Clinical decision support implemented with academic detailing improves prescribing of key renally cleared drugs in the hospital setting.

OBJECTIVE: Lack of dose adjustment for renally cleared drugs in the presence of poor renal function is a common problem in the hospital setting. The absence of a clinical decision support system (CDSS) from direct clinician workflows such as computerized provider order entry (CPOE) hinders the uptake of CDSS. This study implemented CDSS in an environment independent of CPOE, introduced to prescribers via academic detailing, to address the dosing of renally cleared drugs. DESIGN: GFR+ was designed to automatically calculate and update renal function, doses of key drugs adjusted for renal function, and highlight clinically significant decreases in renal function. Prescribers were made aware of GFR+, its navigation, and surrounding clinical issues, using academic detailing. MEASUREMENT: The rate of dosing conformity and management for key renally cleared drugs in hospitalized patients, before and after GFR+ implementation. RESULTS: Improvements were seen in dosing conformity for enoxaparin (from 68% to 86%, p=0.03), gentamicin (63-87%, p=0.01), and vancomycin (47-77%, p=0.07), as well as the appropriate use of gentamicin therapeutic drug monitoring (70-90%, p=0.02). During episodes of acute renal impairment, renally cleared drugs were held on 38% of instances in the pre-intervention period compared with 62% post-intervention (p=0.01). CONCLUSION: Clinical decision support implemented with academic detailing improved dosing conformity and management of key renally cleared drugs in a hospitalized population. Academic detailing should be strongly considered to facilitate the introduction of CDSS systems that cannot be placed directly into the clinician workflow.

Getting it right the first time: developing nanotechnology while protecting workers, public health, and the environment.

Nanotechnology, the design and manipulation of materials at the atomic scale, may well revolutionize many of the ways our society manufactures products, produces energy, and treats diseases. Innovative nanotechnology products are already reaching the market in a wide variety of consumer products. Some of the observed properties of nanomaterials call into question the adequacy of current methods for determining hazard and exposure, and for controlling resulting risks. Given the limitations of existing regulatory tools and policies, two distinct kinds of initiatives are urgently needed: first, a major increase in the federal investment nanomaterial risk research, and second, rapid development and implementation of voluntary standards of care pending development of adequate regulatory safeguards. The U.S. government should increase federal funding for nanomaterial risk research under the National Nanotechnology Initiative to at least $100 million annually for the next several years. Several voluntary programs are currently at various stages of evolution, though the eventual outputs of each of these are still far from clear. Ultimately, effective regulatory safeguards, harmonized globally, are necessary to provide a level playing field for industry while adequately protecting human health and the environment.