An overview of types of relationships between hospitals and colleges/schools of pharmacy.

Three vignettes describe the details of each of the three types of practice-education relationships in academic hospitals identified in a survey by the University HealthSystem Consortium. The educational affiliation at Penn State's Hershey Medical Center, the affiliated relationship of the Medical College of Virginia, and a fully integrated relationship at the University of Illinois at Chicago are described by the Director of Pharmacy at each institution. The advantages, disadvantages, and future goals are described.

Cost and acceptability of three syringe-pump infusion systems.

The fiscal impact and acceptability of implementing a syringe-pump infusion system at a 900-bed university teaching hospital where the minibag system has been in use is reported. Researchers selected three models of syringe pumps for evaluation: the Bard Harvard Mini-Infuser 150XL, the Becton Dickinson 360 Infuser, and the Strato Stratofuse System. Each pump was evaluated for three weeks on a medical-surgical unit and a hematology-oncology unit. Drugs to be infused were chosen after a literature review to determine which drugs had been successfully infused via syringe pump; 22 formulary medications were selected. Syringes were prepared as singly packaged doses or as doses prepared in bulk and packaged frozen. Control of the syringe pumps and microbore tubing was assigned to the inpatient pharmacy staff. Nurses and pharmacy personnel were apprised of the study and taught how to use the syringe pumps. Time-and-motion studies were performed in the sterile products preparation area, and a cost analysis was done. Nurses preferred syringe pumps over the minibag system because the pumps reduced the nursing time needed to infuse a drug, administered less fluid, provided consistent infusion rates, had alarms, and were relatively easy to use. The time required to prepare syringes did not differ substantially among syringe-pump models. It was estimated that using any of the evaluated pumps in place of the minibag system would save $126,500 during the three-year period 1988-91, primarily because of differences in the cost of disposable items. The syringe-pump infusion system is an acceptable and cost-effective alternative to the minibag system.

Economic consequences of two drug-use control systems in a teaching hospital.

Length of stay (LOS), total cost per admission (TCA), and pharmacy cost per admission (DCA) were determined for two drug-use control systems in a 1058-bed university hospital; a centralized unit dose drug distribution system served as a control. The two study systems were (1) pharmacist monitoring of drug therapy in the patient-care area and (2) centralized pharmacist monitoring of computerized patient profiles. LOS data were collected retrospectively for 659 patients admitted during a seven-month control interval. LOS, TCA, and DCA data were collected prospectively for 496 patients admitted during a five-month experimental interval. Each study system was assigned to one of three teams making rounds among intact patient groups. LOS differences were compared between intervals and by month. After corrections were made for differences in patient mix, the drug-use control system in which pharmacists were assigned to the patient-care area yielded a 1.5-day-shorter average LOS, $1293 lower average TCA (p less than 0.05), and $155 lower average DCA than under the unit dose system. The drug-use control system in which pharmacists were assigned to monitor patients' drug therapy from a central location was associated with a 0.13-day-shorter average LOS, $235 lower average TCA, and $55.13 lower average DCA than under the unit dose system. No systematic differences between teams, other than drug-use control system, appeared to explain the differences in LOS, TCA, and DCA. A drug-use control system based in a patient-care area, overseen by clinically experienced pharmacists, may result in shorter LOSs and lower total costs than centralized systems for general-medical inpatients of teaching hospitals.

Cost analysis of a home intravenous antibiotic program.

A cost analysis of a home intravenous antibiotic program was performed, and the feasibility of the program was evaluated. All fiscal data related to the antibiotic therapy of the 10 study patients were collected from the patients' billing records and charts. Inpatient charges for antibiotics, supplies, laboratory tests, and the hospital room were identified from the patient's bill. Personnel costs were obtained from a log maintained by the home antibiotic team members. Charges accrued were converted to costs using the cost-to-charge ratio for each cost center. Fiscal analysis was performed using a subgroup of six patients with osteomyelitis. For all the patients, the mean duration of home therapy was 26 days. Inpatient treatment averaged 15.9 days. No major catheter-related problems were identified. For the osteomyelitis patients, the total cost of therapy, both inpatient and outpatient, was $57,854. If all of the therapy for this subgroup of patients had been provided on an inpatient basis, the total cost would have been $98,314. The home intravenous antibiotic program was determined to be feasible and cost-effective.

Nonprescription contraceptives: increasing in popularity.

