Showing papers in "American Journal of Health-system Pharmacy in 1992"

Drug-related emergency department visits and hospital admissions

Abstract: The incidence and causes of drug-related hospital admissions and visits to an emergency department were evaluated. A retrospective chart review was conducted to identify drug-related visits and admissions for all patients who visited the emergency department of a 517-bed tertiary-care institution during a four-month period. Drug-related illnesses were classified as adverse drug reaction (ADR), overdose or abuse, noncompliance, drug interaction, or toxicity. Patient data included demographic characteristics, medication history, serum drug concentrations, length of hospital stay, and hospital admission charges. Of 10,184 patients who visited the emergency department, 293 (2.9%) had drug-related illnesses; 71 (24%) of these patients were admitted. The drug classes most commonly involved were drugs of abuse (23.2%), anticonvulsants (17.1%), antibiotics (12.6%), respiratory drugs (8.9%), and pain medications (8.9%). The most common category of drug-related illness was overdose or abuse (35%) followed by noncompliance (28%), ADR (28%), toxicity (8%), and drug interaction (1%). The average length of stay for patients who were admitted was 5.8 days, and the average cost of admission was $8888. Drug-related illnesses accounted for 2.9% of hospital admissions and visits for patients in the emergency department. The most commonly identified drug-related illnesses were overdose or abuse, noncompliance, and ADRs; the drug classes most commonly implicated were drugs of abuse, anticonvulsants, and antibiotics.

Overview of health-related quality-of-life measures.

Abstract: Quality of life (QOL) as a measurable health-care outcome is discussed, and an overview of the field of QOL assessment is provided. QOL assessments can be used to evaluate drugs in clinical trials, to evaluate provider performance, and to monitor the progress of patients receiving drug therapy. QOL information is most useful in evaluating drug therapy when the primary purpose of a drug is palliative rather than curative, when a drug is somewhat effective but also fairly toxic, when lifelong therapy is administered to prevent complications of a relatively asymptomatic disease, and when there are several equally effective therapies for a specific condition but the adverse-effect profiles differ. Contemporary QOL questionnaires are completed by patients, and they most commonly include dimensions of physical function, mental or cognitive function, emotional or psychological function, social and role function, disease symptoms, and perceptions of well-being. The keys to successful QOL assessment in clinical practice will be selection of instruments that are practical to administer and are capable of detecting small changes in health, selective application of those instruments to patient populations most likely to benefit from this more intensive form of monitoring, and efficient use of data management systems. The consumer of QOL literature must assess the validity of QOL data obtained in a given study and their applicability to his or her practice setting.

Guidelines for performing a pharmacoeconomic analysis

Abstract: The fundamentals of pharmacoeconomics are presented. Pharmacoeconomic research is used to identify, measure, and compare the costs, risks, and benefits of programs, services, or therapies and determine which alternative produces the best health outcome for the resources invested. Each pharmacoeconomic method measures costs in monetary terms; the differences lie in the valuation of outcomes. In cost-minimization analysis, the outcomes are considered to be equal and therefore are not measured. Cost-benefit analysis measures outcomes in dollars, whereas cost-effectiveness analysis measures outcomes in nonmonetary units. In cost-utility analysis, outcomes expressed in nonmonetary units are adjusted for health-related quality of life. A well-designed pharmacoeconomic analysis involves 10 steps: (1) defining the problem, (2) determining the study's perspective, (3) determining the alternatives and outcomes, (4) selecting the appropriate pharmacoeconomic method, (5) placing monetary values on the outcomes, (6) identifying study resources, (7) establishing the probabilities of the outcomes, (8) applying decision analysis, (9) discounting costs or performing a sensitivity or incremental cost analysis, and (10) presenting the results, along with any limitations of the study. By adhering to the analytic steps described, the pharmacist undertaking a pharmacoeconomic evaluation has the greatest likelihood of obtaining valid and useful results.

Adverse drug reactions in an elderly outpatient population.

