Structure, stress, and tissue repair in aortic valve leaflets.

During the normal cyclic operation of the aortic valve its leaflets are subjected to continual bending, shearing, and membrane stresses. In vivo studies of marked leaflets have shown that the bending stresses are greatest where leaflets are attached to the aortic wall. Pressure stresses during diastole also appear to be high in this region. The internal shearing stresses are difficult to predict because of the semifluid nature of the tissue in the attachment zone. In the present study a model of the attachment region incorporated measurements of leaflet motion from dogs in vivo and from histological sections. From these measurements bending and membrane stresses were derived in order to estimate the total stresses. In this region the total stresses in systole were negligible because membrane stresses are essentially zero, but those in diastole ranged from 76 to 95 g.mm-2 in the circumferential direction and from 37 to 44 g.mm-2 in the radial direction. The calculated stress suggests that excessive tissue wear and valve failure could occur in the absence of tissue replacement. From radioautographic studies of rat valves, proteins and complex sugars of the valve connective tissues were found to be regularly replaced in patterns predictable from the level of stresses.

Folic acid improves phenytoin pharmacokinetics.

Phenytoin (PHT) therapy to control seizures decreases serum folate levels in half of epileptic patients, thus increasing the risk of folate depletion. Supplementation with folic acid prevents deficiency but also changes PHT pharmacokinetics. Kinetic monitoring of PHT when folic acid is provided as a supplement has not been reported in women of child-bearing age. This study of six fertile women examined the interdependence of PHT and folic acid in a randomized crossover study of two treatments: treatment 1 consisted of 300 mg sodium PHT per day and treatment 2 consisted of 300 mg sodium PHT plus 1 mg folic acid per day. Dietary folic acid intake was calculated daily. During treatment 1, serum folate level decreased 38.0 +/- 18.6% (mean +/- standard deviation) and serum PHT concentration was in the low therapeutic range (43.92 +/- 14.52 mumol/L). During treatment 2, serum folate level increased 26.0 +/- 33.4%, and serum PHT level (39.04 +/- 14.16 mumol/L) was similar to that in treatment 1. Only one subject attained PHT steady state during treatment 1, but four subjects achieved steady state during treatment 2. Dietary folate intakes during treatments 1 and 2 were not significantly different. This study suggests an interdependence between PHT and folic acid and supports the observation that fertile women treated with PHT require folic acid supplementation to maintain a normal serum folate level.

Home parenteral nutrition programs.

The technique of home parenteral nutrition (HPN) is becoming a more widely used method to treat patients who cannot eat for prolonged periods; to date, more than 500 patients have been trained nationwide. Training has been limited for the most part to larger centers which have more experience in providing this complex patient education. As this technique becomes more widely accepted, however, other less experienced health care professionals will be called upon to develop HPN training programs. For this reason, it is important to simplify these training programs, with initial attention directed toward the procedures used to prepare the total parenteral nutrition solution. The chance of potential errors can be reduced by using amino acid solutions with electrolytes included in the formulation. When possible, complexity can be reduced by administering vitamins and extra electrolytes orally. The teaching program can be simplified by developing or using existing training manuals, which standardize procedures so that consistent methods are taught and performed. The manual can serve as a reference for patient and teacher alike. Distribution of supplies can be simplified by employing commercially available shipment programs; but, while these are very convenient for the patient and pharmacy, the costs of such programs could be a limitation. Finally, the extensive work required to arrange reimbursement for services and supplies also can be simplified. Often a social worker can facilitate this process because of experience and training in dealing with payment problems. In addition, training fees should be negotiated with third party payors early in the development of HPN programs. By simplifying these basic elements in an HPN, the task of training patients is less imposing and can be made more widely available to those who need this treatment modality.

Serum zinc concentrations: contamination from laboratory equipment.

The following experiment was designed because of high serum zinc reported in patients who were reciving total parenteral nutrition (TPN) concentrations. Blood samples were collected, divided into 3 containers: a clean glass control test tube, a vacuum collecting tube with a rubber stopper, and paraffin clot activator. It was found that compared to glass control tubes, vacuum collection with rubber stoppers contributed an average of 76 +/- 14 microgram/dl of zinc as contaminants. Moreover, tubes with a rubber stopper and clot activator contributed 198 +/- 42 microgram/dl of zinc as contaminants. It is concluded that care must be used to avoid trace element contaminants when plasma zinc concentrations are analyzed. Without proper methodology, including selection of the container in which the sample is taken, erroneous results will be reported.

