Chronic kidney disease (CKD) confers a higher risk of adverse safety events as a result of many factors including medication dosing errors and use of nephrotoxic drugs, which can cause kidney injury and renal function decline. CKD patients may also have comorbidities such as hypertension and diabetes for which they require more frequent care from different providers, and for which standard, but countervailing treatments, may put them at risk for adverse safety events. Areas covered: In addition to the well-known agents such as iodinated radiocontrast, antimicrobials, diuretics and angiotensin converting enzyme (ACE) inhibitors which can directly affect renal function, safety considerations in the treatment of common CKD complications such as anemia, diabetes, analgesia and thrombosis will also be discussed. Expert opinion: Better outcomes in CKD may be achieved by alerting care providers to the special care needs of kidney patients and encouraging patients to self-manage their disease with the decision support of multidisciplinary patient care teams.
Purpose To assess the clinical impact of a vancomycin dosing protocol and monitoring tool on initial dose, dosing interval, and trough concentrations in adult medicine patients. Methods This was a retrospective chart review of adult medicine patients who received at least one dose of vancomycin and were admitted during the pre-implementation period, February 1 to April 2009, or during the post-implementation period, June 1 to October 31, 2009. All outcomes for patients in the pre-implementation group were compared to those in the post-implementation group. The primary outcomes were frequency of appropriate initial vancomycin dose and dosing interval. The secondary outcomes included frequency of appropriate initial vancomycin trough concentrations, mean number of levels drawn per patient, and mean duration of therapy. Results A total of 450 patients were identified, with 225 patients in each study group. Patients with an appropriate initial vancomycin dose significantly increased in the post-implementation group (56% vs 40%; P < .001). The number of patients with an appropriate original dosing interval (67% vs 63%; P = 0.32), appropriate initial trough concentration (44% vs 45%; P = 0.89), mean number of levels drawn (1.9 vs 2.1; P = 0.56), and duration of therapy (4.9 vs 5.0; P = 0.77) was similar between the 2 groups. Conclusions The implementation of a vancomycin empiric dosing protocol and monitoring tool had a significant impact on the initial dose. Further education regarding vancomycin dosing and monitoring is warranted to improve initial dosing interval, initial trough concentration, number of levels drawn, and duration of therapy.
There is increasing evidence of the role of non–patient-level factors on discharge against medical advice (DAMA), but limited quantitative information regarding the extent of their impact. This study quantifies the contribution of discharge-level and hospital-level factors to the variation in DAMA. We grouped variables from the 2014 National Inpatient Sample data and ran incremental mixed-effects logit models with grouping at the level of the discharge, the hospital, and the census region. We obtained the intraclass correlation coefficients (ICCs), and evaluated the incremental change in ICC. The final sample included 2,687,430 discharges. 12.8% of the identified variation in the probability of DAMA was associated with the hospital, and 1.2% of the variation was associated with the census division in which the hospital was located. The final, fully-adjusted model had 7.3% of variation in DAMA associated with the hospital-level, with the greatest percentage reductions because of the addition of patient demographics. Even after adjusting for measured patient-level characteristics, there was a contribution of non–patient-level factors to DAMA outcomes. The findings identify a role for a multi-level approach to addressing DAMA.
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