Abstract: The prevalence of adverse drug reactions (ADRs) in elderly outpatients was investigated, along with factors that might be associated with their occurrence. The medical records of elderly patients attending an interdisciplinary geriatric clinic and a general medical clinic during 1988 were audited to collect a variety of demographic and treatment data and to detect documentation of first-time ADRs. Subjects were classified as having had an ADR if a physician documented this or if a relevant symptom was noted in the record and a score of 1 or above was obtained on the Adverse Drug Reaction Probability Scale. The presence of potential drug interactions was also assessed. The sample size was 463 patients, of whom 332 attended the medical clinic and 131 attended the geriatric clinic. Potential drug interactions were identified in the records of 143 subjects (31%). There were 107 documented ADRs in 97 patients (21%). Of these patients, 86 were noted by the physicians as having had an ADR. Twelve patients were hospitalized as a direct result of an ADR. Significant risk factors for ADRs were attendance in the geriatric clinic, the use of potentially harmful drug combinations, and the use of drugs that require therapeutic monitoring. Patient age and the number of drugs had no association with ADRs. In the elderly population studied, patients with frailty arising from multiple pathologies were more likely to have ADRs than the more robust elderly, even when their therapeutic regimens were simplified.

Effects of pharmaceutical care on medication cost and quality of patient care in an ambulatory-care clinic.

Abstract: The effects of pharmaceutical care on medication cost and quality of care in a university-based family-practice clinic were studied. Prognostic indicators were used to target patients who should receive pharmaceutical care. Those patients who received care. Those patients who received pharmaceutical care over a 14-month period during 1988-89 were included in the study. A pharmacist interviewed each targeted patient, obtained the patient's medication history, made therapeutic recommendations to the patient's physician, and counseled the patient on his or her therapy. The pharmacist's recommendations were noted, and the outcome of each recommendation was documented on subsequent patient visits. For each recommendation, drug cost avoidance was calculated and patient outcome was analyzed. For quality assessment, a panel of three health-care professionals reviewed the pharmacist's recommendations for 25% of the study patients (randomly selected) and noted their agreement or disagreement with the pharmacist's actions. Over the study period, 184 targeted patients received pharmaceutical care. Clinic physicians accepted 297 (82.5%) of 360 pharmacist recommendations. Annual extrapolated cost avoidance associated with the pharmacist's recommendations was $19,076. For 213 (80.4%) of the 265 accepted recommendations for which outcome data were available, improvement or resolution of the patient's disease state occurred. For 8 (16%) of 50 unaccepted recommendations, the patient's status declined. The peer review panel agreed with 86% of the pharmacist's recommendations. The provision of comprehensive pharmaceutical care in an ambulatory-care clinic can both reduce medication costs and improve quality of care.

Turbidimetric assessment of the compatibility of taxol with selected other drugs during simulated Y-site injection.

Abstract: The compatibility of taxol in 5% dextrose injection with each of 17 other drugs during simulated Y-site injection was studied through visual and turbidimetric assessment. A 4-mL sample of taxol 1.2 mg/mL in 5% dextrose injection was combined with a 4-mL sample of each of 17 drugs at concentrations that are used clinically. Each combination was prepared in duplicate, with the order of mixing reversed between the two samples. The samples were inspected visually in normal fluorescent light, in high-intensity light, and against light and dark backgrounds with a 3-diopter magnification lens initially and at 30 minutes, one hour, and four hours. A turbidimeter was used to measure the turbidity of each drug combination in triplicate initially and at one and four hours after mixing. None of the drug combinations resulted in visual evidence of precipitation, color change, or gas production, and the turbidity was essentially unchanged over the four-hour observation period. Taxol 1.2 mg/mL in 5% dextrose injection exhibited no visual or turbidimetric evidence of incompatibility when combined with each of 17 other drugs during simulated Y-site injection. However, drug combinations for which no visual or turbidimetric incompatibility is apparent may not be chemically stable; therefore, practitioners should be cautious in applying these findings to the clinical setting.

Evaluation of a pharmacy-managed warfarin-monitoring service to coordinate inpatient and outpatient therapy.

Abstract: The effects of implementing a warfarin-monitoring service for inpatients were evaluated. The pharmacy-managed service includes chart review, laboratory interpretation, recommendations for warfarin dosage adjustments, physician and patient education, and coordination of follow-up in the outpatient anticoagulation clinic. In a before-after trial, 52 patients monitored by the warfarin-monitoring service were compared with 97 patients who received warfarin before the service was implemented. Significantly fewer determinations of prothrombin time (PT) and partial thromboplastin time (PTT) were ordered for after-trial patients compared with before-trial patients. PT stability at hospital discharge was significantly improved in after-trial patients. After-trial patients were 12.2 times more likely to be referred to the anticoagulation clinic. No difference was found between the before and after groups in overall compliance with follow-up; however, among patients with no history of substance abuse, after-trial patients were 6.7 times more likely to be compliant. The warfarin-monitoring service had no significant effect on the number of hospital visits and readmissions related to toxicity and recurrence of thrombosis. After-trial patients were 5.4 times more likely to have a therapeutic PT at the initial follow-up appointment. The warfarin-monitoring service improved warfarin dose determination, improved PT stability, and increased referrals to the anticoagulation clinic; among patients with no history of substance abuse, it also improved clinic compliance.

