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UBC Theses and Dissertations

Development of a provincial drug formulary Page, Elizabeth Ann 1973

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DEVELOPMENT OF A PROVINCIAL DRUG FORMULARY by ELIZABETH ANN PAGE Bv. Sc., (Pharm.), University of British Columbia, 1971 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in the Division of Clinical Pharmacy of the Faculty of Pharmaceutical Sciences We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September, 1973 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the requirements f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y purposes may be g r a n t e d by the Head o f my Department or by h i s r e p r e s e n t a t i v e s . I t i s understood t h a t c o p y i n g or p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department o f C l i n i c a l P h a r m a c y , 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 The U n i v e r s i t y o f B r i t i s h Columbia Vancouver 8 , Canada Date September 10, 1973 D E V E L O P M E N T 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 A B S T R A C T The adoption of the L i o n s Gate H o s p i t a l Drug F o r m u l a r y by 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 for d i s t r i b u t i o n and use in a l l p r o v i n c i a l hospitals endorses the growing t r e n d toward r e g i o n a l i z a t i o n of drug i n f o r m a t i o n . S e v e r a l aspects of this F o r m u l a r y were investigated in the p r e s e n t study with the objective of designing a text even m o r e applicable to the v a r i e d needs of the p r o v i n c e . The format of the F o r m u l a r y and a m e c h a n i s m for r e g u l a r l y evaluating and updating the i n f o r m a t i o n t h e r e i n were 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 major change i n format proposed i s the i n c r e a s e i n the number of drug monographs to a p p r oximately 600 f r o m the present 300 e n t r i e s . T h i s i n c r e a s e i s based on the requests for additional drugs f r o m the r e p r e s e n t a -tive hospitals sampled in the p r o v i n c e . Changes in the format of i n d i v i d u a l monographs include an expansion of i n f o r m a t i o n under the heading "Mode of A c t i o n " , that an additional section on "Instructions to the P a t i e n t " be added to f a c i l i t a t e effective i n s t r u c t i o n s for s e l f - a d m i n i s t r a t i o n i n ambulatory s e r v i c e s , that each monograph r e c e i v e a Canadian D r u g Identification Code r e f e r e n c e and that the i n f o r m a t i o n i n each monograph be r e f e r e n c e d where po 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 s o u r c e . i i Changes in the format of the o v e r a l l F o r m u l a r y include a c r o s s -index of monographs to m a n u f a c t u r e r s ' brand names, a bi b l i o g r a p h y of 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 format for use on ind i v i d u a l hospital w a r d s . The latter r ecommendation i s made in rec o g n i t i o n of the potential bulk of the o v e r a l l M a s t e r F o r m u l a r y which would make it awkward for efficient and frequent use. In this r e s p e c t , it is anticipated that one M a s t e r F o r m u l a r y containing a l l 600 eventual monographs, the b i b l i o g r a p h y for each and the va r i o u s indice s be made ava i l a b l e i n each hospital for r e s o u r c e r e f e r e n c e . On each ward a complete F o r m u l a r y of a l l drug mono-graphs but not the accompanying b i b l i o g r a p h i e s would be a v a i l a b l e . Studies showed that something l e s s than 100 of these drugs (less than 20 percent) were used with any frequency on any sp e c i a l t y ward studied. T h e r e f o r e , a " M i n i " F o r m u l a r y containing only the monographs of drugs frequently used in a s p e c i a l t y a r e a would make the i n f o r m a t i o n m o r e r e a d i l y available i n that s e r v i c e . Changes in p r i n t i n g format also are recommended with the objec-tive of red u c i n g the bulk of the proposed F o r m u l a r y . A r e g u l a r updating m e c h a n i s m must be activated to keep the i n f o r -mation i n the F o r m u l a r y c u r r e n t . Such a m e c h a n i s m r e l a t e d to an annual l i t e r a t u r e evaluation assignment by the senior students of the 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 , 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 , i s p r o p o s e d . B a s e d on this academic e x e r c i s e , two types of updating a r e i d e n t i f i e d . F i r s t , a complete evaluation and r e f e r e n c i n g of the ex i s t i n g monograph in f o r m a t i o n is r e q u i r e d . Second, annual updating of this i n f o r m a t i o n f r o m i i i c u r r e n t l i t e r a t u r e should be maintained. To evaluate, r e v i s e and condense the students' evaluations to monograph format, a " s e r v i c e " component of faculty i n s t r u c t o r time and of stenographer time have been p r o j e c t e d . It is anticipated that the p r o v i s i o n of approximately one-half time i n s t r u c t o r per year 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 enable the r e g u l a r updating of the c u r r e n t F o r m u l a r y as defined above. The arrangement for a M e d i c a l Review B o a r d to review the evaluated mono-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 made. The above proj e c t i o n s are based on studies r e l a t e d to the evaluation and updating of 100 drug monographs during 1972-73. A f i n a l recommendation is that the b a s i s for generating, updating and additional r e f e r e n c i n g of the D r u g F o r m u l a r y should be a p r o v i n c i a l D r u g Information C e n t r e . Signature of S u p e r v i s o r A C K N O W L E D G E M E N T S The author wishes to express her gratitude to D r . J.N . Hlynka and D r . D . L . Smith for their i n s t r u c t i o n and as s i s t a n c e throughout the pr e p a r a t i o n of this thesis and her Graduate Student T e a c h i n g A s s i g n m e n t . In addition, the co-operation of the p h a r m a c i s t s of the L i o n s Gate H o s p i t a l , 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 and the B r i t i s h C o l u m b i a p h a r m a c i s t s who p a r t i c i p a t e d in the s e v e r a l surveys conducted during this study is gr e a t l y a p p r e c i a t e d . The f i n a n c i a l a s s i s t a n c e of 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 -ship in P h a r m a c y and the 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 Graduate F e l l o w -ship and Summer R e s e a r c h S c h o l a r s h i p enabled the author to continue her studies and i s hereby acknowledged. V TABLE OF CONTENTS Page ABSTRACT . . i ACKNOWLEDGEMENTS . iv TABLE OF CONTENTS v LIST OF TABLES vii LIST OF FIGURES ix LIST OF APPENDICES x LITERATURE SURVEY 1 I. Need for Drug Information 1 II. Hospital Drug Formularies 5 III. Regional Drug Formularies 11 IV. Provincial Hospital Drug Formulary 18 V. Academic Role 20 STATEMENT OF OBJECTIVES 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 TABLE OF 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 . . 