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ABSTRACT: Optimization of the timing of appropriate antibiotics is crucial to improve the management of patients in severe sepsis and septic shock. Vancomycin is commonly used empirically in cases of nosocomial infections in critically ill patients. Therefore, early optimization of vancomycin pharmacokinetics is likely to improve outcomes.
To evaluate a pharmacokinetic program to predict serum vancomycin concentrations in accordance with administered dose, weight, height, and creatinine clearance in a critically ill population.
We conducted a prospective observational single-center study in a 45-bed intensive care unit (ICU). All patients hospitalized in the ICU requiring intravenous treatment with vancomycin for a suspected infection were enrolled. The modalities of vancomycin therapy and the monitoring of serum concentrations were left to the discretion of the treating clinician. We compared the measured serum vancomycin concentrations with those predicted by the MM-USCPACK program and analyzed the factors influencing the prediction.
Fifty-four intravenous vancomycin courses were administered in 48 critically ill patients over the 3-month study. The precision was considered acceptable, based on a relative precision equal to 8.9% (interquartile range 3.5-18.9%) and the relative bias for all predictions was equal to -1.3%. Overall, 77.3% of predictions were within 20% of observed concentrations; factors correlating with a poorer prediction were a change in renal function, obesity, and the magnitude of organ dysfunction on initiation of vancomycin (expressed by a Systemic Organ Failure Assessment score >11).
The MM-USCPACK program is a useful and reliable tool for prediction of serum vancomycin concentrations in patients hospitalized in ICU and likely reflects the close monitoring of renal function in this setting. For some patients (more severely ill, obese, or significant change in renal function during vancomycin therapy), predictions were less precise.
Annals of Pharmacotherapy 09/2011; 45(10):1193-8. · 2.13 Impact Factor
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ABSTRACT: Insulin is a high-risk medicine which may cause significant patient harm or death when given incorrectly. A 10-fold error in administered insulin dose commonly occurs when the abbreviation 'u' is used for 'units' and subsequently misinterpreted as a 'zero.'
A multidisciplinary working party was convened and mapped insulin prescribing, dispensing and administration. All inpatient orders above 25 units for short-acting insulin and 50 units for other insulin require validation by an additional source. Educational strategies to support adherence to the guideline and product-labelling alerts were developed.
Implementation occurred in August 2008 across the three hospital sites. In 90 weeks after implementation, there were 150 patients identified in which 200 high doses of insulin were prescribed (>25 units for short-acting insulin and 50 units for other insulin). There were eight instances where high doses of insulin were prescribed in error but were detected and rectified through the new validation process. There were 12 dosing errors that occurred, including two 10-fold dosing errors. In contrast, seven major errors resulting in excessive insulin administration were identified over a 2-year period prior to the introduction of the insulin high-dose validation system.
A structured validation process was successful in reducing incorrect prescription and administration of high-dose insulin and has reduced the risk of associated fatalities or significant patient harm. Consideration should be given to adopting this process in any setting where insulin is prescribed and administered.
BMJ quality & safety 07/2011; 20(7):637-44.
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ABSTRACT: Therapeutic drug monitoring is usually required for safe and effective administration of vancomycin. However, dosing recommendations from published guidelines are not suitable in achieving therapeutic vancomycin concentrations in a timely manner in patients with normal renal function.
To audit vancomycin dosing and concentrations at our institution and evaluate the predictive accuracy of a pharmacokinetic simulation program, with a view to implementing a pharmacy-based pharmacokinetic service for vancomycin monitoring.
Patients receiving vancomycin were identified prospectively through the therapeutic drug monitoring archives. Patient information was obtained from medication charts and medical records that were located on wards. Data were entered into the MM-USC*Pack program (Jelliffe R, University of Southern California, 2008, version 12.10). This software was used to predict initial and subsequent concentrations of vancomycin based on patient parameters. The predictive accuracy of this software was evaluated by comparing the predicted concentrations to the observed concentrations.
During a 6-week period, 204 concentrations were measured in 77 patients. The most common dosing regimen was 1 g every 12 hours. Overall, initial trough concentrations were subtherapeutic (<10 mg/L) in 58% of patients and trough concentrations did not become therapeutic at any stage throughout therapy in 25% of patients. The pharmacokinetic modeling software demonstrated little systematic bias (-3.1%), but the precision (median prediction error) was 23% (interquartile range, 11-45%). Predictions were poorer in obese patients (body mass index >35 kg/m(2)) and in patients with unstable renal function.
