The time spent by clinical pharmacists on various activities was measured using a multidimensional work-sampling method to identify their work activities and the staff requirements. This study was conducted over a 10-day period using, as study subjects, two clinical pharmacists working in the surgical wards of a hospital (50 beds each). To analyze the work activities, the hospital pharmacy work was carefully classified, categorized, defined and coded based on information obtain from pharmaceutical studies and interviews conducted during the study. During the study period, 9, 592 observations were collected. The results showed that the study subjects (clinical pharmacists) spent 78.6% of their time or about 6.3 hours per day performing clinical activities. The major work activities included the following : (1) giving instructions and consultations to patients (23.6%); (2) reviewing and assessing the patients' charts and performing drug-use reviews (21.4%); (3) sharing patient information with staff (15.4%); (4) managing drug information (9.9%). On average, a pharmacist provided service to 15.0 patients each day and spent 7.2 minutes with each patient providing inpatient-consultation services. The results showed time variations ranging from 1.0 to 38.5 minutes in the inpatient-consultation activities and a further study was required to investigate the relationship between the casual time variation and the patient's characteristics. In fact, the two pharmacists of this study were able to provide consultation services to only 76.9% of the inpatients in their wards. In conclusion, the results of this study revealed that hospital pharmacists had insufficient time to provide adequate clinical services to all patients. Therefore, staff requirements should be estimated based on the time required to be spent by a pharmacist on each patient while also considering variations in each patient's needs and characteristics.
To explore appropriate antimicrobial usage in Kanazawa University Hospital, the surveillance of antimicrobial use on an individual patient basis was conducted and analyses of outstanding cases were made in detail. All data of inpatients between August 1st and November 30th 1999, who were prescribed at least one of the 11 antimicrobial injections that are frequently used at our hospital were collected by utilizing a computer database support system of the hospital. The overall usage seemed appropriate in terms of the period of use based on an antimicrobial analysis. However, an analysis on an individual-patient basis suggested some inappropriate usage/misuse in certain cases. Imipenem was prescribed from the ophthalmology ward in more than 50% of all cases. This was found to be used as a postoperative prophylactic antibiotic. Since no antibiotic was prescribed to these patients thereafter, this usage cannot be defined as inappropriate although alternative antibiotics may be considered. Vancomycin was prescribed to some methicillin-resistant Staphylococcus aureus-negative patients. We also found some extensively prolonged usage of antimicrobials. All of these were considered to be inappropriate in regard to usage specified for insurance. After investigations of medical charts and consultations with attending physicians, these antimicorobials had been empirically prescribed. In one case, imipenem was prescribed to an imipenem-insensitive patient. A different effective antimicrobial drug should have been prescribed. In conclusion, we were able to uncover some inappropriate usage of antimicrobials in a patient-by-patient investigation. Our findings suggest that further surveillance and on-time suggestions to prescribers should result in a more appropriate administration of antimicrobials.
In this study, the present state of the air cleanliness in the drug preparation room at a hospital pharmacy was evaluated, and factors affecting airborne particle numbers (APN) such as the number and the movement of workers and the materials on working clothes and cloths were investigated. In addition, the effect of environmental conditions on air cleanliness on a clean bench was compared. APN was measured with an Aerosol Particle Counter. The maximum 0.5μm APN values while working in the aseptic preparation room were 3, 610, 1, 312 (less than 10, 000 in GMP) and the non-aseptic room were 8, 008, 2, 660 (less than 100, 000) respectively. The conditions of all rooms were sufficiently suitable for drug preparation according to the criteria of GMP. Concerning factors affecting APN, the movement of workers increased the APN much more than the number of workers. The degree of dispersing particles differed greatly depending on the materials of the working clothes and cloths. A decrease to less than 1 /100 can be obtained by the selection of suitable materials for working clothes such as Overall made of polypropylene non-woven fabric from which few of fibers disperse. It is remarkable that smaller particles are dispersed from clothes even after passing through an air shower. In addition, it was confirmed that the dispersing of particles from cloths and rags was also a problem. As long as prescribed methods were used for the clean bench, the air cleanliness inside the clean bench was kept sufficient even through the external air conditions or locations were not so clean.
To objectively evaluate the compliance with inhaled steroids, we tried to evaluate the patients' understanding of the significance of inhalation (Compliance Score) and their achievement of inhalation technique (Technical Score) after a second instruction of inhaler use. 108 patients using beclomethasone dipropionate with the InspirEase® spacer (BDP+IE) were assessed in 1998 and while another 99 patients were evaluated using fluticasone propionate with Diskhaler® (FP) in 1999. 63% in the BDP+IE group and 85% in the FP group both demonstrated high Compliance and Technical Scores. Concerning age distribution, many middle-aged patients showed low scores in the BDP+ IE group. In the FP group, all patients with high Technical Scores showed high Compliance Scores, in other words, the patients who could master an efficient inhalation technique could actually performed sufficient inhalation. These Findings suggest that FP improves patient compliance because its inhalation technique is easier than that required for BDP+ IE.