Albumin in TPN solutions: potential savings from a prospective review.

As a result of the common usage of albumin in total parenteral nutrition (TPN) solutions at The Ohio State University Hospitals, a review of the use of this product was performed. Albumin therapy in 18 patients was evaluated using prospective criteria. Therapy was considered appropriate if the serum albumin level was less than or equal to 3.0 g%. Using these criteria, 12 of 18 patients (67%) received albumin in the TPN solution. Of these 12 patients, 7 received albumin unnecessarily. During the 3-week review, a total of 168 vials of 50 ml, 25% albumin (2100 g) were administered to patients with serum albumin concentrations greater than 3.0/100 ml at a cost of $6,014. Over a year, this could mean over $100,00 in costs which could be eliminated. Criteria for use of albumin in malnourished patients receiving TPN are not well established. This study demonstrated that developing simple criteria for the prospective review of albumin in TPN solutions and using them to monitor albumin therapy closely, can result in very significant cost savings to patients receiving TPN.

Re-engineering the hospital: a house without rooms.

Re-engineering of health care systems is defined, and the experience with re-engineering at a medical center is discussed. Re-engineering is a business concept that involves totally redesigning work processes to achieve much higher efficiencies and quality; it should not be confused with cost cutting, downsizing, and continuous improvement. Re-engineering seeks to combine multiple jobs into one, empower workers and make them more accountable, sequence the elements of work more naturally, create greater flexibility, and blur or remove organizational boundaries. Re-engineering at The Ohio State University Medical Center began with the formation of an operations improvement team consisting of department heads. Work processes were selected for re-engineering and prioritized, and teams were created to identify activities calling for radical change, such as activities that wasted time, could be done on an outpatient basis, or were duplicative. It was concluded that the redesign had to focus on the entire medical center, not the individual departments. A list of the characteristics of a better organization was prepared and distributed to the staff, along with other documents to help them understand the need for change. The operations improvement team specified expected outcomes of the re-engineering, and each re-engineering team developed measures of these outcomes. Many of the recommendations submitted have been implemented. One innovation has been the consolidation of the duties of utilization-review nurses, continuity-of-care nurses, social workers, and patient-education nurses into a single job category. When the medication-use re-engineering team meets, it will not be re-engineering the pharmacy department, it will be addressing the drug-use process. A medical center is re-engineering itself so that it will be able to continue to meet the health care needs of the community it serves.

ASHP national survey of pharmacy practice in acute care settings: prescribing and transcribing--1998. American Society of Health-System Pharmacists.

Results of the 1998 ASHP national survey of pharmacy practice in acute care settings that pertain to prescribing and transcribing practices are presented. Pharmacy directors at 1058 general and children's medical-surgical hospitals in the United States were surveyed by mail. Data on hospital characteristics were supplied by SMG Marketing Group, Inc.; the survey sample was drawn from SMG's hospital database. The response rate was 51.8%. Respondents reported that at least 90% of hospital and health-system pharmacy and therapeutics (P&T) committees are responsible for formulary development and management, drug policy development, medication-use evaluation, adverse-drug-reaction reporting, and medication error monitoring. More than 90% of the facilities use pharmacoeconomic, clinical and therapeutic, and cost information in formulary development; 83% have a medication-use-evaluation program designed to improve prescribing; more than 95% have P&T committees, infection control committees, and quality control committees; and more than 80% provide pharmacist consultations on drug information, dosage adjustments for patients with renal impairment, antimicrobials, and pharmacokinetics. A majority of respondents reported that accurate transcription of medication orders is ensured by use of standardized physician order forms, clarification of illegible orders, reconciliation of medication administration records (MARs) and pharmacy profiles at least daily, and use of computer-generated MARs. The 1998 ASHP survey results suggest that pharmacists in acute care settings have positioned themselves well to improve the prescribing and transcription components of the medication-use process.

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing--2001.