Use of prescription-refill records to assess patient compliance.

Abstract: Prescription-refill records were used to assess patient compliance, to evaluate factors previously associated with compliance, and to determine the association between selected drugs and compliance. Records were selected from a computerized database containing prescription-coverage claims, based on the following criteria: (1) the prescriptions were refilled during 1987-1989 and within two times the days' supply after the dispensing date, (2) they involved any of 12 drugs selected for study, (3) they required one to four doses per day, and (4) at least 20 records with the same regimen were available. Compliance was defined as refill within 0.2 times the days' supply after the refill-due date, and it was assessed by calculating the compliance rate and the compliance index (which describes the relationship between the refill-due date and the actual refill date). Data from 19,118 prescription-refill records were analyzed. The compliance index improved slightly as the number of concurrent medications increased, worsened as the number of doses per day increased, and improved as the immediacy of the risk of noncompliance increased. Different medications and indications were associated with different degrees of compliance. Medication compliance generally improves as the number of daily doses decreases, may improve slightly as the number of concurrent medications increases, and varies with the particular drug and indication.

Drug prescribing for patients with changing renal function.

Abstract: The prevalence and course of renal dysfunction in hospitalized patients and the prescribing of renally eliminated drugs in these patients were studied. All adult inpatients at a large teaching hospital who had a serum creatinine concentration assay performed were screened for renal dysfunction (an estimated creatinine clearance of < 40 mL/min). Renally compromised patients were monitored for changes in renal function. The regimens of selected renally eliminated drugs prescribed for these patients were compared with the manufacturers' recommended dosages for patients with renal compromise. Of the 3800 patients screened, 195 (5%) had renal dysfunction; most of these patients were older than 65 years. Although improvements in renal function were noted in 49 (30%) of the 169 patients with renal dysfunction who were not receiving hemodialysis, elderly patients were less likely to show an improvement in renal function. Of the 60 patients with renal dysfunction for whom a renally eliminated drug was prescribed, 27 (45%) were receiving dosages in excess of the manufacturers' recommendations. Changes in creatinine clearance estimates are common in hospitalized patients with renal impairment. Programs designed to alert physicians to potentially excessive dosages of renally eliminated drugs need to be sensitive to these changes.

Antibiotic-impregnated cement use in U.S. hospitals.

Abstract: The results of a survey of the use of antibiotic-impregnated bone cement and cement beads in U.S. hospitals are reported. A random sample of hospitals was selected from all hospitals registered with the American Hospital Association. A questionnaire designed to characterize the extent of use of the products and the degree of pharmacy involvement was mailed to the pharmacy directors at 547 hospitals nationwide. The response rate was 61.7% (336 evaluable returns). Ninety hospitals (26.9%) reported using antibiotic-impregnated bone cement or cement beads. Product use was significantly greater in urban hospitals, hospitals larger than 200 beds, teaching hospitals, and hospitals with pharmaceutical services in the operating rooms. Most facilities using the products were community hospitals. Total hip arthroplasty, total knee arthroplasty, and chronic osteomyelitis were the most common indications for use. Systemic antibiotics were also administered in the great majority of hospitals reporting use of the products. The products were generally used in fewer than one procedure per month. Aminoglycosides and various cephalosporins were the antibiotics most commonly used; most have not been adequately studied for this use. Although nearly all the hospital pharmacies purchased antibiotics for these products, none mixed cement and only two premanufactured antibiotic beads. About one fourth of the hospitals surveyed reported using antibiotic-impregnated bone cement and cement beads, although the total number of patients being treated was small.

Evaluation of patient-care interventions by Pharm.D. clerkship students.

