An incentive program to increase revenue in a public hospital.

Using financial reward systems to enhance revenue generation or promote cost savings has been more difficult in public than in private hospitals. The program at the Los Angeles County-University of Southern California Medical Center has demonstrated, however, that it can be done.

Magnesium deficiency in a medical ICU population.

The serum magnesium level was measured in 94 consecutive patients admitted to the medical ICU of Los Angeles County/University of Southern California Medical Center over a 2-month period. Sixty-five percent of patients with serum creatinine concentrations of 1.1 mg/dl or less were hypomagnesemic. Of these, one third had hypocalcemia that was corrected with magnesium supplementation. Physicians should be alert to the high incidence of magnesium deficiency in critically ill patients.

Comprehensive pharmaceutical services in a medical intensive-care unit.

The clinical and distributive services that have been provided by clinical pharmacists for the past 14 years in the medical intensive care unit (MICU) of a 1600-bed urban teaching hospital are described. The MICU pharmacy staff consists of 4.3 full-time equivalent pharmacists who provide daily 24-hour services. The pharmacists are actively involved in all pharmacological decisions with hands-on control of drug distribution from preparation through delivery and administration. They maintain up-to-date patient medication records and monitoring flow sheets for each patients. The pharmacists identify adverse reactions, formulate contingency plans, and promptly intervene to prevent crises. They provide comprehensive pharmacokinetic services, select drug administration times and routes, and prepare and deliver all medications. All i.v. medications are custom-made to meet the patients' fluid, sodium, or potassium restrictions. The pharmacists set up infusion pumps and select the proper infusion rates for i.v. and intra-arterial drugs. They also recommend and monitor the patients' nutritional support therapy. The program has been well accepted by nurses and physicians; however, only 20% of the inpatient clinical pharmacists desire to work in the MICU. The skills and educational requirements for managing patients in an MICU are discussed. Pharmacists have become an integral part of this MICU by optimal drug therapy, increasing productivity and efficiency, providing prompt and accurate services, and participating in research.

Clinical studies with computer-assisted initial lidocaine therapy.

A randomized prospective study compared achievement and maintenance of therapeutic plasma concentrations in patients receiving computer-assisted (CA) initial lidocaine hydrochloride therapy, designed pharmacokinetically to achieve and maintain a chosen plasma concentration, v conventional lidocaine therapy (CT). A separate audit of outcome was also conducted. The CA regimens provided more effective concentrations in the first hour than did CT, 2.65 v 1.5 micrograms/mL average. In the audit, ventricular fibrillation occurred in two of 78 CA v eight of 78 CT patients. Dosage adjustments were required in two CA patients v 33 CT patients. The CA therapy improved therapeutic precision, reduced dosage adjustments, and may have improved safety during initial lidocaine therapy before fitting to plasma concentration data for subsequent feedback. An improved clinical computer program now also fits to plasma concentration data. It is accessed and used routinely by hospitals over an international time-sharing network.

Barbiturate intoxication. Morbidity and mortality.

The complications encountered in caring for 185 patients intoxicated with barbiturates were reviewed. The population consisted of 142 patients with long-acting barbiturate concentrations of 8 mg per 100 ml or greater, 20 patients with short-acting barbiturate concentrations of 3 mg per 100 ml or greater and 23 consecutive patients with short-acting barbiturate intoxication referred for monitoring. Pneumonia was the major cause of morbidity and mortality and correlated best with the initial depth of coma and the use of an endotracheal tube in treatment. Cardiovascular instability manifested by pulmonary edema was the next leading cause of morbidity and mortality and correlated best with the initial depth of coma and the quantity of intravenous fluid administered. In retrospect, use of eliminative measures such as dialysis would probably not have altered the outcome in most of the patients who died and attempts at forced diuresis may have contributed to several deaths. Particular emphasis should be placed on the problems of sepsis and fluid therapy in the management of these patients.