D E V E L O P M E N T O F A PROVINCIAL DRUG FORMULARY by E L I Z A B E T H ANN P A G E Bv. Sc., (Pharm.), University of British Columbia, 1971 A THESIS SUBMITTED IN P A R T I A L F U L F I L M E N T O F T H E REQUIREMENTS FOR T H E D E G R E E OF M A S T E R O F SCIENCE in the Division of Clinical Pharmacy of the Faculty of Pharmaceutical Sciences We accept this thesis as conforming to the required standard T H E UNIVERSITY OF BRITISH COLUMBIA September, 1973 In presenting an advanced degree a t the U n i v e r s i t y the Library I further for this thesis agree that permission s c h o l a r l y p u r p o s e s may this thesis written of B r i t i s h Columbia, I agree f o r reference f o r extensive copying f o r f i n a n c i a l gain shall that study. of this b e g r a n t e d by t h e Head o f my I t i s understood and that thesis Department o r copying or publication n o t be a l l o w e d w i t h o u t my permission. Department o f Clinical Pharmacy, The U n i v e r s i t y o f B r i t i s h Vancouver 8 , Canada Date f u l f i l m e n t of the requirements f o r s h a l l make i t f r e e l y a v a i l a b l e by h i s r e p r e s e n t a t i v e s . of in partial September 10, 1973 Columbia F a c u l t y of P h a r m a c e u t i c a l S c i e n c e s D E V E L O P M E N T OF A PROVINCIAL DRUG FORMULARY ABSTRACT The a d o p t i o n o f the L i o n s G a t e H o s p i t a l D r u g F o r m u l a r y b y B r i t i s h C o l u m b i a H o s p i t a l A s s o c i a t i o n f o r d i s t r i b u t i o n and use the in a l l p r o v i n c i a l h o s p i t a l s e n d o r s e s the g r o w i n g t r e n d t o w a r d r e g i o n a l i z a t i o n of drug information. S e v e r a l a s p e c t s of this F o r m u l a r y w e r e i n v e s t i g a t e d i n the p r e s e n t s t u d y w i t h the o b j e c t i v e o f d e s i g n i n g to the v a r i e d n e e d s o f the p r o v i n c e . The a text e v e n m o r e a p p l i c a b l e f o r m a t o f the F o r m u l a r y a n d m e c h a n i s m f o r r e g u l a r l y e v a l u a t i n g a n d u p d a t i n g the i n f o r m a t i o n a therein w e r e the m a j o r a r e a s r e c e i v i n g c o n s i d e r a t i o n . One m a j o r c h a n g e i n f o r m a t p r o p o s e d i s the i n c r e a s e i n the n u m b e r o f d r u g m o n o g r a p h s to a p p r o x i m a t e l y 600 increase f r o m the p r e s e n t 300 entries. i s b a s e d on the r e q u e s t s f o r a d d i t i o n a l d r u g s f r o m the t i v e h o s p i t a l s s a m p l e d i n the p r o v i n c e . This representa- C h a n g e s i n the f o r m a t of i n d i v i d u a l m o n o g r a p h s i n c l u d e an e x p a n s i o n of i n f o r m a t i o n u n d e r the h e a d i n g " M o d e of A c t i o n " , that an a d d i t i o n a l s e c t i o n on " I n s t r u c t i o n s to the P a t i e n t " be added to f a c i l i t a t e e f f e c t i v e i n s t r u c t i o n s f o r s e l f - a d m i n i s t r a t i o n i n a m b u l a t o r y s e r v i c e s , that e a c h m o n o g r a p h r e c e i v e a C a n a d i a n D r u g I d e n t i f i c a t i o n C o d e reference a n d that the i n f o r m a t i o n i n e a c h m o n o g r a p h be r e f e r e n c e d p o s s i b l e to the p r i m a r y l i t e r a t u r e source. where ii C h a n g e s i n the f o r m a t o f the o v e r a l l F o r m u l a r y i n c l u d e a c r o s s i n d e x o f m o n o g r a p h s to m a n u f a c t u r e r s ' b r a n d n a m e s , a b i b l i o g r a p h y o f the r e f e r e n c e d i n f o r m a t i o n and a " M i n i " F o r m u l a r y f o r m a t for use on individual hospital wards. T h e l a t t e r r e c o m m e n d a t i o n i s m a d e i n r e c o g n i t i o n o f the p o t e n t i a l b u l k o f the o v e r a l l M a s t e r F o r m u l a r y w h i c h w o u l d m a k e i t a w k w a r d for efficient and frequent u s e . In t h i s r e s p e c t , i t i s a n t i c i p a t e d that o n e M a s t e r F o r m u l a r y c o n t a i n i n g a l l 600 e v e n t u a l m o n o g r a p h s , the b i b l i o g r a p h y f o r e a c h a n d the v a r i o u s i n d i c e s b e m a d e a v a i l a b l e i n e a c h h o s p i t a l f o r resource reference. On each ward a complete F o r m u l a r y of all drug mono- g r a p h s b u t n o t the a c c o m p a n y i n g b i b l i o g r a p h i e s w o u l d be a v a i l a b l e . Studies s h o w e d that s o m e t h i n g l e s s t h a n 100 o f t h e s e d r u g s ( l e s s t h a n 20 p e r c e n t ) were u s e d with any frequency on any specialty w a r d studied. Therefore, a " M i n i " F o r m u l a r y c o n t a i n i n g o n l y the m o n o g r a p h s o f d r u g s f r e q u e n t l y u s e d i n a s p e c i a l t y a r e a w o u l d m a k e the i n f o r m a t i o n m o r e r e a d i l y a v a i l a b l e i n that service. C h a n g e s i n p r i n t i n g f o r m a t a l s o a r e r e c o m m e n d e d w i t h the o b j e c - t i v e o f r e d u c i n g the b u l k o f the p r o p o s e d F o r m u l a r y . A r e g u l a r u p d a t i n g m e c h a n i s m m u s t b e a c t i v a t e d to k e e p the i n f o r m a t i o n i n the F o r m u l a r y c u r r e n t . S u c h a m e c h a n i s m r e l a t e d to a n a n n u a l l i t e r a t u r e e v a l u a t i o n a s s i g n m e n t b y the s e n i o r s t u d e n t s o f the F a c u l t y o f P h a r m a c e u t i c a l Sciences, University of B r i t i s h Columbia, is proposed. B a s e d on this a c a d e m i c e x e r c i s e , two t y p e s o f u p d a t i n g a r e i d e n t i f i e d . F i r s t , a c o m p l e t e e v a l u a t i o n a n d r e f e r e n c i n g o f the e x i s t i n g m o n o g r a p h information is required. Second, annual updating o f this i n f o r m a t i o n from iii c u r r e n t l i t e r a t u r e s h o u l d be m a i n t a i n e d . T o evaluate, r e v i s e and condense the s t u d e n t s ' e v a l u a t i o n s to m o n o g r a p h f o r m a t , faculty instructor time and of stenographer a " s e r v i c e " component of t i m e h a v e b e e n p r o j e c t e d . It i s a n t i c i p a t e d that the p r o v i s i o n o f a p p r o x i m a t e l y o n e - h a l f t i m e i n s t r u c t o r p e r y e a r and one-tenth time stenographer w i l l be r e q u i r e d bn a " s e r v i c e " b a s i s to e n a b l e the r e g u l a r u p d a t i n g o f the c u r r e n t F o r m u l a r y a s d e f i n e d a b o v e . The a r r a n g e m e n t f o r a M e d i c a l R e v i e w B o a r d to r e v i e w the e v a l u a t e d m o n o - graphs f r o m a c l i n i c a l v a l i d i t y standpoint also should be m a d e . T h e above p r o j e c t i o n s a r e b a s e d o n s t u d i e s r e l a t e d to the e v a l u a t i o n a n d u p d a t i n g o f 100 d r u g m o n o g r a p h s d u r i n g 1972-73. A f i n a l r e c o m m e n d a t i o n i s that the b a s i s f o r g e n e r a t i n g , u p d a t i n g a n d a d d i t i o n a l r e f e r e n c i n g o f the D r u g should be a p r o v i n c i a l D r u g Information Formulary Centre. Signature of Supervisor ACKNOWLEDGEMENTS The a u t h o r w i s h e s to e x p r e s s h e r g r a t i t u d e to D r . J . N . H l y n k a a n d D r . D . L . S m i t h f o r t h e i r i n s t r u c t i o n a n d a s s i s t a n c e t h r o u g h o u t the p r e p a r a t i o n o f this t h e s i s a n d h e r G r a d u a t e Student T e a c h i n g A s s i g n m e n t . In a d d i t i o n , the c o - o p e r a t i o n o f the p h a r m a c i s t s o f the L i o n s G a t e the B r i t i s h C o l u m b i a H o s p i t a l A s s o c i a t i o n a n d the B r i t i s h Hospital, Columbia p h a r m a c i s t s who p a r t i c i p a t e d i n the s e v e r a l s u r v e y s c o n d u c t e d d u r i n g this study i s g r e a t l y a p p r e c i a t e d . T h e f i n a n c i a l a s s i s t a n c e o f the W a r n e r - L a m b e r t R e s e a r c h F e l l o w s h i p i n P h a r m a c y a n d the U n i v e r s i t y o f B r i t i s h C o l u m b i a G r a d u a t e Fellow- s h i p a n d S u m m e r R e s e a r c h S c h o l a r s h i p e n a b l e d the a u t h o r to c o n t i n u e h e r studies and i s hereby acknowledged. V T A B L E O F CONTENTS Page ABSTRACT .. ACKNOWLEDGEMENTS i . T A B L E OF CONTENTS LIST OF T A B L E S LIST O F FIGURES iv v vii ix LIST O F APPENDICES x L I T E R A T U R E SURVEY 1 I. Need for Drug Information 1 II. Hospital Drug Formularies 5 III. Regional Drug Formularies 11 IV. 18 Provincial Hospital Drug Formulary V. Academic Role 20 S T A T E M E N T OF O B J E C T I V E S 22 METHODOLOGY 23 I. Identifying the Provincial Needs 23 (a) Popularity of Use 24 (b) Number of Drug Monographs 24 (c) Format of Drug Monographs 28 (d) Monograph Utilization Survey 31 vi T A B L E O F CONTENTS (Continued) Page II. Evaluation and Updating the Formulary ..... 34 (a) Mechanism of Updating 37 (b) Nature and Frequency of Change 41 (c) Time Evaluation R E S U L T S AND DISCUSSION I. Identifying the Provincial Needs . . 41 42 42 (a) Popularity of Use 43 (b) Number of Drug Monographs 46 (c) Format of Drug Monographs 48 (d) Format of the Formulary 57 II. Evaluation and Updating the Formulary 70 (a) Nature and Frequency of Change 71 (b) Time Evaluation 74 RECOMMENDATIONS 82 BIBLIOGRAPHY 84 APPENDICES 89 vii LIST O F T A B L E S Table I II Page DRUG F O R M U L A R Y UTILIZATION REASONS FOR NOT USING T H E DRUG FORMULARY III 44 45 F R E Q U E N C Y O F T H E USE O F PROVINCIAL F O R M U L A R Y DRUGS (483) IN PEDIATRIC WARDS O F VARIOUS HOSPITALS IV 61 F R E Q U E N C Y O F T H E USE O F PROVINCIAL F O R M U L A R Y DRUGS (483) IN E M E R G E N C Y WARDS O F VARIOUS HOSPITALS V 62 F R E Q U E N C Y O F T H E USE O F PROVINCIAL F O R M U L A R Y DRUGS (483) IN E X T E N D E D C A R E WARDS O F VARIOUS HOSPITALS VI 64 F R E Q U E N C Y O F T H E USE O F PROVINCIAL F O R M U L A R Y DRUGS (483) IN PSYCHIATRIC VII WARDS O F VARIOUS HOSPITALS 65 MONOGRAPH CHANGES 73 viii LIST O F T A B L E S (Continued) Table VIII IX Page REVISION TIMES F U T U R E REVISION S C H E D U L E ' 75 78 ix LIST O F FIGURES Figure 1 Page E X A M P L E O F T H E FORMAT AND CONTENT O F T H E DRUG MONOGRAPHS O F T H E LIONS G A T E HOSPITAL DRUG FORMULARY . 2 CHIEF PHARMACISTS QUESTIONNAIRE ..... 3 S A M P L E O F DRUG LISTS USED FOR MONOGRAPH UTILIZATION SURVEY 4 8 26 33 INSTRUCTIONS FOR MONOGRAPH UTILIZATION SURVEY 35 5 CHANGE S H E E T E X A M P L E 39 6 S A M P L E MONOGRAPH O F E R Y T H R O M Y C I N F R O M T H E EXISTING DRUG F O R M U L A R Y B E F O R E REVISION 7 49 S A M P L E MONOGRAPH O F ERYTHROMYCIN INCLUDING BIBLIOGRAPHY A F T E R REVISION 51 X LIST O F APPENDICES Appendix I Page COST O F T H R E E MAJOR DRUG INFORMATION SERVICES II 8$ LISTS O F DRUGS RECEIVING TWO OR M O R E REQUESTS FOR INCLUSION IN T H E DRUG F O R M U L A R Y III 90 STUDENT MONOGRAPH UPDATING ASSIGNMENT 1972-73 98 LITERATURE I. SURVEY Need F o r Drug Information " A c c u r a t e a n d u n b i a s e d i n f o r m a t i o n about d r u g s i s e s s e n t i a l i f g o o d m e d i c i n e i s to b e p r a c t i c e d . In t h e s e d a y s w h e n m a n y n e w a n d p o t e n t d r u g s a r e being i n t r o d u c e d s u c h i n f o r m a t i o n m u s t be r e a d i l y available and should include a l l facts r e l e v a n t to the u s e o f the d r u g , i n c l u d i n g b o t h e f f i c a c y and a d v e r s e r e a c t i o n s . " (1). (a) V o l u m e o f D r u g The Literature v o l u m e a n d d i v e r s i t y o f d r u g l i t e r a t u r e a n d the p r o b l e m s o f c o m p i l i n g and d i s t r i b u t i n g d r u g i n f o r m a t i o n have been w i d e l y e x p r e s s e d (2-15). 1963 A W o r l d L i s t of P h a r m a c y P e r i o d i c a l s which was c o m p i l e d i n c o n t a i n s o v e r 900 e n t r i e s . In a d d i t i o n to p h a r m a c e u t i c a l p u b l i c a t i o n s , drug i n f o r m a t i o n i s also found i n other j o u r n a l s such as m e d i c i n e , d e n t i s t r y , b i o l o g y , a g r i c u l t u r e a n d e n g i n e e r i n g (3). Dr. A.F. Langlykke i n 1958 e s t i m a t e d that 200, 000 o r i g i n a l p a p e r s w e r e p u b l i s h e d y e a r l y i n r e g a r d to p h a r m a c y a n d d r u g s ( 4 ) . D r . D . B u r k h o l d e r p r o j e c t e d i n 1967 that 33 p e r c e n t o f p u b l i s h e d b i o m e d i c a l l i t e r a t u r e d e a l t w i t h d r u g s (6). S i n c e B u r k h o l d e r w a s r e f e r r i n g to d o c u m e n t e d s o u r c e s o f d r u g i n f o r m a t i o n such as textbooks, r e v i e w a r t i c l e s , j o u r n a l s and product l i t e r a t u r e , h i s e s t i m a t e w a s p r o b a b l y c o n s i d e r a b l y l a r g e r than L a n g l y k k e ' s w h i c h only with o r i g i n a l p a p e r s . dealt 2 In a d d i t i o n to the l i t e r a t u r e r e g a r d i n g new d r u g s , n e w a p p l i c a t i o n s of d r u g s , dosages and therapeutic indications p r e v i o u s l y m e n t i o n e d , a great deal of i n f o r m a t i o n has been a c c u m u l a t e d r e g a r d i n g a d v e r s e drug r e a c t i o n s b y s e v e r a l o r g a n i z a t i o n s i n c l u d i n g the W o r l d H e a l t h Organization (9, 1 0 ) . In the f i r s t t h r e e y e a r s o f o p e r a t i o n , the C a n a d i a n D r u g A d v e r s e R e a c t i o n P r o g r a m r e c e i v e d 11, 000 r e p o r t s o f s u s p e c t e d (9). adverse reactions Unfortunately, m u c h of this valuable i n f o r m a t i o n i s unpublished and the p u b l i s h e d p o r t i o n i s o f t e n n o t r e p r e s e n t a t i v e o f the o v e r a l l p i c t u r e ( 1 3 ) . F o r e x a m p l e , a l t h o u g h the n u m b e r o f r e p o r t s o f a n a d v e r s e r e a c t i o n i s p u b l i s h e d , i t i s a l m o s t i m p o s s i b l e to d e t e r m i n e the n u m b e r o f p e o p l e e x p o s e d to the p a r t i c u l a r p r o b l e m . F o r t h i s r e a s o n i t i s d i f f i c u l t to o b t a i n a c l e a r p i c t u r e o f the i m p o r t a n c e o f a d v e r s e d r u g r e a c t i o n s . The 900 existence of a list of p h a r m a c y periodicals containing over e n t r i e s , the e s t i m a t e s o f L a n g l y k k e and B u r k h o l d e r , a n d the a m o u n t o f i n f o r m a t i o n c o l l e c t e d i n r e g a r d to a d v e r s e d r u g r e a c t i o n s a r e s o m e i n d i c a t i o n s o f the v o l u m e o f d r u g l i t e r a t u r e w h i c h m u s t b e e f f e c t i v e l y d e a l t w i t h i n p r o v i d i n g " . . . a c c u r a t e a n d u n b i a s e d i n f o r m a t i o n about d r u g s " (1). D r . C.S. Keefer (11), i n r e c o g n i t i o n o f the v a s t a n d d i v e r s e s o u r c e s o f d r u g i n f o r m a t i o n , e x p r e s s e d i t w e l l w h e n he s a i d " . . . t h e r e i s no d e a r t h o f i n f o r m a t i o n about d r u g s . " 3 (b) Compiling Drug Literature It b e c a m e a p p a r e n t that any l i m i t a t i o n s i n d r u g i n f o r m a t i o n t o d a y a r e not due to a s h o r t a g e of d r u g l i t e r a t u r e but r a t h e r to an i n a d e q u a t e o r g a n i z a t i o n a n d e v a l u a t i o n o f the e x i s t i n g i n f o r m a t i o n (16). The need for b e t t e r d i s s e m i n a t i o n of the e x i s t i n g l i t e r a t u r e has b e e n r e c o g n i z e d b y the d e v e l o p m e n t of v a r i o u s d r u g i n f o r m a t i o n and a b s t r a c t i n g s u b s c r i p t i o n services. T h r e e o f the m a j o r d r u g i n f o r m a t i o n s e r v i c e s i n c l u d e : deHaen series "Drugs in Use", " D r u g s i n C o m b i n a t i o n " and R e s e a r c h " ; the Iowa D r u g I n f o r m a t i o n involved with p h a r m a c e u t i c a l s are: A b s t r a c t s , Index M e d i c u s and Other services less Chemical Abstracts, and specifically Biological s p e c i a l i z e d i n d e x s e r v i c e s s u c h as C h e m o t h e r a p y A b s t r a c t s and M e n t a l R e t a r d a t i o n The "Drugs in Service microfliche system International P h a r m a c e u t i c a l A b s t r a c t s . the Cancer Abstracts. m a j o r s u b s c r i p t i o n s e r v i c e s h a v e the c o m m o n f e a t u r e o f b e i n g a b s t r a c t i n g s y s t e m s w h i c h a r e s i m i l a r i n the s e r v i c e s o f f e r e d . The d e H a e n s y s t e m a b s t r a c t s , i n f o r m a t i o n f r o m 400 j o u r n a l s i n the h e a l t h c a r e f i e l d as w e l l as v a r i o u s m e d i c a l a s s o c i a t i o n m e e t i n g s (17). The c a r d s o f the d e H a e n s e r v i c e c o n t a i n s i g n i f i c a n t i n f o r m a t i o n f r o m the o r i g i n a l a r t i c l e i n c l u d i n g the s a m p l e s i z e , d u r a t i o n of the s t u d y , d o s a g e informa- t i o n and the s t a t i s t i c a l s t u d y p e r f o r m e d as w e l l as the r e s u l t s a n d m e n t s o f the a u t h o r . International P h a r m a c e u t i c a l A b s t r a c t s , com- published b y the A m e r i c a n S o c i e t y o f H o s p i t a l P h a r m a c i s t s , i s a s e m i - m o n t h l y b u l l e t i n c o n t a i n i n g a b s t r a c t s f r o m o v e r 1000 p e r i o d i c a l s dealing with 4 p h a r m a c y , m e d i c i n e a n d r e l a t e d f i e l d s (18). The International P h a r m a - c e u t i c a l A b s t r a c t s p u b l i c a t i o n c o m p i l e s the t i t l e of the o r i g i n a l a r t i c l e and a n i n f o r m a t i v e a b s t r a c t w h i c h i s c a t e g o r i z e d u n d e r one o r m o r e o f the 25 s e c t i o n s w h i c h c o v e r the p r a c t i c a l , t h e o r e t i c a l , e c o n o m i c a n d scientific aspects of p h a r m a c y l i t e r a t u r e . In c o n t r a s t to the a b s t r a c t i n g s e r v i c e s , the Iowa D r u g Service presents the c o m p l e t e o r i g i n a l a r t i c l e on m i c r o f i l m , i n d e x e d b y 64 t w o - d i g i t " d e s c r i p t o r s " on a c c o m p a n y i n g f i l e c a r d s . a r e t e r m s u s e d to d e f i n e the c o n t e n t s , The Information The "descriptors" s t r u c t u r e a n d r e s u l t s o f the study. s i g n i f i c a n t i t e m s o f e a c h p a p e r a r e c o d e d b y the " d e s c r i p t o r s " b e f o r e the a r t i c l e i s m i c r o f i l m e d . T h i s p r o c e s s a l l o w s the u s e r to p i n p o i n t h i s a r e a s o f i n t e r e s t f i r s t l y f r o m the i n d e x c a r d a n d f i l m e d a r t i c l e (19). s e c o n d l y o n the m i c r o - It a l s o m a k e s a v a i l a b l e the c o m p l e t e a r t i c l e f o r i m m e d i a t e e v a l u a t i o n b y the u s e r . One d r a w b a c k o f t h i s s y s t e m i s that a m i c r o f i l m r e a d e r o r r e a d e r - p r i n t e r i s r e q u i r e d to m a k e u s e o f the infor- mation. The a d v a n t a g e o f s y s t e m s s u c h a s t h o s e d e s c r i b e d a b o v e l i e s i n the f a c t that t h e y c o v e r a l a r g e n u m b e r of i n f o r m a t i o n s o u r c e s , organizing t h e m into a u s a b l e f o r m a t a n d m a k i n g t h e m a v a i l a b l e to the u s e r s o f d r u g information. One d i s a d v a n t a g e i s that t h e y do not p r e s e n t e v a l u a t e d infor- m a t i o n (14) but r a t h e r p r e s e n t a l l i n f o r m a t i o n r e g a r d l e s s o f the v a l i d i t y or significance. A p p e n d i x I). The A n o t h e r d i s a d v a n t a g e of t h e s e s y s t e m s is the c o s t (see p r i c e , the s t o r a g e a r e a n e e d e d a n d the e q u i p m e n t 5 n e c e s s a r y to m a k e u s e o f s y s t e m s s u c h a s the Iowa D r u g I n f o r m a t i o n S e r v i c e l i m i t the a b i l i t y o f the i n d i v i d u a l h o s p i t a l to a c q u i r e a n d m a i n t a i n them. As explained by Burkholder (14) a n d s u p p o r t e d b y o t h e r s (12, 16, 20, 21) the p r o b l e m i s to m a k e a v a i l a b l e to m e m b e r s o f the h e a l t h p r o f e s s i o n s v a l i d and useful drug i n f o r m a t i o n when and where it i s needed. A c o r o l l a r y to the p r o b l e m c o u l d b e that the i n f o r m a t i o n a l s o s h o u l d b e u n b i a s e d (1). II. Hospital Drug (a) Definition The Formularies m a j o r a p p r o a c h t a k e n b y h o s p i t a l s to o v e r c o m e the p r o b l e m o f not h a v i n g the r i g h t d r u g i n f o r m a t i o n a v a i l a b l e at the r i g h t t i m e i s the d e v e l o p m e n t o f h o s p i t a l d r u g f o r m u l a r i e s i n c o n j u n c t i o n w i t h the P h a r m a c y a n d T h e r a p e u t i c s C o m m i t t e e s o f the i n d i v i d u a l i n s t i t u t i o n s (23-31). A f o r m u l a r y i s d e f i n e d b y the A m e r i c a n S o c i e t y o f H o s p i t a l P h a r m a c i s t s a s : ". ..a continually r e v i s e d compilation of p h a r m a c e u t i c a l s w h i c h r e f l e c t s the c u r r e n t c l i n i c a l j u d g m e n t o f the m e d i c a l s t a f f " (34). " M i r r o r to H o s p i t a l P h a r m a c y " i n d i c a t e s that a b o u t 60 p e r c e n t o f h o s p i t a l s i n the U n i t e d S t a t e s o p e r a t e u n d e r a f o r m u l a r y s y s t e m , d e f i n i n g a formulary system as: 6 " . . . a m e t h o d w h e r e b y the m e d i c a l s t a f f o f a hospital, working through a p h a r m a c y therapeutics appraises and committee..., and evaluates, s e l e c t s f r o m a m o n g the numerous medicinal that a r e c o n s i d e r e d agents a v a i l a b l e those m o s t useful i n patient c a r e , t o g e t h e r w i t h the p h a r m a c e u t i c a l preparations i n w h i c h they may be adminis- t e r e d m o s t e f f e c t i v e l y . " (32). The usefulness o f the f o r m u l a r y s y s t e m i s a c k n o w l e d g e d b y b o t h the C a n a d i a n S o c i e t y of H o s p i t a l P h a r m a c i s t s a n d the A m e r i c a n S o c i e t y o f H o s p i t a l P h a r m a c i s t s i n p u b l i s h i n g s t a t e m e n t s o f g u i d e l i n e s f o r the u s e the h o s p i t a l f o r m u l a r y s y s t e m (33, 34). In a d d i t i o n a l s u p p o r t o f the m u l a r y s y s t e m , the C a n a d i a n C o u n c i l on H o s p i t a l A c c r e d i t a t i o n of for- (35) r e q u i r e s p a r t i c i p a t i o n i n the d e v e l o p m e n t o f a h o s p i t a l f o r m u l a r y as part o f the r e q u i r e m e n t s f o r p h a r m a c e u t i c a l s e r v i c e s of a h o s p i t a l s e e k i n g accreditation. The use of f o r m u l a r i e s i s not a new concept. T h e y have been u s e d i n N o r t h A m e r i c a s i n c e the e a r l y n i n e t e e n t h c e n t u r y (36). Some f o r m u l a - r i e s , f o r e x a m p l e the p r e v i o u s V a n c o u v e r G e n e r a l H o s p i t a l f o r m u l a r y (37), w e r e l i s t s of d r u g s and Other formularies dosage f o r m s a v a i l a b l e for use i n the h o s p i t a l . c o n t a i n e d a d d i t i o n a l i n f o r m a t i o n on t h e r a p e u t i c i n d i c a - t i o n s , side e f f e c t s , and s t a n d a r d d o s e s as i n the f o r m u l a r y o f the O t t a w a C i v i c H o s p i t a l (25) a n d the f o r m u l a r y o f the U n i v e r s i t y o f P e n n s y l v a n i a H o s p i t a l (28). A t h i r d f o r m a t i s that o f the L i o n s G a t e H o s p i t a l D r u g F o r m u l a r y (see F i g u r e 1) w h i c h c o n t a i n s i n d i c a t i o n s , s i d e e f f e c t s and d o s a g e s as w e l l as a d d i t i o n a l i n f o r m a t i o n on c o n t r a i n d i c a t i o n s , d r u g i n t e r - 7 F i g u r e 1. E x a m p l e o f the f o r m a t a n d c o n t e n t o f the d r u g m o n o g r a p h s o f the L i o n s G a t e H o s p i t a l Drug Formulary. 