Bonnie Greenwood

Hypoglycemia and clinical outcomes in patients with diabetes hospitalized in the general ward.

OBJECTIVE Hypoglycemia is associated with adverse outcomes in mixed populations of patients in intensive care units. It is not known whether the same risks exist for diabetic patients who are less severely ill. In this study, we aimed to determine whether hypoglycemic episodes are associated with higher mortality in diabetic patients hospitalized in the general ward. RESEARCH DESIGN AND METHODS This retrospective cohort study analyzed 4,368 admissions of 2,582 patients with diabetes hospitalized in the general ward of a teaching hospital between January 2003 and August 2004. The associations between the number and severity of hypoglycemic (≤50 mg/dl) episodes and inpatient mortality, length of stay (LOS), and mortality within 1 year after discharge were evaluated. RESULTS Hypoglycemia was observed in 7.7% of admissions. In multivariable analysis, each additional day with hypoglycemia was associated with an increase of 85.3% in the odds of inpatient death (P = 0.009) and 65.8% (P = 0.0003) in the odds of death within 1 year from discharge. The odds of inpatient death also rose threefold for every 10 mg/dl decrease in the lowest blood glucose during hospitalization (P = 0.0058). LOS increased by 2.5 days for each day with hypoglycemia (P < 0.0001). CONCLUSIONS Hypoglycemia is common in diabetic patients hospitalized in the general ward. Patients with hypoglycemia have increased LOS and higher mortality both during and after admission. Measures should be undertaken to decrease the frequency of hypoglycemia in this high-risk patient population.

Use of antiepileptics for seizure prophylaxis after traumatic brain injury

PURPOSE Antiepileptics used for seizure prophylaxis after traumatic brain injury (TBI) are reviewed. SUMMARY Of the 275,000 people who are hospitalized with TBI each year, approximately 5-7% experience a posttraumatic seizure (PTS). According to the latest guidelines issued by the Brain Trauma Foundation and the American Academy of Neurology (AAN) for the management of severe TBI, PTS prophylaxis is recommended only during the first seven days after TBI. Of the available antiepileptic drugs, phenytoin has been the most extensively studied for the prophylaxis of PTS. Phenobarbital, valproate, and carbamazepine have not been as extensively researched, and, given their adverse-effect profiles and pharmacodynamic properties, there is no advantage to using these agents over phenytoin. Levetiracetam has demonstrated comparable efficacy to phenytoin for PTS prophylaxis and is associated with fewer adverse effects and monitoring considerations; it may be a reasonable alternative to phenytoin. However, levetiracetam has been associated with an increased seizure tendency. The Brain Trauma Foundation recommends using phenytoin for early PTS prophylaxis. The guidelines also state that valproate has demonstrated similar efficacy to phenytoin but warn that its use may be associated with increased mortality. CONCLUSION The available literature supports the use of antiepileptics for early PTS prophylaxis during the first week after a TBI. Phenytoin has been extensively studied for this indication and is recommended by the AAN and Brain Trauma Foundation guidelines for early PTS prophylaxis. Levetiracetam has demonstrated comparable efficacy to phenytoin for early PTS prophylaxis and may be a reasonable alternative to consider in this patient population.

Improving glycemic control in medical inpatients: A pilot study

BACKGROUND Inpatient hyperglycemia is associated with poor patient outcomes. Current guidelines recommend that in an inpatient non-ICU setting there be treatment to achieve a glucose level below 180 mg/dL. METHODS Objectives of this prospective quality-improvement pilot study were to implement a subcutaneous insulin protocol on a general medicine service, to identify barriers to implementation, and to determine the effect of this protocol on glycemic control. Eighty-nine patients with a preexisting diagnosis of type 2 diabetes or inpatient hyperglycemia were eligible. Study outcomes included resident acceptance of the protocol, insulin-ordering practices, and mean rate of hyperglycemia (glucose > 180 mg/dL) per person. Results were compared with those of a previously conducted observational study. RESULTS Residents agreed to use the protocol in 56% of cases. Reasons for declining the protocol included severity of a patients other disease states, desire to titrate oral medications, and fear of hypoglycemia. Basal and nutritional insulin were prescribed more often in the pilot group compared with at baseline (64% vs. 49% for basal, P = .05; 13% vs. 0% for nutritional, P < .001). Basal insulin was started after the first full hospital day in 42% of patients, and only one-third of patients with any hypo- or hyperglycemia had any subsequent changes in their insulin orders. The mean rate of hyperglycemia was not significantly different between groups (31.6% of measurements per patient vs. 33.3%, P = .85). CONCLUSIONS Adherence to a new inpatient subcutaneous insulin protocol was fair. Barriers included fear of hypoglycemia, delays in starting basal insulin, and clinical inertia. Quality improvement efforts likely need to target these barriers to successfully improve inpatient glycemic control.