In recent years, genome science has undergone radical changes and numerous advances have led to the development of its use in medical practice. In particular developments in pharmacogenetics have demonstrated that genetic polymorphism is responsible for inter-individual differences in the drug metabolism. This study was conducted to identify the genetic polymorphisms of CYP2C9 and CYP2C19 using PCR-RFLP, and the application of a gene analysis was investigated in TDM or pharmaceutical management and in counseling services for patients. In a patient with the following pharmacokinetic parameters for phenytoin, for Km=6.69 μg/mL and Vmax = 3.62 mg/day/kg, and a largely decreased metabolic activity of CYP2C9 compared to the general population, the genetic differences in CYP2C9 could be determined in genomic DNA based on the patient's peripheral blood. Based on this finding, the effective dose for medication was calculated and administered to the patient. In addition, during medical consultations, both written and oral information in an easily comprehensible form could be given to patients with genetic polymorphism. These procedures allow a for the careful matching of the patient to the right medication and dose. This study indicates the possible application of a genetic analysis of CYP to “Evidence-Based Medicine” in the field of pharmaceutical management in order to control the dosage in individuals and to improve patient counseling.
In Japan, pharmacy students are not well trained in either communicating with patients/customers nor providing information about drugs. At our university, most of fourth year students have practical training in hospital or community pharmacy. To complement this practical training, we have a pre-training program modeling exchanges between pharmacists and their customers. As we have no communication training in our curriculum, we implemented training for providing drug information, while taking the necessity of communication training activities into consideration. The program was as follows : one was role-play at the pharmacy counter and the other was for documenting and supplying information for junior high school students about drug and health information. After providing drug information, the students evaluated each other and discussed the various aspects of the communication activities. Through such training, the students were able to overcome some communication barriers and in the end felt satisfied with their own presentations. This training proved to be a useful way of improving the information and communication skills of pharmacy students.
This paper investigated the distribution of environmental bacteria during the 13-year-period after Iwate Prefectural Central Hospital moved to a new building. (1) The change in airborne bacteria during the 13-year-period was found to be virtually the same as when the building was new. (2) A reduction in airborne bacteria through the use of HEPA filters was observed. (3) Within the hospital and depending on the season, the number of airborne bacteria fluctuated. (4) The detection ratios of airborne bacteria during the 13-year-period hovered in the following ranges : Gram Positive Coccus (GPC) : 75.9 to 77.3%; Gram Positive Bacillus (GPB) : 17.3 to 18.3%; Neisseria spp. : 0.2 to 1.3%; Gram Negative Rod (GNR) : 2.9% to 4.8%; and mycetes : 1.2%. (5) With respect to the number of airborne bacteria detected, assigning a semi-sterile room as 1.0, the nurse's center registered 4.81 times this number and general wards registered 7.22 times this number. (6) The installation of HEPA filters is an effective way of reducing bacteria in the hospital. (7) Cooperation with epidemiologists is needed for improved in-hospital surveillance of airborne bacteria.
A system that included both images and voice using a personal computer was developed to provide pharmaceutical instructions for outpatients at the medication counter. A touch panel was adopted for easy use by a wide range of age groups. The system consisted of such items as the “usage of externally applied drug”, “information on disease”, “patient education” and comprised eight items over all. A survey of 105 patients was conducted and almost all patients (95%) understood the drug-related information provided. This system was found to be an effective method for providing patients with easily understood drug-related information and most patients actually enjoyed using this system which led to an improved dissemination of important medication related information.
We developed a computer program for drug information for patients using File Maker Pro® software package (ver 4.0). This program consists of four databases : 1) a main database which manages data of drug efficacies, the initial symptoms of serious side effects, cautions, drug interactions, 2) standardization for drug efficacies, 3) standardization of the initial symptoms of serious side effects, and 4) information on the package insert for drugs. These four databases enabled pharmacists to provide standardized drug information rapidly not only to patients but also to other medical staff members. Moreover, these four databases connected with a relational function of File Maker Pro® enabled us to automatically update the data on drug efficacies and initial symptoms of serious side effects by in putting the drug code numbers designated by the Ministry of Health Labor and Welfare into this program. These results suggested this program to be useful for the standardization of drug information and the automatic updating of the data.