41 RESULTS AND DISCUSSION 42 I. Identifying the Provincial Needs 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 OF TABLES Table Page I DRUG FORMULARY UTILIZATION 44 II REASONS FOR NOT USING THE DRUG FORMULARY 45 III FREQUENCY OF THE USE OF PROVINCIAL FORMULARY DRUGS (483) IN PEDIATRIC WARDS OF VARIOUS HOSPITALS 61 IV FREQUENCY OF THE USE OF PROVINCIAL FORMULARY DRUGS (483) IN EMERGENCY WARDS OF VARIOUS HOSPITALS 62 V FREQUENCY OF THE USE OF PROVINCIAL FORMULARY DRUGS (483) IN EXTENDED CARE WARDS OF VARIOUS HOSPITALS 64 VI FREQUENCY OF THE USE OF PROVINCIAL FORMULARY DRUGS (483) IN PSYCHIATRIC WARDS OF VARIOUS HOSPITALS 65 VII MONOGRAPH CHANGES 73 viii LIST OF TABLES (Continued) Table Page VIII REVISION TIMES ' 7 5 IX FUTURE REVISION SCHEDULE 78 ix LIST OF FIGURES Figure Page 1 EXAMPLE OF THE FORMAT AND CONTENT OF THE DRUG MONOGRAPHS OF THE LIONS GATE HOSPITAL DRUG FORMULARY . 8 2 CHIEF PHARMACISTS QUESTIONNAIRE ..... 26 3 SAMPLE OF DRUG LISTS USED FOR MONOGRAPH UTILIZATION SURVEY 33 4 INSTRUCTIONS FOR MONOGRAPH UTILIZATION SURVEY 35 5 CHANGE SHEET EXAMPLE 39 6 SAMPLE MONOGRAPH OF ERYTHROMYCIN FROM THE EXISTING DRUG FORMULARY BEFORE REVISION 49 7 SAMPLE MONOGRAPH OF ERYTHROMYCIN INCLUDING BIBLIOGRAPHY AFTER REVISION 51 X LIST OF APPENDICES Appendix Page I COST OF THREE MAJOR DRUG INFORMATION SERVICES 8$ II LISTS OF DRUGS RECEIVING TWO OR MORE REQUESTS FOR INCLUSION IN THE DRUG FORMULARY 90 III STUDENT MONOGRAPH UPDATING ASSIGNMENT 1972-73 98 L I T E R A T U R E S U R V E Y I. Need F o r Drug Information " A c c u r a t e and unbiased i n f o r m a t i o n about drugs is e s s e n t i a l if good m e d i c i n e i s to be p r a c t i c e d . In these days when many new and potent drugs a r e being introduced such i n f o r m a t i o n must be r e a d i l y a v a i l a b l e and should include a l l facts r e levant to the use of the drug, including both e f f i c a c y and adverse r e a c t i o n s . " (1). (a) Volume of Drug L i t e r a t u r e The volume and d i v e r s i t y of drug l i t e r a t u r e and the pr o b l e m s of co m p i l i n g and di s t r i b u t i n g drug i n f o r m a t i o n have been widely e x p r e s s e d (2-15). 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 co m p i l e d i n 1963 contains over 900 e n t r i e s . In addition to p h a r m a c e u t i c a l pu b l i c a t i o n s , drug i n f o r m a t i o n is also found in 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 , biology, a g r i c u l t u r e and engineering (3). D r . A. F . Langlykke in 1958 estimated that 200, 000 o r i g i n a l papers were published y e a r l y i n r e g a r d to p h a r m a c y and drugs (4). D r . D. Bur k h o l d e r p r o j e c t e d i n 1967 that 33 percent of published b i o m e d i c a l l i t e r a t u r e dealt with drugs (6). Since B u r k h o l d e r was r e f e r r i n g to documented s o u r c e s of drug 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 , his estimate was probably c o n s i d e r a b l y l a r g e r than Langlykke's which dealt only with o r i g i n a l p a p e r s . 2 In addition to the l i t e r a t u r e r e g a r d i n g new drugs, new applications of drugs, dosages and therapeutic indications p r e v i o u s l y mentioned, a great deal of i n f o r m a t i o n has been accumulated r e g a r d i n g adverse drug rea c t i o n s by s e v e r a l organizations including the W o r l d Health O r g a n i z a t i o n (9, 10). In the f i r s t three y e a r s of operation, the Canadian D r u g A d v e r s e Reac 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 of suspected a d v e r s e r e a c t i o n s (9). Unfortunately, much of this valuable i n f o r m a t i o n is unpublished and the published p o r t i o n i s often not r e p r e s e n t a t i v e of the o v e r a l l p i c t u r e (13). F o r example, although the number of r e p o r t s of an adverse r e a c t i o n i s pub-l i s h e d , i t i s almost i m p o s s i b l e to determine the number of people exposed to the p a r t i c u l a r p r o b l e m . F o r this r e a s o n it i s d i f f i c u l t to obtain a c l e a r p i c t u r e of the importance of adverse drug r e a c t i o n s . The existence of a l i s t of pharmacy p e r i o d i c a l s containing over 900 e n t r i e s , the estimates of Langlykke and B u r k h o l d e r , and the amount of 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 adverse drug r e a c t i o n s are some indications of the volume of drug l i t e r a t u r e which must be ef f e c t i v e l y dealt with i n p r o v i d i n g ". . .accurate and unbiased i n f o r m a t i o n about drugs" (1). D r . C.S. Ke e f e r (11), i n r e c o g n i t i o n of the vast and d i v e r s e sources of drug i n f o r m a t i o n , e x p r e s s e d it well when he sai d " . . .there i s no dearth of i n f o r m a t i o n about dr u g s . " 3 (b) C o m p i l i n g D r u g L i t e r a t u r e It became apparent that any l i m i t a t i o n s i n drug i n f o r m a t i o n today are not due to a shortage of drug l i t e r a t u r e but rather to an inadequate o r g a n i z a t i o n and evaluation of the existing i n f o r m a t i o n (16). The need for better d i s s e m i n a t i o n of the existing l i t e r a t u r e has been r e c o g n i z e d by the development of v a r i o u s drug 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 s e r v i c e s . T h r e e of the m a j or drug i n f o r m a t i o n s e r v i c e s include: the deHaen s e r i e s "Drugs in Use", "Drugs in Combination" and "Drugs i n R e s e a r c h " ; the Iowa Drug Information S e r v i c e m i c r o f l i c h e s y s t e m and International P h a r m a c e u t i c a l A b s t r a c t s . Other s e r v i c e s l e s s s p e c i f i c a l l y i nvolved with p h a r m a c e u t i c a l s are: C h e m i c a l A b s t r a c t s , B i o l o g i c a l A b s t r a c t s , Index M e d i c u s and s p e c i a l i z e d index s e r v i c e s such as C a n c e r Chemotherapy A b s t r a c t s and M e n t a l Re t a r d a t i o n A b s t r a c t s . The 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 