A delay in attaining target trough concentrations was observed in a significant proportion of patients. Pharmacokinetic modeling software is a potential tool to improve the timeliness of achieving adequate dosing by allowing concentrations to be determined prior to steady-state. The program was able to predict vancomycin concentrations across a heterogeneous patient population with little systematic bias, but only moderate precision.
Annals of Pharmacotherapy 06/2011; 45(6):757-63. · 2.13 Impact Factor
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The Medical journal of Australia 10/2010; 193(7):427. · 2.81 Impact Factor
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ABSTRACT: To implement and evaluate a flexible palliative care education program for Australian community pharmacists.
After identifying pharmacists' education needs, the program content and format were developed. This included identifying expert writers to create modules, assigning education and palliative care specialists to review content, and designing Web hosting of materials. The program was comprised of 11 modules and 79 activities.
An average of 28 responses was posted for each of the 20 noticeboard activities. Of the 60 pharmacists who began the program, 15 contributed to the discussion group, with an average of 3 posts each. Participants' responses to an online questionnaire indicated the program addressed their education needs and improved their knowledge and confidence in providing palliative cancer care.
A program that pharmacists could access at a time and place convenient to them via the Internet was developed. Pharmacists indicated the program positively impacted their practice.
American journal of pharmaceutical education 03/2010; 74(2):24. · 1.21 Impact Factor
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ABSTRACT: To identify current prescribing and administration practices in relation to intravenous potassium chloride (IV KCl).
A prospective multicentre assessment of IV KCl prescribing and administration at six public hospitals (three large metropolitan hospitals, a smaller metropolitan specialty hospital, and two rural hospitals) in Victoria between August and December 2006. Data were collected for either a 4-week period or for 200 IV KCl orders, whichever occurred first, in clinical areas where concentrated KCl ampoules were available.
Number and type of IV KCl prescriptions and dose administrations; method of preparation and administration of each dose.
A total of 888 prescriptions and 1088 administrations were assessed across the six hospitals. There were 69 different types of orders for IV KCl, varying in either concentration or volume. KCl ampoules were used in 59% of all administrations of IV KCl. In instances where the prescription matched an available premixed IV KCl infusion, the premix was used on 89% of occasions.
There is significant variability in the prescribing and administration of IV KCl in these Victorian hospitals. New formulations of premixed IV KCl infusions may enable the removal of ampoules from patient care areas. The medical profession can play a major role in driving the adoption of consistent practice and supporting and leading this important safety initiative.
The Medical journal of Australia 12/2008; 189(10):575-7. · 2.81 Impact Factor
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ABSTRACT: The objective of this study was to determine the educational needs of community pharmacists in Australia related to palliative cancer care, to guide the development of an online educational program for pharmacists.
Questionnaires were posted to a random sample of community pharmacies in Australia. The questionnaire sought information pertaining to pharmacists': demographics; educational needs by rating the importance of learning more about 18 palliative cancer care topics and self-perceived level of knowledge of them; preference for format(s) for the program; willingness to participate in the program; and perception regarding their practice of palliative cancer care. Results were analysed using Statistical Package for the Social Sciences (SPSS) version 11.5 software.
A questionnaire return rate of 10.3% was achieved. The characteristics of respondents were reflective of community pharmacy practice in Australia when compared with the latest available labour force figures by the Australian Institute of Health and Welfare. Pharmacists rated all 18 topics as "important/essential", and their level of knowledge of them as "poor/good". Pharmacists preferred information provided in these formats: text (89.8%), case studies (80.6%) and multi-choice questions (69.4%). Most pharmacists (85.2%) indicated that they would participate in the program. The majority of pharmacists (71.3%) reported that they deliver palliative cancer care services; usually less-than-monthly (24.1%) or weekly (21.3%).
Educational needs of community pharmacists in palliative cancer care were identified. The information gathered will assist in guiding the development of an online educational program for pharmacists to improve their knowledge and skills in palliative cancer care.