8 GLUTETHIMIDE DORIDEN 28:24 ACTION A s e d a t i v e - h y p n o t i c s t r u c t u r a l l y s i m i l a r to b a r b i t u r a t e s . G r e a t e r d e g r e e of h y p o t e n s i o n than b a r b i t u r a t e s . Onset: 20 m i n u t e s . Duration: Approximately 6 hours. INDICATIONS Sedative, hypnotic. CONTRAINDICATIONS None known. U s e with caution when impending d e p r e s s i o n o r suicidal tendencies exist. DOSAGE ADULTS: Daytime sedation: Insomnia: - . 5 gm. 125-250 m g . t.i.d. h . s., m a y be r e p e a t e d n o t l e s s than 4 h o u r s b e f o r e a r i s i n g . In l o n g t e r m u s e the total d a i l y dose s h o u l d not e x c e e d 1 gm. SIDE E F F E C T S Nausea, vomiting, anorexia, headache, dizziness, confusion, g e n e r a l i z e d skin r a s h . R a r e l y acute a l l e r g i c r e a c t i o n s , blood d y s c r a s i a s , p o r p h y r i a and jaundice. Hypotension and c i r c u l a t o r y s h o c k r e p r e s e n t the m a j o r p r o b l e m i n t o x i c d o s e s . P s y c h i c a n d p h y s i c a l dependence with prolonged u s e . DRUG INTERACTIONS I n h i b i t s a c t i o n o f o r a l a n t i c o a g u l a n t s i n c r e a s i n g the r i s k o f t h r o m b u s f o r m a t i o n d u r i n g therapy and b l e e d i n g tendency on w i t h d r a w a l . C N S depressant effects of glutethimide a r e potentiated by n a r c o t i c s , alcohol, phenothiazines ( L a r g a c t i l , Stelazine, Phenergan, etc.), M A O inhibitors (Parnate, N a r d i l , etc.), anaesthetics, and R e s e r p i n e . G l u t e t h i m i d e i n h i b i t s (by e n z y m e i n d u c t i o n ) a n a l g e s i c s , antihistamines (Benadryl, P e r a z i n e ) , phenylbutazone, diphenlyhydantoin, griseofulvin ( G r i s a c t i n , F u l v i c i n ) , meprobamate, (Equanil), c o r t i c o s t e r o i d s (oral c o n t r a c e p t i v e s , h y d r o c o r t i s o n e , etc. ) other hypnotics. NURSING IMPLICATIONS P e r i o d i c b l o o d counts and l i v e r function tests a r e a d v i s a b l e . With p r o l o n g e d u s e , w i t h d r a w l f r o m d r u g s h o u l d be g r a d u a l to m i n i m i z e withdrawal reactions. G i v e w i t h f o o d to r e d u c e g a s t r i c i r r i t a t i o n . M o n i t o r v i t a l signs i f being taken r e g u l a r l y . tion b y a l c o h o l . D o e s not p r o d u c e sedation i n h i g h l y d i s t u r b e d patients o r those i n p a i n . M a y produce p h y s i c a l and p s y c h o l o g i c a l dependence. PRESENTATION Tablets: 500 Exaggerated potentia- mg. FIGURE 1 9 actions and nursing i m p l i c a t i o n s . As w e l l a s d e v e l o p m e n t s i n the f o r m a t a n d c o n t e n t o f f o r m u l a r i e s , a d v a n c e s h a v e b e e n m a d e i n the f i e l d o f f o r m u l a r y p r o d u c t i o n . Electronic Data P r o c e s s i n g (E.D. P . ) i s being u s e d i n f o r m u l a r y production i n both C a n a d a a n d the U n i t e d S t a t e s (25, 2 7 , 28, 38, 39, 40, 4 1 ) . T h e I o w a D r u g I n f o r m a t i o n S e r v i c e u s e d E . D . P . to p r o d u c e a d r u g f o r m u l a r y f r o m t h e i r a u t o m a t e d d r u g i n f o r m a t i o n f i l e (27). A t the U n i v e r s i t y o f P e n n s y l v a n i a H o s p i t a l (28) a n d t h e O t t a w a C i v i c H o s p i t a l (25, 38) f o r m u l a r i e s w e r e pro- d u c e d f r o m d e c k s o f c o m p u t e r c a r d s o n w h i c h the i n f o r m a t i o n h a d b e e n key-punched. A t p r e s e n t , the O t t a w a C i v i c H o s p i t a l h a s c o n v e r t e d p r o d u c t i o n o f the f o r m u l a r y their to a u t o m a t e d p h o t o c o m p o s i t i o n a n d m a g n e t i c tape f o r i n f o r m a t i o n s t o r a g e (38). T h e s e o p e r a t i o n s h a v e d e m o n s t r a t e d that i n the s e v e r a l w a y s o f a p p l y i n g E . D . P . to f o r m u l a r y p r i n t i n g (28), the c o s t o f l o n g - t e r m p r o d u c t i o n o f the f o r m u l a r i e s b y E . D . P . w a s l e s s than the c o s t o f c o n v e n t i o n a l p r i n t i n g m e t h o d s (27, 3 8 ) . E d i t i n g a n d u p d a t i n g o f d r u g i n f o r m a t i o n c o n t a i n e d i n the f o r m u l a r i e s a l s o w a s f a s t e r a n d e a s i e r (25, 28, (b) 38). Limitations F r o m the w i d e - s p r e a d u s e o f d r u g f o r m u l a r i e s i t a p p e a r s that t h e y h a v e b e e n f a i r l y s u c c e s s f u l i n p r o v i d i n g d r u g i n f o r m a t i o n to the h e a l t h p r a c t i t i o n e r s at the p o i n t o f u s e i n t h e i r r e s p e c t i v e h o s p i t a l s . there a r e also some specific limitations i n their e f f e c t i v e n e s s . However, 10 It h a s b e e n r e c o g n i z e d that a t r u e f o r m u l a r y p r e h e n s i v e t h a n m e r e l y a d r u g l i s t (27). com- It h a s b e e n i d e n t i f i e d a l s o that the c o s t o f the d r u g i n f o r m a t i o n r e s o u r c e s ( s e e A p p e n d i x I) r e q u i r e d to evaluate and c o m p i l e i n f o r m a t i o n for a f o r m u l a r y i n d i v i d u a l h o s p i t a l to m a i n t a i n h a s to b e m o r e the r e s o u r c e s with additional i n f o r m a t i o n when n e c e s s a r y . l i m i t s the a b i l i t y o f e a c h to b a c k - u p t h e i r formulary It s h o u l d be n o t e d that the s m a l l e r n o n - t e a c h i n g h o s p i t a l i s p e r h a p s ate.a g r e a t e r d i s a d v a n t a g e i n t h i s r e g a r d s i n c e a c c e s s to l a r g e m e d i c a l l i b r a r i e s i s l i m i t e d (42). Neverthe- l e s s , these s m a l l e r hospitals r e q u i r e drug i n f o r m a t i o n as m u c h as, o r m o r e t h a n the l a r g e t e a c h i n g i n s t i t u t e s ( 3 1 ) . A s e c o n d o b s t a c l e to the e f f e c t i v e p r o d u c t i o n o f i n d i v i d u a l f o r m u l a r i e s i s the c o n s i d e r a b l e t i m e a n d e x p e r t i s e r e q u i r e d to e v a l u a t e the l i t e r a t u r e a n d p r o d u c e the d r u g m o n o g r a p h s (43). The responsibility for p r o d u c i n g the d r u g m o n o g r a p h s r e s t s w i t h the p h a r m a c i s t s who i n t h e i r s p a r e t i m e e v a l u a t e the l i t e r a t u r e a n d p r o d u c e the d r u g m o n o g r a p h s ( 4 3 ) . F r a n c k e r e c o g n i z e d t h e s e o b s t a c l e s to the p r e p a r a t i o n o f a d r u g formulary i n h i s o w n h o s p i t a l (43). the c o s t l y i n f o r m a t i o n s o u r c e s , the f o r m u l a r y w h e r e (43). H e a l s o r e c o g n i z e d that the p u r c h a s e o f a n d the t i m e a n d e f f o r t r e q u i r e d to p r o d u c e were being duplicated many times by pharmacists every- F r a n c k e s u g g e s t e d that m u c h o f the d u p l i c a t i o n m e n t i o n e d a b o v e c o u l d b e e l i m i n a t e d i f the A m e r i c a n S o c i e t y o f H o s p i t a l P h a r m a c i s t s would sponsor a national hospital f o r m u l a r y to the h o s p i t a l s a t a r e a s o n a b l e c o s t (43). s e r v i c e and m a k e it a v a i l a b l e T h i s p e r h a p s w a s the f i r s t s t e p 11 to r e g i o n a l i z e d f o r m u l a r y p r o d u c t i o n . III. Regional Drug Formularies (a) T h e A m e r i c a n Hospital F o r m u l a r y Service A l t h o u g h the P h y s i c i a n s ' D e s k R e f e r e n c e * ( P . D . R . ) h a d s e r v e d the general m e d i c a l p r a c t i t i o n e r s ' needs for drug information for m a n y y e a r s (47), it r e p r e s e n t s a national c o m p i l a t i o n of drug m a n u f a c t u r e r s ' l i t e r a - t u r e (44). P e r h a p s the f i r s t , a n d s t i l l m o s t p o p u l a r r e g i o n a l d r u g formu- l a r y that p r o v i d e s a c c u r a t e a n d u n b i a s e d i n f o r m a t i o n i s the A m e r i c a n Hospital F o r m u l a r y A.H. F.S. S e r v i c e * * ( A . H . F . S. ). The d r u g m o n o g r a p h s o f the a r e p r e p a r e d b y the C o m m i t t e e o n P h a r m a c y a n d c a l s o f the A m e r i c a n S o c i e t y o f H o s p i t a l P h a r m a c i s t s . The Pharmaceutid i r e c t o r of the c o m m i t t e e e d i t s the m o n o g r a p h s to e n s u r e a c o n s t a n t f o r m a t a n d t h e y are r e v i e w e d by three s u b c o m m i t t e e s of p r a c t i t i o n e r s , p h a r m a c i s t s manufacturers A.H. F.S. f o r suggestions and c o m m e n t s . and S u p p l e m e n t s to the a r e p u b l i s h e d a n d d i s t r i b u t e d to the s u b s c r i b e r s at r e g u l a r i n t e r v a l s c o n t a i n i n g b o t h new existing monographs. d r u g m o n o g r a p h s a n d u p d a t e d i n f o r m a t i o n on T h e m o n o g r a p h s p r o d u c e d a r e b e l i e v e d to r e p r e s e n t a c c u r a t e , e v a l u a t e d a n d u n b i a s e d i n f o r m a t i o n (46). *The P h y s i c i a n s ' Desk R e f e r e n c e , 23rd. edition, M e d i c a l E c o n o m i c s , Inc., s u b s i d i a r y of L i t t o n P u b l i c a t i o n s , I n c . , O r a d e l l , New **The A m e r i c a n Hospital F o r m u l a r y S e r v i c e , C o m m i t t e e on Jersey, 1969. Pharmacy a n d P h a r m a c e u t i c a l s o f the A m e r i c a n S o c i e t y o f H o s p i t a l P h a r m a c i s t s ; The H a m i l t o n P r e s s , H a m i l t o n , Illinois. 12 The C o m m i t t e e on P h a r m a c y and P h a r m a c e u t i c a l s recognized two i m p o r t a n t u s e s f o r the A . H . F . S. : (1) As a basis for p r e p a r i n g individual hospital f o r m u l a r i e s ; (2) As a c o m p a r a t i v e l y c o m p l e t e d r u g r e f e r e n c e u s e f u l to p r a c t i t i o n e r s a n d t e a c h e r s i n a l l the h e a l t h p r o f e s s i o n s concerned The w i t h d r u g s (46). f i r s t o b j e c t i v e i n t e n d e d that e a c h h o s p i t a l P h a r m a c y a n d Therapeutics C o m m i t t e e w o u l d a c c e p t the r e s p o n s i b i l i t y to a d a p t the A . H . F . S. to the s p e c i f i c n e e d s o f the i n d i v i d u a l h o s p i t a l (57). Francke P r o m o t i n g this concept s u g g e s t e d that the r e s p e c t i v e p h a r m a c i s t s also might maintain f i l e a l l a d d i t i o n a l d r u g m o n o g r a p h s s u p p l i e d b y the A . H . F . S . drug i n f o r m a t i o n . on as a d d i t i o n a l T h i s p r a c t i c e w o u l d e n a b l e the p h a r m a c i s t to p r o v i d e i n f o r m a t i o n to the P h a r m a c y a n d T h e r a p e u t i c s C o m m i t t e e i n v e s t i g a t i n g a new lary f o r m u l a r y a d d i t i o n o r to o t h e r s t a f f m e m b e r s r e q u e s t i n g a n o n - f o r m u drug. (b) H o s p i t a l D r u g I n f o r m a t i o n The Centres s e c o n d p r o j e c t e d u s e o f the A . H . F . S . b e c a m e m o r e p o p u l a r w i t h the d e v e l o p m e n t o f h o s p i t a l d r u g i n f o r m a t i o n c e n t r e s (24, 30, 31, 50). T h e s e c e n t r e s w e r e i n i t i a t e d to p r o v i d e a c c u r a t e , d e t a i l e d a n d 49, up-to- date i n f o r m a t i o n on d r u g s to a l l m e m b e r s o f the p a t i e n t c a r e s t a f f o f the h o s p i t a l s (31) a n d " . . .to s u p p o r t , a s s i s t a n d p r o m o t e a r a t i o n a l d r u g t h e r a p y p r o g r a m " (24). A l t h o u g h o t h e r f o r m u l a r i e s s u c h as the A . H . F.S. (51, 52) a d e q u a t e l y p r o v i d e d e v a l u a t e d , a c c u r a t e a n d u n b i a s e d i n f o r m a t i o n 13 (46), i t w a s d i f f i c u l t f o r t h e s e s e r v i c e s to p r o v i d e u p - t o - d a t e i n f o r m a t i o n . T h i s p r o b l e m was due l a r g e l y to the t i m e l a g b e t w e e n the o r i g i n a l p u b l i c a - t i o n o f the l i t e r a t u r e a n d the p r o d u c t i o n o f the r e s p e c t i v e s u p p l e m e n t s . An a c t i v e d r u g i n f o r m a t i o n c e n t r e o n the o t h e r h a n d w i t h i n f o r m a t i o n r e s o u r c e s s i m i l a r to t h o s e l i s t e d b y B u r k h o l d e r p r o v i d e up-to-date (6), b e t t e r e n a b l e d the p h a r m a c i s t to i n f o r m a t i o n , to a n s w e r q u e s t i o n s that w e r e b e y o n d the s c o p e o f the f o r m u l a r y a n d to p r o v i d e i n f o r m a t i o n o n n o n - f o r m u l a r y (27, 29, 30, 31, 42, 48, 49, drugs 50). A g a i n , as w i t h the p r o d u c t i o n o f h o s p i t a l f o r m u l a r i e s , the s m a l l e r c o m m u n i t y h o s p i t a l w i t h l i m i t e d a c c e s s to l i t e r a t u r e r e s o u r c e s , f a c i l i t i e s a n d s t a f f i s at a d i s a d v a n t a g e 53). i n o p e r a t i n g a d r u g i n f o r m a t i o n c e n t r e (42, In o r d e r to o v e r c o m e d u p l i c a t i o n a n d i n a d e q u a t e h o s p i t a l s i n t h i s r e s p e c t , i t was efforts by small r e c o g n i z e d that s u c h n e e d s f o r d r u g m a t i o n m i g h t b e t t e r be s e r v e d b y d e v e l o p i n g one infor- large drug information c e n t r e at a u n i v e r s i t y - a f f i l i a t e d h o s p i t a l to s e r v e a s p e c i f i c r e g i o n of s m a l l e r i n s t i t u t i o n s (42). (c) R e g i o n a l D r u g I n f o r m a t i o n The Centres d e v e l o p m e n t o f R e g i o n a l D r u g I n f o r m a t i o n C e n t r e s , l i k e the p r o d u c t i o n o f the r e g i o n a l A m e r i c a n H o s p i t a l F o r m u l a r y S e r v i c e , r e s u l t e d i n a c e n t r a l i z e d s e r v i c e s u p p o r t i n g s m a l l e r s e r v i c e s at the l o c a l l e v e l (42, 7, 3 4 , 55, 56) a n d , consequently, of c o s t s , f a c i l i t i e s , and staff. the e l i m i n a t i o n o f s o m e o f the d u p l i c a t i o n T h e r e h a v e b e e n two m a j o r t r e n d s i n the 14 d e v e l o p m e n t o f R e g i o n a l D r u g I n f o r m a t i o n C e n t r e s b a s e d on and c e n t r a l i z e d a p p r o a c h e s . These may decentralized be e x e m p l i f i e d b y the Michigan R e g i o n a l D r u g I n f o r m a t i o n N e t w o r k a n d the K e n t u c k y R e g i o n a l D r u g I n f o r mation Centre The respectively. M i c h i g a n Regional D r u g Information Network with its m a i n c e n t r e at the U n i v e r s i t y o f M i c h i g a n s u p p l i e s d r u g i n f o r m a t i o n to n i n e a f f i l i a t e d h o s p i t a l s t h r o u g h o u t the s t a t e . V a r i o u s s o u r c e s of drug infor- m a t i o n i n c l u d i n g the A m e r i c a n H o s p i t a l F o r m u l a r y S e r v i c e , the d e H a e n s y s t e m s , the F e d e r a l D r u g A d m i n i s t r a t i o n ( F . D . A . ) C l i n i c a l Experience A b s t r a c t s , the F . D . A . S u s p e c t e d A d v e r s e R e a c t i o n , I n t e r n a t i o n a l P h a r m a c e u t i c a l A b s t r a c t s a n d s e v e r a l j o u r n a l s s e r v e as r e s o u r c e s (57, 58). E a c h affiliated centre is responsible for answering drug information r e q u e s t s f r o m i t s own a r e a w h e n e v e r p o s s i b l e (58). The main centre is available as a r e f e r r a l centre o r c l e a r i n g house for m o r e c o m p l e x requests that c a n n o t be a n s w e r e d a d e q u a t e l y at the l o c a l c e n t r e (59) as w e l l as a n s w e r i n g r e q u e s t s f r o m the U n i v e r s i t y o f M i c h i g a n M e d i c a l C e n t r e . This s y s t e m h a s a t t e m p t e d to m a i n t a i n a s m u c h a u t o n o m y as p o s s i b l e at e a c h a f f i l i a t e d c e n t r e w i t h i n the f r a m e w o r k o f a r e g i o n a l s y s t e m a n d i s t h e r e f o r e a n e x a m p l e o f the d e c e n t r a l i z e d t r e n d i n R e g i o n a l D r u g I n f o r m a t i o n The s y s t e m i n o p e r a t i o n at the U n i v e r s i t y o f K e n t u c k y a n d , Centres. simi- l a r l y , i n the A p p a l a c h i a n R e g i o n a l H o s p i t a l s S y s t e m i s d e s i g n e d to p r o v i d e m e d i c a l l i b r a r y and d r u g i n f o r m a t i o n s e r v i c e s on a r e g i o n a l b a s i s f r o m a s i n g l e c e n t r a l i z e d s o u r c e (55, 56). In the K e n t u c k y R e g i o n a l D r u g I n f o r - 15 mation C e n t r e , the c e n t r a l i n f o r m a t i o n s o u r c e i s a v a i l a b l e to the h e a l t h p r o f e s s i o n a l s i n the state b y a t o l l - f r e e , d i r e c t - d i a l t e l e p h o n e l i n e (called a Wide A r e a Telephone S e r v i c e o r W A T S ) for i n c o m i n g calls. W h e n a r e t u r n c a l l i s n e c e s s a r y the i n f o r m a t i o n i s p r o v i d e d v i a the e x i s t ing telephone l i n e s . B y u s i n g the e x i s t i n g t e l e p h o n e s y s t e m i n s t e a d o f the W A T S n e t w o r k f o r o u t - g o i n g c a l l s the K e n t u c k y R e g i o n a l D r u g I n f o r m a t i o n C e n t r e h a s r e d u c e d the h i g h c o s t o f c o m m u n i c a t i o n i n h e r e n t i n a c e n t r a l i z e d s y s t e m (55, 6 8 ) . In the A p p a l a c h i a n r e g i o n , c o m m u n i c a t i o n b e t w e e n the m a i n c e n t r e a n d the r e g i o n a l h o s p i t a l s i s m a i n t a i n e d b y a t e l e t y p e n e t w o r k , n e w s l e t t e r s , a n d t e l e p h o n e c o n f e r e n c e s (56). T h e p o p u l a r i t y o f the A . H . F . S . general, and D r u g Information Centres i n i s r e f l e c t e d b y the i n c r e a s i n g u s e a n d d e v e l o p m e n t o f b o t h o f t h e s e c o n c e p t s (24, 3 1 , 38, 4 5 , 51, 59, 6 0 , 6 1 , 6 2 , 6 3 , 64). c o m b i n a t i o n o f the A . H . F . S . A l t h o u g h the and a D r u g Information Centre has resulted i n the D r u g I n f o r m a t i o n C e n t r e b e i n g l a b e l l e d a s the " . . . g u a r d i a n o f the f o r m u l a r y " (48), the A . H . F . S . alone still has definite limitations for u s e in g e n e r a l and, m o r e s p e c i f i c a l l y , i n C a n a d a . (d) L i m i t a t i o n s o f the A . H . F . S . S o m e o f the g e n e r a l l i m i t a t i o n s o f the A . H . F . S . w h i c h h a v e b e e n cited include: 1. T h e A.H. F.S. 1030 h a s e x p a n d e d to i n c l u d e , (as o f 1967) d r u g m o n o g r a p h s a n d 2766 p a g e s i n a t w o - v o l u m e s e t (43). A s a r e s u l t o f the s i z e , the A . H . F . S . v e r y b u l k y a n d a w k w a r d b o o k to u s e (47, 65). is a The 16 b u l k i n e s s alone can i m p e d e r a p i d i n f o r m a t i o n r e t r i e v a l (47); 2. M a n y p r o d u c t s c o v e r e d i n the A . H . F . S. m a y be u s e d i n a s p e c i f i c h o s p i t a l . Burkholder not showed that the a v e r a g e n u m b e r o f d r u g m o n o g r a p h s r e q u i r e d b y a h o s p i t a l i s about 400 A.H. F.S. c o n t a i n s 1030 (43). (66) w h i l e the T h i s i m p l i e s that a s e t o f the A . H . F . S. i n the a v e r a g e h o s p i t a l i s about two 3. The and o n e - h a l f t i m e s l a r g e r than n e c e s s a r y ; f o r m a t o f the A . H . F . S . problem. The is a third potential f o r m a t of p a r a g r a p h s r a t h e r than p o i n t f o r m r e q u i r e s that the u s e r r e a d w h o l e s e n t e n c e s to f i n d the r e q u i r e d i n f o r m a t i o n . Also, the i n f o r m a t i o n d o e s not s e e m to be d i v i d e d into enough s u b s e c t i o n s . T h i s r e q u i r e s that the u s e r m u s t r e f e r to the s u b s e c t i o n on "pharmacology a n d a c t i o n " to f i n d i n f o r m a t i o n on s i d e e f f e c t s . 4. F i n a l l y , the d r u g m o n o g r a p h s a r e not r e f e r e n c e d a n d to s u p p l y a d d i t i o n a l i n f o r m a t i o n on a s p e c i f i c p o i n t of i n t e r e s t b e c o m e s q u i t e d i f f i c u l t w i t h o u t the s t a r t i n g p o i n t of the o r i g i n a l r e f e r e n c e . * In the U n i t e d S t a t e s , a t t e m p t s to o v e r c o m e the b u l k i n e s s o f the A . H . F . S. h a v e t a k e n the f o r m of m o d i f i e d f o r m u l a r i e s as s u g g e s t e d b y the p r o d u c e r s o f the A . H . F . S. (46). H o w e v e r , this i s a v e r y t i m e c o n s u m i n g task a n d the r e s u l t i n g f o r m u l a r y p r i n t e d o n s m a l l p a g e s to m a t c h the A . H . (46) F.S. i s s t i l l b u l k y (65). In a d d i t i o n to the a b o v e , t h e r e a r e at l e a s t two d r a w b a c k s to the of the A m e r i c a n H o s p i t a l F o r m u l a r y S e r v i c e i n C a n a d i a n h o s p i t a l s : 1. The A . H . F . S. u s e s A m e r i c a n b r a n d n a m e s w h i c h i n m a n y i n s t a n c e s do not c o r r e s p o n d to the b r a n d n a m e s c o m m o n l y in use in Canada. problem are: Some e x a m p l e s of this chlorpromazine which is T h o r a z i n e ^ in R the U n i t e d S t a t e s a n d Largactil in Canada; cyclophos- p h a m i d e w h i c h i s Cytoxan-"- i n the U n i t e d S t a t e s a n d R R Procytox in Canada; isoniazid which is D i n a c r i n in * Presently being undertaken. use 17 the U n i t e d S t a t e s a n d R i m a f o n in Canada; and d i e t h y l R • stilboestrol diphosphate which i s M i l e s t r o l i n the U n i t e d States and H o n v o l i n C a n a d a (70.67). ' 2. A s e c o n d p r o b l e m o f the u s e o f a n y A m e r i c a n drug r e f e r e n c e i n a C a n a d i a n h o s p i t a l i s the p o s s i b i l i t y o f d i f f e r e n t f o r m u l a t i o n s o f p r o d u c t s b e a r i n g the same brand name. This problem is represented b y the d i f f e r e n t f o r m u l a t i o n s o f a C a n a d i a n and an A m e r i c a n p r o d u c t w h i c h b o t h h a v e the b r a n d name Infantol. supplement The Canadian product is a dietary containing v i t a m i n A, v i t a m i n D, thiamine, r i b o f l a v i n , v i t a m i n C, n i a c i n a m i d e a n d p y r i d o x i n e (70) w h i l e the A m e r i c a n p r o d u c t is an a n t i d i a r r h e a l containing, p e c t i n , zinc phenosulphonate, b i s m u t h s u b s a l i c y l a t e and I r i s h M o s s E x t r a c t ( 6 7 ) . T h i s i s p o s s i b l y one o f the m o s t s i g n i f i c a n t f o r m u l a t i o n d i f f e r e n c e s . A l t h o u g h t h e r e i s no r e g i o n a l f o r m u l a r y i n C a n a d a c o m p a r a b l e to the A . H . F . S . , one p u b l i c a t i o n w h i c h o v e r c o m e s s o m e o f the a b o v e l i m i t a t i o n s i s the C o m p e n d i u m o f P h a r m a c e u t i c a l s a n d S p e c i a l t i e s * ( C . P . S . ). T h e C . P . S . i s a c o m p i l a t i o n of i n f o r m a t i o n on p h a r m a c e u t i c a l p r o d u c t s and i s c o m m o n l y u s e d i n C a n a d i a n h o s p i t a l s , c l i n i c s , c o m m u n i t y p h a r m a c i e s a n d p h y s i c i a n s ' o f f i c e s ( 6 8 ) . H o w e v e r , s o m e o f the c h a r a c t e r i s t i c s o f the C . P . S . m a k e i t s o m e w h a t i n a d e q u a t e i n a h o s p i t a l s e t t i n g : 1. T h e f o r m a t of the C . P . S . i s not thought to be suitable for r a p i d r e f e r e n c e since it is p r e p a r e d i n p a r a g r a p h s r a t h e r than point f o r m ; 2. T h e i n f o r m a t i o n i n the d r u g m o n o g r a p h s i s not d i v i d e d into e n o u g h s u b s e c t i o n s to e n a b l e the u s e r s to r a p i d l y f i n d the d e s i r e d i n f o r m a t i o n ; 3. T h e m o n o g r a p h s o f the C . P . S . a r e a r r a n g e d a l p h a b e t i c a l l y by both b r a n d and g e n e r i c n a m e s . A s a r e s u l t of this p r a c t i c e , there m a y * be C o m p e n d i u m of P h a r m a c e u t i c a l s and S p e c i a l t i e s , R o t e n b e r g , G.N. H u g h e s , F . N., ed. Canadian P h a r m a c e u t i c a l Association, Toronto and 1972. 