Aminoglycoside dosing service provided by baccalaureate-level pharmacists

An aminoglycoside pharmacokinetic dosing service operated primarily by baccalaureate-level pharmacists is described. The service was initiated gradually by the clinical pharmacy coordinator. After detailed policies and procedures were developed, staff pharmacists received 14 hours of training in pharmacokinetics. The training program consisted of written study material and application to actual patient cases. The pharmacokinetic dosing service is initiated upon the written request of a physician. Nurses on the pharmacy i.v. team administer aminoglycoside doses, collect blood samples, and record sample collection and drug infusion times whenever possible; when workload is heavy, floor nurses and laboratory personnel assist in these functions. The entire dosing consult requires approximately one hour of pharmacist time per patient. A $20 fee is assessed for completed dosing consults. Approximately 50 consults are provided per months, and a survey showed that 50-70% of all hospital patients (except newborns in intensive care) receiving aminoglycosides had their dosages calculated by the service. A carefully developed limited aminoglycoside dosing service provided primarily by baccalaureate-level pharmacists has given the pharmacy department at this hospital an opportunity to further expand its involvement in clinical pharmacokinetics.     

Clinical privileges program for pharmacists.

A clinical privileges program for pharmacists is described. In 1985 and 1989 the Department of Veterans Affairs (VA) issued circulars defining policy on clinical privileges for pharmacists at its medical centers. Pharmacists at one large VA medical center responded by developing a clinical privileges program. Bylaws under which medical staff members are granted clinical privileges were used as a model for the pharmacist program. A pharmacist seeking privileges prepares an application detailing his or her background and the practice areas involved in the request; the applicant also drafts a quality assurance protocol. The application is reviewed by a pharmacist clinical privileges review board (PCPRB). The PCPRB uses the quality assurance plan to verify that adequate measures are in place to meet standards of care. If a question of patient safety arises, the board meets to review the pharmacist's activities. Each pharmacist who is granted privileges must have a physician sponsor. Since the first meeting of the PCPRB in 1990, clinical privileges have been requested by all 24 clinical pharmacy specialists at the center. No pharmacist has been denied privileges, although the board has required additional training or improved quality assurance protocols for many. Acceptance of the program by the medical staff has been good. A clinical privileges program at a VA medical center offers pharmacists the opportunity to practice pharmaceutical care.     

Evaluation of warfarin dosing by pharmacists for elderly medical in-patients

OBJECTIVE: To compare the effectiveness of pharmacists dosing warfarin for in-patients, in comparison to that of junior doctors, in order to establish the value of a pharmacist-controlled in-patient anti-coagulation service. Setting: Brighton and Sussex University Hospitals NHS Trust (BSUH). METHOD: Two wards at Brighton General Hospital were under pharmacist-control of warfarin dosing and three wards remained under the care of doctors. Data was collected for 11 months and a total of 33 patients were recruited into each arm. RESULTS: Pharmacists prescribed more appropriate loading and maintenance doses (according to the Trust's Prescribing Guidelines) compared to doctors. This resulted in more patients reaching their target INR sooner. Documentation of indication, duration of treatment and target INR was also much improved compared to medical staff. However, more patients (73%) in the doctors' group were within range on discharge and at the out-patient clinic (79%), compared to the pharmacists (68% & 61% respectively). This could not be explained entirely. Significantly fewer patients dosed by pharmacists had episodes of over or under anti-coagulation (91% vs 67%) and fewer INR tests were requested (2.3/patient/week) compared to those dosed by doctors (2.7). Patients under the control of pharmacists also had fewer adverse events (6% vs 12%). One major GI bleed occurred in the doctors' group. CONCLUSION: Pharmacist dosing of warfarin for in-patients had a beneficial effect on most aspects of anti- coagulation control. This study therefore provides further evidence to support the extended role pharmacists can play with the benefit of reducing risk, junior doctors' hours and improving patient care.     

