Community-based residential care for the minimally impaired elderly: a survey analysis.

Foster home care for the elderly, as an alternative to living independently, living with relatives or living in an institution, has been a neglected area of investigation, although such care is a nationwide phenomenon. This survey of all licensed Family Care Home operators in the Louisville, Kentucky area provides baseline data regarding the characteristics of providers of adult foster care and the recipients. Data were obtained from 183 persons caring for minimally impaired adults in their own homes and on 422 residents in these foster home settings. Of the residents, 69.5 percent were aged 65 or over. Care providers are described on the basis of age, race, sex, educational level, family size and composition, previous employment, reasons for entering the business, and problems encountered. Residents are described on the basis of age, race, sex, physical condition, care required, and outside contacts. Foster home care for the aged can furnish many advantages if the resident is properly placed and support services are provided. This form of care deserves much greater emphasis in future research of the provision of services for the elderly.

Compatibility of cefmetazole sodium with commonly used drugs during Y-site delivery.

The compatibility of cefmetazole sodium and selected other drugs during Y-site delivery was evaluated. Cefmetazole 100 mg/mL (as the sodium salt) in sterile water for injection and each of 34 drugs or solutions commonly used with it were mixed together by Y-site injection. Secondary drugs were administered at selected concentrations and rates and delivered by the method (i.v. push, i.v. infusion, or syringe pump) commonly used for the drug at the institution where the study was done. Each injection set included a filter system with a 0.8-micron filter disk. Tests were done in triplicate. After each test, the Y injection site and the tubing after it were visually inspected for precipitate and color change. If no particles or color change was detected, the filter disk was observed under a microscope. Drugs were deemed compatible with cefmetazole if unaided observation detected no color change or particles and the number of particles detected by microscopic examination was below that specified in USP guidelines. A precipitate formed when cefmetazole sodium mixed with diphenhydramine hydrochloride, droperidol, erythromycin (50 mg/mL, as the lactobionate), haloperidol lactate, prochlorperazine edisylate, promethazine hydrochloride, or vancomycin (50 mg/mL, as the hydrochloride salt). No particles or color change was detected by unaided observation of mixtures containing dobutamine or erythromycin 10 mg/mL, but the number of particles detected by microscopic examination exceeded USP limits. All other drugs tested were compatible with cefmetazole. Cefmetazole 100 mg/mL (as the sodium salt) in sterile water for injection was shown to be compatible with 25 of 34 tested drug solutions during Y-site delivery.

Mail-in questionnaire for monitoring nausea and vomiting in oncology outpatients.

A patient questionnaire designed to help pharmacists monitor nausea and vomiting in outpatients receiving cancer chemotherapy was studied. A 12-item questionnaire was designed by combining items from the Morrow Assessment of Nausea and Emesis (MANE) and the Functional Living Index-Emesis (FLIE). Items included number of vomiting episodes, duration of nausea, number of antiemetics, severity of nausea and vomiting, impact on quality of life, and adverse effects. The questionnaire was printed on an addressed, postage-paid card. Over an eight-week period, outpatients in a hospital's oncology clinic were asked to complete the questionnaire at home during the three days after chemotherapy. Of 48 patients asked, 42 (88%) agreed to complete the questionnaire, and 36 (86%) of these patients mailed it back to the clinic. Of the respondents, 11 reported at least one episode of vomiting, and 22 reported nausea. Thirteen respondents logged nausea ratings of 3 or higher on a 7-point scale. Twenty respondents used antiemetics. Responses given by the patients in follow-up telephone interviews did not differ significantly from the responses collected with the questionnaire. More than 90% of patients who returned the questionnaire rated it as simple to complete. Pharmacists used the self-reports of nausea or vomiting in 7 (17%) of 42 cases to recommend alternative antiemetic regimens. A mail-in questionnaire for monitoring nausea and vomiting in outpatients undergoing chemotherapy was completed and returned by a high percentage of patients and was useful to clinic pharmacists.