Abstract: A program is described in which Pharm.D. clerkship students provide pharmaceutical care by identifying drug-related problems, suggesting interventions to solve the problems, and documenting the patient's outcome. Four doctor of pharmacy degree students under the direct guidance of a clinical pharmacy preceptor suggested 231 patient-care interventions during their clinical rotations; 219 (94.8%) of the interventions were either fully or partially accepted by the prescriber. The most commonly solved drug-related problems were underdose (31.5%) and overdose (17.4%), followed by untreated indications (14.1%) and drug given without indication (13.7%). The remainder of the drug-related problems that the students solved were improper drug selection, failure to receive drug, adverse drug reactions, or drug interactions. All but 10 interventions were considered by preceptors to be significant contributions to patient care. The interventions were estimated to have decreased drug costs in 50.7% of the cases, increased drug costs in 23.7% of the cases, and not changed drug costs in 25.6% of the cases. Patient outcomes were documented by the students in 58.9% of cases; the desired goals of the accepted intervention were achieved in all documented cases. A preceptor-supervised intervention program was beneficial to Pharm.D. students and patients and was well received by prescribers.

Use of an automated medication storage and distribution system

Abstract: The effects of an automated medication storage and distribution system in a hospital setting were evaluated. The Pyxis Medstation system was implemented on two nursing units at a 1000-bed tertiary-care referral hospital. The system, which is designed like an automated bank teller, dispenses items to authorized users and records all transactions. Floor-stock controlled substances and noncontrolled medications, large-volume i.v. solutions, and i.v. administration sets were stocked in the system. The system was evaluated (1) by comparing the mean patient charge capture rates for six months before and for three months after implementation, (2) by measuring nurse and pharmacy technician time required for various tasks before and after implementation, and (3) through questionnaires filled out by nurses and technicians. After the system was installed, nursing personnel spent less time on medication-related activities, charting, and documentation and more time interacting with patients. Pharmacy technicians spent more time on floor-stock activities and less time on billing activities. Nurses indicated positive attitudes toward the system features. Both nurses and pharmacy technicians indicated that the system should remain in use. After implementation, the charge capture rate for noncontrolled medications, i.v. solutions, and i.v. sets increased from 63% to 97%. This increase, extrapolated to the entire hospital, reflects $35,000 in additional revenue over the total costs of implementation of the system. Implementation of an automated medication storage and dispensing system is expected to increase hospital revenue and enable nurses to spend more time interacting with patients at this institution.

Changing relationship between pharmacists and physicians.

Abstract: The changing professional relationship between pharmacists and physicians in the United States from the beginning of the nineteenth century to the present is described. Throughout the nineteenth century, physicians intruded heavily on the pharmacist's domain, and medicine often viewed pharmacy with condescension. Toward the century's end, pharmacists gained more respect and recognition as the medical and pharmaceutical sciences grew and physicians found themselves relying on pharmacists. Hundreds of years of friction were not easily forgotten, though, and the two professions continued to hurl charges and countercharges and vie for power. With the emergence of the pharmacist as a full member of the health-care team and the crush of medical information in the twentieth century, greater cooperation is occurring, although irritations persist, especially in the areas of physician dispensing and therapeutic interchange. Improvements in the relationship between pharmacists and physicians were driven by growth in their fields and the trend toward specialization. As tensions ease, patient care should benefit.

Pharmaceutical services in U.S. hospitals in 1989.

Abstract: The results of a spring 1989 national survey of hospital-based pharmacy services are reported. The study group (n = 2112) comprised half of U.S. acute-care general surgical or medical hospitals with 50 or more licensed beds. Pharmacy directors were asked about their hospital's provision of 14 clinical pharmacy services. The survey had a response rate of 56% (1174 usable responses). Provision levels varied significantly with the pharmacy drug delivery system for 14 services, pharmacy director's education for 12 services, hospital teaching affiliation for 12 services, hospital ownership for 9 services, hospital size for 9 services, and geographic region for 5 services. The following percentages of respondents offered specific services: drug-use evaluation, 90%; inservice education, 66%; adverse drug reaction (ADR) management, 46%; drug therapy monitoring, 41%; pharmacokinetic consultations, 40%; parenteral-enteral nutrition team participation, 28%; patient medication counseling, 26%; drug therapy protocol management, 25%; cardiopulmonary resuscitation (CPR) team participation, 25%; clinical research, 22%; drug information, 16%; participation in medical rounds, 13%; poison information, 9%; and medication histories, 2%. Pharmacist staffing requirements for clinical services usually centralized within the department were highest for drug information and poison information. Within hospitals offering the services, four of nine patient-specific services were potentially available to more than half the patients: ADR management, CPR team participation, drug therapy monitoring, and nutrition team participation. Drug therapy protocol management required the most pharmacist staff time. Only one service, pharmacokinetic consultations, was justified by more than half of the providers of that service. Respondents expected all the services to undergo net growth during 1989-90. The 1989 National Clinical Pharmacy Services Survey showed that provision of clinical pharmacy services varied with the pharmacy drug delivery system, pharmacy director's education, hospital teaching affiliation, hospital ownership, hospital size, and geographic region.