have the common feature of being a b s t r a c t i n g systems which ar e s i m i l a r in the s e r v i c e s o f f e r e d . The deHaen s y s t e m abst 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 in the health 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 meetings (17). The cards of the deHaen s e r v i c e contain significant 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 including the sample s i z e , duration of the study, dosage i n f o r m a -tion and the s t a t i s t i c a l study p e r f o r m e d as well as the r e s u l t s and com-ments of the author. International P h a r m a c e u t i c a l A b s t r a c t s , published by the 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 , is a semi-monthly b u l l e t i n containing a b s t r a c t s f r o m over 1000 p e r i o d i c a l s dealing with 4 p harmacy, medic i n e and r e l a t e d f i e l d s (18). The International P h a r m a -ce 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 title of the o r i g i n a l a r t i c l e and an i n f o r m a t i v e a b s t r a c t which is c a t e g o r i z e d under one or m o r e of the 25 sections which cover the p r a c t i c a l , t h e o r e t i c a l , economic and s c i e n t i f i c aspects of p h a r m a c y l i t e r a t u r e . In contrast 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 Information S e r v i c e presents the complete 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 , indexed by 64 two-digit " d e s c r i p t o r s " on accompanying f i l e c a r d s . The " d e s c r i p t o r s " are t e r m s used to define the contents, s t r u c t u r e and r e s u l t s of the study. The significant items of each paper are coded by the " d e s c r i p t o r s " before the a r t i c l e is m i c r o f i l m e d . T h i s p r o c e s s allows the u s e r to pinpoint his areas of i n t e r e s t f i r s t l y f r o m the index c a r d and secondly on the m i c r o -f i l m e d a r t i c l e (19). It also makes a v a i l a b l e the complete a r t i c l e for immediate evaluation by the u s e r . One drawback of this 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 or r e a d e r - p r i n t e r is r e q u i r e d to make use of the i n f o r -m a t i on. The advantage of systems such as those d e s c r i b e d above l i e s i n the fact that they cover a l a r g e number of i n f o r m a t i o n s o u r c e s , o r g a n i z i n g them into a usable format and making them av a i l a b l e to the u s e r s of drug i n f o r m a t i o n . One disadvantage is that they do not present evaluated i n f o r -mation (14) but rather present a l l i n f o r m a t i o n r e g a r d l e s s of the v a l i d i t y or s i g n i f i c a n c e . Another disadvantage of these systems is the cost (see Appendix I). The p r i c e , the storage a r e a needed and the equipment 5 n e c e s s a r y to make use of systems such as the Iowa D r u g Information S e r v i c e l i m i t the a b i l i t y of the in d i v i d u a l hospital to ac q u i r e and maintain them. As explained by Bu r k h o l d e r (14) and supported by others (12, 16, 20, 21) the p r o b l e m is to make available to m e m b e r s of the health 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 could be that the i n f o r m a t i o n also should be unbiased (1). II. H o s p i t a l D r u g F o r m u l a r i e s (a) D e f i n i t i o n The m a j o r approach taken by hospitals to overcome the p r o b l e m of not having the right drug i n f o r m a t i o n available at the right time is the development of hosp i t a l drug f o r m u l a r i e s i n conjunction with the P h a r m a c y and T h e r a p e u t i c s Committees of the ind i v i d u a l institutions (23-31). A f o r m u l a r y is defined by the 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 as: ". . .a continually r e v i s e d c o mpilation of ph a r m a c e u t i c a l s which r e f l e c t s the c u r r e n t c l i n i c a l judgment of the m e d i c a l staff" (34). " M i r r o r to Ho s p i t a l P h a r m a c y " indicates that about 60 percent of hospitals i n the United States operate under a f o r m u l a r y s y s t e m , defining a f o r m u l a r y s y s t e m as: 6 " . . . a method whereby the m e d i c a l staff of a h o s p i t a l , working through a p h a r macy and t h e r a p e u t i c s committee..., evaluates, a p p r a i s e s and s e l e c t s f r o m among the numerous m e d i c i n a l agents available those that are c o n s i d e r e d most useful i n patient c a r e , together with the p h a r m a c e u t i c a l preparations in which they may be a d m i n i s -tered most e f f e c t i v e l y . " (32). The usefulness of the f o r m u l a r y s y s t e m is acknowledged by both the Canadian Society of H o s p i t a l P h a r m a c i s t s and the 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 in publishing statements of guidelines for the use of 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 additional support of the f o r -m u l a r y s y s t e m , the Canadian 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 (35) r e q u i r e s p a r t i c i p a t i o n in the development of a h o s p i t a l f o r m u l a r y as part of the r e q u i r e m e n t s for p h a r m a c e u t i c a l s e r v i c e s of a hospital seeking a c c r e d i t a t i o n . The use of f o r m u l a r i e s is not a new concept. T h e y have been used in N o r t h A m e r i c a since the e a r l y nineteenth century (36). Some f o r m u l a -r i e s , for example the p r evious Vancouver 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), were l i s t s of drugs and dosage f o r m s available for use in the h o s p i t a l . Other f o r m u l a r i e s contained additional i n f o r m a t i o n on therapeutic i n d i c a -tions, side effects, and standard doses as in the f o r m u l a r y of the Ottawa C i v i c H o s p i t a l (25) and the f o r m u l a r y of the U n i v e r s i t y of 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 format i s that of 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 (see F i g u r e 1) which contains i n d i c a t i o n s , side effects and dosages as w e l l as additional 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 , drug i n t e r -7 F i g u r e 1. E x a m p l e of the format and content of the drug monographs of 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 . 8 G L U T E T H I M I D E D O R I D E N 28:24 A C T I O N A sedative-hypnotic 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 degree of hypotension than b a r b i t u r a t e s . Onset: 20 minutes. Duration: A p p r o x i m a t e l y 6 h o u r s . INDICATIONS Sedative, hypnotic. C O N T R A I N D I C A T I O N S None known. Use with caution when impending d e p r e s s i o n or s u i c i d a l tendencies e x i s t . D O S A G E A D U L T S : Daytime sedation: 125-250 mg. t . i . d . Insomnia: - . 