PIP: The nonprescription forms of birth control now receive much attention due to the ongoing controversy about the prescription contraceptive methods. Condoms, 1 of these nonprescription methods, are the most effective nonprescription contraceptives available and among the most widely used. They are simple to use, inexpensive, and not associated with any major adverse effects. Condoms are unique in that they are a reliable contraceptive for males. It is estimated that 1 of 3 people who use contraception worldwide will rely on a male method. In the US this figure is somewhat lower, 18%. In other countries, such as Japan, condoms are the chief contraceptive method. If properly used, the failure rate for condoms is quite low; the lowest observed failure rate is 2%. In contrast, with typical users, the failure rate approaches 10%. The industry has taken several quality control measures to produce a safe and reliable condom. The principal material tested is usually either of the 2 ingredients used to make them, latex or collagenous tissue taken from the lamb cecum. Condoms definitely can protect against sexually transmitted diseases, simply because they prevent the infecting organisms from being transferred across the condom wall. The contraceptive efficacy of the condom is greatly enhanced when a spermicide is used at the same time. In terms of effectiveness, of 100 users that start the year using foams, creams, jellies, or vaginal suppositories containing nonoxynol 9 and used them consistently, the lowest observed rate of failure has been 3-5%. In actual use, the pregnancy rate is probably closer to 18%. Few side effects have been reported with spermicides. The most common of these is a burning sensation. The foaming suppository has been widely promoted as an effective vaginal contraceptive. It does not really offer any advantage over any of the other dosage forms except for convenience. It is the combination of foam and condom that pharmacists need to pay particular attention to because it is these 2 nonprescription methods that, used concurrently and correctly, can rival the efficacy of oral contraceptives. 1 of the newest dosage forms for a vaginal spermicide is a disposable polyurethane foam sponge which is impregnated with nonoxynol 9, but vaginal irritation has been reported frequently as an adverse effect.^ieng

Warfarin resistance with nafcillin therapy.

Drug-induced warfarin resistance may be mediated by the direct effect of a drug on warfarin's absorption, excretion, distribution, or metabolism. A 29-year-old man on long-term stable anticoagulation therapy with warfarin sodium developed resistance to warfarin while receiving nafcillin. His prothrombin time ranged between 14 and 17 s (control, 12 s) despite an increase in his warfarin dosage to 25 mg/d. Pharmacokinetic studies showed that the decreased hypoprothrombinemic effect of warfarin was most likely due to rapid metabolism of the anticoagulant induced by nafcillin. Warfarin's half-life was 11 hours when the patient was on nafcillin therapy and 44 hours when he was off nafcillin therapy. This interaction may be clinically important in patients requiring concomitant administration of nafcillin and warfarin.

Prediction of maintenance warfarin dosage from initial patient response.

This study was conducted to determine the reliability of two methods of predicting maintenance warfarin dosage. Fifty-nine patients were studied using Method 1 and 44 using Method 2. Both methods produced a statistically significant correlation between predicted and actual dose for the two populations. However, actual vs. predicted doses for individual patients were significantly different. Method 1 predicted a dose within +/- 2.5 mg/d of actual dose in only 40.7 percent of patients. With Method 2, the corresponding value was 56.8 percent. Although the linear regression was statistically significant in our population, many patients would have excessive or subtherapeutic dosage predictions.

Acquired warfarin resistance and weight-reducing diet.

A frequent cause of acquired warfarin resistance is drug interaction; however, ingestion of large amounts of vitamin K in food may also be an etiologic factor. A 31-year-old woman on a weight-reducing diet showed evidence of resistance to warfarin sodium therapy. On a regimen of 35 mg of oral warfarin sodium daily, prothrombin time was 14 s (control, 12 s). Pharmacokinetic studies did not reveal any evidence of impaired adsorption or increased catabolism of the drug. The half-life of her oral warfarin was 26 hours (normal, 15 to 56 hours). Although end-organ resistance was not studied fully, a change of her vegetable-rich, weight-reducing diet (vitamin K content, 1,277 microgram) to a regular diet (vitamin K content, 360 microgram) resulted in substantial reduction in her warfarin resistance. We conclude that in patients on vegetable-rich, weight-reducing diets, a relative resistance to warfarin may be secondary to their increased dietary intake of vitamin K.

Pharmacist management of anticoagulant therapy in ambulant patients.

The development, operation, patient management protocol and teaching activities of a pharmacist-managed anticoagulant clinic for ambulatory patients are described. Pharmaceutical services provided in the ambulatory clinic include (1) contribution to the problem-oriented medical record; (2) patient education; (3) therapeutic response monitoring; (4) drug information; (5) drug distribution; and (6) inservice education. A pharmacist completes a medication history on initial visit; assesses and adjusts anticoagulant therapy based on physical examination, detection of adverse drug reactions and laboratory test results; schedules return clinic visits; provides patient education; and records, in the patient's medical record, the assessment and results of treatment. Treatment adjustments made by the pharmacist are based on an oral anticoagulant protocol and reviewed by the clinic cardiologist. The clinic serves as a teaching site for undergraduate pharmacy students, Doctor of Pharmacy students and hospital pharmacy residents. The anticoagulant clinic gives the pharmacist a unique opportunity to provide comprehensive pharmaceutical services, to establish effective, long-term professional relationships with ambulant patients and their families, and to foster interdisciplinary health team activities.

Pharmacist's role in management of hypertensive patients in an ambulatory care clinic.

A program involving a pharmacist in the management of ambulatory hypertensive patients is discussed. A hypertension monitoring protocol was developed by a physician and a pharmacist. The protocol provided for initial patient assessment and treatment by the physician, counseling and education of the patient by the pharmacist, patient follow-up by the pharmacist every one to two months and follow-up by the physician every four to six months. In the first four months of the program, 28 of 75 newly diagnosed hypertensive patients were referred by the physician to the pharmacist for follow-up.