Fat emulsion particle-size distribution in total nutrient admixtures.

Abstract: The fat particle-size distribution in and physical stability of two commercially available lipid emulsions before and after their use in total nutrient admixtures (TNAs) are reported. Four TNAs without electrolytes and four TNAs with electrolytes were prepared; each type of TNA was prepared with Liposyn II and with Intralipid. Particle size was measured in the < 1-micron range by using photon correlation spectroscopy and in the 2-60-microns range by using light blockage. Admixtures with or without electrolytes were stored for two or nine days at 4 degrees C followed by one day at 25 degrees C. For the fraction of fat particles of < 1 micron in diameter, Intralipid and Liposyn II had a mean particle size of 374 and 313 nm, respectively. The admixtures containing electrolytes showed a decrease in mean particle size of about 7%. Admixtures with Intralipid contained 2 x 10(7) particles larger than 2 microns per milliliter (1.7% of total fat), compared with 1 x 10(6) particles per milliliter (0.05-0.15% of total fat) for admixtures with Liposyn II. The addition of electrolytes increased the particle counts for Liposyn II-containing admixtures. Upon storage, Intralipid-containing admixtures with electrolytes showed an initial increase followed by a decrease in the mean diameter of particles of < 1 micron. All the admixtures were stable in terms of pH and visual appearance. Intralipid-containing admixtures with electrolytes showed a decrease in the number of particles in the 2-60-microns size range, while Liposyn II-containing admixtures with electrolytes showed an increase.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors affecting practice-area choices by pharmacy students in the Midwest.

Abstract: The results of a survey to determine the first-choice practice intentions of midwestern pharmacy students and to describe and quantify the factors affecting their decisions are reported. Questionnaires were sent to 12 pharmacy schools in American Association of Colleges of Pharmacy District IV and distributed during November 1988 to January 1989. The questionnaires were given to entry-level pharmacy students who were in their final year of study. The students were asked to indicate their preferred practice setting upon graduation and to rate the importance of 21 factors that a pharmacist might consider when selecting a first position. A total of 715 usable responses were received (response rate, 6.75%). OF the respondents, 83.2% were enrolled in B.S. degree programs and 16.8% in entry-level Pharm.D. degree programs. The distribution of first choices of a practice area was as follows: chain community pharmacy, 33.1%; hospital pharmacy, 27.6%; independent community pharmacy, 12.4%; industry, 8.4%; "other," 5.5%; ambulatory-care clinic, 5.2%; graduate school, 3.8%; department store, discount store, or grocery store, 1.7%; home health care, 1.5%; and nursing home, 0.8%. The three factors ranked as most important in affecting the choice of a practice area were personal fulfillment, salary, and the opportunity to use one's abilities and education. The ranking of the factors varied depending on the practice area chosen. Midwestern pharmacy students were most interested in chain community and hospital pharmacy practice settings. Retail-oriented students placed salary concerns first, whereas clinically oriented students emphasized personal fulfillment. These findings have implications for recruitment strategies.

Association between formulary strategies and hospital drug expenditures

Abstract: National survey data were analyzed to determine whether an association existed between formulary strategies and hospital drug expenditures. Data on community hospitals were obtained from (1) ASHP's 1987 national survey of pharmaceutical services, (2) the American Hospital Association, and (3) the Health Care Financing Administration. Along with size, case mix, and salary information, data were collected on whether the hospitals used a well-controlled formulary, whether they used therapeutic interchange, and how much money they spent on drugs. A logarithmic cost-function model was used to obtain a straight-line equation that expressed the relationships between drug cost per patient day and the other variables assessed. Summary statistics were calculated with data from 514 hospitals. The adjusted coefficient of multiple determination indicated that the model was able to explain 24.6% of the observed variation in drug cost per patient day. A significant association was found between decreased costs and a well-controlled formulary, therapeutic interchange, or both. Hospitals that used either strategy spent 10.7% less for drugs than those that used neither. Hospitals that used both strategies spent 13.4% less than those that used neither. Analysis of national survey data suggests that use of a well-controlled formulary, therapeutic interchange, or both are associated with lower pharmacy drug expenditures.

Pharmacy-based antimicrobial-monitoring service.