The purpose of this article was to clarify the patient's condition before and after the prescription of Losartan, an angiotensin II receptor antagonist, and the frequency of its adverse effects at Yamaguchi University Hospital. Of the patients receiving Losartan in our hospital over a 9 month period from January 1 to September 30, 1999, 71 were selected based on their prescription records. Most of the patients were both 60 years old or over (72%) and outpatients (68%). Eight patients were prescribed only Losartan as an antihypertensive drug, while the other patients were concomitantly prescribed Losartan along with a mean of 2.4 kinds of other antihypertensive drugs. The main combined medicines were calcium antagonist (47), diuretic (41), ACE inhibitor (41), and beta blocker (24). Thirty-five patients had their prescriptions changed from other antihypertensive drugs to Losartan. The reasons for the prescription changes were 6 cases of coughing, 3 cases of hyperuricemias, 2 cases of itching, one case of hypertension, one case of edema, and an unknown cause in 21 cases. Seventeen patients had their prescriptions changed from Losartan to another drug (24%). The reasons for the change were 2 cases of hypotension, 2 cases of anacatesthesia, one case of coughing, one case of edema, and one case due to an insufficient effect. The frequency of adverse effects due to Losartan administration was 8.5%. The administration period of Losartan in patients who exhibited adverse effects was a mean of 24 days (14-46 days). These results indicate that it is important to be aware of the occurrence of adverse effects due to Losartan treatment at the initial administration stage.
In the present study, we implemented the self-monitoring of side effects in surgical outpatients with breast cancer to improve their quality of life (QOL). Self-monitoring of side effects was carried out by entering the early symptoms (myelosuppression and gastrointestinal failures) on a specially prepared side effect checking-sheet. Six outpatients participated in this study. The chemotherapeutic regimens consisted of cyclophosphamide, adriamycin and 5-fluorouracil, i.e. CAF therapy. In these patients, a mild myelosuppression was seen after the completion of half of each protocol (from approximately day 8 to 14). However, there was no relationship between the early symptoms of myelosuppression (“fever”, “general fatigue” and “throat pain” score) and the number of leucocytes. On the other hand, the self-monitoring of side effects showed a better influence on the subjective score for the symptoms of gastrointestinal failures (i.e. “nausea”). In the present study, the self-monitoring of side effects in outpatients with breast cancer was thus suggested to be a useful tool for improving the patient's QOL.
Life-saving treatments for patients experiencing a drug overdose are important fields to participate for hospital pharmacists. In this study, we described the therapeutic and pharmacokinetic considerations for the lifesaving treatment of a 71-year-old female patient who ingested at once 25 sustained-release capsules of diltiazem hydrochloride (Herbessor R 100mg), which is widely used for the treatment of angina pectoris and hypertension. The administrations of norepinephrine, dopamine and isoproterenol proved to be useful in overcoming the acute symptoms of poisoning by diltiazem, while the administration of calcium gluconate was effective in bringing the patient back to life just before falling into atrioventricular block. Except for periods of strong cardiotonic therapy, the plasma diltiazem concentrations correlated with multiplying products by the heart rate and blood pressure, and well reflected the transit of hemodynamics. Plasma exchange therapy in this patient after receiving high doses of catecholamines provided a rapid recovery from symptoms of anuria, and the plasma diltiazem concentration also rapidly decreased. This phenomenon might be due to the rapid and effective removal of catecholamines remaining in the circulation by the plasma exchange therapy. Although direct hemoperfusion and continuous hemodiafiltration did not seem to remove the plasma diltiazem effectively, these therapeutic methods were useful in removing uremic toxins while the patient's renal function was slowed. Using gastrointestinal lavage and activated charcoal administration together, an immediate recovery from the symptoms of poisoning due to a diltiazem overdose would be obtained.
We reviewed the medical charts and conducted a questionnaire survey of 298 outpatients to examine the use of antidiabetic drugs and side effects. Of the first prescribed medicines, the ratio of Rastinon® (tolbutamide) was the highest and about 90%were sulfonylureas. At present, 52% of the prescribed medicines are sulfonylureas, 21 % are sulfonylureas and either an α-glucosidase inhibitor or a reducer of insulin resisitance, while 11% receive insulin. The side effects of these antidiabetic drugs include hypoglycemia by sulfonylureas or insulin, digestive symptoms due to α-glucosidase inhibitor, among others.
PCA (Patient Controlled Analgesia) by Fentanyl citrate is used as a method of pain control after orthopaedic surgery and NSAIDs is prescribed after PCA at Hiroshima City Asa Hospital. There are many cases in which the effect by NSAIDs is insufficient, even if the analgetic effect by PCA is sufficient. In addition, the use of Opioid's adaptation is limited, because it is designated as a narcotic in Japan. Thus we examined the analgetic effect, for the purpose of early rehabilitation, by relieving the pain that patients experience when moving their bodies by using Codeine phosphate tablets which are both effective and can be orally administered. Codeine phosphate 20mg tablets were administered at a dosage of 80mg just after PCA and thereafter 60mg every 4 hours until bedtime. Patients were next administered 80mg when they got up in the morning and 40mg of each every 3 hours until bedtime from the 2 nd day after the operation. We classified the analgetic effect of Codeine phosphate into 5 grades by using a face scale pain score. Codeine phosphate had no effect on the pain when the patients lay quietly in bed. However the pain score significantly decreased to less than 3 (painful) after operation after the administration of Codeine phosphate when they moved their bodies. The pain score on males decreased significantly in comparison with females. Accordingly, it seems that the administration of Codeine phosphate is an effective means to reduce pain when patients move their bodies after operations in the field of orthopaedic surgery.