Call to action: finding solutions for the drug shortage crisis in the United States.

In their article in this issue of CPT, Woodcock and Wosinska are the first to clearly outline the quality and manufacturing problems causing drug shortages of generic injectables. These authors have focused on the main issue, namely, that manufacturing problems and the lack of incentives for quality products are the primary reasons for most recent shortages of generic injectable drugs.

Career expectations of pharmacists with postgraduate training in drug information.

The career expectations of pharmacists who have completed postgraduate training in drug information were studied. A questionnaire was mailed to all pharmacists who completed fellowships or residencies in drug information from 1989 to 1993 and the current preceptors of such programs. Recipients were asked to provide information about past and present positions, residency or fellowship training goals, characteristics of an ideal practice setting, satisfaction with current positions, professional activities, and future career goals. Seventy-five pharmacists (26 preceptors and 49 former trainees) returned questionnaires with usable information, for an 86% response rate. Preceptors and former trainees gave similar responses regarding the desired characteristics of an ideal practice setting, overall satisfaction with one's current position, expectations after postgraduate training in drug information, and long-term career goals. However, many former trainees did not list drug information-related positions as the desired first job after training, suggesting that the career opportunities in drug information may need to be stressed more heavily in training programs. Former drug information residents and fellows had career expectations similar to those held by current program preceptors.

Development of a hospital-based adverse drug reaction reporting program.

The development of an adverse drug reaction (ADR) reporting program at a university hospital is described in this article. Critical steps in the development process included identifying the personnel responsible for the program, defining ADRs and reportable ADRs, developing an ADR data form, promoting the program, and providing feedback to the health care professionals of the institution. A standing ADR subcommittee was formed to develop, implement, and coordinate the program. Two approaches to data collection were used: the standard format of voluntary reporting and a targeted drug method (targeting specific agents, typically newly approved drugs or those in which new, or potentially serious adverse reactions have been noted). The program was promoted through memorandums to department chairpersons and through a P & T Committee newsletter. The number of ADRs reported per quarter steadily increased from nearly zero to approximately 60 cases per quarter. Details on the implementation of this ADR program, its limitations and successes, are described.

Hospital pharmacy compliance with JCAHO standards and ASHP guidelines for reporting adverse drug reactions.

The extent to which institutional pharmacies comply with the accreditation standards of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the ASHP guidelines for reporting adverse drug reactions (ADRs) was evaluated. A survey was mailed to directors of pharmacy at 444 randomly selected hospitals to collect information on their institutions' ADR programs; the survey addressed each point in the JCAHO accreditation standards and the ASHP guidelines. The 176 usable responses indicated that 89.8% of the institutions met all three of the JCAHO standards and 98.9% met at least two of them; 28.4% of the institutions complied with all 11 of the ASHP guidelines, and 89.2% complied with at least eight of them. Approximately 97% of the institutions had policies for ADR reporting. Respondents reported an average of 70.5 ADRs per hospital during 1989, of which 6.8 per hospital were reported to the FDA. More than 95% of all respondents indicated that they most frequently identified ADRs through voluntary reporting by health-care professionals. Respondents indicated methods and individuals responsible for reporting ADRs, notifying the physician and the FDA, and assessing severity and causality. Sixty-seven percent of the respondents indicated that they did not have a formal ADR committee for monitoring and evaluating ADRs. Almost 90% of the surveyed hospitals complied with all of the JCAHO standards for ADR reporting programs and at least 8 of the 11 ASHP guidelines for ADR monitoring and reporting.

Computer-based system for maintaining and printing a hospital formulary.

