integral component of healthcare organisations. Currently, 4 models of PCIS exist: the centralised model, the hub-and-spoke model, the network model, and the distributed model. The centralised model has the advantage of a central patient database; however, a major disadvantage of this model is the inability to easily interface with other software packages. The hub-and-spoke model links satellite or feeder systems into a mainframe computer; thus, each satellite has the ability to work independently. This system is limited by the ability to interface satellite systems with the mainframe computer. The network model works via a local area network (LAN) using client server technology which allows for high speed data access and transfer. The network model does not provide an integrated view of patient information and can access only 1 host system at a time. The distributed model is similar to the network model in design but provides for data and system integration via relational databases. This allows for the creation of a central data repository and support for decision-support tools. Computer-assisted decision support has the potential to significantly improve clinical decision-making. Six types of computer-assisted decision-support have been defined: alerting, interpreting, assisting, critiquing, diagnosing and managing. Software representing each type of decision-support software has been incorporated into clinical practice; however, with the exception of drug interaction programs, widespread incorporation of decision-support software into PCIS is uncommon. Clinical pharmacokinetic programs are a category of pharmacy-related decision-support software, and current clinical pharmacokinetic software systems can be categorised as interpreting, assisting or critiquing decision-support. Despite the potential for significant clinical contributions, the integration of clinical pharmacokinetic software into PCIS is uncommon. Most packages are available only as stand alone programs or as a module of a pharmacy information system. These packages usually maintain their own centralised database and require special file transfer protocols for integration. Although PCIS are becoming more commonplace, the integration of commercial clinical pharmacokinetic packages into PCIS is limited. New technology using standardised and relational databases should allow for easier integration in the future.

Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes.

OBJECTIVE: To determine the clinical and financial outcomes of antibiotic practice guidelines implemented through computer-assisted decision support. DESIGN: Descriptive epidemiologic study and financial analysis. SETTING: 520-bed community teaching hospital in Salt Lake City, Utah. PATIENTS: All 162 196 patients discharged from LDS Hospital between 1 January 1988 and 31 December 1994. INTERVENTION: An antibiotic management program that used local clinician-derived consensus guidelines embedded in computer-assisted decision support programs. Prescribing guidelines were developed for inpatient prophylactic, empiric, and therapeutic uses of antibiotics. MEASUREMENTS: Measures of antibiotic use included timing of preoperative antibiotic administration and duration of postoperative antibiotic use. Clinical outcomes included rates of adverse drug events, patterns of antimicrobial resistance, mortality, and length of hospital stay. Financial and use outcomes were expressed as yearly expenditures for antibiotics and defined daily doses per 100 occupied bed-days. RESULTS: During the 7-year study period, 63 759 hospitalized patients (39.3%) received antibiotics. The proportion of the hospitalized patients who received antibiotics increased each year, from 31.8% in 1988 to 53.1% in 1994. Use of broad-spectrum antibiotics increased from 24% of all antibiotic use in 1988 to 47% in 1994. The annual Medicare case-mix index increased from 1.7481 in 1988 to 2.0520 in 1993. Total acquisition costs of antibiotics (adjusted for inflation) decreased from 24.8% ($987,547) of the pharmacy drug expenditure budget in 1988 to 12.9% ($612,500) in 1994. Antibiotic costs per treated patient (adjusted for inflation) decreased from $122.66 per patient in 1988 to $51.90 per patient in 1994. Analysis using a standardized method (defined daily doses) to compare antibiotic use showed that antibiotic use decreased by 22.8% overall. Measures of antibiotic use and clinical outcomes improved during the study period. The percentage of patients having surgery who received appropriately timed preoperative antibiotics increased from 40% in 1988 to 99.1% in 1994. The average number of antibiotic doses administered for surgical prophylaxis was reduced from 19 doses in the base year to 5.3 doses in 1994. Antibiotic-associated adverse drug events decreased by 30%. During the study, antimicrobial resistance patterns were stable, and length of stay remained the same. Mortality rates decreased from 3.65% in 1988 to 2.65% in 1994 (P < 0.001). CONCLUSIONS: Computer-assisted decision support programs that use local clinician-derived practice guidelines can improve antibiotic use, reduce associated costs, and stabilize the emergence of antibiotic-resistant pathogens.