18 s e v e r a l s e p a r a t e m o n o g r a p h s for one g e n e r i c name drug. A n e x a m p l e of this p r o b l e m i s A m p i c i l l i n which is monographed five times u n d e r d i f f e r e n t b r a n d n a m e s a n d o n c e a s the g e n e r i c n a m e d r u g (70); 4. T h e C . P . S . does not contain any r e f e r e n c e s for the m o n o g r a p h s so that i t i s n o t p o s s i b l e to e v a l u a t e the o r i g i n a l i n f o r m a t i o n s o u r c e o n a specific statement o r point of interest; 5. T h e C . P . S . does not include s p e c i f i c subsec- tions r e g a r d i n g drug a d m i n i s t r a t i o n and u s e . The p o p u l a r i t y o f u s e o f the A . H . F . S . a n d the C . P . S . i n C a n a d a e n d o r s e the n e e d f o r a r e g u l a r l y p r o d u c e d f o r m u l a r y information. on current drug R e c o g n i z i n g the l i m i t a t i o n s o f the a b o v e two s e r v i c e s , h o w - e v e r , i t w o u l d a p p e a r that a n e e d s t i l l e x i s t s f o r a C a n a d i a n h o s p i t a l formulary IV. service. Provincial Hospital Drug The Formulary d e v e l o p m e n t o f c l i n i c a l p h a r m a c y s e r v i c e s a n d the i n c r e a s e d i n v o l v e m e n t o f the L i o n s G a t e H o s p i t a l * p h a r m a c y s t a f f i n d r u g l e d to the r e c o g n i t i o n o f the l i m i t a t i o n s o f the A . H . F . S . this h o s p i t a l (71, 72). information a n d the C . P . S . i n B e t w e e n the y e a r s 1965-1970, the p h a r m a c i s t s at the L i o n s G a t e H o s p i t a l p r e p a r e d a d r u g f o r m u l a r y c o n t a i n i n g o n e o r two t y p e w r i t t e n p a g e s o f c l i n i c a l l y r e l e v a n t i n f o r m a t i o n o n a b o u t 300 d r u g s i n u s e at the h o s p i t a l (37). Working f r o m many sources of drug information, the a u t h o r s w e r e a b l e to c o m p i l e f o r t h e i r d r u g m o n o g r a p h s i n f o r m a t i o n o n * L i o n s Gate H o s p i t a l , N o r t h V a n c o u v e r , B r i t i s h Columbia. 19 p e d i a t r i c d o s a g e s , d o s a g e s i n k i d n e y and l i v e r f a i l u r e , i n t r a v e n o u s patibilities, incom- d r u g i n t e r a c t i o n s a n d n u r s i n g i m p l i c a t i o n s w h i c h f o r the m o s t p a r t h a d b e e n u n a v a i l a b l e i n the m o n o g r a p h s of the A . H . F . S. and the C . P . S . T h i s i n f o r m a t i o n was a d d e d to the b a s i c d r u g i n f o r m a t i o n c o m m o n l y a v a i l - a b l e on i n d i c a t i o n s , d o s a g e s , s i d e e f f e c t s a n d c o n t r a i n d i c a t i o n s to p r o d u c e the d r u g m o n o g r a p h s o f the L i o n s G a t e H o s p i t a l D r u g F o r m u l a r y F i g u r e 1). A l t h o u g h m u c h o f t h i s i n f o r m a t i o n was available in journals, t e x t b o o k s a n d h a n d b o o k s , the r e s u l t i n g f o r m u l a r y was a l l of t h i s i n f o r m a t i o n into one u s a b l e (see unique i n c o m p i l i n g s o u r c e of d r u g i n f o r m a t i o n f o r the h e a l t h p r o f e s s i o n a l s i n the h o s p i t a l (71, 72). F o r the L i o n s G a t e H o s p i t a l , the p r o d u c t i o n o f the L i o n s Gate H o s p i t a l D r u g F o r m u l a r y * a l s o o v e r c a m e the c o n f l i c t b e t w e e n C a n a d i a n a n d A m e r i c a n b r a n d n a m e s that i s i n h e r e n t i n u s i n g an A m e r i c a n s u c h as the A . H . F . S . in a Canadian hospital. The reference authors also attempted to r e d u c e the s e a r c h t i m e f o r i n f o r m a t i o n b y p r e p a r i n g t h e i r f o r m u l a r y i n p o i n t f o r m r a t h e r t h a n p a r a g r a p h s a n d b y d i v i d i n g the m o n o g r a p h s into s u b sections of s p e c i f i c i n f o r m a t i o n . The subsections included action, i n d i c a - tions, c o n t r a i n d i c a t i o n s , dosage, side effects, intravenous t i e s , d r u g i n t e r a c t i o n s and n u r s i n g i m p l i c a t i o n s . incompatibili- With these a n d a d d i t i o n s to the f o r m a t a n d c o n t e n t o f the A . H . F . S . alterations a n d the C . P . S . , s o m e o f the l i m i t a t i o n s p r e v i o u s l y m e n t i o n e d w e r e o v e r c o m e . However, the L i o n s G a t e H o s p i t a l D r u g F o r m u l a r y s t i l l h a d one m a j o r d r a w b a c k to * L i o n s Gate H o s p i t a l D r u g F o r m u l a r y , L i o n s Gate H o s p i t a l , P h a r m a c y Department, North Vancouver, 1971. 20 its continuing u s e as a s o u r c e o f d r u g i n f o r m a t i o n . T h e r e w a s no e s t a b - l i s h e d m e c h a n i s m f o r r e g u l a r l y u p d a t i n g the d r u g m o n o g r a p h s . The p r e v i o u s w o r k o f u p d a t i n g the m o n o g r a p h s a n d the p r o d u c t i o n o f n e w m o n o graphs when n e c e s s a r y s o o n p r o v e d to be a m o n u m e n t a l t a s k (71). R e c o g n i z i n g the u n i q u e f e a t u r e s o f the L i o n s G a t e H o s p i t a l D r u g F o r m u l a r y to the p r o v i n c e a s a w h o l e , the B r i t i s h C o l u m b i a H o s p i t a l A s s o c i a t i o n ( B . C H . A . ) a d o p t e d the text a s a p r o v i n c i a l D r u g a n d i t w a s m a d e a v a i l a b l e to a p p r o x i m a t e l y (37). Formulary 100 B r i t i s h C o l u m b i a h o s p i t a l s A l s o r e c o g n i z i n g that the m o n o g r a p h s r e p r e s e n t e d o n l y t h o s e d r u g s u s e d at o n e h o s p i t a l a n d that a r e g u l a r u p d a t i n g m e c h a n i s m w a s r e q u i r e d to m a i n t a i n t h e p o t e n t i a l o f the n e w D r u g F o r m u l a r y , the B . C . H . A . a s t u d y at the F a c u l t y o f P h a r m a c e u t i c a l supported S c i e n c e s , U n i v e r s i t y of B r i t i s h C o l u m b i a , d i r e c t e d at d e s i g n i n g a m e c h a n i s m to o v e r c o m e t h e s e limita- tions . V. Academic One Role o f the m a j o r a s s i g n m e n t s f o r s e n i o r p h a r m a c y s t u d e n t s at the Faculty of P h a r m a c e u t i c a l S c i e n c e s , U n i v e r s i t y of B r i t i s h Columbia, r e q u i r e s a n e x t e n s i v e l i t e r a t u r e e v a l u a t i o n o f the s c i e n t i f i c a n d c l i n i c a l validity o f new drug i n f o r m a t i o n . A c c o r d i n g l y , the i n f o r m a t i o n r e l a t i v e to about 100 d r u g s i s e v a l u a t e d a n n u a l l y . Although these a s s i g n m e n t s were not e x t e n d e d to p r o d u c e the r e s u l t s i n d r u g m o n o g r a p h f o r m a t , it became a p p a r e n t that m u c h o f the t i m e a n d e f f o r t e x p e n d e d b y s t u d e n t s a n d 21 i n s t r u c t o r s r e p r e s e n t e d the type o f r e s o u r c e u p d a t i n g r e q u i r e d to a n n u a l l y r e v i s e the p r o v i n c i a l D r u g It w a s Formulary. f u r t h e r r e c o g n i z e d that to r e v i s e , c o n d e n s e , e d i t a n d the a c a d e m i c a s s i g n m e n t s into u s e f u l F o r m u l a r y monograph format, compile some " s e r v i c e " c o m m i t t m e n t i n t e r m s of p h a r m a c i s t and s t e n o g r a p h i c p e r s o n n e l w o u l d be r e q u i r e d . T h e degree of this c o m m i t t m e n t i n t e r m s of " s e r v i c e " to a n n u a l l y u p d a t e a n d r e v i s e the D r u g F o r m u l a r y present study. i s the o b j e c t i v e o f the 22 STATEMENT OF The OBJECTIVES d i s t r i b u t i o n o f the D r u g F o r m u l a r y , o r i g i n a l l y p r o d u c e d at the L i o n s G a t e H o s p i t a l , to the p r o v i n c i a l h o s p i t a l s b y the B r i t i s h H o s p i t a l A s s o c i a t i o n r e f l e c t s the n e e d f o r a f o r m a l p r o v i n c i a l D r u g lary. T h e o b j e c t i v e s o f the p r e s e n t s t u d y a r e to: 1. I d e n t i f y how the p r e s e n t D r u g F o r m u l a r y may b e c o m e m o r e u s e f u l on a p r o v i n c i a l b a s i s through m o d i f i c a t i o n o f the m o n o g r a p h a n d Formulary formats; 2. D e f i n e a m e c h a n i s m w h e r e b y the F o r m u l a r y may be e v a l u a t e d a n d u p d a t e d o n a r e g u l a r b a s i s ; 3. P r o j e c t p e r s o n n e l r e q u i r e m e n t s to a c h i e v e the above. Columbia Formu- 23 METHODOLOGY T h i s r e s e a r c h was i n s t i t u t e d w i t h the r e a l i z a t i o n that the D r u g F o r m u l a r y w h e n a d o p t e d a n d d i s t r i b u t e d b y the B r i t i s h C o l u m b i a Hospital A s s o c i a t i o n ( B . C . H.A. ) would p o s s i b l y r e q u i r e s o m e a l t e r a t i o n s i n f o r m a t a n d c o n t e n t to m a k e i t m o r e a c c e p t a b l e a n d u s e f u l to the p r o v i n c i a l h o s p i t a l s . It was r e c o g n i z e d a l s o that the D r u g F o r m u l a r y s h o u l d be u p d a t e d at r e g u l a r i n t e r v a l s f r o m the c u r r e n t l i t e r a t u r e w i t h i n f o r m a t i o n that i s b o t h s c i e n t i f i c a l l y and c l i n i c a l l y v a l i d . I. I d e n t i f y i n g the P r o v i n c i a l N e e d s In a n a t t e m p t to d e t e r m i n e the a c c e p t a b i l i t y o f the p r e s e n t D r u g F o r m u l a r y a n d w h a t m o d i f i c a t i o n s w e r e d e s i r a b l e i n r e g a r d to f o r m a t content, three studies w e r e u n d e r t a k e n . F i r s t l y , a questionnaire and was d i s t r i b u t e d to the c h i e f p h a r m a c i s t s o f the p r o v i n c i a l h o s p i t a l s to d e t e r m i n e the e x t e n t o f u s e o f the D r u g F o r m u l a r y a n d t h e i r o p i n i o n s i n r e g a r d to the f o r m a t a n d c o n t e n t s . o f the p r o v i n c e was S e c o n d l y , a s u r v e y of four m a j o r h o s p i t a l s c o n d u c t e d to d e t e r m i n e how many additional drug m o n o g r a p h s w e r e d e s i r e d w h i c h w o u l d e v e n t u a l l y i n f l u e n c e the s i z e o f the Formulary. T h i r d l y , a s t u d y was c o n d u c t e d o f the d r u g u s a g e p a t t e r n s i n s p e c i f i c c a r e a r e a s o f f i v e h o s p i t a l s to d e t e r m i n e i f a c o n d e n s e d v e r s i o n o f the F o r m u l a r y c o u l d be m a d e to f a c i l i t a t e a m o r e e f f e c t i v e u s e o f the D r u g F o r m u l a r y at the w a r d l e v e l . 24 (a) P o p u l a r i t y of U s e A q u e s t i o n n a i r e was s e n t to the c h i e f p h a r m a c i s t s o f a l l B r i t i s h C o l u m b i a h o s p i t a l s w h i c h l i s t e d a c h i e f o r d i r e c t o r o f p h a r m a c y i n the 1971 e d i t i o n o f the " C a n a d i a n H o s p i t a l D i r e c t o r y " * . The questionnaire d e s i g n e d to g i v e the F o r m u l a r y u s e r s the o p p o r t u n i t y to e x p r e s s t h e i r was own o p i n i o n s a n d t h o s e o f t h e i r c o l l e a g u e s o n the c o n t e n t a n d f o r m a t o f the present Drug F o r m u l a r y . It a l s o g a v e t h e s e p r o f e s s i o n a l s a c h a n c e to s u g g e s t c h a n g e s i n the f o r m a t a n d c o n t e n t a n d a d d i t i o n a l d r u g m o n o g r a p h s f o r i n c l u s i o n i n the F o r m u l a r y . F i g u r e 2 i l l u s t r a t e s the q u e s t i o n n a i r e . A l l q u e s t i o n n a i r e s that w e r e c o m p l e t e d a n d r e t u r n e d w e r e r e v i e w e d to d e t e r m i n e the n u m b e r o f h o s p i t a l s that w e r e u s i n g the F o r m u l a r y a n d to o b t a i n s u g g e s t i o n s f o r f u t u r e c h a n g e s i n the F o r m u l a r y f o r m a t a n d the monograph format. the The lists of additional drug monographs requested by c h i e f p h a r m a c i s t s f o r i n c l u s i o n i n the F o r m u l a r y w e r e i n c l u d e d i n the r e s u l t s o f the A d d i t i o n a l D r u g s S u r v e y . (b) N u m b e r o f D r u g M o n o g r a p h s Before requesting which additional drug monographs were needed b y the F o r m u l a r y u s e r s , i t was d e e m e d n e c e s s a r y to d e t e r m i n e the n u m b e r of d r u g m o n o g r a p h s i n the e x i s t i n g D r u g F o r m u l a r y a n d the n u m b e r o f C "**Canadian H o s p i t a l D i r e c t o r y , V o l . 19, T h e Association, Toronto, 1971. Canadian Hospital 25 F i g u r e 2. E x a m p l e o f the q u e s t i o n n a i r e s e n t to the c h i e f p h a r m a c i s t s o f the p r o v i n c i a l hospitals. 26 THE UNIVERSITY OF BRITISH COLUMBIA VANCOUVER 8, C A N A D A FACULTY OF PHARMACEUTICAL SCIENCES November 21st, 1972 Dear Fellow Pharmacists: The Faculty of Pharmaceutical Sciences i s undertaking a provincially sponsored study to "update" and make "more provincial" the present Drug Formulary (Lion's Gate) being distributed by the B.C.H.A. The objective here is to design and maintain on a regular basis a provincial formulary for a l l hospitals in British Columbia. Accordingly, so that the design might represent "provincial" thinking, we are asking for your support and the contribution of your ideas as related to the following questions: 1. Is the Drug Formulary i n general use i n your hospital? . 2. If the answer to question 1 i s no, please comment i n regard to the reasons in your hospital for not using the Drug Formulary. Did you previously have a formulary of your own i n your hospital? If yes, i s i t s t i l l being used? Is the formulary satisfactory i n regard to: (a) overall format ' (b) monograph format (c) introductory information (d) monograph information (e) other as related to the physicians, pharmacists and nursing views i n your hospitals. Are there any additional monographs you would like to see included? i f yes, please l i s t them . As the information that you supply to us w i l l be used to determine the cost and usefulness of regular updating and making the formulary more provincially useful, we request that you reply before the 15th of December, 1972. A reply by that date w i l l enable us to evaluate your comments and to incorporate your ideas into our project in early 1973. Thank you for any assistance which you can give to us and for your interest in promoting better drug information to your hospital i n the future. Yours sincerely, EAP/cs Elizabeth A. Page, B.Sc.(Pharm). Division of C l i n i c a l Pharmacy cc. Dr. J . Hlynka, chairman, Division of C l i n i c a l Pharmacy FIGURE 2 27 d r u g s a n d d r u g p r o d u c t s l i s t e d i n the F o r m u l a r y a l p h a b e t i c a l i n d e x . The d r u g m o n o g r a p h s i n the F o r m u l a r y w e r e c o u n t e d , e x c l u d i n g the s p e c i a l i z e d m o n o g r a p h s o n " E a r , E y e , N o s e a n d T h r o a t P r e p a r a t i o n s " , "Skin and M u c o u s M e m b r a n e P r e p a r a t i o n s " , and "Intravenous and I r r i g a tion S o l u t i o n s " . T h e a b o v e l i s t e d s e c t i o n s w e r e e x c l u d e d b e c a u s e the monographs r e p r e s e n t specialized uses of drugs which are usually monog r a p h e d i n the m a i n s e c t i o n o f the F o r m u l a r y u n d e r g e n e r i c n a m e s . To d e t e r m i n e the n u m b e r o f d r u g s a n d d r u g p r o d u c t s l i s t e d i n the F o r m u l a r y a l p h a b e t i c a l i n d e x , m o s t o f the b r a n d n a m e s o f the d r u g s w h i c h a r e i n c l u d e d i n the i n d e x a s a c r o s s - r e f e r e n c e to the g e n e r i c d r u g n a m e w e r e e l i m i n a t e d . The r e m a i n i n g drug names were counted and a r r a n g e d i n alphabetical o r d e r . The r e s u l t i n g d r u g l i s t w a s l a t e r u s e d i n the s t u d y o f d r u g u s a g e p a t t e r n s in special care a r e a s of five p r o v i n c i a l hospitals. Additional Drugs Survey T o d e t e r m i n e w h i c h , i f any, additional drug m o n o g r a p h s w e r e n e e d e d to m a k e the D r u g F o r m u l a r y m o r e a d e q u a t e l y r e f l e c t the d r u g i n f o r m a t i o n n e e d s o f the p r o v i n c i a l h o s p i t a l s , a s a m p l e s u r v e y w a s d u c t e d i n f o u r m a j o r h o s p i t a l s o f the p r o v i n c e . Vancouver con- General H o s p i t a l , St. Paul's Hospital (Vancouver), V i c t o r i a G e n e r a l H o s p i t a l and R o y a l J u b i l e e H o s p i t a l ( V i c t o r i a ) w e r e c h o s e n b e c a u s e they a l l o f f e r h o s p i t a l p h a r m a c y r e s i d e n c y p r o g r a m m e s a n d t h e r e f o r e e x p e c t e d to h a v e s u f f i c i e n t s t a f f to c o m p l e t e the s u r v e y . 28 T h e h o s p i t a l p h a r m a c y r e s i d e n t i n e a c h h o s p i t a l w a s a s k e d to r e v i e w the d r u g s s t o c k e d i n h i s h o s p i t a l a n d to l i s t a l l d r u g s u s e d w h i c h w e r e n o t m o n o g r a p h e d i n the p r e s e n t D r u g F o r m u l a r y . They were asked a l s o to i n d i c a t e w h e n e v e r p o s s i b l e w h i c h d r u g s i n the l i s t s t h e i r h o s p i t a l w o u l d l i k e to s e e i n c l u d e d i n the F o r m u l a r y . T h e r e s u l t s of this survey w e r e c o r r e l a t e d w i t h the l i s t s o f a d d i t i o n a l d r u g m o n o g r a p h s r e q u e s t e d b y the c h i e f p h a r m a c i s t s . The additional drug monographs requested w e r e c a t e g o r i z e d a c c o r d i n g to the f r e q u e n c y o f r e q u e s t s r e c e i v e d f o r e a c h d r u g f r o m the f o u r h o s p i t a l s a n d the c h i e f p h a r m a c i s t s . r e s u l t s , the e v e n t u a l s i z e a n d c o n t e n t o f the D r u g F o r m u l a r y e s t i m a t e d p r o v i d i n g that the a d d i t i o n a l d r u g s F r o m the c o u l d be suggested above were r e p r e - s e n t a t i v e o f the o t h e r p r o v i n c i a l h o s p i t a l n e e d s a s w e l l . (c<) F o r m a t o f the D r u g M o n o g r a p h s In c o m p l e t i n g the c h i e f p h a r m a c i s t s q u e s t i o n n a i r e ( s e e p a g e 26) the c h i e f p h a r m a c i s t s w e r e a s k e d to c o m m e n t o n the a c c e p t a b i l i t y a n d u s e f u l n e s s o f the d r u g m o n o g r a p h f o r m a t . Suggestions for changes and a d d i t i o n s w e r e r e v i e w e d i n a d d i t i o n to t h o s e that w e r e i d e n t i f i e d f r o m a n a n a l y s i s o f the l i t e r a t u r e a n d f r o m the c o m m e n t s o f the m e m b e r s o f the Faculty of P h a r m a c e u t i c a l Sciences, University of B r i t i s h Columbia w e r e i n v o l v e d i n the c u r r e n t r e v i s i o n s . who A l l of these w e r e noted and some of t h e m w e r e a d o p t e d f o r f u r t h e r e v a l u a t i o n s i n the p r e s e n t s t u d y . 29 Canadian D r u g Identification Code The r e c e n t p u b l i c a t i o n b y the f e d e r a l H e a l t h P r o t e c t i o n B r a n c h o f the C a n a d i a n D r u g I d e n t i f i c a t i o n C o d e s t i m u l a t e d i n t e r e s t i n a d d i n g to the d r u g m o n o g r a p h s a d r u g c o d e w h i c h was nature. specifically Canadian in T h i s w o u l d s u p p l e m e n t the e x i s t i n g A m e r i c a n H o s p i t a l F o r m u l a r y S e r v i c e ( A . H . F.S.) therapeutic classification number. S i n c e the C a n a d i a n D r u g Identification Code contains four unique drug codes, t e c t i o n B r a n c h p u b l i c a t i o n was the H e a l t h Pro- s t u d i e d to d e t e r m i n e w h i c h o f the f o u r c o d e s w o u l d be m o s t u s e f u l to the F o r m u l a r y u s e r s f o r d r u g i d e n t i f i c a t i o n as w e l l as s t o c k c o n t r o l a n d o t h e r procedures. Ambulatory Considerations In r e c e n t y e a r s , h o s p i t a l s a n d h o s p i t a l p h a r m a c i s t s h a v e b e c o m e i n c r e a s i n g l y i n v o l v e d i n a m b u l a t o r y a n d o u t p a t i e n t s e r v i c e s (60). In a t t e m p t i n g to p r o d u c e a D r u g F o r m u l a r y w h i c h m i g h t be u s e f u l to a l l h e a l t h p r o f e s s i o n a l s o f the p r o v i n c e , c o n s i d e r a t i o n was g i v e n to t h o s e a r e a s w h i c h d e a l w i t h a m b u l a t o r y p a t i e n t s i n an o u t p a t i e n t c l i n i c as w e l l a s i n the i n p a t i e n t s e t t i n g . F o r t h i s r e a s o n a n a t t e m p t was m a d e to s u p p l y i n f o r m a t i o n on the d r u g m o n o g r a p h s to a s s i s t the h e a l t h c a r e p r o f e s s i o n a l s i n i n s t r u c t i n g the a m b u l a t o r y p a t i e n t s about the p r o p e r h a n d l i n g and of their m e d i c a t i o n s . The use m e c h a n i s m that i s b e i n g e v a l u a t e d a s a m e a n s of u p d a t i n g the D r u g F o r m u l a r y m o n o g r a p h s was a d o p t e d as the b a s i s f o r a l s o a c c o m p l i s h i n g the o b j e c t i v e o f s u p p l y i n g i n s t r u c t i o n s to the p a t i e n t s . 30 E l e c t r o n i c Data P r o c e s s i n g and F o r m u l a r y P r o d u c t i o n Because the p r e s e n t m e t h o d o f p r i n t i n g the D r u g Formulary r e q u i r e s that the w h o l e m o n o g r a p h be r e - t y p e d e a c h t i m e that i t i s upd a t e d , i t was s h o u l d be d e c i d e d that a n o t h e r m e a n s o f p r o d u c i n g the F o r m u l a r y investigated. T h e use of e l e c t r o n i c data p r o c e s s i n g ( E . D . P . ) and c o m p u t e r i zation i s b e c o m i n g m o r e c o m m o n i n m e d i c a l and p h a r m a c y p r a c t i c e s e v e r a l drug f o r m u l a r i e s have been p r o d u c e d by these m e a n s . tigate the p o s s i b i l i t y o f c o m p u t e r i z e d p r o d u c t i o n o f the D r u g i n f u t u r e y e a r s , the r e c e n t l i t e r a t u r e on t h i s s u b j e c t was letter was a l s o s e n t to M r . To and inves- Formulary reviewed. A H . S m y t h e , D i r e c t o r o f P h a r m a c y at the O t t a w a C i v i c H o s p i t a l , ( O t t a w a , O n t a r i o ) r e q u e s t i n g i n f o r m a t i o n o n the c o s t s , s t o r a g e o f i n f o r m a t i o n , a n d the m e t h o d u s e d to u p d a t e the m o n o g r a p h s b y E.D.P. T h e O t t a w a C i v i c H o s p i t a l was c h o s e n a s the s o u r c e o f t h i s i n f o r m a t i o n b e c a u s e i t i s a C a n a d i a n h o s p i t a l u s i n g E . D . P . to p r o d u c e a d r u g f o r m u l a r y a n d i t was thought that the c o s t s a n d p r o c e d u r e s at a C a n a d i a n h o s p i t a l w o u l d m o r e c l o s e l y r e s e m b l e the p o s s i b l e c o s t s a n d methods also available in B r i t i s h C o l u m b i a . A c o m p a r i s o n b e t w e e n the costs of E . D . P . f o r m u l a r y p r i n t i n g as supplied by M r . S m y t h e a n d the c o s t s o f the c o n v e n t i o n a l m e t h o d s a s u s e d to p r o d u c e the B r i t i s h D r u g F o r m u l a r y was done. Columbia 31 (d) M o n o g r a p h U t i l i z a t i o n SurveyOne o f the l i m i t a t i o n s o f the A m e r i c a n H o s p i t a l Formulary S e r v i c e i s that the t w o - v o l u m e set i s too b u l k y f o r e a s y u s e (47, 65). S i m i l a r l y , the p r e s e n t D r u g F o r m u l a r y a l s o i s a w k w a r d due to i t s s i z e . F o r t h i s r e a s o n a n d b e c a u s e the c o n t e n t o f the F o r m u l a r y m a y h a v e to be f u r t h e r i n c r e a s e d to c o v e r the d r u g i n f o r m a t i o n n e e d s o f the p r o v i n c e , attempt was an m a d e to f i n d a m e t h o d ( s ) b y w h i c h the w a r d s o f the h o s p i t a l s c o u l d be s u p p l i e d w i t h u s e f u l , c o m p a c t f o r m u l a r i e s t h r o u g h i d e n t i f y i n g the unique drug use patterns i n each patient c a r e a r e a . A s t u d y was conducted i n this r e g a r d i n five p r o v i n c i a l hospitals to d e t e r m i n e the f r e q u e n c y o f u s e o f the d r u g s a n d d r u g p r o d u c t s l i s t e d i n the a l p h a b e t i c a l i n d e x o f the F o r m u l a r y a c c o r d i n g to s p e c i a l t y w a r d s . c o m p l e t e d r u g l i s t was t r i b u t e d to V a n c o u v e r t y p e d ( f i r s t p a g e e x e m p l i f i e d i n F i g u r e 3) a n d G e n e r a l H o s p i t a l , St. Paul's H o s p i t a l , L i o n s The dis- Gate H o s p i t a l , V i c t o r i a G e n e r a l H o s p i t a l and R o y a l Jubilee H o s p i t a l . I n f o r m a t i o n i n this r e s p e c t was g e n e r a t e d o n the f r e q u e n c y of u s e o f the l i s t e d d r u g s i n the s p e c i f i c c a r e a r e a s o f P e d i a t r i c s , P s y c h i a t r y and E x t e n d e d C a r e . Emergency, T h e s e a r e a s w e r e c h o s e n to e x e m p l i f y s p e c i a l t i e s b e c a u s e o f the w i d e v a r i e t y o f d r u g s that m i g h t b e u s e d i n e a c h of t h e m . F o r e a c h l i s t e d d r u g the f r e q u e n c y o f u s e was d e t e r m i n e d as " f r e q u e n t l y " , " o c c a s i o n a l l y " o r " r a r e l y " i n e a c h o f the f o u r a r e a s . "Fre- q u e n t l y U s e d D r u g s " w e r e d e f i n e d a s t h o s e d r u g s w h i c h w e r e s u p p l i e d to 32 F i g u r e 3. S a m p l e of D r u g L i s t s u s e d f o r Monograph Utilization Survey. 