Results of the 2001 ASHP national survey of pharmacy practice in hospital settings that pertain to prescribing and transcribing are presented. A stratified random sample of pharmacy directors at 1091 general and children's medical-surgical hospitals in the United States was surveyed by mail. SMG Marketing Group, Inc., supplied data on hospital characteristics; the survey sample was drawn from SMG's hospital database. The response rate was 49.0%. During 2001, nearly all hospitals are estimated to have pharmacy and therapeutics (P&T) committees that meet an average of seven times per year. It is estimated that more than 90% of P&T committees are responsible for formulary development and management, drug policy development, adverse-drug-reaction review, and medication-use evaluation. More than 90% of hospitals use clinical and therapeutic, cost, and pharmacoeconomic information in the formulary management process, while nearly two thirds consider quality-of-life issues. Nearly 70% use clinical practice guidelines in the formulary management process, and 78% have a medication-use evaluation program designed to improve prescribing. Pharmacists in more than 75% of hospitals provide consultations on drug information, dosage adjustments for patients with renal impairment, antimicrobials, and pharmacokinetics. Further, a majority of hospitals ensure accurate transcription of medication orders by clarifying illegible orders before transcription or entry into medication administration records (MARs), using standardized prescriber order forms, requiring prescribers to countersign all oral orders, and reconciling MARs and pharmacy patient profiles at least daily. In 2001, large hospitals are most likely to use prescriber order-entry systems to improve patient safety and are least likely to require the reentry of medication orders into the pharmacy computer system. The 2001 ASHP survey results suggest that pharmacists in hospital settings have positioned themselves well to improve the prescribing and transcribing components of the medication-use process.

ASHP national survey of pharmacy practice in acute care settings: dispensing and administration--1999.

Results of the 1999 ASHP national survey of pharmacy practice in acute care settings that pertain to drug dispensing and administration practices are presented. Pharmacy directors at 1050 general and children's medical-surgical hospitals in the United States were surveyed by mail. The response rate was 51%. About three-fourths of respondents described their inpatient pharmacy's distribution system as centralized. Of those with centralized distribution, 77.4% indicated that their system was not automated. Decentralized pharmacists were used in 29.4% of the hospitals surveyed; an average of 58.9% of their time was spent on clinical, as opposed to distributive, activities. About 67% of directors reported pharmacy computer access to hospital laboratory data, 38% reported access to automated medication-dispensing-unit data, and 19% reported computer access to hospital outpatient affiliates. Only 13% of hospitals had an electronic medication order-entry system; another 27% reported they were in the process of developing such a system. Decentralized medication storage and distribution devices were used in 49.2% of hospitals, while 7.3% used bedside information systems for medication management. Machine-readable coding was used for inpatient pharmacy dispensing by 8.2% of hospitals. Ninety percent reported a formal, systemwide committee responsible for data collection, review, and evaluation of medication errors. Virtually all respondents (98.7%) reported that their staff initiated manual reports. Only two thirds tracked these reports and reported trends to the staff. Fewer than 15% reported that staff were penalized for making or contributing to an error. Pharmacists are making a significant contribution to the safety of medication distribution and administration. The increased use of technology to improve efficiency and reduce costs will require that pharmacists continue to focus on the impact of changes on the safety of the medication-use system.

Cost of medication-related problems at a university hospital.

The cost to an institution of medication-related problems (MRPs) was studied. A retrospective chart review covering the period from July 1992 through June 1994 was performed for patients at a university-affiliated medical center hospital who were known to have had clinical consequences from an adverse drug reaction (ADR) or medication error. All interventions resulting directly from the problem were recorded. A detailed list of patient charges was reviewed for each patient, and specific charges for the MRP-associated interventions were tabulated. The clinical outcomes used to evaluate intervention costs were categorized as extra laboratory tests, noninvasive procedures, additional treatments, invasive monitoring or procedures, increased length of stay, and intensive care. The cost of each intervention was calculated by applying the cost-to-charge ratio used in the institution's patient-charge-based accounting system. A total of 109 patient charts were reviewed. A total of 349 clinical outcomes associated with MRPs, or an average of 3 outcomes per patient, were detected. The mean +/- S.E. cost of MRP-associated clinical outcomes to the institution ranged from $95 +/- 11 for additional laboratory tests to $2640 +/- 596 for intensive care. The next most costly outcomes were increased length of stay and invasive monitoring or procedures. For the 1911 MRPs reported in 1994, the estimated total cost was almost $1.5 million. A review of the medical records of patients for whom an ADR or medication error had been recorded showed a high cost of these events to the institution, with the cost varying with clinical outcome, and a correspondingly strong opportunity for pharmacists to intervene to save money and improve the quality of care.

ASHP national survey of pharmacy practice in acute care settings: monitoring, patient education, and wellness--2000.