5 gm. h. s., may be repeated not l e s s than 4 hours before a r i s i n g . In long t e r m use the total d a i l y dose should not exceed 1 gm. SIDE E F F E C T S Nausea, vomiting, a n o r e x i a , headache, d i z z i n e s s , 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 shock r e p r e s e n t the major p r o b l e m i n toxic doses. P s y c h i c and p h y s i c a l dependence with prolonged u se. D R U G I N T E R A C T I O N S Inhibits action of o r a l anticoagulants i n c r e a s i n g the r i s k of thrombus f o r m a t i o n during therapy and bleeding tendency on with-d r a w a l . CNS depressant effects of glutethimide are potentiated by n a r c o t i c s , a l c o h o l , phenothiazines ( L a r g a c t i l , S t elazine, Phenergan, et c . ) , M A O i n h i b i t o r s (Parnate, N a r d i l , e t c . ) , anaesthetics, and R e s e r p i n e . Glutethimide inhibits (by enzyme induction) a n a l g e s i c s , antihistamines ( B e n a d r y l , P e r a z i n e ) , phenylbutazone, diphenlyhydan-toin, g r i s e o f u l v i n ( 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. N U RSING I M P L I C A T I O N S P e r i o d i c blood counts and l i v e r function tests a r e a d v i s a b l e . With prolonged use, withdrawl f r o m drug should be gradual to m i n i m i z e withdrawal r e a c t i o n s . Give with food to reduce 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 . E x a g g e r a t e d potentia-tion by a l c o h o l . Does not produce sedation i n highly d i s t u r b e d patients or those i n pa 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. P R E S E N T A T I O N T a b l e t s : 500 mg. F I G U R E 1 9 actions and n u r s i n g i m p l i c a t i o n s . A s well as developments i n the format and content of f o r m u l a r i e s , advances have been made in the f i e l d of f o r m u l a r y p r o d u c t i o n . E l e c t r o n i c 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 Canada and the United States (25, 27, 28, 38, 39, 40, 41). The Iowa D r u g Information S e r v i c e used E.D.P. to produce a drug f o r m u l a r y f r o m their automated drug i n f o r m a t i o n f i l e (27). At the U n i v e r s i t y of P e n n s y l v a n i a H o s p i t a l (28) and the Ottawa 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 were p r o -duced f r o m decks of computer c a r d s on which the in f o r m a t i o n had been key-punched. At pres e n t , the Ottawa C i v i c H o s p i t a l has converted their p roduction of the f o r m u l a r y to automated photocomposition and magnetic tape for i n f o r m a t i o n storage (38). T h e s e operations have demonstrated that in the s e v e r a l ways of applying E.D.P. to f o r m u l a r y p r i n t i n g (28), the cost of lo n g - t e r m production of the f o r m u l a r i e s by E.D.P. was l e s s than the cost of conventional p r i n t i n g methods (27, 38). E d i t i n g and updating of drug i n f o r m a t i o n contained i n the f o r m u l a r i e s also was faster and e a s i e r (25, 28, 38). (b) L i m i t a t i o n s F r o m the wide-spread use of drug f o r m u l a r i e s it appears that they have been 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 drug i n f o r m a t i o n to the health p r a c t i t i o n e r s at the point of use in their r e s p e c t i v e h o s p i t a l s . However, there a r e also some s p e c i f i c l i m i t a t i o n s i n their e f f e c t i v e n e s s . 10 It has been r e c o g n i z e d that a true f o r m u l a r y has to be more com-prehensive than m e r e l y a drug l i s t (27). It has been iden t i f i e d also that the cost of the drug i n f o r m a t i o n r e s o u r c e s (see Appendix I) r e q u i r e d to evaluate and compile i n f o r m a t i o n for a f o r m u l a r y l i m i t s the a b i l i t y of each ind i v i d u a l hospital to maintain the r e s o u r c e s to back-up their f o r m u l a r y with additional i n f o r m a t i o n when n e c e s s a r y . It should be noted that the s m a l l e r non-teaching ho s p i t a l i s perhaps ate.a greater disadvantage i n this r e g a r d since 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 is l i m i t e d (42). N e v e r t h e -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 much as, or m o r e than the large teaching institutes (31). A second obstacle to the effective production of in d i v i d u a l f o r m u -l a r i e s is the con s i d e r a b l e time and ex p e r t i s e r e q u i r e d to evaluate the l i t e r a t u r e and produce the drug monographs (43). The r e s p o n s i b i l i t y for producing the drug monographs r e s t s with the p h a r m a c i s t s who in their spare time evaluate the l i t e r a t u r e and produce the drug monographs (43). F r a n c k e r e c o g n i z e d these obstacles to the p r e p a r a t i o n of a drug f o r m u l a r y i n his own hospital (43). He also r e c o g n i z e d that the purchase of 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 , and the time and effort r e q u i r e d to produce the f o r m u l a r y were being duplicated many times by p h a r m a c i s t s e v e r y -where (43). F r a n c k e suggested that much of the duplication mentioned above could be e l i m i n a t e d i f the A m e r i c a n Society of Ho 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 s e r v i c e and make it available to the hospitals at a reasonable cost (43). T h i s perhaps was the f i r s t step 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. R e g i o n a l D r u g F o r m u l a r i e s (a) 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 Although the P h y s i c i a n s ' Desk R e f e r e n c e * (P.D.R.) had 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 i n f o r m a t i o n for many 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 -ture (44). Perhaps the f i r s t , and s t i l l most popular r e g i o n a l drug f o r m u -l a r y that p r o v i d e s accurate and unbiased i n f o r m a t i o n i s the A m e r i c a n Ho 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. ). The drug monographs of the A.H. F . S . are p r e p a r e d by the Committee on P h a r m a c y and P h a r m a c e u t i -cals of the 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 . The d i r e c t o r of the committee edits the monographs to ensure a constant format and they are r e v i e w e d by three subcommittees 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 and m a n u f a c t u r e r s for suggestions and comments. Supplements to the A.H. F . S . are published and 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 containing both new drug monographs and updated i n f o r m a t i o n on existing monographs. The monographs produced are 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 , evaluated and unbiased 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 , Inc., O r a d e l l , New J e r s e y , 1969. **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 , Committee 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 of the A m e r i c a n Society of Ho 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 , I l l i n o i s . 