33 DRUG EMERGENCY PEDIATRICS F 0 i. F R i 0 R EXTENDED CARE PSYCHIATRIC F 0 i R F I i Acetaminophen Acetazolamide Acetycholine Acetylcysteine A c e t y l s a l i c y l i c acid Achromycin ACTH Adephinine Adrenalin Aerosporin A e r o s p o r i n (Ear) Agarol Airbron Alcohol Alkeran Allopurinol Alpha-Chymotrypsin i j I 1 1 i R I 0 i 1 i 1 1 | I1 1 i ii • i !• 1 i | 1 ! Alpha-Tocopherol Aluminum Hydroxide Americaine Amesec Amethopterin Aminocaproic a c i d ii Aminophyllin |j A m i n o p h y l l i n Compounds|| Amitriptyline Ammonium Carbonate Mixture Ammonium C h l o r i d e Ammonium C h l o r i d e Mixture Amobarbital Sodium Amphotercin Amphyl Ampicillin Amyl N i t r i t e Artectine Anileridine Annanase Antepar Anusol i Apresoline Argyrol Ascorbic acid A t r o p i n e (eye) I 1 t1t ' 1 1 | i ! .i i ! 1 • 1 1 1 i ! FIGURE 3 1 • 34 an a r e a a s w a r d s t o c k , u s e d d a i l y o r s e v e r a l t i m e s a w e e k . "Occasional U s e d D r u g s " w e r e t h o s e u s e d i n an a r e a o n l y o n c e o r t w i c e a m o n t h , " R a r e l y U s e d D r u g s " w e r e i n t e r p r e t e d a s t h o s e d r u g s u s e d i n an only once or twice a y e a r , or n e v e r . w e r e r e v i e w e d and p h a r m a c i s t s To and area obtain this i n f o r m a t i o n , records a n d n u r s e s w e r e i n t e r v i e w e d a c c o r d i n g to s p e c i f i c d r u g u s e p a t t e r n s (see F i g u r e 4 ) . The l i s t s f r o m e a c h h o s p i t a l w e r e a n a l y s e d a c c o r d i n g to the s p e c i f i c t r e a t m e n t a r e a s to d e t e r m i n e the n u m b e r o f d r u g s a n d the a p p r o x i m a t e p e r c e n t a g e o f the d r u g s u s e d " f r e q u e n t l y " , " o c c a s i o n a l l y " and " r a r e l y " for each hospital. It was a n t i c i p a t e d that the r e s u l t s c o u l d then be u s e d to p r o p o s e a s y s t e m w h e r e b y the m o n o g r a p h s o f the "Fre- q u e n t l y U s e d D r u g s " c o u l d be m a d e m o r e r e a d i l y a v a i l a b l e to the h e a l t h p r o f e s s i o n a l s o n the n u r s i n g w a r d w i t h o u t s a c r i f i c i n g the a v a i l a b i l i t y of the r e m a i n i n g in each a r e a . m o n o g r a p h s f o r d r u g s u s e d " O c c a s i o n a l l y " and It was "Rarely" h o p e d a l s o to k e e p the p o t e n t i a l b u l k o f a p r o v i n c i a l D r u g F o r m u l a r y to a m i n i m u m . II. E v a l u a t i o n a n d U p d a t i n g the F o r m u l a r y F o r the p a s t two y e a r s a l i m i t e d n u m b e r o f s e n i o r y e a r s t u d e n t s at the F a c u l t y o f P h a r m a c e u t i c a l pharmacy S c i e n c e s , U n i v e r s i t y of B r i t i s h . C o l u m b i a have been p a r t i c i p a t i n g i n a p r o g r a m m e of l i t e r a t u r e evaluation in conjunction with a pilot course in C l i n i c a l P h a r m a c y . that the w o r k done b y the s t u d e n t s was It was recognized v a l u a b l e a n d that m u c h o f t h i s w o r k 35 FIGURE 4 INSTRUCTIONS FOR MONOGRAPH UTILIZATION SURVEY O F DRUG USE FOR SPECIALTY SURVEY FORMULARIES Hospital Name Resident's N a m e INSTRUCTIONS: 1. C o m p l e t e the f o l l o w i n g c h a r t s w i t h r e g a r d to the f r e q u e n c y o f d r u g use i n s p e c i a l i z e d c a r e a r e a s in your 2. F = hospital. F r e q u e n t l y - f l o o r s t o c k to a r e a o r u s e d d a i l y , s e v e r a l times a week? O = O c c a s i o n a l l y - u s e d i n s p e c i f i c a r e a only once o r twice a month. R = R a r e l y - u s e d i n s p e c i f i c a r e a only once o r twice p e r y e a r o r never.. Other than f l o o r s t o c k , f r e q u e n c y o f u s e i s to be d e t e r m i n e d b y Resident's experience, pharmacists' opinions and nurses' opinions. 3. A s e c t i o n o n the l a s t p a g e i s p r o v i d e d f o r e v a l u a t i o n o f the f r e q u e n c y of u s e o f d r u g s that a r e n o t l i s t e d h e r e , b u t a r e u s e d i n y o u r h o s p i t a l . 4. D r u g s a r e l i s t e d b y g e n e r i c n a m e o n l y , to p r e v e n t c o n f u s i o n w i t h b r a n d s that m a y n o t be u s e d i n a l l h o s p i t a l s . ( E x c e p t i o n : t h o s e medications which a r e combination products). 5. P l e a s e c o m p l e t e a n d r e t u r n f o r m s b e f o r e D e c e m b e r 20, 1972. 36 c o u l d be f u r t h e r a p p l i e d to a p r a c t i c a l u s e i n f u l f i l l i n g the n e e d o f u p d a t i n g the p r e s e n t D r u g F o r m u l a r y . A c c o r d i n g l y a m e c h a n i s m w a s p r o p o s e d to the M e d i c a l S e r v i c e s F o u n d a t i o n o f B r i t i s h C o l u m b i a w h e r e b y the m o n o g r a p h s o f the D r u g F o r m u l a r y educational assignment c o u l d be u p d a t e d a s a c l i n i c a l l y r e l a t e d to the s e n i o r y e a r p h a r m a c y c l a s s i n 1 9 7 2 - 7 3 . T h e p r o p o s e d m e c h a n i s m o f u p d a t i n g the d r u g m o n o g r a p h s to b e e v a l u a t e d i n the p r e s e n t s t u d y r e p r e s e n t s a s e q u e n c e o f s e n i o r y e a r C l i n i c a l P h a r m a c y student a s s i g n m e n t s and i n s t r u c t o r r e v i e w , both as an " a c a d e m i c " r e s p o n s i b i l i t y a n d o n a " s e r v i c e " b a s i s to e n s u r e the a c c u r a c y of the s t u d e n t w o r k . T h e i n s t r u c t o r " s e r v i c e " input r e p r e s e n t s the r e v i s i o n a n d c o n d e n s i n g o f the l i t e r a t u r e e v a l u a t i o n r e p o r t to s u i t a b l e monograph format. T h e above Foundation approved a one-year g r a n t to e n a b l e the f i n a n c i n g o f t h i s " s e r v i c e " c o m p o n e n t b y the i n s t r u c t o r a s w e l l as s o m e s t e n o g r a p h i c a s s i s t a n c e . The q u e s t i o n s that w e r e to b e a n s w e r e d b e f o r e a c o n t i n u i n g p r o - g r a m m e o f this n a t u r e c o u l d be u n d e r t a k e n on an annual b a s i s i n c l u d e : 1. Is t h e r e a n e e d f o r r e g u l a r u p d a t i n g o f the d r u g monographs ? 2. W h a t a r e the t i m e r e q u i r e m e n t s o f the s t u d e n t s a n d what i s the e x t e n t o f t h e i r c o n t r i b u t i o n to the u p d a t i n g m e c h a n i s m ? 3. W h a t i s the t i m e r e q u i r e m e n t o f the i n s t r u c t o r s beyond their a c a d e m i c 4. involvement? W h a t i s the t i m e r e q u i r e m e n t of; the s t e n o g r a p h i c s t a f f to type the u p d a t e d m o n o g r a p h s o n a n a n n u a l basis ? 37 (a) M e c h a n i s m of Updating Student A s s i g n m e n t E a c h s t u d e n t i n the s e n i o r y e a r p h a r m a c y c l a s s w a s a s s i g n e d t h r e e d r u g s (see A p p e n d i x III) to c o m p l e t e l y e v a l u a t e the e x i s t i n g m o n o graph i n f o r m a t i o n and r e f e r e n c e f r o m o r i g i n a l literature a l l statements i n the m o n o g r a p h s e c t i o n s o f " D r u g I n t e r a c t i o n s " a n d " I n t r a v e n o u s Incompatibilities". T h e s t u d e n t s w e r e s u p p l i e d w i t h a s t a t e m e n t o f the type o f p a p e r s a n d r e f e r e n c e s w h i c h w e r e a c c e p t a b l e l i t e r a t u r e sources a n d w e r e i n s t r u c t e d to u s e o n l y s c i e n t i f i c a l l y v a l i d i n f o r m a t i o n to u p d a t e the m o n o g r a p h s . In a d d i t i o n the s e c t i o n o f the m o n o g r a p h concerning " A c t i o n " w a s to b e e x p a n d e d to i n c l u d e the m e c h a n i s m o f a c t i o n , t i o n , d i s t r i b u t i o n , m e t a b o l i s m a n d e x c r e t i o n o f the d r u g . absorp- A new s e c t i o n o f " I n s t r u c t i o n s to the P a t i e n t " w a s a d d e d a l s o to f u l f i l l the o b j e c t i v e o f s u p p l y i n g d r u g i n f o r m a t i o n to a m b u l a t o r y c a r e a r e a s . T h r o u g h o u t the a s s i g n m e n t the s t u d e n t s w e r e r e q u i r e d to a d d a n y new i n f o r m a t i o n f r o m the l i t e r a t u r e o f the p a s t y e a r a s w e l l a s to e v a l u a t e e x i s t i n g m o n o g r a p h information from earlier years. T h e s t u d e n t s a l s o w e r e d i r e c t e d to r e c o r d a n y c h a n g e s o r c o r r e c t i o n s that w e r e f o u n d f r o m the l i t e r a t u r e a n d to r e f e r e n c e t h e s e a l t e r a t i o n s o n a C h a n g e S h e e t ( s e e F i g u r e 5) w h i c h w e r e p r e s e n t e d to the i n s t r u c t o r w i t h b o t h the o r i g i n a l a n d e v a l u a t e d m o n o graphs. T h r o u g h o u t the a s s i g n m e n t the s t u d e n t s r e c o r d e d the t i m e r e q u i r e d to u p d a t e e a c h m o n o g r a p h . T h e r e s u l t s o f the t i m e s t u d y w e r e 38 F i g u r e 5. S a m p l e of a Change Sheet as d i s t r i b u t e d to the s t u d e n t s , w i t h s e c t i o n s f o r the u p d a t e d i n f o r m a t i o n s i m i l a r to the monograph format. 39 Pharmacy 403 Drug and Poison Information Centre Revisions and Updating of Drug Monograph GENERIC NAME O F DRUG 1. General Information 2. Action 3. Spectrum of Activity 4. Indications 5. Contraindications 6. Cautions 7. Dosage 8. Side Effects 9. Drug Interactions 10. Intravenous Incompatibilities 11. Nursing Implications 1 2. Instructions to the Patient 13. Presentation FIGURE 5; 40 u s e d to p r o j e c t the s t u d e n t i n v o l v e m e n t i n a n n u a l u p d a t i n g a n d a t i m e schedule for future r e v i s i o n s . Pharmacist The Involvement r e q u i r e d i n s t r u c t o r i n v o l v e m e n t i n t o t a l r e v i s i o n o f the d r u g m o n o g r a p h s r e p r e s e n t s the p a r t i c i p a t i o n o f the i n s t r u c t o r s b e y o n d t h e i r "academic" responsibility. The "academic" responsibility included being p r e s e n t at the s t u d e n t p r e s e n t a t i o n s o f the e v a l u a t e d m o n o g r a p h s a n d g r a d i n g the w o r k o n the b a s i s o f a c a d e m i c m e r i t . F o r F o r m u l a r y purposes, the i n s t r u c t o r s t h e n r e v i e w e d the r e v i s e d m o n o g r a p h s f o r a l l changes, a d d i t i o n s a n d c o r r e c t i o n s m a d e b y the s t u d e n t s , a n d e v a l u a t e d the w o r k and c i t e d r e f e r e n c e s f o r s c i e n t i f i c v a l i d i t y on a " s e r v i c e " b a s i s . When the i n s t r u c t o r s h a d c o m p l e t e d the e v a l u a t i o n o f the r e v i s e d m o n o g r a p h s t h e y t h e n e d i t e d a n d c o n d e n s e d the m o n o g r a p h s into the s t a n d a r d f o r m a t o f the D r u g Formulary. T h e i n s t r u c t o r s w e r e r e q u e s t e d to m a i n t a i n a r e c o r d o f t h e i r time r e q u i r e m e n t s beyond their "academic" involvement. These time r e c o r d s w e r e u s e d to p r o j e c t the p h a r m a c i s t " s e r v i c e " r e q u i r e m e n t s f o r u p d a t i n g the m o n o g r a p h s o n a f u t u r e a n n u a l b a s i s . Stenographic The Requirements r e v i s e d , c o r r e c t e d and condensed monographs were r e q u i r e d to b e t y p e d i n a u n i f o r m f o r m a t f o r d u p l i c a t i o n a n d d i s t r i b u t e d to the 41 participating hospitals. Accordingly, a stenographic service input was required for this purpose. As for other personnel, the time required for the stenographic work was recorded to enable a projection of this service on a potential annual basis. (b) Nature and Frequency of Changes One hundred completed Change Sheets (see Figure 5, page 39) were selected and reviewed to estimate the need for regular revision of the Drug Formulary monographs. These one hundred Change Sheets were analyzed to show the average total number of changes in each monograph and the average number of changes which appeared specifically in the sections of "Drug Interactions" and "Intravenous Incompatibilities". The latter two sections were segregated since it was expected that the majority of the future updating time might be required in these areas. (c) Time Evaluation F r o m each of the time records of the above three groups (students, instructors and stenographers) one hundred records were evaluated. These records were used to determine the average approximate time needed for updating the monographs on a "service" basis, to propose a schedule for future revisions and to project the personnel that might be needed to accomplish this objective. 42 R E S U L T S AND DISCUSSION T h e t h r e e b a s i c i s s u e s to b e r e s o l v e d i n the p r e s e n t studyi n c l u d e d the d e f i n i t i o n o f the d r u g m o n o g r a p h a n d F o r m u l a r y format c h a n g e s r e q u i r e d to p r e s e n t a m o r e p r o v i n c i a l l y u s e f u l r e f e r e n c e , the p r o j e c t i o n o f a n e v a l u a t i o n m e c h a n i s m w h i c h c o u l d e f f e c t i v e l y u p d a t e the F o r m u l a r y o n a r e g u l a r b a s i s , a n d a d e s c r i p t i o n o f the t y p e a n d n u m b e r of p e r s o n n e l r e q u i r e d to p r o d u c e I. such updated drug m o n o g r a p h s . I d e n t i f y i n g the P r o v i n c i a l N e e d s T h r e e a p p r o a c h e s w e r e u s e d to d e t e r m i n e the n e c e s s a r y f o r m a t c h a n g e s a n d how provincially useful Drug to i m p l e m e n t t h e s e c h a n g e s to p r o d u c e a m o r e Formulary. (1) A q u e s t i o n n a i r e w a s s e n t to the c h i e f p h a r m a c i s t s o f all B r i t i s h Columbia hospitals which listed a chief or d i r e c t o r of p h a r m a c y i n the 1971 e d i t i o n o f the C a n a dian Hospital D i r e c t o r y * . (2) A s a m p l e o f f o u r h o s p i t a l s o f the p r o v i n c e w e r e s u r v e y e d to d e t e r m i n e w h i c h , i f a n y , a d d i t i o n a l d r u g monographs were needed. (3) A n e v a l u a t i o n o f the d r u g u s e p a t t e r n s o f the d r u g s l i s t e d i n the a l p h a b e t i c a l i n d e x o f the F o r m u l a r y i n s p e c i a l t y c a r e a r e a s o f f i v e p r o v i n c i a l h o s p i t a l s was c o n d u c t e d to d e t e r m i n e i f m o r e e f f e c t i v e u s e c o u l d be m a d e o f the F o r m u l a r y at the w a r d l e v e l . * C a n a d i a n H o s p i t a l D i r e c t o r y , V o l . 19, T h e Toronto, 1971. Canadian Hospital Association, B y r e v i e w i n g the r e s u l t s o f t h e s e t h r e e a p p r o a c h e s , f o r m a t a n d c o n t e n t c h a n g e s that w o u l d m a k e the D r u g F o r m u l a r y some more u s e f u l to a l l h o s p i t a l s o f the p r o v i n c e w e r e i d e n t i f i e d . (a) P o p u l a r i t y o f U s e O f the 46 h o s p i t a l s m o n i t o r e d i n the c h i e f p h a r m a c i s t s q u e s t i o n n a i r e , 32 o r a p p r o x i m a t e l y 70 p e r c e n t r e p l i e d to the q u e s t i o n n a i r e a n d o f t h e s e , 19 o r a p p r o x i m a t e l y 60 p e r c e n t r e p o r t e d u s i n g the D r u g F o r m u l a r y ( s e e T a b l e I). T h e m a j o r r e a s o n s f o r n o t u s i n g the F o r m u l a r y a n d the i n c i d e n c e o f t h e s e r e a s o n s a r e p r e s e n t e d i n T a b l e II. - S i n c e the m a j o r i t y o f the r e s p o n d e n t s a p p e a r to b e u s i n g the F o r m u l a r y a n d s i n c e the l i m i t a t i o n s f o r w a r d e d c a n b e o v e r c o m e , i t w o u l d a p p e a r to b e w o r t h w h i l e to p u r s u e a n a t t e m p t to m a k e the F o r m u l a r y m o r e p r o v i n c i a l l y a c c e p t a b l e . T h o s e h o s p i t a l s u s i n g the D r u g F o r m u l a r y submitted some e x c e l l e n t r e c o m m e n d a t i o n s f o r i m p r o v e m e n t s and the f o l l o w i n g l i s t o f r e c o m m e n d e d m o d i f i c a t i o n s r e p r e s e n t a s u m m a r y o f these as w e l l as those f r o m the o t h e r s o u r c e s m e n t i o n e d o n p a g e 4 2 : (1) (2) that a d d i t i o n a l d r u g m o n o g r a p h s , b e a d d e d to the F o r m u l a r y to c o v e r the d r u g i n f o r m a t i o n n e e d s o f the p r o v i n c e ; that the m o d e o f a c t i o n b e i n c l u d e d o n the d r u g m o n o g r a p h s a n d that m o r e e x t e n s i v e i n f o r m a tion on s o m e drugs be added; (3) that c o n s i d e r a t i o n b e g i v e n to s u p p l y i n g i n f o r m a t i o n to t h o s e a r e a s o f p r a c t i c e that d e a l w i t h the a m b u l a t o r y p a t i e n t i n a h o s p i t a l s e t t i n g 44 TABLE I DRUG F O R M U L A R Y UTILIZATION As Determined By a Survey of Chief Pharmacists Number of Hospitals Hospitals in British Columbia Percentage^ 104 Hospitals Surveyed 46 44 Hospitals which replied 32 70 19 60 Hospitals which use the Provincial Drug Formulary 2 1. Determined to the nearest percentage point. 2. Of those hospitals which replied. 45 T A B L E II REASONS FOR NOT USING T H E DRUG F O R M U L A R Y Reason 1 Number of Hospitals Using American Hospital Formulary Service Using Compendium of Pharmaceuticals and Specialties Do not have sufficient Copies for all areas (more on order) Specialized Hospitals (Mental Health, Rehabilitation) Use it but as Back-up Reference only Total 1. Acs determined from the survey of chief pharmacists. 13 46 s u c h a s the O u t p a t i e n t C l i n i c , N u r s i n g S t a t i o n s i n r e m o t e a r e a s a n d the M e n t a l H e a l t h C l i n i c s ; (4) that r e f e r e n c e s o f the d r u g m o n o g r a p h s w o u l d a s s i s t the u s e r s i n o b t a i n i n g a d d i t i o n a l i n f o r m a t i o n as r e q u i r e d ; (5) that a C a n a d i a n D r u g C o d e be i n c l u d e d o n the monographs for drug identification; (6) that the D r u g F o r m u l a r y i s too b u l k y a n d c u m b e r s o m e for quick reference; (7) that e l e c t r o n i c d a t a p r o c e s s i n g ( E . D . P . ) be c o n s i d e r e d a s a m e a n s o f p r o d u c i n g the D r u g F o r m u l a r y w h i c h m i g h t be c h e a p e r f a c i l i t a t e q u i c k e r u p d a t i n g and (8) and editing; that the F o r m u l a r y s h o u l d be u p d a t e d at r e g u l a r i n t e r v a l s so that i t r e m a i n s a n a c c u r a t e , u p - t o date s o u r c e o f d r u g i n f o r m a t i o n to the u s e r s . • S o m e o f the a b o v e r e c o m m e n d a t i o n s w e r e i m p l e m e n t e d i n the c u r r e n t r e v i s i o n o f the F o r m u l a r y . O t h e r s h a v e b e e n i n v e s t i g a t e d i n the p r e s e n t study f o r p o s s i b l e future adaptations. are The results in each area c o n s i d e r e d a s f o l l o w s u n d e r the s u b - h e a d i n g s o f " N u m b e r o f D r u g M o n o g r a p h s " , " F o r m a t o f D r u g M o n o g r a p h s " , " F o r m a t o f the F o r m u l a r y " a n d " E v a l u a t i o n a n d U p d a t i n g of the F o r m u l a r y " . (b) N u m b e r o f D r u g M o n o g r a p h s B e f o r e r e q u e s t i n g w h i c h a d d i t i o n a l d r u g m o n o g r a p h s m i g h t be n e e d e d b y the p r o v i n c i a l h o s p i t a l s , the n u m b e r o f d r u g m o n o g r a p h s i n c l u d e d i n the p r e s e n t D r u g F o r m u l a r y w a s determined. T h i s was done to e n a b l e a 47 p r o j e c t i o n o f the p o s s i b l e s i z e o f the F o r m u l a r y i f a d d i t i o n a l d r u g m o n o graphs a r e r e q u i r e d . ing Formulary The T h e t o t a l n u m b e r o f d r u g m o n o g r a p h s i n the e x i s t - i s 306. a l p h a b e t i c a l i n d e x o f the F o r m u l a r y , drugs and drug p r o d u c t s . h o w e v e r , l i s t s 483 T h e d i s c r e p a n c y that e x i s t s i s due to the f a c t that the l a t t e r n u m b e r i n c l u d e s the v a r i o u s s a l t s o f the g e n e r i c n a m e drugs as w e l l a s s o m e b r a n d n a m e s o f c o m b i n a t i o n p r o d u c t s w h i c h m a y be m o n o g r a p h e d i n the F o r m u l a r y u n d e r a s i n g l e g e n e r i c n a m e . In r e c o g n i t i o n o f the f a c t that the p r e s e n t D r u g F o r m u l a r y t a i n s m o n o g r a p h s o f o n l y t h o s e d r u g s u s e d at o n e h o s p i t a l , a s u r v e y conwas c o n d u c t e d i n f o u r a d d i t i o n a l p r o v i n c i a l h o s p i t a l s o f v a r y i n g s i z e to d e t e r m i n e w h a t a d d i t i o n a l d r u g m o n o g r a p h s m i g h t be r e q u i r e d to s u p p l y c o m p r e h e n s i v e d r u g i n f o r m a t i o n i n the p r o v i n c e . The hospitals included in this s t u d y ( s e e M e t h o d o l o g y , p a g e 27) w e r e r e q u e s t e d to l i s t the d r u g s that they s t o c k w h i c h a r e not i n c l u d e d p r e s e n t l y i n the D r u g Formulary It w a s f e l t that b y c o r r e l a t i n g t h e s e l i s t s w i t h t h o s e s u b m i t t e d b y f i v e c h i e f p h a r m a c i s t s o n the c h i e f p h a r m a c i s t s q u e s t i o n n a i r e ( s e e M e t h o d o l o g y , p a g e 24), the f i n a l r e s u l t w o u l d r e f l e c t m o s t o f the d r u g m o n o g r a p h s n e e d e d b y the p r o v i n c i a l h o s p i t a l s . O f a t o t a l o f 904 d r u g m o n o g r a p h s e v e n t u a l l y r e q u e s t e d i n a d d i t i o n to the e x i s t i n g m o n o g r a p h s , 592 r e c e i v e d one r e q u e s t , 204 w e r e r e q u e s t e d b y two h o s p i t a l s , 71 w e r e r e q u e s t e d b y t h r e e h o s p i t a l s , 32 o t h e r s 48 were r e q u e s t e d b y four institutions and five drug m o n o g r a p h s were r e q u e s t e d b y f i v e h o s p i t a l s (see A p p e n d i x II). In t e r m s o f p r i o r i t i e s f o r n e w d r u g m o n o g r a p h s to b e p r o d u c e d i n the f u t u r e , i t i s r e c o m m e n d e d that t h o s e d r u g s w h i c h r e c e i v e d two o r m o r e r e q u e s t s s h o u l d be c o n s i dered firstly. O n this b a s i s , a future p r o v i n c i a l D r u g F o r m u l a r y m i g h t be e x p e c t e d to c o n t a i n i n e x c e s s o f 600 d r u g m o n o g r a p h s ; 306 e x i s t i n g m o n o g r a p h s , p l u s a p p r o x i m a t e l y 300 n e w m o n o g r a p h s r e q u e s t e d b y two or m o r e institutions. (c) F o r m a t o f the D r u g M o n o g r a p h s A m o n g the m a n y w a y s i n w h i c h the f o r m a t o f the p r e s e n t d r u g m o n o g r a p h s w e r e r e c o m m e n d e d to b e c h a n g e d to o b t a i n a m o r e p r o v i n c i a l F o r m u l a r y , the i n c l u s i o n o f " M o d e o f A c t i o n " , a m b u l a t o r y u s e i n s t r u c t i o n s , b i b l i o g r a p h y r e f e r e n c e s a n d the C a n a d i a n D r u g I d e n t i f i c a t i o n C o d e w e r e s o m e w h i c h w e r e a d o p t e d d u r i n g the c u r r e n t F o r m u l a r y r e v i s i o n . Figure 6 and F i g u r e res- 7 p r e s e n t c o p i e s o f the m o n o g r a p h s o f E r y t h r o m y c i n , pectively, before a n d a f t e r r e v i s i o n f e a t u r i n g the a b o v e a d d i t i o n s . Mode of A c t i o n A l t h o u g h the e x i s t i n g m o n o g r a p h s h a v e a s e c t i o n f o r i n f o r m a t i o n o n the a c t i o n o f the d r u g , it i s o f t e n o n l y a s t a t e m e n t o f the t h e r a p e u t i c c l a s s i f i c a t i o n o f the d r u g (see F i g u r e 6 ) . In v i e w o f the r e q u e s t that the m o d e o f a c t i o n b e i n c l u d e d o n the m o n o g r a p h s , e a c h r e v i s e d m o n o g r a p h now c o n t a i n s i n f o r m a t i o n o n the m e c h a n i s m , a b s o r p t i o n , distribution. 