Results of the 2000 ASHP national survey of pharmacy practice in acute care settings that pertain to patient medication monitoring, education, and wellness are presented. Pharmacy directors at 1063 general and children's medical-surgical hospitals in the United States were surveyed by mail. The response rate was 50.2%. Although the respondents indicated that most pharmacists spent less than 20% of their time on medication-monitoring activities, the amount of time devoted to such activities was increasing. Pharmacists were selective about which patients they chose to monitor for medication-related problems. Patients were frequently chosen on the basis of service or medication. Pharmacists used a number of mechanisms to monitor patients for adverse drug events (ADEs). Although internal ADE reporting had generally increased within the preceding three years, 81% of the Institutions had implemented strategies to improve reporting. When ADEs were reported externally (59% of the respondents), FDA was most commonly alerted. About 92% of the respondents indicated that nursing had primary responsibility for counseling patients about medications. Pharmacists were infrequently involved in medication education during the hospital stay; however, 48% of the institutions used some method to identify patients needing counseling by pharmacists. Slightly more than half of the respondents reported having wellness programs. Pharmacists were most commonly involved in disease-based wellness programs. Pharmacists in acute care settings appear to be well positioned to improve the patient-monitoring, education, and wellness components of the medication-use process.

How to make good black and white enlarged pictures from color transparencies.

The greatest obstacle in obtaining high-quality black and white prints for publication, from a high-quality color transparency, is the making of an excellent internegative. A process is described for making high resolution internegatives simply and quickly.

A congenital band about the pelvis. Case report with a 24-year postoperative follow-up.

A patient with a congenital band about the pelvis is presented. She was operated on in her early years. Photographs document the result during a 24-year follow-up.

Review of the justification for pharmacy parenteral admixture preparation.

Pharmacy-based intravenous admixture programs are still not present in many hospitals today, despite the length of time these programs have been advocated. This paper reviews the scientific, legal, and administrative basis for pharmacy-based centralized intravenous admixture programs. Key elements in developing admixture programs based on these points are reviewed.

Use of severity-indexed medication error reports to improve quality.

A severity-indexed medication error reporting system using data from voluntary incident reports has provided enough information to target opportunities for quality improvement. Reports are ranked by severity and categorized by error type, system breakdown, drug category, and nursing unit. Specific reports are generated for review by different quality improvement committees in the hospital. Based on these data and the actions of these quality improvement committees, four problem areas in medication use have been identified. Recommendations for improvements have been made to solve problems with late IV antibiotic doses, narcotic errors, anticoagulant errors and transcription errors. Two of these initiatives have resulted in objective improvement. Two others are being actively pursued to resolve medication related problems.

Trends in cost containment: where do we cut?

The current emphasis on cost containment and its impact on pharmacy practice is reviewed. Methods by which existing standards of practice can be maintained are presented. Strategies for increasing the pharmacist's role in patient care within this climate are discussed. Examples of cost-effective approaches to pharmacy management and practice are outlined. Specific approaches include fiscal management of inventory, efficient use of personnel, and developing programs that reduce health-care cost.

Patients' perceptions of pharmaceutical services offered by an ambulatory clinic pharmacy.

The importance that patients place on various patronage motives and service offerings of an ambulatory pharmacy associated with a university hospital was studied. Questionnaires were distributed to 193 patients and 8 pharmacists employed at the pharmacy. The patient questionnaire contained a list of 13 patronage motives and 18 service offerings. Respondents rated the importance of each patronage motive in their decision to visit the pharmacy and their view of the importance of each pharmaceutical service offering on an anchored scale (1 = not important, 5 = very important). The pharmacist questionnaire included the 18 service offerings. Pharmacists rated their perceptions of the importance patients place on each service. The response rates were 52.8% for patients and 100% for pharmacists. Patients indicated acceptance of insurance plan, availability of prescription medication, and presence of a knowledgeable pharmacist as the most important patronage motives. Ability to call in refills by telephone and various interactions with the pharmacist were identified as the most important service offerings. The results showed congruence between the pharmacists' perceptions of important patient services and the importance patients actually place on the services. Understanding the importance of patronage motives and service offerings is necessary in the development of marketing activities to attract new patients and retain current patients.

Comprehensive intravenous admixture services: logistics and quality assurance in a university affiliated teaching institution.

The role of supportive personnel, as well as the supervision of intravenous (IV) admixture compounding by staff pharmacists, should be clearly identified by the departmental manager. In doing so, the department should strive to achieve an optimal mix of professional and technical personnel with automated technology. Close attention must be paid to quality assurance in order to maintain the highest quality parenteral admixture. The logistics of comprehensive IV admixture services are described for a university affiliated teaching institution. Emphasis is made on a three-faceted approach to quality assurance, including technician training, end-product testing, and equipment maintenance.