临床药师对临床不合理用药事先干预模式的探索

目的 探讨临床药师对临床不合理用药医嘱进行事先干预的方法和成效。方法 临床药师对住院用药医嘱进行审核,对不合理的用药医嘱进行干预。分析全年数据,对不合理用药的干预方式、数量、类型、科室分布、药品种类、医生采纳率、被干预药品的用量变化等进行评价。结果 全年共干预不合理住院用药医嘱共718条,有效采纳率为92.5%;不合理用药的主要类型有:无指征或超适应证用药、重复用药、用法用量及疗程过长等问题;前10位被干预药品的用量下降10%~40%。结论 临床药师对住院不合理用药医嘱的事先干预有显著效果,比事后点评更有实际的效用。此方法可将不合理用药防患于未然,被干预药品的不合理情况及用量明显下降;同时也锻炼和提高了临床药师的用药技能水平。     

临床药师对急性脑梗死治疗的干预效果分析

目的探讨急性脑梗死治疗中临床药师的干预作用。方法采取回顾性调查方法,随机抽取我院临床药师干预前（2011年7—12月）和干预后（2012年1—6月）的各200例急性脑梗死病例,对其合理用药情况进行评价,并运用药物经济学原理对其成本效果进行统计分析。结果干预前后,用药合理率分别为59．5％和86％;人均住院总费用分别为10069．80元和8627．50元,其中药费分别为5527．57元和4294．34元;平均住院天数分别为12．48d和11．61d;治疗有效率分别为74％和90％;神经功能缺损评分减少率分别为33．43％和48．79％。干预前后,用药合理性、住院及药品费用以及治疗效果方面差异均有统计学意义。结论临床药师干预可促进药物的合理利用,为临床安全、有效、经济的治疗急性脑梗死提供合理用药依据。     

Reengineering a pharmacist intervention program.

At the beginning of a period of rapid growth in clinical pharmacy services in our integrated health system, we realized that there was no mechanism to address how pharmacist interventions were processed, evaluated, and followed up. Interventions were inconsistently documented, and the documentation served no more purpose than to record workload statistics. There was little assessment of the value or quality of interventions, no peer review, and no reporting of aggregate data to improve system-related problems. How are others handling the documentation and assessment of pharmacist interventions?     

Establishing a rehabilitation program for impaired pharmacists

The Texas Pharmaceutical Association (TPA) rehabilitation program for impaired pharmacists and pharmacy students is described. Since its inception in 1983, the TPA Pharmacists Rehabilitation Program has provided assistance to impaired pharmacists and pharmacy students, as well as their families, friends, customers, and coworkers. The program uses a carefully developed intervention process designed to assist impaired pharmacists and pharmacy students in obtaining evaluation and treatment of their condition. After a referral, an appointment is made for the impaired person at 1 of 15 regional evaluation and referral centers across the state, where arrangements for appropriate treatment are made. After treatment, the Committee on Pharmacists Rehabilitation aids the pharmacist or student in reentering the profession or returning to school. Intervenors are pharmacists registered in the state of Texas who have participated in TPA's training sessions; TPA also provides an intervenor's workbook. Amendments to the Texas Pharmacy Act passed in 1983 and 1985 provide protection for intervenors who are working with pharmacists and pharmacy students with impairment problems. Referrals are made by means of a 24-hour, toll-free hotline funded by a pharmaceutical manufacturing company. Other funding comes from individual donors, member associations affiliated with TPA, chain drugstores, wholesalers, and the Texas State Board of Pharmacy. A successful rehabilitation program for impaired pharmacists and students must be carefully designed and implemented, with attention paid to legal, financial, and intervention-related issues associated with substance abuse.     

Assessment of eptifibatide dosing in renal impairment before and after in-service education provided by pharmacists