Evaluation of the financial impact of ketorolac tromethamine therapy in hospitalized patients.

This retrospective cohort study aimed to determine the resource utilization and cost consequences of ketorolac tromethamine in postoperative pain management in a variety of clinical circumstances. All patients were treated at LDS Hospital, Salt Lake City, Utah, a 520-bed teaching hospital. A long-term archive of clinical and financial data from a computerized hospital information system was searched for patients with specified primary International Classification of Diseases, 9th Revision, Clinical Modification discharge diagnoses treated from June 1, 1990, to July 1, 1992, who received ketorolac (n = 229). These patients were matched with cohort patients (n = 821) treated from July 1, 1989, to May 31, 1990, who did not receive ketorolac. The archive contained information on ketorolac exposure as well as concurrent drug therapy and adverse drug events that had been prospectively evaluated during hospitalization throughout the study and cohort periods. Detailed costs were available for each patient. The study examined attributable differences in lengths of stay and total costs using linear regression modeling. We found a statistically significant attributable decreased length of stay for ketorolac patients of 1.15 days. Case patients also had reduced usage of narcotic drugs (4.39 fewer doses than cohorts and 15.6 hours shorter duration of narcotics than cohorts), reduced use of antiemetic and antipruritic medications, and reduced numbers of adverse events. Linear regression modeling showed that ketorolac use was significantly related to reduced cost using inflation-adjusted dollars. We believe that ketorolac has significant cost advantages over opiate analgesics because of its narcotic-sparing effects. Advantages of ketorolac use include reduced rates of adverse drug events, reduced lengths of stay, especially for orthopedic surgery, and reduced overall hospital costs for diagnosis-related groups associated with cholecystectomy.

A retrospective analysis of twice-daily cefotaxime compared to conventional therapy for the treatment of infections in a USA hospital.

A retrospective, matched cohort study was performed to determine the cost outcomes among 495 hospitalized patients who received twice-daily dosing of cefotaxime and 3949 matched cohorts who received other antibiotics. By an attribution model, twice-daily use was associated with shorter mean lengths of stay (-0.498 day, P < .7) and lower mean total costs of hospitalization (-$623, P < .8). Twice-daily dosing of cefotaxime is commonly employed for the treatment of a variety of serious infections, and appears to be cost effective.

A decision support tool for antibiotic therapy.

We developed a decision support tool to assist physicians anticipating the need for antibiotic therapy. The initial screen alerts physicians of pertinent patient information, provides direct access to other essential medical information, and stimulates clinical judgment by suggesting an antibiotic regimen. The decision support tool also suggests the dose and interval for any ordered antibiotics selected by the physicians. During a 7-month pilot study, all antibiotics for patients admitted to the Shock/Trauma/Respiratory Intensive Care Unit (STRICU) were ordered using the decision support tool. Clinical data from the study period and a 12-month control period (the previous year) were collected and compared. The decision support tool was used to order antibiotics 588 times during the study period and the suggested antibiotics were used 218 (37%) times. The computer suggested dosages were used over 90% of the time. The mean cost of antibiotics was $87.00 (p < 0.04) less per patient during the study period as compared to the control period. Prospective assessment revealed only 3 antibiotic adverse drug events (ADEs) (0.9%) among 336 study patients as compared to 15 ADEs (2.4%) among 626 control patients (p = 0.164).

Preventing adverse drug events in hospitalized patients.