Use of a pharmacy department personal computer (PC) with database management and word processing (WP) systems to maintain a hospital formulary is described. Data input and formatting were accomplished with IBM-PC/XT-compatible equipment, the Nutshell (Leading Edge) database management system, and the Wordperfect (WordPerfect Corporation) WP system. Computer-generated pages were photocopied and placed in loose-leaf binders; reduced copies were made for pocket-size binders. The cost of an outside printing service was eliminated, and the loose-leaf format made it possible to replace only the pages with revisions. The large binders were prominently placed and clearly marked to encourage use by physicians; the number of copies needed was reduced because individual copies were no longer provided to each physician. Excluding first-year one-time costs, the annual formulary maintenance cost (for 250 copies) was projected to be approximately one sixth the cost incurred previously, when 1300 bound formularies were printed annually. Maintaining and printing the hospital formulary on a PC facilitated the updating of the formulary and reduced printing costs.

Documenting the provision of pharmaceutical care.

There is a growing importance and need for the documentation of the clinical work done by the pharmacist in providing pharmaceutical care. The data provided by documentation of care are critical to the effective and efficient transition from a product-based profession to a patient-care, service-based profession, especially during a period of great scrutiny of resource utilization in the hospital industry. Intervention documentation can serve both to document the provision of pharmaceutical care to individual patients and to provide critical information to managers to justify and expand the level of service provided.

Effect of gentamicin on heparin activity.

The importance of the effect of gentamicin on heparin activity was investigated. Heparin activity was assessed using the activated partial thromboplastin time (APTT), thrombin clotting time (TCT), and Factor X heparin assay. Drug concentrations used were 0.1, 0.2, 0.3, and 0.4 units/ml heparin with 40, 80, and 400 microgram/ml gentamicin, in vitro in human plasma. The drugs were precipitated at concentrations of 10, 20, 30, and 40 units/ml heparin with 4 and 40 mg/ml gentamicin. After centrifuging, the supernate was diluted to 0.1-0.4 units/ml heparin for assay. There was no change in heparin activity in the presence of gentamicin (in the unprecipitated solutions) as measured by the TCT, Factor X assay, and the APTT; however, APTT was prolonged by gentamicin. In the precipitated samples, heparin activity was lost in the precipitate. No significant clinical interaction that would affect the therapeutic efficacy of heparin was demonstrated except for a pharmaceutical incompatibility between gentamicin and heparin. The APTT, performed with ellagic acid as an activator, is prolonged by gentamicin.

Modified processing of prescriptions for discharged patients.

A process for designing and implementing a new procedure for handling discharge prescriptions is described. Hospital administration requested that the pharmacy department develop a new procedure to handle discharge medications. The old procedure, in which discharge prescriptions were filled by decentralized pharmacy personnel and delivered to patients' rooms, resulted in lost revenues from third-party payers and in delays for patients leaving the hospital. Under the new procedure, prescriptions are given to patients at the time of discharge; these prescriptions then may be filled either at the central ambulatory-care pharmacy or at a community pharmacy. This new procedure was designed and implemented according to a planned approach: (1) reviewing the problem, (2) evaluating the arguments for and against change, (3) using strategies to minimize resistance, and (4) evaluating the results. Resistance of pharmacy personnel, physicians, nurses and patients to the new procedure was managed by allowing pharmacy personnel to participate in the design of the new procedure; educating all affected hospital staff members about the procedure; structuring the procedure to address the problems of delayed discharge and patient ability to pay for medications; and negotiating with ambulatory-care pharmacists and technicians about the increased workload. The new procedure was implemented on July 1, 1987. The new procedure was evaluated to determine how well it worked and whether continuity of care had been compromised. As a result of this evaluation, the level of staffing and hours of operation of the ambulatory-care pharmacy were increased. A planned approach to implementing a change in the procedure for handling discharge medications was successful in identifying and overcoming resistance to that change.

Prospective evaluation of adverse drug interactions in the emergency department.