Evaluation of Compliance with a Paper-based, Multiplication-factor, Intravenous Insulin Protocol

Background: Hyperglycemia is common in critically ill patients and is an independent risk factor for in-hospital morbidity and mortality. Objective: To assess compliance with a paper-based, multiplication-factor, intravenous insulin protocol. Methods: A retrospective chart review was conducted in a 720-bed urban, academic medical center in Boston, Massachusetts. During a 1-month period, compliance with and the consequent safety and efficacy of the Brigham and Womens Hospital paper-based, multiplication-factor, intravenous insulin protocol was evaluated. Results: The primary endpoint of protocol compliance, defined as correct adjustment to insulin infusion rate and correct timing of bedside blood glucose concentration (BBGC) checks ±10 minutes of prespecified BBGC check according to the Brigham and Womens Hospital Intravenous Insulin Protocol (BHIP), was 47.2%. Seventy-two patients met inclusion criteria. Appropriate adjustment of infusion rates occurred 68.2% (1206/1768) of the time. Compliance with the timing of BBGC checks was found to be the majority of protocol violations. BBGCs were monitored ±5 minutes of indicated time per the protocol 26.2% (463/1768) of the time. Blood glucose concentration checks within extended timing of ±10 minutes of indicated time per the protocol occurred 793 (44.8%) times. Blood glucose concentration monitoring took place greater than 20 minutes past indicated time 450 (25.5%) times. In 1768 measurements, blood glucose concentrations between 40 and 60 mg/dL occurred 23 (1.3%) times in 12 (16.7%) patients. Blood glucose concentrations 40 mg/dL or less were detected 3 (0.17%) times in 2 (2.7%) patients. None of these hypoglycemic events led to documented complications. Conclusions: Overall, a rather low level of compliance with a paper-based, multiplication-factor, intravenous insulin protocol was observed, which warrants further investigation. Compliance rates in this evaluation were found to be similar to the rates observed in previously evaluated fixed-dose intravenous insulin protocols. Protocol noncompliance may be associated with hypo- and hyperglycemia.

Pharmacist-Driven Aminoglycoside Quality Improvement Program

Abstract Our objective was to determine the impact of a pharmacist-driven aminoglycoside quality improvement program on the dosing methods of aminoglycosides at our institution. We assessed our current quality through retrospective review of all patients receiving aminoglycosides during a 5-month period. We then developed and implemented a pharmacist-driven aminoglycoside dosing program and prospectively assessed patients during a matched 5-month period. Two hundred and sixteen patients were evaluated, 87 pre-program and 129 post-program. Prior to standardized pharmacist intervention, 44% of patients achieved optimal therapy. Post implementation, patients achieving optimal therapy increased to 80% (p < 0.001). Patients in the pre-program group had a higher rate of acute changes in renal function compared to the post-pro-gram group (14.9% versus 6.2% [p <0.05]). This pharmacist-driven aminoglycoside dosing quality improvement program increased the frequency of optimal dosing of aminoglycosides and reduced the incidence of nephrotoxicity at our institution.

Pharmacodynamic target attainment with high-dose extended-interval tobramycin therapy in patients with cystic fibrosis

Abstract Utilization of high-dose extended-interval aminoglycoside therapy (HEAT) in patients with cystic fibrosis (CF) is supported by primary literature and national guidelines. We sought to evaluate the effectiveness of a local aminoglycoside guideline to achieve pharmacodynamic goals in patients with CF that received ≧3 doses of HEAT from 2005 to 2011. Patients with renal dysfunction at baseline, status-post-lung transplant, or receiving inhaled tobramycin were excluded. In the 282 patient admissions, the average initial tobramycin dose was 10·3 mg/kg with an average initial peak of 21·5 mg/l. At least one dose titration was seen in 39% of patients. Patients who achieved the pharmacodynamic goal received a higher dose (10·4 mg/kg versus 9·7 mg/kg; P<0·001). A mean starting dose of tobramycin at 10·3 mg/kg every 24 hours achieved an average peak above goal. Higher initial dosing resulted in a higher likelihood of achieving the pharmacodynamic goal.