OBJECTIVE: To use computerized adverse drug event (ADE) surveillance to help identify methods to reduce the number of ADEs in hospitalized patients. DESIGN: Prospective study of 79,719 hospitalized patients during a 44-month period. SETTING: LDS Hospital, a 520-bed tertiary care center affiliated with the University of Utah School of Medicine, Salt Lake City. INTERVENTION: Sequential study periods of at least one year each were compared. In the first period, data were collected but not reported to physicians, pharmacists, or nurses. In the subsequent study periods, three interventions (computerized alerts of drug allergies, standardized antibiotic administration rates, and timely physician notification of all ADEs) were made to reduce the number of type B (allergic or idiosyncratic reactions) and severe ADEs. RESULTS: In the first study period, we identified 56 type B ADEs during 120,213 patient days. During two subsequent study periods that included alerts to physicians of known drug allergies and standardized antibiotic administration rates, 8 type B events were identified during 113,237 patient days and 18 during 107,868 patient days, respectively (p < 0.002). Early notification of physicians of all confirmed ADEs regardless of severity was associated with a significant reduction of ADEs classified as severe from 41 during 113,859 patient days in the first study period to 12 during 103,071 patient days and 15 during 108,320 patient days in two subsequent study periods, respectively (p < 0.001). CONCLUSIONS: Prospective surveillance of computer-based medical records for known drug allergies and appropriate drug administration rates can reduce the number of type B ADEs. Early ADE detection and notification of physicians permit drug and dosage changes that reduce the progression of mild and moderate ADEs to more severe conditions.

Improving empiric antibiotic selection using computer decision support.

BACKGROUND: Physicians frequently need to start antibiotic therapy before the results of bacterial cultures and antibiotic susceptibility tests are available. We developed and evaluated a computerized antibiotic consultant to assist physicians in the selection of appropriate empiric antibiotics. METHODS: We used a two-stage random-selection study to compare antibiotics suggested by the antibiotic consultant with 482 associated antibiotic susceptibility results and the concurrent antibiotics ordered by physicians. The antibiotics ordered by randomized physicians were then compared between crossover periods of antibiotic consultant use. RESULTS: The antibiotic consultant suggested an antibiotic regimen to which all isolated pathogens were shown to be susceptible for 453 (94%) of 482 culture results, while physicians ordered an antibiotic regimen to which all isolated pathogens were susceptible for 369 culture results (77%) (P < .001). The physicians who prescribed antibiotics to which all pathogens were susceptible did so a mean of 21 hours after the culture specimens were collected. Physicians ordered appropriate antibiotics within 12 hours of the culture collection significantly more often when they had use of the antibiotic consultant than during the period before use (P < .035). Moreover, 88% of the physicians stated they would recommend the program to other physicians, 85% said the program improved their antibiotic selection, and 81% said they felt use of the program improved patient care. CONCLUSIONS: Information from computer-based medical records can be used to help improve physicians' selection of empiric antibiotics for infections.

Applications of medical informatics in antibiotic therapy.

The Infectious Disease Society of America is concerned about the excessive and inappropriate use of antibiotics in U.S. hospitals. Applications of Medical Informatics can help improve the use of antibiotics and help improve patient care by monitoring and managing enormous amounts of patient information. Monitoring the duration of every antibiotic ordered in the hospital or keeping tract of the antibiotic susceptibilities for five years are examples of tasks better performed by computers. The impact of computers in medicine is seen by some as disappointing. The computer revolution has not had the impact in medicine experienced by other areas. The acceptance and use of computers by medicine will be evolutionary rather than revolutionary. In 1979, the MYCIN project demonstrated that the computer could aid physicians in the selection of antibiotics. However, MYCIN was never clinically used because physicians were require to enter all patient information into the computer. The development of computerized medical records is an essential step to further the development and implementation of computer-aided decision support. The science of Medical Informatics is still relatively new but is emerging as a distinct academic field. A few hospitals are now installing information systems and have determined that these systems will play an essential role in their ability to survive into the next century. The telephone and the automobile have been recognized as two of the most important tools for improving medical care during the past 100 years. People could more readily get medical care and the time to transmit medical information was greatly reduced through physician use of the telephone and automobile. The computer is a tool that can be used to help physicians manage the great amount of medical information being generated every day. The computer can also alert the physician of patient conditions that need attention. However, it is the physician who must use and apply the computer provided information. Thus, the computer will assist but not replace physicians in providing medical care.