12 The Committee 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 r e c o g n i z e d two important uses for the A. H. F . S. : (1) A s a b a s i s for p r e p a r i n g i n d i v i d u a l hospital f o r m u l a r i e s ; (2) A s a c o m p a r a t i v e l y complete drug r e f e r e n c e useful to p r a c t i t i o n e r s and teachers in a l l the health p r o f e s s i o n s concerned with drugs (46). The f i r s t objective intended that each hospital P h a r m a c y and T h e r a p e u t i c s Committee would accept the r e s p o n s i b i l i t y to adapt the A. H. F . S. to the s p e c i f i c needs of the i n d i v i d u a l hospital (57). P r o m o t i n g this concept F r a n c k e suggested 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 on f i l e a l l additional drug monographs supplied by the A.H. F . S . as additional drug i n f o r m a t i o n . T h i s p r a c t i c e would enable the p h a r m a c i s t to provide i n f o r m a t i o n to the P h a r m a c y and T h e r a p e u t i c s Committee investigating a new f o r m u l a r y addition or to other staff m e m b e r s requesting a non-formu-l a r y drug. (b) H o s p i t a l Drug Information C e n t r e s The second p r o j e c t e d use of the A.H. F . S . became m o r e popular with the development of hospital drug i n f o r m a t i o n centres (24, 30, 31, 49, 50). T h e s e centres were i n i t i a t e d to provide a c c u r a t e , detailed and up-to-date i n f o r m a t i o n on drugs to a l l m e m b e r s of the patient c a r e staff of the hospitals (31) and ". . .to support, a s s i s t and promote a r a t i o n a l drug therapy p r o g r a m " (24). Although other f o r m u l a r i e s such as the A.H. F . S . (51, 52) adequately p r o v i d e d evaluated, accurate and unbiased i n f o r m a t i o n 13 (46), it was d i f f i c u l t for these s e r v i c e s to provide up-to-date 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 time lag between the o r i g i n a l p u b l i c a -tion of the l i t e r a t u r e and the production of the r e s p e c t i v e supplements. An active drug i n f o r m a t i o n centre on the other hand with 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 those l i s t e d by B u r k h o l d e r (6), better enabled the p h a r m a c i s t to provide up-to-date i n f o r m a t i o n , to answer questions that were beyond the scope of the f o r m u l a r y and to provide i n f o r m a t i o n on n o n - f o r m u l a r y drugs (27, 29, 30, 31, 42, 48, 49, 50). A g a i n , as with the production of ho 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 community hosp i t a l with 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 and staff i s at a disadvantage i n operating a drug i n f o r m a t i o n centre (42, 53). In o r d e r to o v ercome duplication and inadequate efforts by s m a l l hospitals in this r e s p e c t , it was r e c o g n i z e d that such needs for drug i n f o r -mation might better be s e r v e d by developing one large drug i n f o r m a t i o n centre at a u n i v e r s i t y - a f f i l i a t e d hospital to serve a s p e c i f i c r e g i on of s m a l l e r institutions (42). (c) Regional D r u g Information C e n t r e s The development of Regional D r u g Information C e n t r e s , like the production of 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 in a c e n t r a l i z e d s e r v i c e supporting 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, 34, 55, 56) and, consequently, the e l i m i n a t i o n of some of the duplication of c o s t s , f a c i l i t i e s , and staff. T h e r e have been two m a j o r trends in the 1 4 development of Regional D r u g Information Centres based on d e c e n t r a l i z e d and c e n t r a l i z e d approaches. These may be e x e m p l i f i e d by the M i c h i g a n Regional D r u g Information Network and the Kentucky Reg i o n a l D r u g I n f o r -mation Centre r e s p e c t i v e l y . The M i c h i g a n R e g i o n a l D r u g Information Network with its m a i n centre at the U n i v e r s i t y of M i c h i g a n supplies drug i n f o r m a t i o n to nine a f f i l i a t e d hospitals throughout the state. V a r i o u s sources of drug i n f o r -mation including 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 deHaen sy s t e m s , the F e d e r a l Drug 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 E x p e r i e n c e A b s t r a c t s , the F.D.A. Suspected A d v e r s e R e a c t i o n , International P h a r -m a c e u t i c a l A b s t r a c t s and s e v e r a l j o u r n a l s serve as r e s o u r c e s (57, 58). E a c h a f f i l i a t e d centre is r e s p o n s i b l e for answering drug i n f o r m a t i o n requests f r o m its own a r e a whenever p o s s i b l e (58). The m a i n 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 complex requests that cannot be answered adequately at the l o c a l centre (59) as well as answering requests f r o m the U n i v e r s i t y of M i c h i g a n M e d i c a l C e n t r e . T h i s s y s t e m has attempted to m a i n t a i n as much autonomy as p o s s i b l e at each a f f i l i a t e d centre within the f r amework of a r e g i o n a l s y s t e m and i s therefore an example of the d e c e n t r a l i z e d trend in Regional D r u g Information C e n t r e s . The s y s t e m in operation at the U n i v e r s i t y of Kentucky and, s i m i -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 System i s designed to provide m e d i c a l l i b r a r y and drug 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 single c e n t r a l i z e d source (55, 56). In the Kentucky Reg i o n a l D r u g Infor-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 source i s available to the health p r o f e s s i o n a l s i n the state by a t o l l - f r e e , d i r e c t - d i a l telephone line ( c alled a Wide A r e a Telephone S e r v i c e or WATS) for in c o m i n g c a l l s . When a r e t u r n c a l l is n e c e s s a r y the i