49 Figure 6. Sample monograph of Erythromycin from the existing Drug Formulary before revision. so ERYTHROMYCIN ILOSONE ERYTHROCIN 8:12:12 ACTION: P r i m a r i l y b a c t e r i o s t a t i c a n t i b i o t i c . S p e c t r u m s i m i l a r to P e n i c i l l i n , i . e . , m a i n l y g r a m p o s i t i v e b a c t e r i a . E x c r e t e d m a i n l y i n b i l e . P e a k of A c t i o n : 2-4 h o u r s . D u r a t i o n 6 h o u r s . N o r m a l s e r u m h a l f - l i f e : 1.5 h o u r s . S e r u m h a l f - l i f e i n r e n a l f a i l u r e : 5 h o u r s . BACTERIAL SPECTRUM: S t a p h y l o c o c c i , B - h e m o l y t i c s t r e p t o c o c c i , C l o s t r i d i a , D. p n e u m o n i a e , H . p e r t u s s i s , * C . d i p h t h e r i a e , t r e p o n e m a , * M y c o p l a s m a p n e u m o n i a e ( E a t o n agent)., v i r u s e s c a u s i n g t r a c h o m a and l y m p h o g r a n u l o m a v e n e r e u m . ( ^ G e n e r a l l y c o n s i d e r e d a n t i b i o t i c of 1st c h o i c e . ) O t h e r p r i n c i p a l u s e i s a g a i n s t g r o u p A , b e t a - h e m o l y t i c s t r e p t o c o c c i and p n e u m o c o c c a l i n f e c t i o n s i n p a t i e n t s a l l e r g i c to P e n i c i l l i n . INDICATIONS: . B a c t e r i o s t a t i c against staphylocci, pneumococci, beta-hemolytic s t r e p t o c o c c i . t i s s u e , r e s p i r a t o r y and s k i n i n f e c t i o n s . U s e d i n soft CONTRAINDICATIONS: H y p e r s e n s i t i v i t y . E r y t h r o m y c i n e s t o l a t e (Ilosone) i s c o n t r a i n d i c a t e d i n c h o l e s t a t i c j a u n d i c e o r l i v e r d i s e a s e . K i d n e y d i s f u n c t i o n i s not a c o n t r a i n d i c a t i o n to use of E r y t h r o m y c i n . DOSAGE: O R A L : A D U L T S AND . I. V . : A D U L T S : C H I L D R E N o v e r 23 k g : 250 m g . e v e r y 6 h o u r s . S e v e r e i n f e c t i o n s : 500 m g . e v e r y 6 h o u r s . T a k e n 1-1-1/2 h o u r s p r i o r to o r a f t e r m e a l s . D o s a g e r a n g e 1-4 gm. d a i l y . C H I L D R E N 11. 5-23 k g : 125 m g . q.6.hl C H I L D R E N 4. 5-11. 5 k g : 11 m g . / k g . q.6.h. R e s e r v e d f o r s e v e r e i n f e c t i o n s : 1-4 CHILDREN: gm. d a i l y i n d i v i d e d d o s e s q. 6.h. 1 2 - (24)- 48 mg./kg/24 h o u r s d i v i d e d q. 8. h . M a x i m u m s i n g l e d o s e : 0.5 gm. M a x i m u m d a i l y d o s e : 1.5 In r e n a l f a i l u r e ( c r e a t i n i n e c l e a r a n c e 10 m l . / m i n . o r l e s s ) : i n i t i a l dose f o l l o w e d by h a l f - d o s e s at i n t e r v a l s o f 8 h o u r s . gm. Normal SIDE E F F E C T S : N a u s e a , v o m i t i n g , d i a r r h e a , s k i n r a s h , j a u n d i c e , I.M. i n j e c t i o n of m o r e than 100 m g . s e v e r a and p e r s i s t e n t p a i n . I.V. i n f u s i o n of 1 gm. d o s e s f r e q u e n t l y c a u s e s p h l e b i t i s . produces DRUG INTERACTIONS: E r y t h r o m y c i n antagonizes action of P e n i c i l l i n s . NURSING IMPLICATIONS: O r a l s o l u t i o n s m u s t be r e f r i g e r a t e d , s t a b i l i t y v a r i e s w i t h p r o d u c t . I n j e c t i o n s t a b l e 14 d a y s u n d e r r e f r i g e r a t i o n . I.V. i n j e c t i o n m u s t be m i x e d w i t h w a t e r f o r i n j e c t i o n w i t h o u t p r e s e r v a t i v e o t h e r w i s e the d r u g p r e c i p i t a t e s . It i s a d v i s a b l e to g i v e o r a l p r e p a r a t i o n s b e t w e e n m e a l s u n l e s s g a s t r i c i r r i t a t i o n i s too s e v e r e . P e r i o d i c b l o o d c e l l counts a r e a d v i s a b l e . Liver f u n c t i o n t e s t s a r e a d v i s a b l e i n p r o l o n g e d t h e r a p y w i t h the e s t o l a t e s a l t . I.V. I N C O M P A T I B I L I T I E S : L o s s of a c t i v i t y i n s o l u t i o n i s r a p i d at a p H b e l o w 5. C o m p a t i b l e w i t h m o s t I.V. s o l u t i o n s but m a y be p r e c i p i t a t e d by a d d i t i o n of h i g h c o n c e n t r a t i o n s of i n o r g a n i c s a l t s . I n c o m p a t i b l e w i t h B c o m p l e x w i t h C, b a r b i t u r a t e s , h e p a r i n . T e t r a c y c l i n e , C e p o r a n , D i p h e n y l h y d a n t o i n (Dilantin). Chloramphenicol, Aminophyllin, Streptomycin. PRESENTATION: Capsules or Tablets: Suspension: 250 m g . 125mg./5cc. Drops: Vial: 100 m g . / c c . 1 gm. 51 Figure 7. Sample monograph of Erythromycin including the bibliography after revision, showing the Canadian Drug Identification Code Active Ingredient Group Number in the top left-hand corner and the American Hospital Formulary Therapeutic Classification number in the top right-hand corner. 52 00431 ERYTHROCIN (STEARATE) ILOSONE (ESTOLATE) E - M Y C I N (BASE) ERYTHROMYCIN AND ITS E S T E R S 8:14:12 ACTION: Bacteriostatic Antibiotic. M e c h a n i s m : P r i m a r i l y b a c t e r i o s t a t i c . I n h i b i t s p r o t e i n s y n t h e s i s at r i b o s o m a l l e v e l (1). Absorption: O r a l - readily, p r i m a r i l y f r o m upper part of s m a l l intestine. The base and s t e a r a t e s a l t a b s o r p t i o n d e c r e a s e s i f t a k e n w i t h f o o d b u t the e s t o l a t e s a l t i s u n a f f e c t e d ( 3 ) . H i g h l y p r o t e i n b o u n d , p e a k b l o o d l e v e l s i n about two h o u r s w i t h e s t o l a t e s a l t , i n a b o u t f o u r h o u r s w i t h s t e a r a t e salt o r w i t h base i n a c i d r e s i s t a n t coated tablets (3). B l o o d l e v e l s a r e at l e a s t t w i c e a s h i g h (1), m o r e p r e d i c t a b l e a n d m o r e p r o l o n g e d (3) w h e n a n e q u i v a l e n t d o s e of estolate given as c o m p a r e d with base o r s t e a r a t e . D i s t r i b u t i o n : A l l t i s s u e s e x c e p t b r a i n c o n t a i n h i g h e r c o n c e n t r a t i o n s than i n b l o o d (1); i n t o p e r i t o n e a l , p l e u r a l , a s c i t i c and a m n i o t i c f l u i d s ; into s a l i v a ; a c r o s s mucous m e m b r a n e o f the t r a c h e o - b r o n c h i a l t r e e ; i n t o p l a c e n t a l c i r c u l a t i o n ( 3 ) . P o o r l y i n t o s p i n a l f l u i d u n l e s s m e n i n g e s i n f l a m e d (3). M e t a b o l i s m : N o r m a l s e r u m h a l f - l i f e 1. 5 h o u r s . H a l f - l i f e i n r e n a l i m p a i r m e n t u p to f i v e h o u r s ( l 1). E x c r e t i o n : T h e d r u g i s c o n c e n t r a t e d i n the l i v e r a n d i s m a i n l y e x c r e t e d i n the a c t i v e f o r m i n the b i l e ( 1 ) . A l s o e x c r e t e d i n the u r i n e , f e c e s a n d m i l k ( 3 ) . SPECTRUM OF ACTIVITY: ' S i m i l a r to p e n i c i l l i n s , i . e . , m a i n l y G r a m p o s i t i v e b a c t e r i a . B a c t e r i o s t a t i c a g a i n s t S t a p h y l o c o c c i , B - h e m o l y t i c s t r e p t o c o c c i , C l o s t r i d i a , D. pneumoniae, H. p e r t u s s i s , *C. diphtheriae, t r e p o n e m a , ^ M y c o p l a s m a pneumoniae (Eaton agent), v i r u s e s causing t r a c h o m a and l y m p h o g r a n u l o m a v e n e r e u m . * - g e n e r a l l y c o n s i d e r e d antibiotic of 1st c h o i c e . No c r o s s r e s i s t a n c e with p e n i c i l l i n . C r o s s resistance with c a r b o m y c i n , oleandomycin and s p i r a m y c i n . Staphyloc o c c i s t r a i n s develop r e s i s t a n c e f a i r l y r a p i d l y (3). INDICATIONS: ' P r i n c i p a l use i s i n group A beta-hemolytic streptococcal and pneumococcal infections i n p a t i e n t s who a r e a l l e r g i c to p e n i c i l l i n ( 2 ) . P r o p h y l a c t i c a l l y - f o r p r e v e n t i o n o f b a c t e r i a l e n d o c a r d i t i s p r i o r to d e n t a l o r o t h e r o p e r a t i v e p r o c e d u r e s o n p a t i e n t s w i t h a h i s t o r y o f r h e u m a t i c r e f e v e r o r congenital heart disease (2). U s e d i n soft t i s s u e , r e s p i r a t o r y i n f e c t i o n s . CONTRAINDICATIONS: H y p e r s e n s i t i v i t y . Estolate salt i s contraindicated i n cholestatic jaundice o r l i v e r disease, and i n c h r o n i c d i s o r d e r s ( e . g . , a c n e a n d f u r u n c u l o s i s ) ( 3 ) . K i d n e y d y s f u n c t i o n i s not a c o n t r a i n d i c a t i o n to u s e ( 1 ) . CAUTIONS: P a t i e n t s w i t h p r e - e x i s t i n g l i v e r d y s f u n c t i o n (4). DOSAGE: O r a l : A d u l t s a n d c h i l d r e n o v e r 23 K g . 250 m g e v e r y 6 h o u r s . S e v e r e i n f e c t i o n - 500 m g e v e r y 6 h o u r s . T a k e n 1 h o u r p r i o r to o r 2 h o u r s a f t e r m e a l s . D o s a g e r a n g e 1-4 G m d a i l y . C h i l d r e n : 11. 5 to 23 K g : 125 m g q. 6. h.; 4. 5 to 1 1 . 5 K g : 11 m g / K g q . 6 . h . I V . : R e s e r v e d f o r s e v e r e i n f e c t i o n s . A d u l t s : 1-4 G m d a i l y i n d i v i d e d d o s e s q. 6.h. Maximum s i n g l e d o s e : 0.5 G m . M a x i m u m d a i l y d o s a g e : 1,5 G m . In r e n a l f a i l u r e ( c r e a t i n i n e c l e a r a n c e 10 m l / m i n o r l e s s ) : N o r m a l i n i t i a l d o s e f o l l o w e d by h a l f d o s e a t i n t e r v a l s o f 8 h o u r s . SIDE E F F E C T S : R a r e l y s e r i o u s a d v e r s e r e a c t i o n s (5), i n f r e q u e n t l y n a u s e a , v o m i t i n g , d i a r r h o e a , s k i n r a s h , j a u n d i c e (only w i t h e s t o l a t e s a l t a n d e x t e n d e d t h e r a p y ( 3 , 8 ) ) . I . M . i n j e c t i o n o f m o r e than 100 m g m produces s e v e r e and p e r s i s t e n t p a i n . I.V. infusion o f l G m doses f r e q u e n t l y causes phlebitis. 53 00431 - 2 - ERYTHROMYCIN INTERACTIONS: E r y t h r o m y c i n antagonizes action of penicillin (12). Antibacterial effect in the urine appears to be enhanced by agents which alkalinize the urine - e.g., acetazolamide, sodium bicarbonate ( 6 , 7 ) . The drug should not be administered p r i o r to fruit juice o r other acid drink - activity of drug greatly decreases in acid solution ( 3 ) . I.V. I N C O M P A T I B I L I T I E S : E r y t h r o m y c i n is extremely pH dependent - most stable above pH 6-8. L o s s of activity in solution is rapid at a pH below 5 - avoid concurrent use of additives which will result in an admixture pH below 5 (9). Compatible with most I.V. solutions but may be precipitated by addition of high concentrations of inorganic salts. Incompatible with: Vitamin B complex with C, barbiturates, heparin, tetracycline, cephaloridine, diphenylhydantoin, chloramphenicol, aminophyllin, streptomycin, ascorbic acid, dextrose in lactated Ringer's injection (10). NURSING I M P L I C A T I O N S : O r a l solutions must be refrigerated, store in a cool place, protected f r o m light (4); stability v a r i e s . Injection stable 7 days under refrigeration (4). I.V. injection must be mixed with water for injection without preservatives, otherwise the drug precipitates. I. M . injections i r r i t a t i n g and too painful and should not exceed 100 mg. It is advisable to give o r a l preparations between meals unless gastric irritation is too severe. Antacid may be given for gastric i r r i t a t i o n . P e r i o d i c blood counts are advisable in prolonged therapy with the estolate salt. Venous irritation and thrombosis may occur if I.V. solution extravasates - watch site of infusion, stop flow before removing needle (4). Observe for symptoms of overgrowth of nonsus- . ceptible organisms (black furry tongue, enteritis) during prolonged therapy (4). The commercial I . M . product is not m i s c i b l e with water, so only a d r y syringe and needle should be used (2). INSTRUCTIONS T O P A T I E N T : Take one tablet one hour before meals (or two hours after) and at bedtime - 4 a day. Take antacid i f stomach gets upset after taking medication. Don't drink fruit juice or any acid drink with or after taking tablet. Store medication in a cool place, protected f r o m light. PRESENTATION: ^ Capsules or Tablets Suspension Drops Vial Date P r e p a r e d : March, 1973 250 125 100 1 mgm mgm/5 cc mgm/cc Gm 54 00431 Erythromycin REFERENCES: 1. 2. G o o d m a n , L . a n d G i l m a n , A.: The p e u t i c s , 4th e d i t i o n . 1274-7. C o m p e n d i u m o f P h a r m a c e u t i c a l s a n d S p e c i a l t i e s , 6th e d i t i o n . 1972 . 3. (1970) p. Canada, Canadian P h a r m a c e u t i c a l A s s o c i a t i o n , Inc. American Hospital F o r m u l a r y Service. P h a r m a c i s t s , Washington, D.C. 4. P h a r m a c o l o g i c a l B a s i s of T h e r a - American Society of H o s p i t a l (1971). Govoni, L . E . and H a y e s , J . : D r u g s and N u r s i n g I m p l i c a t i o n s , edition, p. 2nd 128. 5. AMA D r u g E v a l u a t i o n s , 1 st e d i t i o n (1971). 6. Savath, L.D., p. 402. et a l . : E x c r e t i o n o f e r y t h r o m y c i n a n d i t s e n h a n c e d activity i n urine against g r a m negative b a c i l l i with alkalinization. J. Lab. Clin. Med. ~ 72:916 (1968). 7. Z i n n e r , S.H., et a l . : E r y t h r o m y c i n a n d a l k a l i n i z a t i o n i n t h e r a p y o f b a c t e r i u r i a . A n t i m i c r o b . A g e n t s C h e m o t h e r . 9th c o n f . (1969) 36 A b s t . 85, 1969. 8. FDA R e p o r t s o f s u s p e c t e d a d v e r s e r e a c t i o n s to d r u g s , 1967, No. 671103-002-00501. 9. 10. Anon., Compatibility Digest, A m e r . J . Hosp. P h a r m . 26:410, Intravenous Additive Incompatibilities. . Health, Education, Welfare. J a n u a r y (1970). U.S. 1969. Dept. 11. F r a n c k e , D . E . and Whitney, H. A . K. : P e r s p e c t i v e s i n C l i n i c a l P h a r m a c y . D r u g I n t e l l i g e n c e P u b l i c a t i o n s , H a m i l t o n , I l l i n o i s (1972). 12. Jawetz, E . : The use of a n t i m i c r o b i a l d r u g s . 8:151 (1968). Date P r e p a r e d : March, 1973 Ann. Rev. Pharmacol. 55 m e t a b o l i s m and e x c r e t i o n of the d r u g w h e r e a p p l i c a b l e ( s e e F i g u r e 7). As w e l l as a d d i n g the a b o v e i n f o r m a t i o n to the m o n o g r a p h s , the r e v i s e d m o n o g r a p h s now also include m o r e extensive i n f o r m a t i o n i n e a c h o f the o t h e r s e c t i o n s of the m o n o g r a p h on " I n d i c a t i o n s " , " S i d e E f f e c t s " , c a t i o n s " and Contraindi- "Intravenous I n c o m p a t i b i l i t i e s " . Such additional information c o n t a i n e d i n the d r u g m o n o g r a p h s s h o u l d b e t t e r m e e t the n e e d s o f m o s t u s e r s i n the f u t u r e . Ambulatory Use Instructions S i n c e the D r u g F o r m u l a r y i s i n u s e the p r o v i n c e , and i n h o s p i t a l s i n a l l p a r t s of since s o m e of these h o s p i t a l s a r e a c t i v e i n m a n y s e r v i c e s i n c l u d i n g o u t p a t i e n t c l i n i c s , it was d e t e r m i n e d that a s e c t i o n s h o u l d be a d d e d to t h i s y e a r ' s r e v i s e d m o n o g r a p h s on " I n s t r u c t i o n s to the (see F i g u r e 7). T h i s s e c t i o n a l s o i s e x p e c t e d to be o f u s e within Patient" the h o s p i t a l s e t t i n g i t s e l f to a s s i s t i n the i n s t r u c t i o n o f p a t i e n t s r e c e i v i n g d i s charge medications. The addition of this s e c t i o n may further prove useful i f a n A m b u l a t o r y D r u g F o r m u l a r y i s p r o d u c e d at s o m e f u t u r e date f o r in Community Health C e n t r e s . In a n A m b u l a t o r y F o r m u l a r y the s e c t i o n on " I n s t r u c t i o n s to the P a t i e n t " c o u l d be u s e d i n p l a c e o f the s e c t i o n s on travenous I n c o m p a t i b i l i t i e s " and use "In- " N u r s i n g I m p l i c a t i o n s " w h i c h at p r e s e n t d e a l p r i m a r i l y w i t h i n f o r m a t i o n r e q u i r e d i n the h o s p i t a l s e t t i n g . R e f e r e n c e s and Bibliography F r o m p r e v i o u s e x p e r i e n c e w i t h the A m e r i c a n H o s p i t a l F o r m u - 56 l a r y S e r v i c e ( A . H . F . S . ) a n d o t h e r r e f e r e n c e s o u r c e s s u c h as standard textbooks, difficulty is experienced frequently in conducting additional i n f o r m a t i o n s e a r c h e s on the p r e s e n t e d i n f o r m a t i o n b e c a u s e t h e s e s o u r c e s c o n t a i n no i n d i c a t i o n o f w h e r e the o r i g i n a l i n f o r m a t i o n w a s found. Although it is p o s s i b l e to o b t a i n the r e f e r e n c e s to the A . H . F . S . b y w r i t i n g to the A m e r i c a n S o c i e t y o f H o s p i t a l P h a r m a c i s t s , e x p e r i e n c e d i c t a t e s that t h i s s y s t e m i s too a w k w a r d and t i m e c o n s u m i n g f o r efficient u t i l i z a t i o n . was F o r these r e a s o n s , it d e c i d e d to r e f e r e n c e the c o n t e n t s o f the d r u g m o n o g r a p h s a n d to p r o v i d e a c o m p l e t e b i b l i o g r a p h y f o r e a c h m o n o g r a p h i n the D r u g F o r m u l a r y F i g u r e 7). The (see p r e s e n c e o f the. r e f e r e n c e s a n d b i b l i o g r a p h y i s e x p e c t e d to e n a b l e the u s e r to f u r t h e r r e s e a r c h i n f o r m a t i o n and to i d e n t i f y the i n f o r m a tion s o u r c e quickly. Canadian D r u g Identification Code The H e a l t h P r o t e c t i o n B r a n c h o f the C a n a d i a n g o v e r n m e n t h a s r e c e n t l y p u b l i s h e d the C a n a d i a n D r u g I d e n t i f i c a t i o n C o d e . The publication c o n t a i n s f o u r s e c t i o n s o f d i f f e r e n t c o d e s - the S e q u e n t i a l I d e n t i f i e r ; a n a l p h a b e t i c a l l i s t i n g b y T r a d e n a m e s ; the M a n u f a c t u r e r s ' A s s i g n e d C o d e and the A c t i v e I n g r e d i e n t G r o u p N u m b e r . A f t e r r e v i e w i n g the a b o v e f o u r c o d e s , i t was d e c i d e d to a d o p t the A c t i v e I n g r e d i e n t G r o u p N u m b e r f o r i n c l u s i o n i n the d r u g m o n o g r a p h s b e c a u s e it a p p e a r e d to be the m o s t u s e f u l c o d e w i t h o u t l i m i t i n g i d e n t i f i c a t i o n to o n l y one m a n u f a c t u r e r ' s p r o d u c t ( s e e F i g u r e 7, top l e f t ) . It was f e l t that as w e l l 57 a s h a v i n g the C a n a d i a n D r u g I d e n t i f i c a t i o n C o d e A c t i v e I n g r e d i e n t G r o u p Number h o w e v e r , the A m e r i c a n H o s p i t a l F o r m u l a r y S e r v i c e ( A . H . F . S . ) T h e r a p e u t i c C l a s s i f i c a t i o n n u m b e r (8:12:12) s h o u l d be r e t a i n e d on the m o n o g r a p h ( s e e F i g u r e 7, top r i g h t ) as a c o r r e l a t i o n to the A . H . F . S . f o r t h o s e h o s p i t a l s w h i c h w i s h to f i l e the m o n o g r a p h s b y the A . H . and F.S. Therapeutic Classifications. (d) F o r m a t o f the F o r m u l a r y T h e m a j o r c r i t i c i s m o f the p r e s e n t D r u g F o r m u l a r y f o r m a t a s d e t e r m i n e d f r o m the c h i e f p h a r m a c i s t s q u e s t i o n n a i r e , f r o m the m e m b e r s o f the F a c u l t y o f P h a r m a c e u t i c a l S c i e n c e s who w e r e i n v o l v e d w i t h the c u r r e n t r e v i s i o n s a n d f r o m the c o m m e n t s o f the F o r m u l a r y u s e r s , i s that i t i s too bulky. The F o r m u l a r y , i f e x p a n d e d i n i t s p r e s e n t f o r m a t to a p p r o x i m a t e l y 600 m o n o g r a p h s a s a n t i c i p a t e d ( s e e p a g e 48) w o u l d be f u r t h e r r e d u c e d i n u s e f u l n e s s , p a r t i c u l a r l y o n the n u r s i n g s t a t i o n w h e r e l i m i t e d t i m e a n d space i s a v a i l a b l e . . It w o u l d a p p e a r that the l a r g e r the r e f e r e n c e b o o k , the l e s s i t i s l i k e l y to be used. Monograph Utilization Survey In a n a t t e m p t to r e d u c e the b u l k a n d to i n c r e a s e the u s e f u l n e s s o f the D r u g F o r m u l a r y , a s u r v e y was c o n d u c t e d to d e t e r m i n e the f r e q u e n c y of u s e o f the 483 d r u g s a n d d r u g p r o d u c t s l i s t e d i n the F o r m u l a r y a l p h a b e t i c a l i n d e x (see p a g e s 31-35). T h i s a p p r o a c h s h o u l d r e f l e c t the f r e q u e n c y 58 o f m o n o g r a p h r e q u i r e m e n t s i n s p e c i a l t y a r e a s w i t h i n the h o s p i t a l s a c c o r d i n g l y , the m i n i m u m n u m b e r ^ r e q u i r e d i n e a c h / . The survey conducted i n five B r i t i s h C o l u m b i a hospitals (see Methodology, The and page s t u d y r e q u e s t e d i n f o r m a t i o n o n the f r e q u e n c y o f u s e o f the d r u g s was 31 ). and t h e r e f o r e d r u g m o n o g r a p h s i n the f o l l o w i n g f o u r s p e c i a l i z e d c a r e a r e a s : P e d i a t r i c s , E m e r g e n c y , P s y c h i a t r y and E x t e n d e d C a r e . e v a l u a t e d at the f i v e h o s p i t a l s was The information c o m p i l e d into the f o l l o w i n g t a b l e s u n d e r the h e a d i n g s o f " F r e q u e n t l y " , " O c c a s i o n a l l y " a n d " R a r e l y " u s e d d r u g s . It was a s s u m e d that s h o u l d s o m e f o r m a t o f the D r u g F o r m u l a r y e v e n t u a l l y be d e s i g n e d f o r s p e c i f i c w a r d a r e a s , o n l y t h o s e d r u g s i d e n t i f i e d a s " F r e q u e n t l y " a n d / o r " O c c a s i o n a l l y " u s e d m i g h t be i n c l u d e d f o r u s e i n t h o s e areas. T h e a n t i c i p a t e d a d v a n t a g e o f s u c h a s y s t e m w o u l d be to r e d u c e the b u l k o f the F o r m u l a r y w h i l e s u p p l y i n g the r e q u i r e d d r u g i n f o r m a t i o n o n the d r u g s m o s t f r e q u e n t l y u s e d i n the w a r d a r e a . In the a r e a o f P e d i a t r i c s , f i v e h o s p i