BACKGROUND: Anticoagulant and antithrombotic agents are frequently cited as sources of medication errors. Several factors increase the risk of receiving excess dosing of glycoprotein IIb/IIIa inhibitors in the management of acute coronary syndrome (ACS), including older age, female gender, elevated serum creatinine, a history of diabetes mellitus, and a history of heart failure. In June 2003, the manufacturer of eptifibatide released a recommendation adjusting infusion rate downward to 1 mcg per kg per minute for eptifibatide in patients with renal impairment, defined as an estimated creatinine clearance (CrCl) < 50 ml per minute. Eptifibatide is known to accumulate in patients with renal impairment, thereby increasing hemorrhagic risk. OBJECTIVE: To assess the impact of education on physician adherence to the renal dosing recommendation for eptifibatide at 2 academic medical centers. The primary outcome measure was the proportion of patients with renal impairment dosed appropriately with eptifibatide before and after in-service education provided by a clinical pharmacist. Secondary outcome measures included the difference in the improvement in dosing adherence between the 2 sites and the influence of patient variables on the incidence of bleeding events. METHODS: This prospective study was conducted in patients with renal impairment who received eptifibatide for the medical management of unstable angina (UA) or non-ST-elevation myocardial infarction (NSTEMI) or for the interventional management of chronic stable angina, UA, NSTEMI, or ST-elevation myocardial infarction (STEMI, not a Food and Drug Administration-approved use). Patient data were assessed at 2 tertiary care teaching institutions between June 2003 and December 2005. The preeducation phase for the sites ran from June 2003 through April 2005 for Site A and from June 2003 through May 2005 for Site B. The posteducation phase ran from May 2005 through December 2005 for Site A and from June 2005 through December 2005 for Site B. At site A, a 1-hour educational seminar on ACS management strategies was employed, in which 5 minutes focused on adherence of prescribers to the guideline for renal dosing recommendations for eptifibatide. This tutorial was accomplished through (1) an in-service provided by 1 clinical pharmacist to the cardiology department, and (2) handouts containing the renal dosing recommendations for eptifibatide along with dosing for other medications used to manage ACS. The intervention at Site B involved an eptifibatide-focused seminar presented to cardiologists by a clinical pharmacist, 10 minutes of which was devoted to renal dosing recommendations that included (1) a summary of literature supporting the infusion rate reduction in patients with renal impairment and (2) the specific updated dosing recommendation for eptifibatide. The data collected in retrospective chart review included patient demographics, baseline laboratory values, and risk factors for bleeding. An appropriate eptifibatide dose was defined as a physician order for a continuous infusion of 1 mcg per kg per minute in patients with an estimated CrCl < 50 ml per minute. RESULTS: A total of 148 patients with renal impairment who received eptifibatide were evaluated (106 in the preeducation phase and 42 in the posteducation phase). A significant increase in the adherence rate for eptifibatide dosing in patients with renal impairment was observed from 36.8% in the preeducation phase to 69.0% in the posteducation phase (P < 0.001) for the 2 sites combined. The incidence of major and minor bleeding was 16.7% in the preeducation phase and 14.3% in the posteducation phase (P = 0.742). When bleeding incidence was stratified by the appropriateness of infusion, the incidence of major and minor bleeding was also similar for appropriate dosing (1 mcg per kg per minute, 16.4%) versus inappropriate dosing (2 mcg per kg per minute, 15.7%; P = 0.916). CONCLUSION: This educational intervention provided by a clinical pharmacist was associated with improved prescriber adherence to dosing recommendations for eptifibatide in patients with renal impairment. Improved adherence to the dosing guideline and administration of an appropriate infusion rate were not associated with reduction in either minor or major bleeding events.     

临床药师对肿瘤患者抗菌药物干预效果分析

目的:动态分析某三甲医院肿瘤患者抗菌药物的使用情况,考察临床药师用药干预对合理使用抗菌药物的促进效果。方法:利用回顾性调查方法对某医院肿瘤患者抗菌药物使用情况进行动态分析。每月每个病区随机抽取使用抗菌药物的患者进行审核。应用PDCA循环管理对一病区抗菌药物使用的合理性进行干预。比较一病区和二病区抗菌药物的动态变化。结果:肿瘤内科一病区和二病区抗菌药物使用率分别为(6.3±1.5)%和(12.5±2.8)%(P<0.01)、抗菌药物费用占药费总额百分率分别为(1.6±1.2)%和(2.8±1.0)%(P<0.05);2个病区抗菌药物合理率分别为82.3%和66.6%(P<0.05)。不合理用药主要表现在用法用量不合理、无用药指征、用药级别高、特殊级抗菌药物无感染专科会诊单、越级使用抗菌药物。结论:老年肿瘤患者感染发病率较高,PDCA干预病区的抗菌药物使用率、使用强度、抗菌药物费用低于非干预病区。临床药师用药干预实践能够促进抗菌药物的合理使用。     

