Intervention Study On Optimizing Medication Orders Of Inpatient With Advanced Renal Insufficiency

Subject:To investigate the rate of advanced renal insufficiency and the situation of inappropriate dosage in inpatients, we retrospectively surveyed the medicine orders of inpatients with advanced renal insufficiency. In the prospective intervention stage, to investigate the model and effect of pharmaceutical care for renal insufficiency patients, pharmacist interference the physician face to face, optimized the medicine order, improve the prescription habits. We also attempt to establish a method to evaluate renal function and a medicine order screening standard.Method:Fristly, the renal function of all inpatients hospitalized in December,2006 in China-Japan Friendship Hospital were evaluated by MDRD formula. We surveyed prescribed medications from November 1,2006 to January 31,2007 of inpatients whose estimated glomerular filtration rate (eGFR) were less than 30 mL/min. Secondly, consecutive 3-month intervention was executed by pharmacists in March 23,2007 to June 22,2007. Everyday, the pharmacist evaluated the patients'renal function by Laboratory Information System (LIS) with MDRD formula. The medication orders of inpatient with advanced renal insufficiency (eGFR<40mL/min) were screened by pharmacists everyday in Pharmacy Information System (PIS), and then the inappropritate orders will be discussed by pharmacist and physician. After the pharmacist given suggestion on drug selection, dose amount and frequency to optimize medication, the orders will be checked again to assessment the effect of intervention.Result:In the retrospectively surveying stage, among 3552 inpatients hospitalized in December,2006, there were 114 inpatients (3.21%, male 62, female 52) whose eGFR were less than 30 mL/min.There were 120 inappropriate prescriptions in the 56 inpatients' medical order recorders. Antimicrobial medications were involved in 69.2% of the problem (83 times); In intervention stage, we established a drug dictionary as a screen standard, which is consists of 569 medicines. There were 31 contraindication medicines (5.45%),67 medicines (11.78%) which need dosage adjusting and 23 medicines (4.04%) which should be used with caution for advanced renal insufficiency. A total of 235 inpatients (male 113, female 122) were found have advanced renal insufficiency with estimated creatinine clearance values less then 40mL/min. The mean age was 68.4±13.6y; the mean eGFR was 25.00±11.92 mL/min years. In this group, 27722 daily orders were written by physician and checked by pharmacists.96 of 235 (40.85%) patients had at least one inappropriate order. The total inappropriate orders were 157 times. The pharmacist discussed 123 inappropriate orders with physicians face to face to optimize the orders; finally 68.29% inappropriate orders (84 vs 123) were corrected by intervention. Within the 3 months, the baseline rate of inappropriate order was 3.90%, the rate fell to 1.66% and 1.45% in the last two weeks (p<0.01).Conclusions In spite of contraindication and excessive doses of medication is common in advanced renal insufficiency inpatients, guiding medication selecting and dosing for inpatients with advanced renal insufficiency by pharmacist appears to result in corrected most inappropriate orders. The prescription habits can be improved by intervention. This intervention demonstrates a way in which pharmacist can improve medicine safety.