t a l s r e p l i e d w h e r e a s i n E x t e n d e d C a r e a n d P s y c h i a t r y o n l y t h r e e h o s p i t a l s s u p p l i e d the n e c e s s a r y i n f o r m a t i o n b e c a u s e the o t h e r two h o s p i t a l s do not h a v e f a c i l i t i e s f o r t h e s e services. In r e g a r d to E m e r g e n c y c a r e , one i n s t i t u t i o n , t h e R o y a l J u b i l e e H o s p i t a l , was u n a b l e to s u p p l y c o m p l e t e i n f o r m a t i o n o n d r u g u s a g e a n d t h e r e f o r e was not i n c l u d e d i n the r e s u l t s . T a b l e III s h o w s the f r e q u e n c y o f u s e o f the 483 d r u g s l i s t e d i n the F o r m u l a r y a l p h a b e t i c a l index on P e d i a t r i c w a r d s . T h e n u m b e r of drugs 59 " F r e q u e n t l y " u s e d r a n g e d f r o m 63 at L i o n s G a t e H o s p i t a l to 111 at the Vancouver General Hospital. T h e difference i n these figures m a y b e b u t a b l e to the l a r g e t e a c h i n g a t m o s p h e r e o f the l a t t e r h o s p i t a l . attri- The average n u m b e r o f " F r e q u e n t l y " u s e d d r u g s i n the f i v e h o s p i t a l s w a s 86 o r a p p r o x i m a t e l y 18 p e r c e n t o f the t o t a l n u m b e r o f d r u g s l i s t e d . T h i s w o u l d s e e m to i n d i c a t e that a F o r m u l a r y o f 600 m o n o g r a p h s w o u l d n o t o n l y b e c u m b e r s o m e but o f l i t t l e v a l u e f o r u s e o n P e d i a t r i c w a r d s . T a b l e I V s h o w s s i m i l a r r e s u l t s f o r f o u r h o s p i t a l s o n the s t u d y o f E m e r g e n c y W a r d drug use. L i o n s G a t e H o s p i t a l a g a i n h a d the l o w e s t n u m b e r o f " F r e q u e n t l y " u s e d d r u g s at 68 w h i l e S t . P a u l ' s H o s p i t a l i n d i c a t e d that 178 drugs were "Frequently" used. T h e r e a s o n f o r this d i f f e r e n c e was difficult to d e t e r m i n e b u t m a y h a v e b e e n due to the u r b a n , c e n t r a l s e t t i n g o f the l a t t e r hospital which might r e q u i r e a m o r e d i v e r s e pattern of e m e r g e n c y c a r e . In E m e r g e n c y W a r d s the a v e r a g e n u m b e r o f '".Frequently" u s e d d r u g s i n the f o u r h o s p i t a l s w a s 122 o r a p p r o x i m a t e l y 25 p e r c e n t o f the t o t a l n u m b e r o f d r u g s l i s t e d i n the c u r r e n t F o r m u l a r y a l p h a b e t i c a l i n d e x . A g a i n , the l i m i t e d n u m b e r o f m o n o g r a p h s a p p a r e n t l y u s e d i n t h i s a r e a f u r t h e r s u p p o r t s the a p p a r e n t n e e d l e s s n e s s o f the c o m p l e t e D r u g F o r m u l a r y i n a n y s p e c i a l t y a r e a . In E x t e n d e d C a r e ( T a b l e V ) , V a n c o u v e r G e n e r a l H o s p i t a l r e c o r d e d the l o w e s t n u m b e r o f " F r e q u e n t l y " u s e d d r u g s at 4 3 , a n d L i o n s G a t e H o s p i t a l h a d the h i g h e s t n u m b e r at 106. It i s thought that the V a n c o u v e r General H o s p i t a l h a d the l o w e s t n u m b e r i n t h i s c a t e g o r y b e c a u s e t h e y h a d j u s t o p e n e d 60 T A B L E III FREQUENCY O F USE O F PROVINCIAL F O R M U L A R Y DRUGS (483) IN PEDIATRIC WARDS O F VARIOUS HOSPITALS FREQUENTLY Hospital Number (%) 1 OCCASIONALLY 4 Number (%) 4 111 (23) 2 RARELY 3 Number (%) Vancouver General 93 (19) St. Paul's 75 (16) 88 (18) 320 (66) Lions Gate 63 (13) 40 (8) 387 (79) 111 (23) 134 (27) 238 (50) 86 (18) 103 (21) 294 (61) 86 (18) 93 (20) 304 (62) Victoria General Royal Jubilee 5 Average 1. Drugs used daily. 2. Drugs used once or twice a month. 3. Drugs used once or twice a year or never. 4. To nearest percentage point, of total 483 drugs. 5. Averaged to nearest whole number and percentage point. 279 (58) 4 61 T A B L E IV FREQUENCY O F USE O F PROVINCIAL F O R M U L A R Y DRUGS (483) IN E M E R G E N C Y WARDS OF VARIOUS HOSPITALS FREQUENTLY Hospital Number (%) 4 1 OCCASIONALLY Number (%) 4 2 RARELY 3 Number (% St. Paul's 178 (37) 53 (11) 252 (52) Vancouver General 137 (28) 112 (23) 234 (49) 68 (14) 65 (13) 350 (73) Lions Gate Victoria General 103 (21) Average^ 122 (25) 125 (26) 255 (53) 89 (18) 272 (57) 1. Drugs used daily. 2. Drugs used once or twice a month. 3. Drugs used once or twice a year or never. 4. To nearest percentage point, of total 483 drugs. 5. Averaged to nearest whole number and percentage point. 4 62 t h e i r new f a c i l i t y a n d t h e r e f o r e m e d i c a t i o n r e q u i r e m e n t s w e r e quite l o w . T h e a v e r a g e n u m b e r o f " F r e q u e n t l y " u s e d d r u g s f o r the t h r e e h o s p i t a l s w i t h E x t e n d e d C a r e f a c i l i t i e s w a s 83 o r a p p r o x i m a t e l y 17 p e r c e n t o f the 483 drugs. S h o u l d a f u t u r e D r u g F o r m u l a r y c o n t a i n a s m a n y a s 600 m o n o g r a p h s , some m e c h a n i s m f o r separating those m o n o g r a p h s " F r e q u e n t l y " u s e d i n s p e c i a l t y a r e a s , s u c h as E x t e n d e d C a r e , s h o u l d be d e s i g n e d f o r e a s e o f u s e . In the f i e l d o f P s y c h i a t r y ( T a b l e V I ) , L i o n s G a t e H o s p i t a l a n d the Vancouver G e n e r a l H o s p i t a l h a d s i m i l a r d r u g u s e n e e d s w i t h 50 a n d 53 drugs "Frequently" used respectively. 193 d r u g s " F r e q u e n t l y " u s e d . The R o y a l Jubilee Hospital listed T h e l a r g e d i f f e r e n c e s e e n h e r e m a y be due to the f a c t that the R o y a l J u b i l e e H o s p i t a l o p e r a t e s a v e r y l a r g e P s y c h i a t r i c f a c i l i t y w h i l e b o t h L i o n s G a t e H o s p i t a l a n d the V a n c o u v e r operate considerably s m a l l e r units. General Hospital The average number of "Frequently" u s e d d r u g s f o r the t h r e e h o s p i t a l s w a s 98 o r a p p r o x i m a t e l y 20 p e r c e n t o f the n u m b e r o f d r u g s l i s t e d i n the a l p h a b e t i c a l i n d e x o f the p r e s e n t D r u g mulary. For- A g a i n , the c o m p l e t e D r u g F o r m u l a r y o n p s y c h i a t r i c w a r d s w o u l d a p p e a r to p r o v e u n n e c e s s a r y a n d a w k w a r d a s d e m o n s t r a t e d t h r o u g h o u t T a b l e s III to V I . T h e m a j o r c r i t i c i s m o f the p r e s e n t F o r m u l a r y i s that i t i s too b u l k y f o r c o n v e n i e n t u s e at the w a r d l e v e l . A t t e m p t s to m a k e the F o r m u l a r y m o r e p r o v i n c i a l i n n a t u r e ( s e e p a g e 46 ) s u g g e s t that t h i s p r o b l e m m a y b e i n c r e a s e d w i t h the a d d i t i o n o f a p p r o x i m a t e l y 300 a d d i t i o n a l m o n o g r a p h s i n the future. T h e d a t a p r e s e n t e d i n T a b l e s III to V I , h o w e v e r , r e v e a l that 63 TABLE V F R E Q U E N C Y O F USE O F PROVINCIAL F O R M U L A R Y DRUGS (483) IN E X T E N D E D C A R E WARDS O F VARIOUS HOSPITALS FREQUENTLY Hospital Vancouver General Number (%) 4 1 OCCASIONALLY Number (%) 4 2 RARELY 3 Number (%) 43 (9) 73 (15) 367 (76) Lions Gate 106 (22) 67 (14) 310 (64) Victoria General 100 (20) 120 (25) 463 (55) 83 (17) 86 (18) 314 (65) Average^ 1. Drugs used daily. 2. Drugs used once or twice a month. 3. Drugs used once or twice a year or never. 4. To nearest percentage point, of total 483 drugs. 5. Averaged to nearest whole number and percentage point. 4 64 T A B L E VI F R E Q U E N C Y O F USE O F PROVINCIAL F O R M U L A R Y DRUGS (483) IN PSYCHIATRIC WARDS OF VARIOUS HOSPITALS FREQUENTLY Hospital Number (%) 4 1 OCCASIONALLY Number (%) 4 2 RARELY 3 Number (%) Vancouver General 53 (11) 116 (24) 314 (65) Lions Gate 50 (10) 49 (10) 384 (80) 91 (19) 199 (41) 85 (18) 300 (62) Royal Jubilee 5 Average 193 (40) 98 (20) 1. Drugs used daily. 2. Drugs used once or twice a month. 3. Drugs used once or twice a year or never. 4. To nearest percentage point, of total 483 drugs. 5. Averaged to nearest whole number and percentage point. 4 65 c o n s i d e r a b l y f e w e r d r u g s t h a n t h o s e that m i g h t a p p e a r i n a f u t u r e F o r m u l a r y a r e u s e d w i t h a n y d e g r e e o f f r e q u e n c y i n any g i v e n s p e c i a l t y w a r d . w o u l d s u g g e s t that t h e r e i s no n e e d f o r the b u l k o f the c o m p l e t e in these a r e a s . areas may This Formulary It a l s o s u g g e s t s that " S p e c i a l t y F o r m u l a r i e s " f o r s p e c i a l t y f u n c t i o n w e l l i n r e l a t i o n to a " M a s t e r F o r m u l a r y " f o r the e n t i r e hospital. Master-"Mini" The Formulary p r e v i o u s r e s u l t s p r o j e c t that e a c h h o s p i t a l m i g h t h a v e a M a s t e r F o r m u l a r y of a l l p r o v i n c i a l d r u g m o n o g r a p h s as w e l l as " M i n i " Formularies d e s i g n e d f o r and c o n t a i n i n g m o n o g r a p h s for o n l y those "Frequently" used in specialty ward areas. T h e s e two drugs types of F o r m u l a r i e s w i t h i n a h o s p i t a l w o u l d be f u r t h e r d i f f e r e n t i a t e d a c c o r d i n g to the i n d i v i d u a l m o n o g r a p h content. F o r e x a m p l e (see F i g u r e 7, p a g e 5 1 ) , the M a s t e r F o r m u l a r y w o u l d c o n t a i n the c o m p l e t e m o n o g r a p h p l u s the b i b l i o g r a p h y w h e r e a s the " M i n i " F o r m u l a r y i n u s e on the w a r d w o u l d not be encumbered b y the b i b l i o g r a p h y . A n o t h e r f e a t u r e that m i g h t be i n c l u d e d i n a f u t u r e M a s t e r (but not " M i n i " ) F o r m u l a r y i s a c r o s s - i n d e x . In r e c o g n i t i o n of the l a r g e n u m b e r of different m a n u f a c t u r e r s and b r a n d n a m e s for e a c h g e n e r i c n a m e drug or drug product, i t i s s u g g e s t e d that a c o m p l e t e c r o s s - i n d e x o f b r a n d to g e n e r i c n a m e s be p r o d u c e d . In t h i s i n d e x i t i s s u g g e s t e d a l s o that the C a n a d i a n D r u g I d e n t i f i c a t i o n C o d e A c t i v e I n g r e d i e n t G r o u p N u m b e r s h o w n on the present r e v i s e d m o n o g r a p h s be i n c l u d e d to f a c i l i t a t e the u s e o f n a t i o n a l e l e c t r o n i c 66 data p r o c e s s i n g indexing and stock c o n t r o l s y s t e m s when these a r e i n t r o d u c e d into the h o s p i t a l s at s o m e f u t u r e d a t e . It i s r e c o m m e n d e d f u r t h e r that t h i s c r o s s - i n d e x b e p r o d u c e d a s s o o n a s p o s s i b l e a n d u p d a t e d a s b r a n d n a m e d r u g s a r e i n t r o d u c e d a n d a s new i n c l u s i o n i n the D r u g new monographs are produced for Formulary. A s c a n b e d e d u c e d f r o m the i n c r e a s e d a m o u n t o f i n f o r m a t i o n p r o p o s e d f o r a d d i t i o n to the F o r m u l a r y a s w e l l a s a c o m p l e t e b i b l i o g r a p h y f o r e a c h m o n o g r a p h a n d a c r o s s - i n d e x , the M a s t e r D r u g F o r m u l a r y c o u l d become a massive volume. T h e v a l u e of s u c h a v o l u m e f o r r e s o u r c e i n f o r - m a t i o n and r e s e a r c h , h o w e v e r , b e c o m e s a p p a r e n t . O n the o t h e r h a n d , i t b e c o m e s a p p a r e n t a l s o that the M a s t e r F o r m u l a r y a s d e s c r i b e d h e r e w o u l d not b e e f f e c t i v e l y u s e d at the w a r d l e v e l due to i t s b u l k . F r o m t h i s s t u d y t h e r e a p p e a r to be f o u r w a y s to r e d u c e the b u l k i n e s s o f the D r u g F o r m u l a r y o n the w a r d b y u s i n g a " M a s t e r " - " M i n i " F o r mulary arrangement. F i r s t l y , b y r e m o v i n g the b i b l i o g r a p h y f r o m the " M i n i " F o r m u l a r i e s l o c a t e d at the w a r d l e v e l the b u l k s h o u l d be d e c r e a s e d b y t h i r d to o n e - h a l f . one- In t h i s r e s p e c t , i t i s p r o p o s e d that the m o n o g r a p h s w i t h the r e f e r e n c e n u m b e r s be k e p t o n the w a r d w h i l e the b i b l i o g r a p h i e s be m a i n t a i n e d i n the M a s t e r F o r m u l a r y i n the C e n t r a l P h a r m a c y o r D r u g I n f o r m a tion C e n t r e . T h i s w o u l d e n a b l e the r e d u c t i o n o f the D r u g F o r m u l a r y o n the w a r d w h i l e s t i l l a l l o w i n g the u s e r s a c c e s s to the b i b l i o g r a p h i e s w h e n n e c e s s a r y b y c o n t a c t i n g the p h a r m a c y . 67 A s e c o n d a p p r o a c h to r e d u c i n g t h e . b u l k o f the F o r m u l a r y w o u l d be to p r o d u c e " M i n i " F o r m u l a r i e s f o r e a c h s p e c i f i c w a r d , i n c l u d i n g o n l y those drugs which a r e " F r e q u e n t l y " u s e d i n each a r e a . U n f o r t u n a t e l y , this s o l u t i o n i f u n d e r t a k e n b y the p r o d u c e r s o f the D r u g F o r m u l a r y w o u l d p r o b a b l y be too c o s t l y to b e c o m e f e a s i b l e . was If a s p e c i f i c " M i n i " Formulary to b e p r o d u c e d f o r e a c h w a r d o f e a c h h o s p i t a l o f the p r o v i n c e (100 p r o v i n c i a l h o s p i t a l s w i t h an a v e r a g e o f 8 to 10 w a r d s each) t h e r e c o u l d be f r o m 800 to 1000 s p e c i f i c f o r m u l a r i e s to c o l l a t e s e p a r a t e l y . g r e a t l y i n c r e a s e the p e r s o n n e l r e q u i r e d to p r o d u c e the D r u g This would Formulary a n d i n c r e a s e the c o s t s p o s s i b l y b e y o n d the p r e s e n t c o s t s . A t h i r d a p p r o a c h to p r o d u c i n g a " M i n i " F o r m u l a r y could o v e r - c o m e t h i s p r o b l e m b y h a v i n g the p h a r m a c i s t s o f e a c h h o s p i t a l c o n d u c t s u r v e y s s i m i l a r to the M o n o g r a p h U t i l i z a t i o n S u r v e y ( s e e p a g e s 31-34) o n the w a r d s o f t h e i r h o s p i t a l to d e t e r m i n e t h o s e d r u g s m o s t f r e q u e n t l y u s e d i n each patient c a r e a r e a . O n c e t h i s h a s b e e n d e t e r m i n e d , i t i s s u g g e s t e d that the m o n o g r a p h s f o r t h e s e d r u g s (without the b i b l i o g r a p h y ) c o u l d be removed f r o m a c o m p l e t e F o r m u l a r y a n d be p l a c e d i n c l e a r p l a s t i c e n v e l o p e s a n d i n s e r t e d i n a t h r e e - r i n g b i n d e r w h i c h c o u l d be p e r m a n e n t l y a f f i x e d to e i t h e r a c o u n t e r o r w a l l at the l o c a t i o n o f g r e a t e s t u s e . In t h i s m a n n e r , the m o n o - g r a p h s w o u l d be a v a i l a b l e to the u s e r s but c o u l d not be r e m o v e d f r o m the p l a c e o f u s e , r e s u l t i n g i n l e s s p o s s i b i l i t y o f the m o n o g r a p h s b e i n g l o s t . r e m a i n i n g m o n o g r a p h s c o u l d be m a i n t a i n e d i n the o r i g i n a l b i n d e r a n d o n the n u r s i n g s t a t i o n i n a d r a w e r o r c u p b o a r d . The stored These monographs should be k e p t o n the n u r s i n g s t a t i o n so that t h e y a r e a v a i l a b l e w h e n o c c a s i o n a l l y 68 or r a r e l y u s e d d r u g s a r e b e i n g a d m i n i s t e r e d and i n f o r m a t i o n on these m e d i c a t i o n s i s r e q u i r e d b y the m e d i c a l o r n u r s i n g staff. T h e a b o v e p r o p o s e d s y s t e m m i g h t be e x p e c t e d to c o s t a p p r o x i m a t e l y $ 1 0 . 00 p e r w a r d b e y o n d the c o s t o f the b a s i c D r u g F o r m u l a r y . ( T h i s i s b a s e d o n $ 2 . 50 f o r a h a r d c o v e r , t h r e e - r i n g b i n d e r a n d $ 0 . 15 x 50 = $ 7 . 50 f o r 50 p l a s t i c e n v e l o p e s ) . T h i s s y s t e m would allow between 50 a n d 100 m o n o g r a p h s to b e p l a c e d i n the " M i n i " F o r m u l a r y . s y s t e m a l o n g s i m i l a r l i n e s was Another investigated using K a r d e x f r a m e s of x 11 i n c h s i z e to c o n t a i n the m o n o g r a p h s . The 8-1/2 cost of this type of s y s t e m was a p p r o x i m a t e l y 40 t i m e s g r e a t e r t h a n the a b o v e s y s t e m a n d t h e r e f o r e was thought to be p r o h i b i t i v e f o r w i d e s p r e a d u s e . T h e f o u r t h s u g g e s t i o n f o r r e d u c i n g the b u l k o f the F o r m u l a r y i s to p r i n t the m o n o g r a p h s o f two p a g e s o r m o r e i n l e n g t h o n b o t h s i d e s o f a p a g e ( s e e F i g u r e 7, p a g e 51 ). T h e b i b l i o g r a p h i e s o f two o r m o r e p a g e s a l s o c o u l d be p r i n t e d o n b o t h s i d e s o f a p a g e . T h i s suggestion could have the p o s s i b l e e f f e c t o f r e d u c i n g the s i z e o f the F o r m u l a r y b y up to o n e - h a l f . U n d e r the p r o p o s e d c o n d i t i o n s , the M a s t e r F o r m u l a r y w o u l d be m a i n t a i n e d i n the p h a r m a c y ( c o n t a i n i n g the m o n o g r a p h s o f a l l d r u g s u s e d i n the h o s p i t a l , the b i b l i o g r a p h i e s f o r e a c h m o n o g r a p h a n d the c o m p l e t e i n d e x o f the F o r m u l a r y ) . T h e cross- " M i n i " F o r m u l a r y w o u l d c o n t a i n o n l y the d r u g m o n o g r a p h s o f the d r u g s f r e q u e n t l y u s e d o n the w a r d w i t h the r e m a i n i n g m o n o g r a p h s b e i n g s t o r e d i n the o r i g i n a l b i n d e r i n a d r a w e r o r c u p b o a r d o n the w a r d . 69 P r e s e n t P u b l i c a t i o n and E l e c t r o n i c D a t a P r o c e s s i n g . As Ray E l e c t r o n i c D a t a P r o c e s s i n g ( E . D . P . ) a n d the u s e of C a t h o d e T u b e (C.R. T.) r e a d e r - p r i n t e r s b e c o m e m o r e acceptable i n h o s p i t a l s , a n o t h e r m e a n s o f r e d u c i n g the b u l k o f the p r e s e n t D r u g F o r m u l a r y w i l l become feasible. T h i s would enable the r e m o v a l of the p r i n t e d F o r m u l a r y c o m p l e t e l y f r o m the w a r d a r e a s a n d the m a i n t e n a n c e of a l l d r u g i n f o r m a t i o n i n a c e n t r a l d a t a b a n k w h i c h w o u l d be c o n n e c t e d to e a c h a r e a b y a C . R . T . reader-printer. The p r e s e n t c o s t o f t h i s s y s t e m i s p r o h i b i t i v e , but a s the s y s t e m b e c o m e s m o r e available and less expensive, reader-printers may the u s e o f C . R . T . b e c o m e a m o r e f e a s i b l e m e a n s of supplying drug i n f o r m a t i o n to h e a l t h p r a c t i t i o n e r s . A n o t h e r a p p r o a c h to E . D . P . h o w e v e r , m i g h t r e d u c e the cost of F o r m u l a r y p r o d u c t i o n . The p r o d u c t i o n o f the D r u g present Formulary p r e s e n t l y i s b e i n g u n d e r t a k e n b y the B r i t i s h C o l u m b i a H o s p i t a l A s s o c i a t i o n at a c o s t to the h o s p i t a l s o f a b o u t $ 1 5 . 00 p e r c o p y o r a p p r o x i m a t e l y cents a page. T h i s c o s t r e p r e s e n t s o n l y the d u p l i c a t i o n a n d four distribution c o s t s a n d d o e s not i n c l u d e p e r s o n n e l a n d s t e n o g r a p h i c e x p e n s e s i n r e s e a r c h i n g a n d p r e p a r i n g the i n f o r m a t i o n f o r e a c h m o n o g r a p h . H o s p i t a l was Ottawa C i v i c c o n t a c t e d i n r e g a r d to the p r o d u c t i o n c o s t s o f E . D . P . F o r m u - lary printing. H o s p i t a l was The The c o s t of p r o d u c i n g e a c h F o r m u l a r y at the O t t a w a C i v i c $ 5 . 00 o r a b o u t two approximately tional method. cents per page. T h i s cost represents o n e - h a l f the c o s t o f p r i n t i n g the D r u g F o r m u l a r y b y a c o n v e n It i s f e l t that the c o s t d i f f e r e n c e c a n be a t t r i b u t e d to t h r e e 70 factors: the m e t h o d o f p r o d u c t i o n ; the n u m b e r o f p a g e s ; a n d f i n a l l y , the n u m b e r of f o r m u l a r i e s p r i n t e d . The Ottawa C i v i c Hospital F o r m u l a r y is p r i n t e d b y E . D . P . m e t h o d s w h i c h , f r o m the l i t e r a t u r e (27, 38) w e r e n o t e d to be l e s s e x p e n s i v e f o r l o n g - t e r m p r i n t i n g , w h i l e the p r o v i n c i a l D r u g F o r m u l a r y is produced by conventional methods. H o s p i t a l p r i n t s a b o u t 600 c o p i e s of a p p r o x i m a t e l y The Ottawa C i v i c 270 p a g e s e a c h , w h e r e a s the c u r r e n t D r u g F o r m u l a r y c o n t a i n s 400 p a g e s a n d the n u m b e r o f F o r m u l a r i e s p r i n t e d i s a b o u t 250. f o r the A c c o r d i n g l y , the a d o p t i o n of E . D . P . p r i n t i n g P r o v i n c i a l F o r m u l a r y s h o u l d not be c o n s i d e r e d b e f o r e the m a j o r r e v i s i o n s a r e m a d e a n d the r e g u l a t i o n p u b l i c a t i o n i s The decided upon. a b o v e s t u d i e s r e f l e c t that s e v e r a l m o d i f i c a t i o n s o f the p r e s e n t D r u g F o r m u l a r y s h o u l d be c o n s i d e r e d i n a d d i t i o n to u p d a t i n g , i n m a k i n g i t m o r e u s e f u l on a p r o v i n c i a l b a s i s . The future n u m b e r of m o n o - g r a p h s , a d d i t i o n a l i n f o r m a t i o n i n e a c h , an e x t e n s i v e b i b l i o g r a p h y , a Master-"Mini" f o r m a t f o r m o r e e f f e c t i v e h o s p i t a l u s e and p r o d u c t i o n a i d s s u c h as e l e c t r o n i c d a t a p r o c e s s i n g , a l l w o u l d a s s i s t i n p r o d u c i n g a F o r m u l a r y of a m o r e valuable f o r m a t . II. E v a l u a t i n g and U p d a t i n g the Formulary P e r h a p s the g r e a t e s t l i m i t a t i o n of the p r e s e n t D r u g F o r m u l a r y i s that no m e c h a n i s m e x i s t s f o r u p d a t i n g and e v a l u a t i n g the d r u g m o n o g r a p h s o r f o r r e v i e w i n g the s c i e n t i f i c a n d c l i n i c a l v a l i d i t y o f the i n f o r m a t i o n con- 71 tained therein. T h e p r o p o s e d m e t h o d that w a s e v a l u a t e d i n the p r e s e n t s t u d y i s the o n e w h i c h w a s u s e d to p r o d u c e 100 e x i s t i n g m o n o g r a p h r e v i s i o n s b a s e d on a s e n i o r p h a r m a c y s t u d e n t a s s i g n m e n t ( s e e M e t h o d o l o g y , p a g e 37 ) d u r i n g 1972-73. T o e v a l u a t e the p r o p o s e d m e c h a n i s m , two p o i n t s w e r e (1) studied: T h e n u m b e r a n d n a t u r e o f c h a n g e s i n the m o n o g r a p h s a s s u g g e s t e d f r o m the s t u d e n t u p d a t i n g a s s i g n m e n t ( s e e M e t h o d o l o g y , p a g e 37 ); (2) T h e time r e q u i r e m e n t f o r student, i n s t r u c t o r and s t e n o g r a p h e r input f o r m o n o g r a p h updating ( s e e M e t h o d o l o g y , p a g e 41 ) , F r o m the r e s u l t s o f t h e s e s t u d i e s , p r o j e c t i o n s w e r e m a d e r e g a r d i n g a s c h e d u l e f o r u p d a t i n g the m o n o g r a p h s o n a n a n n u a l c o m b i n e d e d u c a t i o n a n d " s e r v i c e " b a s i s a n d r e g a r d i n g the p e r s o n n e l w h i c h m i g h t b e r e q u i r e d to c o n t i n u e the a n n u a l u p d a t i n g o f the F o r m u l a r y . (a) N a t u r e a n d F r e q u e n c y of Changes F o r e a c h u p d a t e d m o n o g r a p h the s t u d e n t s c o m p l e t e d a C h a n g e Sheet (see M e t h o d o l o g y , page 39) w h i c h i n d i c a t e d a l l a d d i t i o n s , a n d c h a n g e s to the o r i g i n a l m o n o g r a p h . w e r e a n a l y z e d to d e t e r m i n e monographs. corrections One h u n d r e d of these Change Sheets the n e e d f o r a n n u a l u p d a t i n g o f the e x i s t i n g T h e r e s u l t s o f this study a r e p r e s e n t e d i n T a b l e V I I . B e c a u s e i n s o m e c a s e s , t h r e e to f i v e y e a r s h a d e l a p s e d s i n c e the o r i g i n a l m o n o g r a p h was p r o d u c e d , a g r e a t deal of new i n f o r m a t i o n and, 72 I T A B L E VII MONOGRAPH CHANGES 1 B a s e d o n I n f o r m a t i o n F r o m the L i t e r a t u r e i n 1969-73 Average Total Changes 2 Range 13.26 3-30 Changes i n sections on D r u g Interactions and .,. 