STUDY OBJECTIVE: To determine the incidence and risk factors of clinically relevant adverse drug interactions occurring in emergency department patients. DESIGN: This report describes the drug interactions identified in an emergency population. Patients' drug regimens were evaluated prospectively at the time of the emergency evaluation. SETTING: University hospital ED. TYPE OF PARTICIPANTS: Convenience sample of 341 patients. INTERVENTIONS: Patients' medications on arrival at the ED (current medications) and medications initiated in the ED were entered into Hansten's computer-based drug interaction program to identify potential drug interactions. All potential drug interactions were brought to the attention of the attending emergency physician, whose subsequent actions were noted. Clinically relevant interactions were determined by a physician panel based on the ED attendings' actions, set criteria, and a review of hospital charts and four-week telephone follow-up of patients with potential drug interactions. MEASUREMENTS AND MAIN RESULTS: Three hundred forty patients were enrolled. One hundred thirty-five potential drug interactions were identified in 61 patients. Among these 135 potential drug interactions and 61 patients, we identified 20 clinically relevant interactions in 15 patients. The incidence of clinically relevant interactions was significantly higher (chi 2 = 3.95, P = .047) among current medication (9.7%) than medication added in the ED (3.1%). Clinically relevant interaction from both current and ED-initiated medication was associated with taking three or more medications on ED arrival (P = .016 and .045, respectively). Multiple regression showed age of 60 years or older to be the sole predictor of clinically relevant interaction among current medication (P = .05). CONCLUSION: Clinically relevant adverse drug interaction was significantly less from medication administered or prescribed in the ED than from current medication.

The future of medication information practice: a consensus.

OBJECTIVE: To analyze the current practice of drug information and develop a strategic plan for a "valued" specialty of medication information practice. DATA SOURCES: The Consortium for the Advancement of Medication Information, Policy, and Research (CAMIPR) met in June 1994 to initiate a strategic plan for a future of medication information practice. A multidimensional situation analysis and strategic planning process was conducted and the results are discussed. RECOMMENDATIONS: Trends in health care (e.g., healthcare reform, managed care) will impact the future of medication information practice, and the medication information specialist must evolve with society's values. Medication information practice must transform and attention will likely focus on medication policy research/ development and information systems. However, new skills, resources, and relationships must be developed to facilitate this evolution. In addition, interest in the practice of drug information has declined. Strategies are presented to enhance the "value" and "image" of future medication information practice.

Consensus statement on the live organ donor.

OBJECTIVE: To recommend practice guidelines for transplant physicians, primary care providers, health care planners, and all those who are concerned about the well-being of the live organ donor. PARTICIPANTS: An executive group representing the National Kidney Foundation, and the American Societies of Transplantation, Transplant Surgeons, and Nephrology formed a steering committee of 12 members to evaluate current practices of living donor transplantation of the kidney, pancreas, liver, intestine, and lung. The steering committee subsequently assembled more than 100 representatives of the transplant community (physicians, nurses, ethicists, psychologists, lawyers, scientists, social workers, transplant recipients, and living donors) at a national conference held June 1-2, 2000, in Kansas City, Mo. CONSENSUS PROCESS: Attendees participated in 7 assigned work groups. Three were organ specific (lung, liver, and kidney) and 4 were focused on social and ethical concerns (informed consent, donor source, psychosocial issues, and live organ donor registry). Work groups' deliberations were structured by a series of questions developed by the steering committee. Each work group presented its deliberations to an open plenary session of all attendees. This information was stored and shaped into a statement circulated electronically to all attendees for their comments, and finally approved by the steering committee for publication. The term consensus is not meant to convey universal agreement of the participants. The statement identifies issues of controversy; however, the wording of the entire statement is a consensus by approval of all attendees. CONCLUSION: The person who gives consent to be a live organ donor should be competent, willing to donate, free from coercion, medically and psychosocially suitable, fully informed of the risks and benefits as a donor, and fully informed of the risks, benefits, and alternative treatment available to the recipient. The benefits to both donor and recipient must outweigh the risks associated with the donation and transplantation of the living donor organ.