Supportive Care Cancer 03/2006; 14(2):177-84. · 2.60 Impact Factor
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ABSTRACT: Off-label prescribing occurs when a practitioner prescribes a drug for a use, or in a manner, not listed in the 'approved product information' (API) for that drug. The literature suggests that this is a frequent occurrence in many areas of medicine, but data are limited in the hospitalized oncology setting. The aim of this study was to quantify the extent of off-label prescribing in a hospitalized oncology population in Australia. The study was conducted at Peter MacCallum Cancer Centre, Australia. On a single day the medication charts of all hospitalized patients were prospectively reviewed. Drug prescribing was assessed for licensing status by comparison with the API as approved by the Therapeutic Goods Administration of Australia. Prescriptions were classified as licensed, off-label or unlicensed. Medication charts of 130 patients were assessed. There were 1351 prescriptions. In 293 (22%) of the prescriptions the drug was either off-label (242, 18%) or unlicensed (51, 4%). Among the 130 patients, 110 (85%) received at least one drug that was prescribed off-label or that was unlicensed. Off-label dosing was the most frequent reason for a drug being off-label (139, 10% of all prescriptions). Off-label due to use for an unapproved indication was found in 118 prescriptions (9%), and off-label due to an unapproved route of administration was found in 38 prescriptions (3%). Off-label prescribing is widespread in the acute hospitalized oncology population, with approximately 22% of all prescriptions being for off-label or unlicensed medication. Such prescribing affects a significant proportion of patients.
Supportive Care Cancer 06/2004; 12(5):302-5. · 2.60 Impact Factor
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ABSTRACT: To determine the cost savings of pharmacist initiated changes to hospitalized patients' drug therapy or management in eight major acute care government funded teaching hospitals in Australia.
This was a prospective study performed in eight hospitals examining resource implications of pharmacists' interventions assessed by an independent clinical panel. Pharmacists providing clinical services to inpatients recorded details of interventions, defined as any action that directly resulted in a change to patient management or therapy. An independent clinical review panel, convened at each participating centre, confirmed or rejected the clinical pharmacist's assessment of the impact on length of stay (LOS), readmission probability, medical procedures and laboratory monitoring and quantified the resultant changes, which were then costed.
A total of 1399 interventions were documented. Eight hundred and thirty-five interventions impacted on drug costs alone. Five hundred and eleven interventions were evaluated by the independent panels with three quarters of these confirmed as having an impact on one or more of: length of stay, readmission probability, medical procedures or laboratory monitoring. There were 96 interventions deemed by the independent panels to have reduced LOS and 156 reduced the potential for readmission. The calculated savings was $263 221 for the eight hospitals during the period of the study. This included $150 307 for length of stay reduction, $111 848 for readmission reduction.
The annualized cost savings relating to length of stay, readmission, drugs, medical procedures and laboratory monitoring as a result of clinical pharmacist initiated changes to hospitalized patient management or therapy was $4 444 794 for eight major acute care government funded teaching hospitals in Australia.
British Journal of Clinical Pharmacology 05/2004; 57(4):513-21. · 2.96 Impact Factor
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ABSTRACT: To develop a standard weight descriptor that can be used for estimation of patient size for obese patients.
Data were available from 3849 patients: 2839 from oncology patients (index data set) and 1010 from general medical patients (validation data set). The patients had a wide range of age (16-100 years), weight (25-165 kg) and body mass index (BMI) [12-52 kg/m2] in both data sets. From the normal-weight patients in the oncology data set, an equation for male and female patients was developed to predict their normal weight as the sum of the lean body mass and normal fat body mass. The equations were evaluated by predicting the weight of patients in the general medical data set who had a normal BMI (<25 kg/m2). In addition, the clinical utility of the predicted normal weight (PNWT) descriptor was assessed by (i) comparing body surface area and allometric scaling calculations based on actual weight of obese patients versus PNWT; and (ii) comparing the predictive performance of creatinine clearance using the Cockcroft and Gault equation when using actual weight of obese patients versus PNWT to predict gentamicin clearance.
The PNWT equations developed from the oncology data set predicted accurately the actual weight of normal weighted (BMI <25 kg/m2) general medical patients (R2 = 0.968 men, R2 = 0.946 women). Using actual weight when computing body surface area and when allometric scaling for obese patients results in significant overestimation of patient size, especially for female patients and those with BMIs >35 kg/m2. The use of PNWT in the Cockcroft and Gault equation provided better predictions of gentamicin clearance than when using actual weight.
A standard weight descriptor has been developed that can be used in dosing algorithms for patients who are obese (BMI >30 kg/m2).
Clinical Pharmacokinetics 01/2004; 43(15):1167-78. · 5.40 Impact Factor