Abstract: A pharmacy-based antimicrobial-monitoring service at a university teaching hospital is described. The service was developed and implemented by the pharmacy department in 1987. Antimicrobial drugs that can be misused, that are expensive, or for which bacterial resistance is a concern were targeted. When a pharmacist receives an order for a targeted antimicrobial, an antimicrobial-monitoring card is completed. Monitored drugs meeting approved criteria are dispensed as ordered. When the antimicrobial does not meet the criteria, the pharmacist contacts the physician and suggests an alternative. If the alternative is not accepted, the infectious diseases service is contacted and then informs the pharmacy department about the status of the drug. The agent is dispensed if no response is received within two hours. Qualified staff pharmacists rotate through the position of antimicrobial pharmacist, whose responsibilities include reviewing antimicrobial use throughout the hospital, checking relevant laboratory test results, and recommending adjustments to regimens. From July 1989 to June 1990, 3546 orders for monitored antimicrobials were reviewed; of these, 86% met the criteria, 9% did not meet the criteria but were approved, 2% were for drugs that were replaced by alternative therapies, 1% were for agents that were dispensed because the pharmacist was not contacted, and 2% represented medical staff overrides or drugs dispensed inappropriately. Pharmacist and physician compliance with the monitoring policy has been high. A positive, constructive, and educational relationship exists between pharmacists and physicians vis-a-vis the service. A pharmacy-based antimicrobial-monitoring service has been accepted by pharmacists and physicians and appears to be having a positive impact on prescribing habits.

Stability of an extemporaneously compounded clonidine hydrochloride oral liquid.

Abstract: The stability of clonidine hydrochloride in an extemporaneous oral liquid formulation refrigerated for 28 days was studied. A suspension was prepared by grinding commercially available 0.2-mg clonidine hydrochloride tablets, adding Purified Water, USP, to form a paste, and then adding Simple Syrup, NF. A control solution was prepared from analytical grade clonidine hydrochloride powder in Simple Syrup, NF. The final concentration of clonidine hydrochloride in both formulations was 0.1 mg/mL. Three samples of each preparation were stored in 2-ounce amber glass prescription bottles in the dark at 4 degrees C. Immediately after preparation and at 3, 7, 14, 21, and 28 days, samples were visually inspected, tested for pH, and assayed in duplicate by high-performance liquid chromatography. On day 28, the mean percentages of the initial clonidine hydrochloride concentrations remaining were 92.4% in the suspension and 93.7% in the solution. The color, odor, and pH of the samples did not change appreciably over the study period. An extemporaneously compounded oral liquid preparation of clonidine hydrochloride in Simple Syrup, NF, is stable under the conditions studied for up to 28 days.

Stability and sorption of FK 506 in 5% dextrose injection and 0.9% sodium chloride injection in glass, polyvinyl chloride, and polyolefin containers

Abstract: The effects of the diluent, the storage container, light, and infusion through various types of tubing on the stability and sorption of FK 506 were studied. Solutions of FK 506 in 0.9% sodium chloride injection or 5% dextrose injection were stored at room temperature (24 +/- 2 degrees C) in glass i.v. bottles, polyvinyl chloride (PVC) minibags, and polyolefin containers. FK 506 solution in 0.9% sodium chloride injection was stored in plastic syringes at room temperature and either exposed to normal room light or stored in the dark. FK 506 solution in 5% dextrose injection was placed in plastic syringes and infused through PVC anesthesia extension tubing, PVC i.v. administration set tubing, and fat emulsion tubing over a two-hour period. The infused samples and samples collected from the containers and syringes at intervals up to 48 hours were analyzed for FK 506 concentration by high-performance liquid chromatography. FK 506 concentrations remained greater than 90% of initial concentration for admixtures in 5% dextrose injection stored in glass bottles for 48 hours and for admixtures in 5% dextrose injection or 0.9% sodium chloride injection stored in polyolefin containers for 48 hours. No change in concentration was measured for admixtures in 0.9% sodium chloride injection stored in plastic syringes, and exposure to light did not affect the stability of FK 506 solution. No substantial change in concentration occurred in FK 506 solution in 5% dextrose injection infused through PVC anesthesia extension tubing, PVC i.v. administration set tubing, or fat emulsion tubing. FK 506 admixtures prepared with 5% dextrose injection or 0.9% sodium chloride injection should be stored in polyolefin containers. If polyolefin containers are not available, solutions should be prepared with 5% dextrose injection and stored in glass bottles.