3 Intravenous Incompatibilities T 4. T - „„ 5. 77 „ 2-18 1. A s d e t e r m i n e d b y r e v i e w i n g the C h a n g e S h e e t s f o r 100 r a n d o m l y s e l e c t e d e x i s t i n g m o n o g r a p h s d u r i n g the u p d a t i n g a s s i g n m e n t . 2. T h e a v e r a g e n u m b e r o f r e q u i r e d c h a n g e s f o u n d o n one m o n o g r a p h . 3. T h e n u m b e r o f c h a n g e s f o u n d o n the m o n o g r a p h s e c t i o n s thought to be m o s t r e q u i r e d i n annual u p d a t i n g s . 73 t h e r e f o r e , c h a n g e s a p p e a r e d i n the u p d a t e d m o n o g r a p h s . a p p a r e n t w h e n the C h a n g e S h e e t s w e r e Due This became studied. to the s i g n i f i c a n t n u m b e r o f c h a n g e s r e q u i r e d , two f o r m s of u p d a t i n g s h o u l d be i d e n t i f i e d i n the t o t a l r e v i s i o n r e q u i r e m e n t s - c o m p l e t e e v a l u a t i o n and annual updating. Complete evaluation includes referencing o f the e x i s t i n g m o n o g r a p h i n f o r m a t i o n , a d d i t i o n o f the new "Mode of A c t i o n " and and c u r r e n t l i t e r a t u r e to the e x i s t i n g m o n o g r a p h ( s e e M e t h o d o l o g y , p a g e s 37-38). T h i s definition of c o m p l e t e i s c o n s i s t e n t w i t h the a s s i g n m e n t c o m p l e t e d b y the s e n i o r p h a r m a c y students i n 1972-73. O n c e t h i s c o m p l e t e e v a l u a t i o n h a s b e e n done on a l l m o n o g r a p h s , o n l y a n n u a l u p d a t i n g f r o m c u r r e n t l i t e r a t u r e w o u l d be in future on " I n s t r u c t i o n s to the P a t i e n t " , a n d the a d d i t i o n o f any- additional information f r o m previous evaluation sections required years. The p r o p o s e d a n n u a l u p d a t i n g , a p a r t o f the t o t a l r e v i s i o n , s i s t s of p r o o f r e a d i n g the r e v i s e d m o n o g r a p h a g a i n s t s t a n d a r d con- reference s o u r c e s s u c h as the A m e r i c a n H o s p i t a l F o r m u l a r y S e r v i c e , t e x t b o o k s and the C o m p e n d i u m of P h a r m a c e u t i c a l s a n d S p e c i a l t i e s , as w e l l as u p d a t i n g the m o n o g r a p h f r o m the l i t e r a t u r e o f the p r e v i o u s the s e c t i o n s of " D r u g I n t e r a c t i o n s " a n d determination year only, with emphasis "Intravenous Incompatibilities". to p l a c e the e m p h a s i s o n t h e s e s e c t i o n s was n u m b e r of changes w h i c h o c c u r r e d on i n t h e s e two The m a d e b e c a u s e the s e c t i o n s was greater than o n e - t h i r d o f the t o t a l n u m b e r o f c h a n g e s p e r m o n o g r a p h i n m o s t c a s e s (see T a b l e VII). 74 (b) T i m e E v a l u a t i o n T h e p u r p o s e o f s t u d y i n g the t i m e r e q u i r e m e n t s o f the s t u d e n t s , i n s t r u c t o r s a n d s t e n o g r a p h e r s f o r u p d a t i n g a n d t y p i n g the d r u g m o n o g r a p h s w a s to d e t e r m i n e a n a p p r o x i m a t e p e r s o n n e l r e q u i r e m e n t f o r u p d a t i n g the D r u g F o r m u l a r y o n a c o n t i n u i n g " s e r v i c e " b a s i s i n the f u t u r e . The indivi- d u a l as w e l l a s c o l l e c t i v e t i m e s w e r e a n a l y z e d to e n a b l e f l e x i b i l i t y i n a n y suggested system. O n e h u n d r e d t i m e s h e e t s a g a i n w e r e a n a l y z e d f o r e a c h o f the three groups (students, i n s t r u c t o r s , and stenographers) f o r i n c l u s i o n i n the t i m e e v a l u a t i o n s . T h e r e s u l t s of this study a r e p r e s e n t e d i n T a b l e VIII. 75 T A B L E VIII REVISION TIMES A V E R A G E TIME FOR MONOGRAPHS - Standard Deviation (Hours) A. STUDENTS 1. Total Revision 2. Annual Updating B. 13.13 - 9.09 4.50 t 3. 72 2 INSTRUCTORS' REVIEW t l . 06 1. Review and Evaluate 3.26 2. Edit and Condense for monograph format 0.84 t 0.31 C. . S E C R E T A R I A L WORK Typing 0.68 t 0.44 3 1. As determined from 100 randomly selected updating time sheets. 2. Portion of the Total Revision time requirement representing "Drug Interactions" and "Intravenous Incompatibilities" as described on page 73 . 3. Does not consider time required to make corrections or typographical errors. 76 As c a n be s e e n f r o m the T a b l e o f R e v i s i o n T i m e s , a p p r o x i m a t e l y 13 h o u r s p e r m o n o g r a p h was lete m o n o g r a p h . r e q u i r e d b y the s t u d e n t s to e v a l u a t e the c o m p - T o u p d a t e o n l y the s e c t i o n s on " D r u g I n t e r a c t i o n s " a n d " I n t r a v e n o u s I n c o m p a t i b i l i t i e s " , the s t u d e n t s r e q u i r e d b e t w e e n f o u r five h o u r s . By and c o r r e l a t i n g t h e s e r e s u l t s w i t h the d e f i n i t i o n s o f c o m p l e t e e v a l u a t i o n a n d a n n u a l u p d a t i n g on p a g e 73 , i t s e e m s r e a s o n a b l e to e s t i m a t e that the a n n u a l u p d a t i n g w o u l d r e q u i r e d a p p r o x i m a t e l y o n e - t h i r d o f the t i m e r e q u i r e d f o r the i n i t i a l c o m p l e t e The e v a l u a t i o n o f the m o n o g r a p h . d e t e r m i n a t i o n o f i n s t r u c t o r t i m e r e q u i r e d c o n c e r n s o n l y the t i m e n e c e s s a r y to c o m p l e t e the " s e r v i c e " p o r t i o n o f t h e i r w o r k a n d d o e s not c o n s i d e r t h e i r a c a d e m i c i n p u t to the u p d a t i n g a s s i g n m e n t M e t h o d o l o g y , page 37). (see T h i s " s e r v i c e " p a r t i n c l u d e s the e v a l u a t i o n o f the o r i g i n a l r e f e r e n c e as c i t e d b y the s t u d e n t f o r s c i e n t i f i c v a l i d i t y , e d i t i n g c o n d e n s i n g the u p d a t e d m o n o g r a p h f o r t y p i n g . o f the i n s t r u c t o r s ' c o m m i t m e n t and It c a n be s e e n that t h i s p o r t i o n r e q u i r e d about f o u r h o u r s p e r m o n o g r a p h . O n c e a l l o f the F o r m u l a r y m o n o g r a p h s h a v e b e e n c o m p l e t e l y e v a l u a t e d h o w e v e r , i t c a n be e x p e c t e d that a p p r o x i m a t e l y one h o u r w i l l b e required to r e v i e w the a n n u a l u p d a t i n g done b y the s t u d e n t s . The t i m e r e q u i r e d b y the s t e n o g r a p h i c s t a f f to type e a c h m o n o g r a p h i n the s t a n d a r d f o r m a t ( s e e F i g u r e 7, p a g e 51), w i t h i t s c o r r e s p o n d i n g b i b l i o g r a p h y , was a p p r o x i m a t e l y 40 m i n u t e s . T h i s f i g u r e d o e s not i n c l u d e the t i m e n e c e s s a r y to c o r r e c t a n y t y p o g r a p h i c a l e r r o r s w h i c h w e r e d i s c o v e r e d w h i l e p r o o f r e a d i n g the e v a l u a t e d m o n o g r a p h s . 77. In t o t a l , the t i m e r e q u i r e d f o r s t u d e n t , i n s t r u c t o r , a n d s t e n o g r a p h e r i n p u t w a s about 18 h o u r s f o r e a c h m o n o g r a p h b a s e d o n the 1972-73 complete evaluation format. P r o p o s e d F u t u r e R e v i s i o n Schedule B y u s i n g the r e s u l t s o f the t i m e e v a l u a t i o n , a s c h e d u l e o f c o m p l e t e e v a l u a t i o n a n d a n n u a l u p d a t i n g o f the r e m a i n i n g a n d f u t u r e m o n o g r a p h s m i g h t be m a d e on a c o m b i n e d e d u c a t i o n a n d " s e r v i c e " b a s i s . This proposal is m a d e o n the a s s u m p t i o n that the e d u c a t i o n a l t i m e a n d c r e d i t v a l u e o f the s t u d e n t a s s i g n m e n t w i l l b e c o n t i n u e d . It i s m a d e a l s o o n the a s s u m p t i o n that a " s e r v i c e " c o m p o n e n t o f i n s t r u c t o r t i m e w i l l b e m a d e a v a i l a b l e . The proposed schedule i s presented in Table IX. A s s u m i n g that the e d u c a t i o n a l a s s i g n m e n t w i l l b e s i m i l a r i n 1973-74, i t i s p r o p o s e d that the s e n i o r y e a r p h a r m a c y s t u d e n t s b e a s s i g n e d c o m p l e t e e v a l u a t i o n s ( a n d a n n u a l u p d a t i n g ) o f the r e m a i n i n g 88 m o n o g r a p h s not done i n 1972-73 a s w e l l a s the a n n u a l u p d a t i n g o f the 218 m o n o g r a p h s evaluated i n 1972-73. O n t h i s p r o p o s e d s c h e d u l e , the r e v i s i o n o f the e x i s t i n g monographs will r e a c h a maintenance 1973-74. l e v e l b y the e n d o f the a c a d e m i c term T h e r e a f t e r , the s t u d e n t a s s i g n m e n t w o u l d c o n s i s t o n l y o f a n n u a l u p d a t i n g o f the e x i s t i n g d r u g m o n o g r a p h s a n d p e r h a p s the c o m p l e t e e v a l u a t i o n of n e w m o n o g r a p h s . In 1 9 7 2 - 7 3 , the i n s t r u c t o r s r e v i e w e d , e d i t e d a n d c o n d e n s e d 100 o f the 218 e v a l u a t e d m o n o g r a p h s . It i s p r o p o s e d that i n 1973-74, the i n s t r u c t o r s 78 TABLE IX F U T U R E REVISION SCHEDULE for D r u g F o r m u l a r y Monographs Number of Revised Monographs Academic Terms Complete Evaluation 7 1972-73 218 1973-74 88 (306) Annual Updating 218 306 Instructor R e v i e w and Condense3 100 206 (306) Total 306 306 1. On a p r o p o s e d education and " s e r v i c e " b a s i s . 2. A s r e l a t e d to s t u d e n t a s s i g n m e n t i n 1972-73 a n d a s d e f i n e d o n p a g e 73 . 3. Instructor c o m m i t t m e n t on a " s e r v i c e " b a s i s 4. T h e t o t a l n u m b e r o f d r u g m o n o g r a p h s i n the p r e s e n t F o r m u l a r y . only. 79 complete the r e m a i n i n g 118 m o n o g r a p h s e v a l u a t e d i n 1972-73 a n d r e v i e w a n d c o n d e n s e the 88 m o n o g r a p h s e v a l u a t e d i n 1 9 7 3 - 7 4 . a s s i g n m e n t s , the " s e r v i c e " c o m m i t m e n t o f the i n s t r u c t o r s w o u l d r e a c h a m a i n t e n a n c e l e v e l b y the e n d o f the a c a d e m i c t e r m a d d i t i o n a l m o n o g r a p h s be a d d e d . instructors' commitment A s w i t h the s t u d e n t 1973-74 s h o u l d no H o w e v e r , i t i s p r o p o s e d that the t h e r e a f t e r s h o u l d b e to p r o d u c e n e w monographs as r e q u e s t e d i n the A d d i t i o n a l D r u g s S u r v e y ( s e e M e t h o d o l o g y , p a g e s 27 , 28 a n d A p p e n d i x II). Future Personnel Requirements T o c o n t i n u e the u p d a t i n g o f the F o r m u l a r y o n a " s e r v i c e " b a s i s f o r d i s t r i b u t i o n to the h o s p i t a l s o f B r i t i s h C o l u m b i a , m e n t s m u s t be quantitated. certain personnel require- T h i s p r o j e c t i o n i s b a s e d on a c o n t i n u e d student i n v o l v e m e n t a n d , t h e r e f o r e , no p r o f e s s i o n a l s t a f f r e q u i r e m e n t w i l l be a s s i g n e d to the p o r t i o n o f e v a l u a t i o n p r e s e n t l y u n d e r t a k e n b y the s t u d e n t s . H o w e v e r , " s e r v i c e " s t a f f w i l l b e n e e d e d to c o n t i n u e the i n s t r u c t o r s ' r e v i e w a n d c o n d e n s i n g o f the u p d a t e d m o n o g r a p h s a s w e l l a s the t y p i n g o f the s a m e . F r o m the T i m e E v a l u a t i o n s t u d i e s , i t w a s n o t e d that the i n s t r u c t o r s r e q u i r e d a n a v e r a g e o f f o u r h o u r s to r e v i e w a n d c o n d e n s e e a c h m o n o g r a p h (see T a b l e V I I I ) . T h e r e f o r e , i t m i g h t be e x p e c t e d that a p p r o x i m a t e l y 800 h o u r s w o u l d b e r e q u i r e d f o r the i n s t r u c t o r s to r e v i e w a n d c o n d e n s e the r e m a i n i n g 206 m o n o g r a p h s ( f o u r h o u r s t i m e s 206 m o n o g r a p h s ) . O n this b a s i s i t i s e x p e c t e d that a b o u t o n e to o n e a n d o n e - h a l f a d d i t i o n a l h o u r s p e r m o n o g r a p h w i l l b e n e c e s s a r y to r e v i e w the 218 m o n o g r a p h s w h i c h w i l l r e q u i r e 8G annual updating i n 1973-74. 300 h o u r s . T h e r e f o r e , to f u l f i l l the " s e r v i c e " c o m m i t t m e n t a s p r o j e c t e d , a total of a p p r o x i m a t e l y 1973-74. T h i s r e p r e s e n t s a p p r o x i m a t e l y an additional 1100 i n s t r u c t o r " s e r v i c e " h o u r s w i l l b e n e e d e d i n F o r t h i s r e a s o n , i t i s a n t i c i p a t e d that o n e - h a l f o f a p h a r m a c i s t ' s t i m e w i l l b e r e q u i r e d i n 1973-74 f o r t h i s c o m m i t t m e n t . R e c o g n i z i n g that t h e r e m i g h t be 206 a d d i t i o n a l m o n o g r a p h s prepared f o r t y p i n g i n 1973-74 ( s e e T a b l e I X ) , a n d that e a c h m o n o g r a p h took a p p r o x i m a t e l y 40 m i n u t e s to type d u r i n g 1972-73 ( s e e T a b l e VIII), i t i s p r o j e c t e d that about 140 h o u r s o f s t e n o g r a p h i c t i m e m i g h t be r e q u i r e d i n 1973-74. S i n c e this e x t r a p o l a t i o n does not a c c o u n t f o r c o r r e c t i o n s o f t y p o g r a p h i c a l e r r o r s , i t i s r e c o g n i z e d that t h i s t i m e e s t i m a t e i s a v e r y m i n i m u m . The r e s u l t s o f the a b o v e s t u d i e s i d e n t i f y that the m o n o g r a p h s o f the e x i s t i n g D r u g F o r m u l a r y r e q u i r e c o m p l e t e e v a l u a t i o n o f the p r e s e n t i n f o r m a t i o n as w e l l a s a n n u a l u p d a t i n g o f n e w i n f o r m a t i o n . Student, instructor a n d s t e n o g r a p h i c t i m e r e q u i r e d to e v a l u a t e a n d u p d a t e 100 m o n o g r a p h s d u r i n g the 1972-73 a c a d e m i c t e r m w e r e r e c o r d e d a n d a n a l y z e d . S u c h a n a l y s e s a r e u s e d to p r o j e c t a c o n t i n u e d e v a l u a t i o n a n d u p d a t i n g r e v i s i o n o f the r e m a i n i n g m o n o g r a p h s d u r i n g 1 9 7 3 - 7 4 . it i s e x p e c t e d that at l e a s t o n e - h a l f o f a p h a r m a c i s t ' s O n this b a s i s , t i m e w i l l h a v e to be m a d e a v a i l a b l e o t h e r than f o r a c a d e m i c i n s t r u c t i o n , a n d that a b o u t 140-150 h o u r s o f s t e n o g r a p h i c t i m e , s i m i l a r l y , w i l l b e r e q u i r e d to c o m p l e t e the 81 r e v i s i o n o f the r e m a i n i n g D r u g F o r m u l a r y m o n o g r a p h s It c a n b e e x p e c t e d that a n n u a l u p d a t i n g committment. thereafter, d u r i n g the n e x t y e a r . will require a similar 82 RECOMMENDATIONS If the p r e s e n t D r u g F o r m u l a r y d i s t r i b u t e d f o r u s e i n B r i t i s h C o l u m b i a h o s p i t a l s i s to r e t a i n i t s p r e s e n t v a l u e , a n d p e r h a p s r e a l i z e a g r e a t e r p o t e n t i a l , s e v e r a l changes i n f o r m a t and a r e g u l a r updating m e c h a n i s m s h o u l d be e f f e c t e d . 1. B a s e d o n the p r e s e n t s t u d y , t h e s e i n c l u d e : The addition of a p p r o x i m a t e l y another 300 d r u g m o n o g r a p h e n t r i e s to m a k e the F o r m u l a r y m o r e u s e f u l to a l l h o s p i t a l s ; 2. The addition of m o r e i n f o r m a t i o n under each m o n o g r a p h , s p e c i f i c a l l y i n the " M o d e o f A c t i o n " a n d " I n s t r u c t i o n s to the P a t i e n t " ; 3. 4. T h e e v a l u a t i o n a n d r e f e r e n c i n g o f the e x i s t i n g i n f o r m a t i o n a n d the a n n u a l u p d a t i n g o f the same; T h e adoption of a M a s t e r F o r m u l a r y containing all provincially used drugs, a complete biblio- graphy for each m o n o g r a p h and a c r o s s - i n d e x o f g e n e r i c to m a n u f a c t u r e r s ' b r a n d n a m e s ; 5. The adoption of a " M i n i " F o r m u l a r y d e r i v e d f r o m the M a s t e r a n d c o n t a i n i n g o n l y the m o n o g r a p h s for those drugs frequently u s e d i n the i n d i v i d u a l h o s p i t a l w a r d a r e a s ; 6. T h e a r r a n g e m e n t f o r a p r i n t i n g r a t h e r than t y p i n g p r o d u c t i o n o f the F o r m u l a r y ; 7. T h e p r o v i s i o n o f at l e a s t o n e - h a l f t i m e p h a r m a c i s t o n a " s e r v i c e " b a s i s to e d i t , r e v i s e and condense student d r u g l i t e r a t u r e e v a l u a t i o n p r o j e c t s to F o r m u l a r y 8. format; T h e p r o v i s i o n o f a m i n i m u m of 200 h o u r s p e r year stenographer time; 83 9. The arrangement for a Medical Review B o a r d to j u d g e the c l i n i c a l s i g n i f i c a n c e o f p r o p o s e d 10. new i n f o r m a t i o n to be added; The e s t a b l i s h m e n t of a c e n t r a l D r u g I n f o r m a - t i o n C e n t r e i n the p r o v i n c e to c o o r d i n a t e the a b o v e f u n c t i o n s a n d to s e r v e as a r e s o u r c e centre for additional information r e q u i r e d on a d a i l y b a s i s f o r the e f f e c t i v e u s e o f the Formulary. 84' BIBLIOGRAPHY 1. A n o n . , D r u g I n t e l l . C l i n . P h a r m . , 4, 109 (1970). 2. R e p o r t P r e p a r e d f o r the Study of ' I n t e r a g e n c y Coordination in Drug R e s e a r c h a n d R e g u l a t i o n s ' b y the S u b c o m m i t t e e o n R e o r g a n i z a t i o n I n t e r n a t i o n a l O r g a n i z a t i o n of the S e n a t e C o m m i t t e e on Operations. Appendix 3. Government U . S.. G o v e r n m e n t P r i n t i n g O f f i c e , A u g u s t 30, 1963. C. R e p o r t P r e p a r e d f o r the S t u d y o f ' I n t e r a g e n c y Coordination in Drug R e s e a r c h a n d R e g u l a t i o n s ' b y the S u b c o m i t t e e o n R e o r g a n i z a t i o n I n t e r n a t i o n a l O r g a n i z a t i o n of the S e n a t e C o m m i t t e e o n Operations. pp. 4. and U.S. and Government G o v e r n m e n t P r i n t i n g O f f i c e , A u g u s t 30, 1963. 1-3. R e p o r t P r e p a r e d f o r the S t u d y o f ' I n t e r a g e n c y Coordination in Drug R e s e a r c h a n d R e g u l a t i o n s ' b y the S u b c o m m i t t e e on R e o r g a n i z a t i o n I n t e r n a t i o n a l O r g a n i z a t i o n of the S e n a t e C o m m i t t e e o n 5. Government Operations, U . S.. G o v e r n m e n t P r i n t i n g O f f i c e , A u g u s t 30, A p p e n d i x A- 1. 1963. R e p o r t P r e p a r e d f o r the S t u d y o f ' I n t e r a g e n c y C o o r d i n a t i o n i n D r u g R e s e a r c h a n d R e g u l a t i o n s ' b y the S u b c o m m i t t e e o n R e o r g a n i z a t i o n a n d I n t e r n a t i o n a l O r g a n i z a t i o n of the S e n a t e C o m m i t t e e o n G o v e r n m e n t O p e r a t i o n s . U . S . G o v e r n m e n t P r i n t i n g O f f i c e , A u g u s t 30, 1963. pp. 6. 6-7. W e l t , I. D., e d . D r u g I n f o r m a t i o n II F o r the H e a l t h P r o f e s s i o n s , G o r d o n and B r e a c h , S c i e n t i f i c P u b l i s h e r s , N e w Y o r k , 1970, pp. 324-325. 7. P e a r s o n , R. E . , S a l t e r , F . J . , B o h l , J . C., T h u d i u m , V . F . , P h i l l i p s , G. L . , A m . J . H o s p . P h a r m . , 27, 911 (1970). 8. T a n e n b a u m , H., 9. Boyd, C.E., 10. , and D r u g I n f o r m a t i o n B u l l . , 4, p p . D r u g I n f o r m a t i o n B u l l . , Z, 112 1-12 and ( J a n / J u n e , 1970). ( J u l y / S e p t , 1968). S a d u s k , J . F . , J r . , D r u g I n f o r m a t i o n B u l l . , 3, p p . 66-72, ( J u l y / S e p t . , 1968). 11. K e e f e r , C.S., Am. J . H o s p . P h a r m . , 23, 55 (1966). 12. W a l t o n , C.A., Am. J . H o s p . P h a r m . , 22, 459 (1965). 85 13. W e s t o n , J . K., D r u g I n f o r m a t i o n B u l l . , 3, 121 ( J u l y / S e p t . , 1968). 14. W e l t , I.D., e d . D r u g I n f o r m a t i o n II f o r the H e a l t h P r o f e s s i o n s , and B r e a c h , S c i e n t i f i c P u b l i s h e r s , New Y o r k , 1970, p p . 3 0 1 - 3 0 3 . 15. Pellegrino, E., Am. 16. Editorial, Am. 17. W e l t , I.D., e d . D r u g I n f o r m a t i o n II f o r the H e a l t h P r o f e s s i o n s , J . H o s p . P h a r m . , 22, 40 (1965). J . H o s p . P h a r m . , 2 0 , 353 (1963). and B r e a c h , S c i e n t i f i c P u b l i s h e r s , New Y o r k , 18. American 1972, 19. 20. Gordon Gordon 1970, p . 4 8 . S o c i e t y o f H o s p i t a l P h a r m a c i s t s N e w s R e l e a s e #25, S e p t . 22, Washington, D. C. . T e s t e r , W.W., a n d O l e s o n , C . H . , H o s p i t a l s , 4 5 , (1971). W e l t , I.D., e d . D r u g I n f o r m a t i o n II f o r the H e a l t h P r o f e s s i o n s , and B r e a c h , S c i e n t i f i c P u b l i s h e r s , New Y o r k , 21. H e n l e y , S., T e s t e r , W. W., 22. T h o m p s o n , C O . , S c h w a r t a u , N.W., J. F., Am. Gordon 1970, p. 329-332. K n o p p , R., H o s p i t a l s , _42, 99 (1968). Trites, D.K., a n d L e c k w a r t , J . H o s p . P h a r m . , 2 7 , 276 (1970). 23. p o x , N . , T h e H o s p i t a l P h a r m a c i s t , 2 0 , 67-70 (1970). 24. D r u g Information S e r v i c e s : Two O p e r a t i o n a l M o d e l s , Department of H e a l t h , E d u c a t i o n a n d W e l f a r e P u b l i c a t i o n s # ( H S M ) 7 2 - 3 0 3 0 , 7(197). 25. Smythe, H. A., B o u g h e r , D . J . , and B a c h y n s k y , J . , T h e H o s p i t a l P h a r m a c i s t s , _21_, 267-276 (1968). 26. N a y l o r , M . J . V . , C a n . J . H o s p . P h a r m . , X X I V , 131 (1971). 27. F r a n k e n f e l d , F . M . B l a c k , H . J . , a n d D i c k , R.W., P h a r m . , 28, 155 (1971). 28. F l a c k , H. L . , Downs, G . E . , and Lanning, L . E . , A m . 24, A m . J . Hosp. J . Hosp. Pharm., 5 (1967). 29. B u r k h o l d e r , D., A m . J . H o s p . P h a r m . , 2 2 , 48 (1965). 30. R o s e n b e r g , J . M . H o s p . P h a r m . , 3, 5 (1968). 86- 31. L i g u o r i , Sister M., D r u g I n f o r m a t i o n S e r v i c e s , p r e s e n t e d at S t . M i c h a e l ' s H o s p i t a l , T o r o n t o , A u g u s t 20, 1968. ( u n p u b l i s h e d ) . 32. F r a n c k e , D.E., J L a t i o l a i s , C . S . , F r a n c k e , G . N . , H o , N . F . H., M i r r o r To Hospital Pharmacy, American Society of H o s p i t a l P h a r m a - c i s t s , W a s h i n g t o n , 1964, p p . 1 4 0 - 1 5 0 . 33. S t a t e m e n t o f G u i d e l i n e s f o r the U s e o f the H o s p i t a l F o r m u l a r y S y s t e m , C a n a d i a n S o c i e t y o f H o s p i t a l P h a r m a c i s t s , T o r o n t o , A u g u s t , 1968. 34. Anon., A m . 35. J . H o s p . P h a r m . , 21_, p p . 40-41 (1964). G u i d e to H o s p i t a l A c c r e d i t a t i o n , 1972, C a n a d i a n C o u n c i l o n H o s p i t a l A c c r e d i t a t i o n , T o r o n t o , 97. 36. S o n n e d e c k e r , G., D r u g I n t e l l . C l i n . P h a r m . , 6, p p . 425-432 (1972). 37. Hlynka, J.M., " T o D e v e l o p the F i r s t Stage o f a D r u g I n f o r m a t i o n Service for British Columbia", 38. A p p e n d i x I, J u l y 20, 1972. S m y t h e , H . A . , C a n . J . H o s p . P h a r m . , X X I V , p p . 169-171 ( S e p t . / O c t . 1971). 39. T o b e r , T.W., Am. J . H o s p . P h a r m . , _21, p p . 105-111 (1964). 