Conversion to insulin devices in the inpatient setting

Adverse drug events related to insulin errors are among the top-reported errors in the U.S. health care system. Methods for reducing the occurrence of these errors include minimizing floor stock of insulin and using patient-specific insulin devices.[1][1] Our institution fully converted all of our

Error Rates Among Clinical Pharmacists in Calculating the APACHE II Score

Background. The Food and Drug Administration recently advocated the use of acuity scoring to determine those patients whose mortality benefits outweigh risks of adverse effects from drotrecogin alfa (activated). Many institutions have adopted an Acute Physiology and Chronic Health Evaluation (APACHE) II cutoff score of 25 (i.e., if > 25, administer the agent) as a component in determining eligibility for treatment with this agent. Concern is increasing that errors in the acquisition of APACHE scores can lead to prescribing errors with drotrecogin alfa (activated).

Evaluation of recombinant activated protein C for severe sepsis at a tertiary academic medical center

Purpose Early clinical trials of recombinant human activated protein C (rhAPC) for severe sepsis excluded patients at high risk of bleeding. Recent literature suggests bleeding rates are higher in clinical practice and may be associated with worsened outcomes. Our objective was to evaluate baseline demographics; incidence, and risk factors for major bleeding; and mortality of patients receiving rhAPC for severe sepsis at our institution. Methods A retrospective study was performed for all patients receiving rhAPC for treatment of severe sepsis at a tertiary academic medical center from January 2002 to June 2009. Demographic information, clinical variables, intensive care unit, and hospital outcomes were recorded. Results Of the 156 patients that received rhAPC, 54 (34.6%) did not meet institutional criteria for safe use at baseline due to bleeding precaution or contraindication. Twenty-three (14.7%) patients experienced a major bleeding event. Multivariate analysis demonstrated baseline International Normalized Ratio ≥2.5 (odds ratio [OR] 3.68, 95% confidence interval [CI]: 1.28–10.56; P = 0.03) and platelet count ≤100 × 103/mm3 (OR 2.86, 95% CI: 1.07–7.67; P = 0.01) as significant predictors of a major bleed. Overall hospital mortality was 57.7%. Multivariate analysis demonstrated the presence of ≥3 organ dysfunctions (OR 2.46, 95% CI: 1.19–5.09; P < 0.05) and medical intensive care unit admission (OR 1.99, 95% CI: 1.00–3.98; P = 0.05) were independent variables associated with hospital mortality. Conclusion Patients receiving rhAPC at our institution had higher APACHE II scores, mortality, and major bleeding events than published postmarketing studies. Risk factors for major bleeding other than package-labeling contraindications and bleeding precautions were identified in our patient population.

Stability of Regular Human Insulin Extemporaneously Prepared in 0.9% Sodium Chloride in a Polyvinyl Chloride Bag

Purpose The purpose of this study was to evaluate the extended stability of extemporaneously prepared regular human insulin 100 units in 0.9% sodium chloride at a total volume of 100 mL under refrigeration. Methods Three admixtures of regular human insulin were prepared aseptically under a laminar flow hood at time zero. They were prepared by withdrawing 1 mL of regular human insulin with a concentration of 100 units/mL and adding it to a sufficient quantity of 0.9% sodium chloride for injection in a Polyvinylchloride (PVC) bag to yield a total volume of 100 mL. The 3 admixtures were stored refrigerated(2°C to 8°C [36°F to 46°F]) and three 1 mL samples of each admixture were withdrawn, transferred to a test tube, and frozen(–30°C to −15°C [–22°F to 5°F]) at hours 0, 6, 12, 36, 48, 72, 96, 120, 144, and 168. Insulin concentrations were measured by chemiluminescent immunoassay. The time points were considered stable if the mean concentration of the samples exceeded 90% of the equilibrium concentration at hour 6. Results The equilibrium concentration was 0.57 units/mL. Time points were considered stable if the mean concentration was at least 0.52 units/mL. All time points retained at least 90% of the equilibrium concentration with the exception of hour 120(0.46 ± 0.05 units/mL). At hour 168, the mean concentration was 0.63 ± 0.07 units/mL. Conclusion Regular human insulin 100 units added to 0.9% sodium chloride for injection in a PVC bag to yield a total volume of 100 mL is stable for 168 hours when stored at 2°C to 8°C(36°F to 46°F).