临床药师在肾内科病区开展医嘱审核工作

目的分析某三甲医院肾内科病区医嘱审核的情况,为临床药师参与肾内科医嘱审核提供参考。方法 2017年 9月至 2018年 8月成都医学院第一附属医院临床药师结合每日查房对肾内科病区医嘱实行审核,并对审核情况进行总结分析。结果临床药师共审核肾内科医嘱 10 383条,其中不合理医嘱 156条,不合理率 1.50%。不合理医嘱类别主要为药物的用法用量与疗程( 29.49%)、重复用药( 25.00%)、药物选择( 14.74%)。临床药师审核干预后,不合理率从 2.26%下降至 0.89%。结论临床药师通过对病区医嘱的审核干预,促进临床合理用药,从而保证临床用药的安全性和有效性。     

临床药师干预药物治疗的评价分析

目的:分析临床药师在临床实践中提出的药物治疗建议,探讨临床存在的用药问题,为药学实践提供参考。方法:回顾性分析临床药师于2013年7月至2014年6月1年中为临床(急诊ICU、骨科、肝胆外科等9个科室)提供并被采纳的治疗建议,对建议数量、干预药物的类别、治疗建议的类型及具体干预内容等进行归纳整理。结果:治疗建议的数量随时间的发展呈上升趋势。干预的药物共56类,前3类药物分别是抗菌药物、营养支持药物及肝胆疾病辅助用药。治疗建议的类型共涉及"给药方案调整"、"疗程管理"等9大类,包括25个亚类型。结论:临床药师的治疗建议有助于促进临床合理用药,同时作为治疗团队的一员,可提供更好的个体化治疗方案。     

临床药师对一例骨科术后感染病人的抗菌治疗干预

目的：探讨临床药师在干预一例骨科术后感染病人的抗菌治疗中所起的作用.方法：通过监测去甲万古霉素血药浓度,找出该病人前期药物治疗效果不佳的原因;规范操作头孢唑林钠皮试,根据感染部位,分析可能致病菌,结合各种药物的抗菌谱和不良反应,重新制定治疗方案,进行药学监护.结果：去甲万古霉素血药浓度低于有效浓度,头孢唑林钠皮试结果为阴性,改用头孢唑林钠（2.0g,iv gtt,tid）进行治疗,2d后自觉疼痛等症状缓解,继续治疗18 d后痊愈出院.结论：临床药师在临床会诊查房中及时有效地干预了病人的抗菌治疗,发挥了重要的作用.     

Clinical toxicology consultation by pharmacists.

The functions of pharmacists in a clinical toxicology consultation service are described. Pharmacists provided three basic services in conjunction with poisonings treated by the emergency department of a children's hospital: (1) assisted with obtaining the history and assessment of the toxicologic proglems, (2) recommended a plan for rational management, and (3) discussed poison prevention with the parents of the victims. Pharmacists were consulted for 189 poisoning cases over a six-month period; 80% of the cases were attended at the bedside and the remainder were monitored by telephone. Drugs were involved in 58% of the patient exposures. Median time for the pharmacist to reach the emergency room after the patient's arrival was 5 to 10 minutes. Physicians and nurses rated the pharmacists' contributions favorably. These results suggest that pharmacists can play an important role in clinical toxicology.     

临床药师对心肌梗死患者个体化用药方案设计的实践

目的:探索临床药师参与制定药物个体化治疗方案设计以及实施有效药学监护的思路。方法:以1例心肌梗死患者为例,从临床药师角度分析患者的病情特征和治疗原则,利用药学理论和循证药学的证据,与临床医师共同商讨和制定药物治疗方案,对患者实施药学监护。结果:临床药师参与对患者个体化治疗方案的制定,同时对患者进行密切的药学监护,提高了患者的药物治疗效果,减少了不良反应,确保患者用药安全,取得了满意的治疗效果。结论:临床药师通过参与个体化用药融入临床药物治疗团队,在对患者的治疗方面发挥越来越重要的作用,为特定患者选用适当的药物、适当的剂量和适当的时间的个体化用药方案将打破传统给药模式,从而进一步促进临床用药更加安全、有效、合理。