40. L a m y , P . P . , B o u r n , I. F . a n d F l a c k , H . L . , A m . J . H o s p . P h a r m . , 18, p p . 641-649 (1961). 41. D a n i e l s o n , F . , H o s p . P h a r m . , 5, p p . 21-24 (1970). 42. Anon., Am. 43. F r a n c k e , D . E . , D r u g I n t e l l . C l i n . P h a r m . , j>, p p . 448-455 (1972). 44. M i l l e r , A . B . , D r u g I n f o r m a t i o n B u l l . , _5, 157 ( J u l y / D e c . 1970). 45. Hetherington, C , (1970). 46. H e l l e r , W.M., 47. Seim, H. C , J . H o s p . P h a r m . , 23, p p . 293-303 (1966). T h e J o u r n a l o f H o s p i t a l P h a r m a c y , 28, p p . 152-155 Am. J . H o s p . P h a r m . , _l€>, p p . 519-523 (1959). and Kabat, H. F . , A m . 4 8 . . B u r k h o l d e r , D., A m . 49. Anderson, (1965). R.D., J . H o s p . P h a r m . , _23, 241 (1966). J . H o s p . P h a r m . , 22, 50 (1965). and L a t i o l a i s , C . J . , A m . J . H o s p . P h a r m . , 22, 55 87-: 50. Parker, P.F., Am. J . H o s p . P h a r m . , _22, p p . 42-47 (1965). 51. V i s c o n t i , J . , D r u g I n f o r m a t i o n S e r v i c e s P o l i c y , O h i o State U n i v e r s i t y H o s p i t a l , D e p a r t m e n t o f P h a r m a c y , 14 (1962, r e v i s e d 1968). 52. Munro, F . J . , J r . , Am. 53. R o s e n b e r g , J.M., 270 (1971). 54. J . H o s p . P h a r m . , 24, 574 and P e r i t o r e , S.P., Am. P e a r s o n , R. E . , S a l t e r , F . J . , B o h l , J . C., P h i l l i p s , G. L . , A m . 55. - A m e r s o n , A . B . , (1971). B a u m g a r t e r , R.P., 57. P e a r s o n , R. E . , S a l t e r , F . J . , B o h l , J . C . , 58. 59. Am.. Am. 56. P h i l l i p s , G.L., J . Hosp. Pharm., Thudium, V.F., J . H o s p . P h a r m . , 29, 229 and W a l t o n , C.A., Am. (1967). 28, and (1972). J . H o s p . P h a r m . , 28, J . H o s p . P h a r m . , 28, 670 (1971). Thudium, V. F . , J . H o s p . P h a r m . , _29, 312 267 and (1972). P e a r s o n , R. E . , P h i l l i p s , G . L . , a n d T h u d i u m , V . F . , " P r o j e c t to D e v e l o p , E v a l u a t e and D e m o n s t r a t e a P i l o t D r u g I n f o r m a t i o n and D r u g T h e r a p y A n a l y s i s a n d R e p o r t i n g S y s t e m " . A p r o j e c t o f the U n i v e r s i t y of M i c h i g a n C o l l e g e o f P h a r m a c y , p p . 8-12 (1971). P e a r s o n , R. E . , P h i l l i p s , G . L . , a n d T h u d i u m , V . F . , " P r o j e c t to D e v e l o p , E v a l u a t e and D e m o n s t r a t e a P i l o t D r u g I n f o r m a t i o n and T h e r a p y A n a l y s i s and R e p o r t i n g S y s t e m " . Drug A p r o j e c t o f the U n i v e r s i t y of M i c h i g a n C o l l e g e o f P h a r m a c y , 17 (1971).60. C o u p e r , I. A . , The 61. Anon., The 62. D u r o n t , W.J., 63. Reilly, 64. W i t t r u p , R.D., 65. R a p p o r t , H., 66. B u r k h o l d e r , D., 67. Wilson, C O . , J o u r n a l o f H o s p i t a l P h a r m a c y , 30, 125 P h a r m a c e u t i c a l J o u r n a l , 209, M.J., The 159 (1972). (1972). Hospital Pharmacist, XXI, 213 ( S e p t . / O c t . 1968). D r u g I n f o r m a t i o n B u l l . , _5, 154 ( J u l y / D e c . , 1970). Am. J . H o s p . P h a r m . , 22, 59 ( 1 9 6 5 ) . H o s p . P h a r m . , 4, 17 (1969). D r u g I n t e l l . , 1, 321 and J o n e s , T . E . , J . B. Lippincott Co., ed. Philadelphia, (1967). American 174. D r u g Index 1967, .88 68. R o t e n b e r g , G . N., D r u g I n f o r m a t i o n B u l l . , _5, 181 69. W e l t , I.D., e d . D r u g I n f o r m a t i o n II F o r the H e a l t h P r o f e s s i o n s , G o r d o n a n d B r e a c h , S c i e n t i f i c P u b l i s h e r s , N e w Y o r k , 1970, p p . 336-341. 70. R o t e n b e r g , G.N., and H u g h e s , F . N . , c a l s a n d S p e c i a l t i e s 7th e d i t i o n , T h e tion, Toronto, ( J u l y / D e c . 1970). ed. C o m p e n d i u m of Pharmaceuti- Canadian Pharmaceutical A s s o c i a - 1972. 71. Zacharis, E., Personal Communication. 72. d u P l e s s i s , D., Personal Communication. 89 APPENDIX I COST O F T H R E E MAJOR DRUG INFORMATION SERVICES 1. d e H a e n S e r v i c e s , P a u l d e H a e n I n c . , 11 W e s t 4 2 n d S t r e e t , N e w Y o r k , N . Y., 2. 10036. A. "Drugs in U s e and Combination" $700.00/year B. "Drugs in R e s e a r c h " $150.00/year C. " D r u g s i n U s e P r o d u c t P r o f i l e Index" $100.00/year D. "Drugs in Prospect" $450.00/year International P h a r m a c e u t i c a l A b s t r a c t s , A m e r i c a n Society of H o s p i t a l P h a r m a c i s t s , 4630 M o n t g o m e r y A v e . , Washington, D.C., 20014. $150.00/year 3. Iowa D r u g I n f o r m a t i o n S e r v i c e s , C o l l e g e o f P h a r m a c y , Iowa State U n i v e r s i t y , Iowa C i t y , I o w a . * A. C u r r e n t S u b s c r i p t i o n Y e a r (1973) B. R e t r o s p e c t i v e F i l e (1966-1972) $900. 0 0 / y e a r * $1500.00* S u b s c r i p t i o n C h a r g e s , Iowa D r u g I n f o r m a t i o n S e r v i c e s , C o l l e g e o f Pharmacy, I o w a State U n i v e r s i t y , Iowa C i t y , I o w a , F e b r u a r y , 1 9 7 3 . APPENDIX II LISTS O F DRUGS RECEIVING TWO OR M O R E REQUESTS FOR INCLUSION IN T H E DRUG F O R M U L A R Y Drugs receiving 5 requests Ethacrynic acid Ethchlorvinyl Perphenazine Protriptyline Vinblastine Drugs receiving 4 requests Clofibrate Cycloserine Cycrimine Cytosine Arabinoside Dehydrocholic acid Dienestrol Dihydroergotamine Echothiophate Iodide Erythrityl Tetranitrate Ethambutal Ethanolamine Oleate Fluocinolone Fluphemazine Hydroxychloroquine Iron-Sorbitol Complex Meclizine Methallenestril Methsuximide Methyltestosterone Nitrofurazone Nortriptyline Orciprenaline Orphenadrine Hydrochloride Oxacillin Oxazepam A P P E N D I X II ( C o n t i n u e d ) Drugs receiving 4 requests (Continued) Oxytetracycline Phenelzine Pseudoephedrine Hydrochloride T e r p i n Hydrate Triethylenethio Phosphoramide (Thio-tep Trimethadione Vancomycin Drugs receiving 3 requests Acenocoumarol Alphaprodine Hydrochloride A l u m i n u m Acetate Ambenonium Chloride Ammoniated Mercury Bendroflumethiazide B l o o d and B l o o d C o m p o n e n t s Butabarbital Sodium Carbinoxamine Carisoprodol Chlorcyclizine C hlo r m e z a n o n e Chlorphenoxamine Maleate Chlorprothixene Chlorthalidone C h l o r o t r i a n i s ene Clindamycin Cyclahdelate Cyclizine Hydrochloride Cyclopentolate Dactinomycin Dapsone Dextrose Dextrothyroxine Dichlorphenir amine Dicloxacillin Dicyclomine Dimethylpolysiloxane Dioxyline Phosphate Doxycycline Estradiol Valerate Ethamival. A P P E N D I X II ( C o n t i n u e d ) Drugs receiving 3 requests (Continued) Ethinyl Estradiol Ethisterone Fludrocortisone Gitalin Glycerin Enema Hydroxyprogesterone Caproate Indomethacin Influenza V a c c i n e (Polyvalent) Inositol Niacinate Isopropamide I s o p r o t e r e n o l Sulphate L i o thyronine Methdilazine Hydrochloride Methocarbamol Methylprednisolone Methysergide Bimalate Metapryone Nandrolone Phenpropionate Nicotinamide Novobiacin Oxymetholone Paramethadione Phenmetrazine Prednisolone Procarbazine Pyrimethamine Quinacrine Quinidine Phenylethyl Barbaturic A c i d Saccharin Sodium S o d i u m T e t r a d e c t y l Sulphate Stanozolol Succinylsulfathiazide Sulfamethiazole Sulfinpyrazone Tetanus Antitoxin T h i o m e r sol T riamcinolone T r ifluopromazine T r i m e p r amine Trimethobenzamine T r i m i p r amine T r i p l e Sulfa C r e a m (equivalent) Trolnitrate Phosphate Witch Hazel A P P E N D I X II (Continued) Drugs receiving 2 requests Acetic Acid Acetohexamide Acnomel Alcaroid Pulvules Alkavervir Allylbarbaturic Acid Alophen Alphosyl Lotion Amaranth Aminopryine Amphetamine Sulphate Antivert Atasorb Azapetine Phosphate Azuresin (Diagnex Blue) Belladonna Leaf Benzoate Benzononate Benzyl Peroxide Betahistine Biperiden Bismuth Formic Acid Compound Bismuth Sodium Triglucollamate Blephamide Brucellergan Butaserpine Butobarbitone Calcium Bromodolactobionate Calcium Undecylenate Carcholin Cassia Oil Chlorophylline Chlorophenesin Chlor quinaldol Chorionic Gonadotropin Citri-cerose Climacterone Clindinium Bromide Coccidioidan Collodion Cophylac Drops Creta Pulvules Cremosuximide Cyclamate A P P E N D I X II ( C o n t i n u e d ) Drugs receiving 2 requests (Continued) Cyclobarbitone Cyclomethylcaine Cyclopentamine Dextromethorphan Diasol Diatroate Sodium Dihexylverine Hydrochloride Dihydrotachysterol Dill Oil Diperidolate Diperidon Dipianone Dimethisoquin D i m e thy Is t e r one Disodium Hydrogen Citrate Doxylamine Dromoran Duo-C V P Entoral Eosine Estradiol Lipropionate Etrafedrine Ethopropazine Ethylenediamine Ethylene Glycol Tetra-acetate Etrafon Eucalyptus O i l Euflavine Evans Blue Fat Emulsion Festol Fibrinogen Flucinonide Fluoescite Fiurandrenolone Folinic Acid Framycetin Sulphate Furazalidone G a l l and O p i u m Ointment Glauber Salts Glycothmoline G o l d Salts A P P E N D I X II ( C o n t i n u e d ) D r u g s r e c e i v i n g 2 r e q u e s t s (Continued) Hemocebrin Heptobarbital Hetacillin Histamine Azoprotein Histoplasmin Hydromorphone Hygroton-Reserpine Ichthyl Immune Serum Globulin Imuvac Iodoform Compounds Iopanoic A c i d Iophendylate Isoflurophate Isometheptene Itramine Tosylate Ketamine Lactated Pepsin Elixir Lactostat (Testosterone Estradiol) Lanatoside C Levopromazine Magenta Magnesium Mefenamic Trisilicate Acid Menadione Mepenzolate Mephenytoil Mephobarbital Mepivacaine Mercuric Mercury Oxide Bichloride Ointment Metaxalone Methacholine Methanthe line Methycellulos e Metimyd Myocrysine Nandrolone Decanoate Neomedrol Nifuroxime Norethandrolone Norisodrine O i l of Cajaput Oral Proteolytics A P P E N D I X II ( C o n t i n u e d ) D r u g s r e c e i v i n g 2 requests (Continued) O x a l i c and M a l o r i c Acid Para-amino Benzoic Acid Papain Pulvules Penicillamine Penthienate Methobrorriide Pentylenetetrazole Pericyazine P e r t u s s i s Immune Globulin Phenaglycodol Phenol Phenoxymethylpenicillin Pimacrin Compound Piperoxan Podophyllin Potassium Bromide P o t a s s i u m Phosphate Proflavine Progfesterone Proguanil Protamide Protein Hydrolysate Pyrimethamine Pyrithen Pyrrobutamine Compound Quandrinal Quinidine Compound Raudixin R a u t r a c t y l #2 #4 Resorcinol Monoacetate Resteclin Restropin Restropinal Rimactane Roniacol Salbutamol Salicylamide Ser-Ap-Es Silver Nitrate Sodium Citrate Sodium Iodide S o d i u m F r e e Salt Sulfa suxidine Sodium Oxychlorosene APPENDIX II ( C o n t i n u e d ) Drugs receiving 2 requests Sodium Para-amino Staphlococcus (Continued) Hippurate Antitoxin Stilboestrol Diphosphate Sodium Sulfamerazine Surfacaine Testolactone T etrahydr azoline Theobromine Calcium Salicylate Theophylline T hyroglobulin Thyrotropin Trichloroacetic Acid T r ifluoper azine T r i p r o l i d i n e and Compounds Troxidone Trypsin Tuberculin PPD T y p h o i d , P a r a t y p h o i d and Tetanus Tyrothricin Urethan Vagisec V a l e r i a n Root V i t a m i n A and D Ointment Viomycin White P i n e Syrup Xanthinol Niacinate Zeobarb Zincafrin Zylene 98 A P P E N D I X III S T U D E N T M O N O G R A P H U P D A T I N G A S S I G N M E N T - 1972-73 D r u g and P o i s o n I n f o r m a t i o n Centre Monograph Assignment Pharmacy 403 1. E a c h s t u d e n t w i l l be a s s i g n e d to p r e p a r e t h r e e d r u g m o n o g r a p h s a n d poison monograph. one 2. T h e c o m p l e t e d m o n o g r a p h s w i l l be t y p e w r i t t e n ( d o u b l e - s p a c e d r e f e r e n c e s ) on 8-1/2" x 11" w h i t e b o n d p a p e r . 3. E a c h p a g e o f the m o n o g r a p h s h a l l h a v e the n a m e o f the d r u g o r p o i s o n a n d the n a m e o f the s t u d e n t . 4. DRUG - including MONOGRAPHS (a) U p d a t e the L i o n ' s G a t e H o s p i t a l F o r m u l a r y m o n o g r a p h u s i n g the m o s t r e c e n t m o n o g r a p h o f the A m e r i c a n H o s p i t a l F o r m u l a r y S e r v i c e . R e f e r e n c e a l l changes or additions. (b) S e a r c h Index M e d i c u s f o r a l l new i n f o r m a t i o n on the p a r t i c u l a r d r u g o r p o i s o n w h i c h h a s b e e n p u b l i s h e d d u r i n g the p r e v i o u s 12 m o n t h s . R e f e r e n c e a l l new i n f o r m a t i o n w i t h o r i g i n a l r e f e r e n c e s o u r c e s . R e s t r i c t the s e a r c h to p e r t i n e n t c l i n i c a l d a t a (do N O T include animal data) - d e H a e n i n f o r m a t i o n c a r d s m a y be u s e d but not q u o t e d as reference source. (c) The f o l l o w i n g s e c t i o n s m u s t be c o m p l e t e l y r e f e r e n c e d with o r i g i n a l reference sources: S e c t i o n IX: Drug Interactions Section I.V. X: Incompatibilities O n l y c l i n i c a l l y s i g n i f i c a n t d r u g i n t e r a c t i o n s s h o u l d be i n c l u d e d i n the m o n o g r a p h . ( " D r u g I n t e r a c t i o n s " b y H a n s t e n c a t e g o r i z e s the c l i n i c a l s i g n i f i c a n c e o f the v a r i o u s d r u g i n t e r a c t i o n s q u i t e w e l l ) . " H a z a r d s of M e d i c a t i o n " by M a r t i n and "Drug Interactions" by H a n s t e n a r e t e r t i a r y r e f e r e n c e s o u r c e s a n d the s t u d e n t m u s t r e v i e w o r i g i n a l a r t i c l e a n d u s e the o r i g i n a l a r t i c l e as the r e f e r e n c e (d) the source. S e c t i o n XI: N u r s i n g I m p l i c a t i o n s . E v e r y s t a t e m e n t s h o u l d be r e f e r e n c e d . The A m e r i c a n Hospital F o r m u l a r y S e r v i c e and/or r e f e r e n c e s used i n p r e p a r i n g S e c t i o n s I - X m a y be r e p e a t e d . (e) S e c t i o n XII: I n s t r u c t i o n s to P a t i e n t E v e r y s t a t e m e n t s h o u l d be referenced. A u s e f u l r e f e r e n c e i s " D r u g s and N u r s i n g I m p l i c a t i o n s 1 1 by and H a y e s . The reference sources may Govoni be e i t h e r p r i m a r y ( o r i g i n a l a r t i c l e s ) or t e r t i a r y (textbooks and f o r m u l a r i e s ) . (f) 6. S e c t i o n XIII: Presentation A. Dosage F o r m s Available - "CPS" is recommended reference. B. Identi-Code C. C o s t - the c o s t to the c o m m u n i t y p h a r m a c i s t f o r 100 t a b l e t s o r c a p s u l e s i s o b t a i n e d f r o m the D r u g B e n e f i t L i s t i n the Student H e a l t h S e r v i c e P h a r m a c y , C u n n i n g h a m B u i l d i n g , U.B.C. Number - if applicable. General (a) The m e t r i c a n d c e n t i g r a d e s c a l e s s h o u l d be (b) The f o l l o w i n g f o r m a t s h o u l d be u s e d f o r the b i b l i o g r a p h y : JOURNAL: B i l l i g , N., used. Propoxyphene Hydrochloride (Darvon) Poisoning in a T h r e e Y e a r Old Child, A m e r . J . P i s . Child. 189 116: 187- (August). T E X T B O O K : Goodman, L.S. a n d G i l m a n , A., The T h e r a p e u t i c s , 4th e d i t i o n , M a c M i l l a n Pharmacological C o . : New York, Basis 1970. 10*0 T h e a b b r e v i a t i o n s o f j o u r n a l n a m e s s h o u l d c o n f o r m to that o f I n d e x M e d i c u s . In r e v i e w i n g c l i n i c a l c a s e r e p o r t s , the s t u d y s h o u l d h a v e a r a n d o m ized double-blind t r i a l with a s a m p l e s i z e of a p p r o x i m a t e l y Z 0 p a t i e n t s b e f o r e the r e s u l t s c a n be c o n s i d e r e d One exception statistically significant. i s a d v e r s e d r u g r e a c t i o n s i n w h i c h c a s e , the s i z e c a n be r e d u c e d to o n l y one sample patient. In c l i n i c a l c a s e r e p o r t s , i t i s i m p o r t a n t to c o n s i d e r p e r t i n e n t p a t i e n t factors: i) ii) kidney function l i v e r function iii) age, iv) other coinciding v) vi) weight, diseases placebo effect spontaneous r e m i s s i o n i.e., vii) sex of the d i s e a s e ( i f a p p l i c a b l e ) rheumatoid arthritis s e a s o n a l v a r i a t i o n of the d i s e a s e i . e . , hay f e v e r (if applicable) 101 P H A R M A C Y 403 DRUG AND POISON INFORMATION F o r m a t for D R U G 1. II. General CENTRE (DPIC) MONOGRAPH Information: A. Heading: A H F S Pharmacologic - Therapeutic B. Non-propriatory C. Trade name or synonyms. Classification Number. name. Action : A. Absorption - includes absorption by usual routes of a d m i n i s t r a t i o n b u t s h o u l d not be c o n f i n e d o n l y to r o u t e s u s e d f o r c o m m e r c i a l l y a v a i l a b l e p r e p a r a t i o n s ; onset; duration of action; peak blood levels following various routes; factors affecting absorption. B. D i s t r i b u t i o n - usual distribution in body t i s s u e s and fluids; indicate protein binding, penetration of blood-brain b a r r i e r , across placental b a r r i e r . transfer C. M e t a b o l i s m - half-life and factors affecting; sites of b i o t r a n s f o r mation; metabolic products and their activity. D. E x c r e t i o n - r o u t e ( s ) o f e l i m i n a t i o n f r o m the b o d y ; f a c t o r s a f f e c t i n g elimination; form in which eliminated. III. S p e c t r u m of A c t i v i t y : ( i f a p p l i c a b l e ; e.g., b a c t e r i a l , fungal, etc.). IV. Indications: Statement of indications and use (Indicate p r o p h y l a c t i c , t h e r a p e u t i c , p a l l i a t i v e , c u r a t i v e , s u p p o r t i v e u s e , e t c . ). V. VI. C o n t r a i n d i c a t i o n s : (include p r e g n a n c y if i n f o r m a t i o n known). Cautions: e.g. u s e i n patients with c e r t a i n d i s e a s e s o r under conditions. certain 102 VII. Dosage: A. Include m i n i m u m , m a x i m u m and m a i n t e n a n c e d o s a g e . B. State r o u t e s of a d m i n i s t r a t i o n a n d C. . G i v e adult and VIII. IX. X. XI. dose schedule. children's dosage. . Side E f f e c t s A. Include incidence (if a v a i l a b l e ) . B. Group according C. R e p o r t changes i n r e n a l or hepatic changes - function, blood dyscrasins, etc. Drug Interactions: to b o d y s y s t e m ( e . g . , G . (include OTC's) A. Drug - drug. B. Drug - food. C. Drug - lab. test. I.V. 1.). I n c o m p a t i b i l i t i e s : (if a p p l i c a b l e ) Nursing Implications: (not a l l c a t e g o r i e s w i l l be a p p l i c a b l e ) . A. Observation for a d v e r s e r e a c t i o n s , hypersensitivity reactions, toxicity. B. M o n i t o r i n g of v i t a l s i g n s , c a r d i a c C. L a b . tests for r e n a l , and/or hepatic function, blood counts, blood chemistry, etc. D. O b s e r v a t i o n f o r p h y s i c a l c h a n g e s i n d r u g - e.g., E. M e t h o d , route, t i m e of a d m i n i s t r a t i o n . F. Storage. status. discolouration. 103 XII. XIII. XIV. XV. I n s t r u c t i o n s to P a t i e n t : A. C o r r e c t m e t h o d s of a d m i n i s t r a t i o n . B. D r u g - f o o d and C. "Selected" D. Contraindications for continued E. Specific storage instructions. drug-drug (including OTC) side e f f e c t s . Presentation: A. Dosage forms available. B. Identi-code n u m b e r . C. Cost. References: Date P r e p a r e d : use. interactions,
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Development of a provincial drug formulary Page, Elizabeth Ann 1973
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Title | Development of a provincial drug formulary |
Creator |
Page, Elizabeth Ann |
Publisher | University of British Columbia |
Date Issued | 1973 |
Description | The adoption of the Lions Gate Hospital Drug Formulary by the British Columbia Hospital Association for distribution and use in all provincial hospitals endorses the growing trend toward regionalization of drug information. Several aspects of this Formulary were investigated in the present study with the objective of designing a text even more applicable to the varied needs of the province. The format of the Formulary and a mechanism for regularly evaluating and updating the information therein were the major areas receiving consideration. One major change in format proposed is the increase in the number of drug monographs to approximately 600 from the present 300 entries. This increase is based on the requests for additional drugs from the representative hospitals sampled in the province. Changes in the format of individual monographs include an expansion of information under the heading "Mode of Action", that an additional section on "Instructions to the Patient" be added to facilitate effective instructions for self-administration in ambulatory services, that each monograph receive a Canadian Drug Identification Code reference and that the information in each monograph be referenced where possible to the primary literature source. Changes in the format of the overall Formulary include a cross-index of monographs to manufacturers' brand names, a bibliography of the referenced information and a "Mini" Formulary format for use on individual hospital wards. The latter recommendation is made in recognition of the potential bulk of the overall Master Formulary which would make it awkward for efficient and frequent use. In this respect, it is anticipated that one Master Formulary containing all 600 eventual monographs, the bibliography for each and the various indices be made available in each hospital for resource reference. On each ward a complete Formulary of all drug monographs but not the accompanying bibliographies would be available. Studies showed that something less than 100 of these drugs (less than 20 percent) were used with any frequency on any specialty ward studied. Therefore, a "Mini" Formulary containing only the monographs of drugs frequently used in a specialty area would make the information more readily available in that service. Changes in printing format also are recommended with the objective of reducing the bulk of the proposed Formulary. A regular updating mechanism must be activated to keep the information in the Formulary current. Such a mechanism related to an annual literature evaluation assignment by the senior students of the Faculty of Pharmaceutical Sciences, University of British Columbia, is proposed. Based on this academic exercise, two types of updating are identified. First, a complete evaluation and referencing of the existing monograph information is required. Second, annual updating of this information from current literature should be maintained. To evaluate, revise and condense the students' evaluations to monograph format, a "service" component of faculty instructor time and of stenographer time have been projected. It is anticipated that the provision of approximately one-half time instructor per year and one-tenth time stenographer will be required on a "service" basis to enable the regular updating of the current Formulary as defined above. The arrangement for a Medical Review Board to review the evaluated monographs from a clinical validity standpoint also should be made. The above projections are based on studies related to the evaluation and updating of 100 drug monographs during 1972-73. A final recommendation is that the basis for generating, updating and additional referencing of the Drug Formulary should be a provincial Drug Information Centre. |
Subject |
Medicine -- Formulae, receipts, prescriptions Formularies |
Genre |
Thesis/Dissertation |
Type |
Text |
Language | eng |
Date Available | 2011-04-01 |
Provider | Vancouver : University of British Columbia Library |
Rights | For non-commercial purposes only, such as research, private study and education. Additional conditions apply, see Terms of Use https://open.library.ubc.ca/terms_of_use. |
IsShownAt | 10.14288/1.0101521 |
URI | http://hdl.handle.net/2429/33210 |
Degree |
Master of Science - MSc |
Program |
Pharmaceutical Sciences |
Affiliation |
Pharmaceutical Sciences, Faculty of |
Degree Grantor | University of British Columbia |
Campus |
UBCV |
Scholarly Level | Graduate |
AggregatedSourceRepository | DSpace |
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