Comparison of two systems for documenting pharmacist interventions in patient care

Abstract: Manual and computerized systems for documenting interventions by pharmacists at a large university teaching hospital are compared. The manual system allows patient data and pharmacist interventions to be quickly documented on written profiles. Completed forms are entered into a personal computer for analysis. The computerized system is a direct-entry version of the manual intervention log. Five screens allow pharmacists to enter information into a mainframe computer from any terminal. Data can be downloaded from the mainframe into a personal computer. During the first part of the study, nine pharmacists used the manual system for seven days. After a two-week pause, the same pharmacists used the computerized system for seven days. The systems were evaluated by using time-and-motion analysis and a questionnaire. Also, the number of interventions documented and the characteristics of each were compared. The mean +/- S.D. time required to document an intervention was significantly less with the computerized system (81.8 +/- 24.9 seconds) than with the manual system (100.7 +/- 37.3 seconds). Administrative time for analysis and report generation was also less with the computerized system. The pharmacists rated the computerized system more highly in terms of ease of use, accessibility, time efficiency, and acceptability. The number of interventions documented did not differ between the systems. A computerized system for documenting pharmacist interventions compared favorably with a manual system.

Current status of drug information centers.

Abstract: The current status of drug information centers in the United States and trends that have developed over the past two decades were studied. In February 1990, questionnaires were sent to 218 pharmacist-operated drug information centers nationwide. The centers were identified through previously published directories and the ASHP electronic bulletin board PharmNet. The survey consisted of 182 questions designed to gather updated data on each drug information center. Responses to each question were coded individually, and data were analyzed by using a statistical analysis program. One hundred fifty-four drug information centers responded; of these, 130 provided usable responses. The results showed that the number of drug information centers has increased compared with earlier surveys. Also, the centers handle substantially larger workloads. Few drug information centers indicate a fee-for-service system. Computer use and online searching by drug information centers have increased. Most of the centers participate in the formal education of pharmacy students. Increases in the number of drug information centers and in their workload substantiate the growing importance of these centers to the health-care professions.

Evaluation of a disposable, elastomeric infusion device in the home environment

Abstract: The use of a disposable, elastomeric infusion device was evaluated in 55 patients receiving home antimicrobial therapy. During a 30-day period, all patients referred to five service centers to receive home antimicrobial therapy for at least one week were enrolled in the study. Pharmacists used an automated pump to fill 110-mL, 100-mL/hr elastomeric devices (Homepump; Block Medical, Carlsbad, CA). Nurses trained patients to use the device. Nurses and pharmacists completed an evaluation form for each patient. Fifty-five patients received a total of 1938 doses; a fresh device was used to administer each dose. Nurses described patient teaching for the device as easy (51) or no different from that for other devices (4). Patient acceptance was reported to be good in 54 patients and poor in 1 patient. A total of 91 restarts were required; 36 patients needed more than one restart. The failure rate of the device was 1.6%; 25 of 44 reported problems occurred in devices that were frozen and thawed before use. The Homepump was determined to be an acceptable device for the intermittent infusion of small-volume antimicrobial solutions in the home environment because of its low failure rate and high degree of patient and nursing preference; its drawbacks include high cost and slowed infusion rates for units that are not thawed properly after freezing.

Causes of non-medication-induced nasogastric tube occlusion.

Abstract: In vitro simulation of nasogastric tube delivery of enteral formulas was used to study the mechanism and prevention of non-medication-induced nasogastric tube occlusion. Enteral nutrition products--Osmolite, Ensure, Vital High Nitrogen, and Vivonex T.E.N.--were placed in glass beakers and titrated with hydrochloric acid to determine the pH at which clotting would occur. Factors such as pH, protein content, viscosity, electrolyte composition, flow rate, and tube design were evaluated to determine their effects on coagulation of formula. Addition of simethicone emulsion and docusate sodium to the formulas and siliconization of the nasogastric tubes were studies for their effect on prevention of clog formation. Clumping began to occur at pH 4.6 (the isoelectric point for casein) for Ensure and Osmolite; addition of protein supplement did not change the pH at which coagulation occurred. Vital High Nitrogen and Vivonex T.E.N. formulations did not clump in the beakers. Ensure and Osmolite coagulated within 35 seconds at pH 4.6 or less and remained unchanged at pH greater than 6.0. Addition of sodium or calcium caseinate greatly increased the tendency of the formulas to coagulate. Viscosity of the formula increased markedly as pH decreased. Addition of electrolytes had no effect on precipitation or clumping. Slow or no flow rates within nasogastric tubes placed in simulated gastric juice decreased the pH and caused clumping of formulas within the tubes in a retrograde manner. Flow time or clog formation was not affected by the addition of simethicone or docusate sodium or siliconization of the nasogastric tube.(ABSTRACT TRUNCATED AT 250 WORDS)

Practical guidelines for preparing and administering amphotericin B.

