ObjectiveElectronic alert systems have shown their capacity for improving the detection of acute kidney injury (AKI). The aim of this study was to design and implement a clinical decision support system (CDSS) for improving drug selection and reducing nephrotoxic drug use in patients with AKI.MethodsThe study was designed as an intervention study comparing a pre and post cohort of patients admitted during April 2014 and April 2015, respectively (phase I and phase II). The intervention was a CDSS which provided kidney function and nephrotoxic drug information. Furthermore, an interruptive alert was designed to detect patients suffering an AKI event while taking a nephrotoxic drug and to see if the dose was then reduced or the drug was discontinued by the physicians.ResultsOne-third of the inpatients were included in the analysis because they met the inclusion criteria (1004 and 1002 patients in phases I and II, respectively). 735 and 761 of them received at least one nephrotoxic alert (73% vs 76%; p=0.763). 65 and 88 patients suffered AKI during admission (6.5% vs 8.8%; p=0.051). In phase I, patients received 384 nephrotoxic alerts (55%) with 78 (20%) of them provoking a change or discontinuation of the nephrotoxic drug. In phase II this value increased to 154 out of 526 (29%) after implementation of the CDSS (p<0.01).ConclusionsA CDSS with interruptive alerts that inform of the development of AKI in real time in patients with nephrotoxic drug prescription has a positive impact on the judicious use of these drugs.

BackgroundImplantable medical devices (IDs) management in the hospital is a complex process, with a large scope for improvement that satisfies technical, logistical, economic and clinical needs.PurposeIntegrate into a single process all the activities and interests related to the use of IDs.Material and methodsProject in a highly specialised hospital with scheduled surgical activity. Designed by a multidisciplinary group and integrated into the hospital information system (HIS). It uses an external company that ‘certifies’ (technical and economic criteria) IDs and providers for insurers and surgeons. Pharmacy service (PS) manages all IDs in the hospital.Stages have been: creation of multidisciplinary working group, SWOT-analysis and pilot economic study. Project approval by the hospital. Software development and IDs data mapping (hospital and company). Providers and insurers were informed. Pilot project was started for 6 months with two surgical departments (SD). The OR-pharmacist was responsible for providing the information, training and incorporation of SDs.ResultsA simple and effective procedure has been designed. Surgical procedure (SP) is scheduled by the doctor in the HIS (patient, SP code and date) recording IDs expected in an electronic form. Doctor’s signature generates automatically two orders: a ‘devices submission proposal’ which is sent by PS to the provider. and an application for ‘economic authorisation’ that the company will manage with the insurer before SP. Pharmacy receives IDs temporary deposits that are registered and sent to the surgical area. All ID are recorded (optical reading of product code, batch, expiration date). When SP is completed OR-pharmacist checks unused IDs with those received and returns the surplus material, issuing an order for IDs implanted to the billing department. Company controls economic agreements between providers, insurers and the hospital. An implant file associated with SPs has been created for safety, results analysis and cost studies. Logistic traceability helps to schedule activity in the surgical area (average delivery time ID/supplier 2–3 days). This procedure ensures the conformity of ID’s cost before surgery, avoiding claims. Nineteen per cent of the spending has been reduced.ConclusionProcess integrated into the SD’s activity and the HIS. It incorporates in a sequential way habitual tasks. A multidisciplinary work with a vision and global resolution has been the leadership by the OR-pharmacist.No conflict of interest

The University Clinic of Navarra is a general teaching hospital with a total of 413 beds, 60 of which are oncology beds. Of the specimens analysed in 1994 by the clinical pharmacokinetics unit, 53.2% were per formed in cancer patients and 27.3% were performed in patients receiving vancomycin. Methods. We established 10 criteria governing both the process and the result in assessing the quality of vancomycin pharmacokinetic monitoring in oncological patients. We performed a retrospective assessment of the data-monitoring follow-up sheets of 100 cancer patients treated with vancomycin and whose serum vancomycin levels were monitored by the clinical pharmacokinetics unit between April 1993 and March 1994. Results. Overall, the degree of compliance with the 10 defined criteria was good, even though 100% compliance was achieved only in criterion 5 (use of the kinetic method) and criterion 8 (repetition of monitoring must be justified). The lowest compliance was obtained in criterion 1 (evaluation of the initial medical prescription) and criterion 6 (the serum creatinine and daily fluid balances, parameters en compassed within the clinical assessment of the pa tient). Conclusions. The detailed analyses of the crite ria performance suggest that the process of serum sample extraction in the wards should be improved and the frequency of serum creatinine testing should be increased. Corrective measures have been pro posed, and once they are developed, accepted, and implemented, the criteria will be reevaluated and a further audit performed to determine the usefulness of the changes made.