Prospective surveillance of imipenem/cilastatin use and associated seizures using a hospital information system.

OBJECTIVE: To develop computerized methods to monitor and recommend dosage changes for patients treated with excessive dosages of imipenem/cilastatin (I/C) and to determine the incidence of I/C-associated seizures in our patient population. DESIGN: Prospective observational and interventional study of all patients admitted to LDS Hospital and treated with I/C from May 1, 1987, through June 30, 1991. SETTING: LDS Hospital, Salt Lake City, UT, a 520-bed, tertiary care center associated with the University of Utah School of Medicine. PATIENTS: Using a hospital information system we developed computerized algorithms to identify and monitor patients receiving I/C. These algorithms screened the computer-stored medical records of all inpatient admissions for I/C prescription orders. Computer-decision support algorithms estimated the renal function of each I/C-treated patient and provided suggestions when dosages were determined to be excessive. Additional computer-generated alerts identified patients who were receiving anticonvulsants concomitantly with I/C or whose therapy reflected dosage changes in the previous 24 hours. A list of all I/C-treated patients with alerts was reviewed daily by a clinical pharmacist and prescribing physicians were contacted if the computer-generated suggestions were clinically relevant. MAIN OUTCOME MEASURE: The number and characterization of I/C-associated seizures. RESULTS: From May 1, 1987, through June 30, 1991, we prospectively monitored 107,600 patients of whom 1951 were treated with I/C. The following risk factors for I/C-associated seizures were observed in the I/C-treated population: CNS disease (6 percent), seizure disorders (0.6 percent), and abnormal renal function (70 percent). The observational and interventional methods employed in this study resulted in 79 percent of the patients receiving I/C dosages appropriate for their corresponding renal function. During the 50-month study period, we detected four seizures (0.20 percent) in the I/C-treated patients. All 4 patients were receiving I/C dosages that were excessive with respect to their renal function. CONCLUSIONS: Our rate of seizure (0.2 percent) was lower than the 1-2 percent rate reported in the literature despite the fact that more than 70 percent of the patients who received I/C had risk factors for seizure. We believe that appropriate dosing of I/C results in a low rate of associated seizures. Computer-assisted monitoring of I/C dosages in relation to renal function resulted in a reduced incidence of seizures.

Using a hospital information system to assess the effects of adverse drug events.

The most common adverse events experienced by hospitalized patients are drug related. While numerous studies have described the incidence and types of adverse drug events (ADEs), the actual effect of these events on patient outcomes have only been estimated. The studies that have described the effects of ADEs on patient outcomes have not stratified patients by severity of illness and hospital costs were estimated based on a percent of hospital charges. We designed a study to utilize the resources of our hospital information system to assess the attributable effects of ADEs on hospital length of stay and cost of hospitalization. This approach emphasized the difference between study patients and their matched control patients rather than overall differences between patients with and without ADEs. In addition, we used nursing acuity data to help adjust severity of illness within DRG groups and actual hospital costs were used instead of estimated costs. This study found that while the average length of stay for patients with ADEs was 8.19 days compared to 4.36 days for matched control patients, the attributable difference due to the ADEs was 1.94 days. Similar methods found that patients with ADEs had an average cost of hospitalization of $10,584 compared to $5,350 for those without and the attributable difference due to ADEs was $1,939. This indicates that the 569 ADEs at our hospital during 1992 resulted in an additional 1,104 extra patient days at a cost of $1,103,291.