n f o r m a t i o n is 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 using the existing telephone s y s t e m instead of the W ATS network for out-going c a l l s the Kentucky Re g i o n a l D r u g Information Centre has reduced the high cost of communication inherent i n a c e n t r a l i z e d s y s t e m (55, 68). In the A p p a l a c h i a n r e g i o n , communication between the m a i n centre and the r e g i o n a l hospitals i s maintained by a teletype network, n e w s l e t t e r s , and telephone conferences (56). The p o p u l a r i t y of the A.H. F . S . and D r u g Information C e n t r e s in gen e r a l , is r e f l e c t e d by the i n c r e a s i n g use and development of both of these concepts (24, 31, 38, 45, 51, 59, 60, 61, 62, 63, 64). Although the combination of the A.H. F . S . and a Drug Information Centre has r e s u l t e d in the D r u g Information Centre being l a b e l l e d as the " . . . guardian of the f o r m u l a r y " (48), the A.H. F . S . alone s t i l l has definite l i m i t a t i o n s for use in general and, m o r e s p e c i f i c a l l y , in Canada. (d) L i m i t a t i o n s of the A.H. F . S . Some of the general l i m i t a t i o n s of the A.H. F . S . which have been cited include: 1. The A.H. F . S . has expanded to include, (as of 1967) 1030 drug monographs and 2766 pages in a two-volume set (43). A s a r e s u l t of the s i z e , the A.H. F.S. i s a v e r y bulky and awkward book to use (47, 65). The 16 b u l k i n e s s alone can impede 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. Many products c o v e r e d i n the A. H. F . S. may not be used i n a s p e c i f i c h o s p i t a l . B u r k h o l d e r showed that the average number of drug monographs r e -q u i r e d by a hospital is about 400 (66) while the A.H. F . S . contains 1030 (43). T h i s i m p l i e s that a set of the A. H. F . S. in the average hospital i s about two and one-half times l a r g e r than n e c e s s a r y ; 3. The format of the A.H. F . S . is a t h i r d potential p r o b l e m . The format of paragraphs rather than point f o r m r e q u i r e s that the u s e r r e a d whole sentences to find the r e q u i r e d i n f o r m a t i o n . A l s o , the i n f o r m a t i o n does not seem to be divided into enough subsections. T h i s r e q u i r e s that the u s e r must r e f e r to the subsection on "pharmacology and a c t i o n " to find i n f o r m a t i o n on side e f f e c t s . 4. F i n a l l y , the drug monographs are not r e f e r e n c e d and to supply additional i n f o r m a t i o n on a s p e c i f i c point of i n t e r e s t becomes quite d i f f i c u l t without the starting point of the o r i g i n a l r e f e r e n c e . * In the United States, attempts to o v e rcome the bulkiness of the A. H. F . S. have taken 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 suggested by the p r o d u c e r s of the A. H. F . S. (46). However, this i s a v e r y time consuming task (46) and 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 on s m a l l pages to match the A.H. F . S . is s t i l l bulky (65). In addition to the above, there are at least two drawbacks to the use 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 in Canadian h o s p i t a l s : 1. The A. H. F . S. uses A m e r i c a n brand names which in many instances do not c o r r e s p o n d to the b r a n d names commonly in use in Canada. Some examples of this p r o b l e m ar e : c h l o r p r o m a z i n e which is T h o r a z i n e ^ i n R the United States and L a r g a c t i l i n Canada; c y c l o p h o s -phamide which is Cytoxan-"- i n the United States and R R P r o c y t o x in Canada; i s o n i a z i d which is D i n a c r i n in * P r e s e n t l y being undertaken. 17 the United States and R i m a f o n in Canada; and d i e t h y l -R • s t i l b o e s t r o l diphosphate which i s M i l e s t r o l i n the United States and Honvol in Canada (70.67). ' 2. A second p r o b l e m of the use of any A m e r i c a n drug r e f e r e n c e in a Canadian hospital is the p o s s i b i l i t y of different f o r m u l a t i o n s of products b e a r i n g the same brand name. T h i s p r o b l e m i s r e p r e s e n t e d by the different f o r m u l a t i o n s of a Canadian and an A m e r i c a n product which both have the b r a n d name Infantol. The Canadian product i s a di e t a r y supplement 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, niacinamide and p y r i d o x i n e (70) while the A m e r i c a n product i s 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 (67). T h i s is p o s s i b l y one of the most sign 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 . Although there i s no r e g i o n a l f o r m u l a r y in Canada comparable to the A. H.F.S., one publication which o v e r c o m e s some of the above l i m i t a -tions is the Compendium 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 * ( C.P.S. ). The C.P.S. is a compilation 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 products and is commonly used in Canadian h o s p i t a l s , c l i n i c s , community phar -m a c i e s and p h y s i c i a n s ' o f f i c e s (68). However, some of the c h a r a c t e r i s t i c s of the C.P.S. make it somewhat inadequate in a hospital setting: 1. The format 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 paragraphs r a t h e r than point f o r m ; 2. The i n f o r m a t i o n in the drug monographs is not divided into enough subsections to enable the u s e r s to r a p i d l y find the d e s i r e d information; 3. The monographs of the C.P.S. are a r r a n g e d al p h a b e t i c a l l y by both brand and generic names. As a r e s u l t of this p r a c t i c e , there may be * Compendium 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 , Rotenberg, G.N. and Hughes, F . N., ed. 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 , Toronto 1972. 