Abstract: Current practices used in the preparation and administration of amphotericin B are evaluated, and updated guidelines are presented. Intravenous admixtures of amphotericin B 0.25 and 1.4 mg/mL in 5% dextrose injection have an expiration date of 35 days and 36 hours, respectively. Since commercial formulations of amphotericin B lack a bacteriostatic agent, admixtures should be stored at 4-8 degrees C. Protection from fluorescent light is unnecessary. Admixtures may be prepared in polyolefin, glass, or polyvinyl chloride intravenous containers; certain evacuated intravenous containers contain buffers that can cause precipitation of amphotericin B. The addition of a buffering agent to the intravenous admixture is unnecessary when the initial pH of the 5% dextrose injection exceeds 4.2. The usual daily maintenance dose of amphotericin B is 0.5-1 mg/kg i.v. The manufacturer recommends beginning intravenous therapy with a 1-mg test dose. The initiation of therapy with incrementally increased doses may be detrimental if it delays the delivery of a therapeutic dose. Amphotericin B can be infused over one to two hours (less than or equal to 50 mg/hr) in patients with adequate renal function. Bladder instillation of amphotericin B 50 mg in 1 L of sterile water has been used to treat fungal cystitis. Ancillary medications administered to treat infusion-related adverse events should be used as prophylaxis in patients with a history of hypersensitivity or unacceptable reactions and as needed for relief of symptoms. Sodium supplementation should be implemented cautiously, on a patient-specific basis.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevention of Lyme disease.

Abstract: Lyme disease and the use of tick repellents and physical protective measures to prevent the disease are discussed Lyme disease is a multiple-organ-system, immune-mediated inflammatory disorder transmitted by the bites of ixodid ticks infected with Borrelia burgdorferi An individual is at greatest risk for infection when a tick has been attached to the skin for more than 24 hours Lyme disease occurs in three stages and may affect the skin, nervous system, cardiac system, and joints Antimicrobials used in management consist primarily of penicillins, cephalosporins, tetracyclines, and erythromycin Tick repellents are divided into those applied to the skin and those applied to clothing Skin repellents include N,N-diethyl-meta-toluamide (DEET), 2-ethyl-1,3-hexanediol, and dimethyl phthalate Permethrin is by far the most effective clothing repellent DEET plus a permethrin-containing clothing repellent offers the best overall protection The adverse effects of repellents are minimal, but cases of hypersensitivity have been reported, especially in children Physical measures to prevent tick bites include avoiding tick-infested areas, wearing light-colored clothing for easy identification of crawling ticks, regularly checking the body and pets for ticks, wearing protective garments and closed-toed shoes, and removing attached ticks promptly by using tweezers or forceps to apply a steady upward pull A vaccine for the active immunization of humans against Lyme disease remains to be developed Although antimicrobial therapy is available for persons with Lyme disease, the best approach for those who may be exposed to infected ticks is to apply topical skin or clothing repellents and to practice common-sense measures of physical protection

Evaluation of six computerized drug interaction screening programs

Abstract: Six widely used computerized drug interaction screening programs were evaluated according to criteria developed by a panel of pharmacists. A panel of six pharmacists from various practice settings developed criteria that were used to evaluate six computerized drug interaction screening programs: Medicom Micro Plus, Medical Letter, S-O-A-P, Drug Interactions by Hansten, Drug Therapy Screening Systems (DTSS), and RxTriage. The criteria were that the programs be user friendly and efficient, provide guidance, and be relevant to the user's practice setting. Also, they should detect interactions, quickly alert the user, and guide the user to the appropriate action. The user should be able to set the level of clinical significance, screen only current drugs in a patient profile, and print out summaries. The panel selected nine known drug interactions to test the programs' knowledge bases. Only Medicom Micro Plus and DTSS detected all nine drug interactions; Medical Letter missed three. RxTriage and Drug Interactions received the highest ratings in user friendliness and efficiency, but both missed two interactions. RxTriage was rated most relevant to their practice by hospital and community pharmacists, and Drug Interactions was rated most relevant by faculty practitioners. S-O-A-P received low ratings overall. Of the six drug interaction screening programs evaluated, none was considered by the panel of pharmacists to be ideal.