18 s e v e r a l separate monographs for one gen e r i c name drug. A n example 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 under different b r a n d names and once as the generic name drug (70); 4. The C.P.S. does not contain any r e f e r e n c e s for the monographs so that it i s not po s s i b l e to evaluate the o r i g i n a l i n f o r m a t i o n source on a s p e c i f i c statement or point of in t e r e s t ; 5. The C.P.S. does not include s p e c i f i c s u b s e c -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 us e . The p o p u l a r i t y of use of the A.H. F . S . and the C.P.S. i n Canada endorse the need for a r e g u l a r l y produced f o r m u l a r y on c u r r e n t drug i n f o r m a t i o n . R e c o g n i z i n g the l i m i t a t i o n s of the above two s e r v i c e s , how-eve r , it would appear that a need s t i l l exists for a Canadian hospital f o r m u l a r y s e r v i c e . IV. P r o v i n c i a l H o s p i t a l D r u g F o r m u l a r y The development of c l i n i c a l p h a r m acy s e r v i c e s and the i n c r e a s e d involvement of the L i o n s Gate H o s p i t a l * pharmacy staff in drug i n f o r m a t i o n led to the r e c o g n i t i o n of the l i m i t a t i o n s of the A.H. F.S . and the C.P.S. in this hospital (71, 72). Between 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 Gate H o s p i t a l p r e p a r e d a drug f o r m u l a r y containing one or two typewritten pages of c l i n i c a l l y relevant i n f o r m a t i o n on about 300 drugs i n use at the hosp i t a l (37). Working f r o m many s o u r c e s of drug i n f o r m a t i o n , the authors were able to compile for their drug monographs i n f o r m a t i o n on * L i o n s Gate H o s p i t a l , N o r t h Vancouver, B r i t i s h C o l u m b i a . 19 p e d i a t r i c dosages, dosages in kidney and l i v e r f a i l u r e , intravenous i n c o m -p a t i b i l i t i e s , drug 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 which for the most part had been unavailable in the monographs 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 added to the b a s i c drug i n f o r m a t i o n commonly a v a i l -able on i n d i c a t i o n s , dosages, side effects and contraindications to produce the drug monographs of 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 (see F i g u r e 1). Although much of this i n f o r m a t i o n was available i n j o u r n a l s , textbooks and handbooks, the r e s u l t i n g f o r m u l a r y was unique i n c o m p i l i n g a l l of this i n f o r m a t i o n into one usable source of drug i n f o r m a t i o n for the health p r o f e s s i o n a l s in the hospital (71, 72). F o r the L i o n s Gate H o s p i t a l , the production of 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 * also o v e r c a m e the co n f l i c t between Canadian and A m e r i c a n b r a n d names that is inherent in u s i n g an A m e r i c a n r e f e r e n c e such as the A.H. F . S . in a Canadian h o s p i t a l . The authors also attempted to reduce the s e a r c h time for i n f o r m a t i o n by p r e p a r i n g their f o r m u l a r y i n point f o r m r a t h e r than paragraphs and by di v i d i n g the monographs into sub-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 ef f e c t s , intravenous i n c o m p a t i b i l i -t i e s , drug 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 . With these alt e r a t i o n s and additions to the format and content of the A.H. F.S. and the C.P.S., some of the l i m i t a t i o n s p r e v i o u s l y mentioned were o v e r c o m e . However, 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 s t i l l had one major drawback 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, N o r t h V a n c o u v e r , 1971. 20 its continuing use as a source of drug i n f o r m a t i o n . T h e r e was no estab-l i s h e d m e c h a n i s m for r e g u l a r l y updating the drug monographs. The previous work of updating the monographs and the production of new mono-graphs when n e c e s s a r y soon p r o v e d to be a monumental task (71). R e c o g n i z i n g the unique features of 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 to the p r o v i n c e as a whole, the B r i t i s h C o l u m b i a Hos p i t a l A s s o c i a t i o n (B. C H . A. ) adopted the text as a p r o v i n c i a l D r u g F o r m u l a r y and it was made ava i l a b l e to app r o x i m a t e l y 100 B r i t i s h C o l u m b i a hospitals (37). A l s o r e c o g n i z i n g that the monographs r e p r e s e n t e d only those drugs used at one hosp i t a l and that a r e g u l a r updating m e c h a n i s m was r e q u i r e d to main t a i n the potential of the new D r u g F o r m u l a r y , the B . C . H.A. supported a study at the 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 , 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 designing a m e c h a n i s m to o v e r c o m e these l i m i t a -tions . V. A c a d e m i c Role One of the m a j or assignments for senior p h a r m a c y students at the 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 , U n i v e r s i t y of B r i t i s h C o lumbia, r e q u i r e s an extensive l i t e r a t u r e evaluation of the s c i e n t i f i c and c l i n i c a l v a l i d i t y of 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 in f o r m a t i o n r e l a t i v e to about 100 drugs i s evaluated annually. Although these assignments were not extended to produce the r e s u l t s i n drug monograph format, it became apparent that much of the time and effort expended by students and 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 of r e s o u r c e updating r e q u i r e d to annually r e v i s 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 . It was further r e c o g n i z e d that to r e v i s e , condense, edit and compile the academic assignments into useful F o r m u l a r y monograph format, some " s e r v i c e " committment in t e rms of p h a r m a c i s t and stenographic personnel would be r e q u i r e d . The degree of this committment i n t e rms of " s e r v i c e " to annually update and r e v i s e the D r u g F o r m u l a r y is the objective of the present study. 22 S T A T E M E N T O F O B J E C T I V E S The d i s t r i b u t i o n of the D r u g F o r m u l a r y , o r i g i n a l l y produced at the L i o n s Gate H o s p i t a l , to the p r o v i n c i a l hospitals by 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 r e f l e c t s the need for a f o r m a l p r o v i n c i a l D r u g F o r m u -l a r y . The objectives of the present study are to: 1. Identify how the present D r u g F o r m u l a r y may become m o r e use 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 of the monograph and F o r m u l a r y f o r m a t s ; 2. Define a m e c h a n i s m whereby the F o r m u l a r y may be evaluated and updated on 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 achieve the above. 23 M E T H O D O L O G Y T h i s r e s e a r c h was instituted with 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 when adopted and d i s t r i b u t e d by 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. ) would p o s s i b l y r e q u i r e some altera t i o n s i n format and content to make it m ore acceptable and useful 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 also that the D r u g F o r m u l a r y should be updated 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 with i n f o r m a t i o n that is both 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. Identifying the P r o v i n c i a l Needs In an attempt to determine the a c c e p t a b i l i t y of the present D r u g F o r m u l a r y and what mo d i f i c a t i o n s were d e s i r a b l e i n r e g a r d to format and content, three studies were undertaken. F i r s t l y , a questionnaire was d i s t r i b u t e d to the chief p h a r m a c i s t s of the p r o v i n c i a l hospitals to d e t e r -mine the extent of use of the D r u g F o r m u l a r y and their opinions in r e g a r d to the format and contents. Secondly, a survey of four m a j or hospitals of the p r o v i n c e was conducted to determine how many additional drug monographs were d e s i r e d which would eventually influence the siz e of the F o r m u l a r y . T h i r d l y , a study was conducted of the drug usage patterns in s p e c i f i c c a r e a r e a s of five hospitals to determine i f a condensed v e r s i o n of the F o r m u l a r y could be made to f a c i l i t a t e a m o r e effective use of the D r u g F o r m u l a r y at the ward l e v e l . 24 (a) P o p u l a r i t y of Use A questionnaire was sent to the chief p h a r m a c i s t s of a l l B r i t i s h C o l u m b i a hospitals which l i s t e d a chief or d i r e c t o r of p h a rmacy in the 1971 edition of the "Canadian H o s p i t a l D i r e c t o r y " * . The questionnaire was designed to give the F o r m u l a r y u s e r s the opportunity to express their own opinions and those of their colleagues on the content and format of the present D r u g F o r m u l a r y . It also gave these p r o f e s s i o n a l s a chance to suggest changes in the format and content and additional drug monographs for 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 questionnaire. A l l questionnaires that were completed and r e t u r n e d were reviewed to determine the number of hospitals that were using the F o r m u l a r y and to obtain suggestions for future changes in the F o r m u l a r y format and the monograph f o r m a t . The l i s t s of additional drug monographs requested by the chief p h a r m a c i s t s for i n c l u s i o n i n the F o r m u l a r y were included in the r e s u l t s of the A d d i t i o n a l Drugs Survey. (b) Number of D r ug Monographs B e f o r e requesting which additional drug monographs were needed by the F o r m u l a r y u s e r s , it was deemed n e c e s s a r y to determine the number of drug monographs in the existing D r u g F o r m u l a r y and the number of C "**Canadian H o s p i t a l D i r e c t o r y , V o l . 19, The Canadian H o s p i t a l A s s o c i a t i o n , T o r o n t o , 1971. 25 F i g u r e 2. E x a m p l e of the questionnaire sent to the chief p h a r m a c i s t s of the p r o v i n c i a l h o s p i t a l s . 26 THE UNIVERSITY OF BRITISH COLUMBIA VANCOUVER 8, CANADA FACULTY OF PHARMACEUTICAL SCIENCES November 21st, 1972 Dear Fellow Pharmacists: The Faculty of Pharmaceutical Sciences is 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 in general use in your hospital? .  2. If the answer to question 1 is no, please comment in regard to the reasons in your hospital for not using the Drug Formulary. Did you previously have a formulary of your own in your hospital? If yes, is i t s t i l l being used? Is the formulary satisfactory in 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 in 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 will 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 will 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 in the future. Yours sincerely, EAP/cs Elizabeth A. Page, B.Sc.(Pharm). Division of Clinical Pharmacy cc. Dr. J. Hlynka, chairman, Division of Clinical Pharmacy FIGURE 2 27 drugs and drug products l i s t e d i n the F o r m u l a r y alphabetical index. The drug monographs i n the F o r m u l a r y were counted, excluding the s p e c i a l i z e d monographs on " E a r , E y e , Nose and T h r o a t P r e p a r a t i o n s " , "Skin and Mucous Membrane P r e p a r a t i o n s " , and "Intravenous and I r r i g a -tion S olutions". The above l i s t e d sections were excluded because the monographs r e p r e s e n t s p e c i a l i z e d uses of drugs which are u s u a l l y mono-graphed i n the m a i n section of the F o r m u l a r y under generic names. To determine the number of drugs and drug products l i s t e d i n the F o r m u l a r y alphabetical index, most of the b r a n d names of the drugs which are included i n the index as a c r o s s - r e f e r e n c e to the generic drug name were 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 in alphabetical o r d e r . The r e s u l t i n g drug l i s t was lat e r used i n the study of drug usage patterns in s p e c i a l care a r e a s of five p r o v i n c i a l h o s p i t a l s . A d d i t i o n a l Drugs Survey To determine which, i f any, additional drug monographs were needed to make the D r u g F o r m u l a r y m o r e adequately r e f l e c t the drug information needs of the p r o v i n c i a l h o s p i t a l s , a sample survey was con-ducted in four m a j o r hospitals of the p r o v i n c e . Vancouver 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 (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 Ro y a l Jubilee H o s p i t a l ( V i c t o r i a ) were chosen because they a l l offer hospital p h a r macy r e s i d e n c y p r o g r a m m e s and therefore expected to have sufficient staff to complete the su r v e y . 28 The hospital p h a r macy res i d e n t i n each hospital was asked to review the drugs stocked i n his hospital and to l i s t a l l drugs used which were not monographed i n the present D r u g F o r m u l a r y . They were asked also to indicate whenever p o s s i b l e which drugs i n the l i s t s their hospital would li k e to see included i n the F o r m u l a r y . The r e s u l t s of this s u r vey were c o r r e l a t e d with the l i s t s of additional drug monographs requested by the chief p h a r m a c i s t s . The additional drug monographs requested were c a t e g o r i z e d a c c o r d i n g to the frequency of requests r e c e i v e d for each drug f r o m the four hospitals and the chief p h a r m a c i s t s . F r o m the r e s u l t s , the eventual siz e and content of the D r u g F o r m u l a r y could be estimated p r o v i d i n g that the additional drugs suggested above were r e p r e -sentative of the other p r o v i n c i a l hospital needs as w e l l . (c<) F o r m a t of the D r u g Monographs In completing the chief p h a r m a c i s t s questionnaire (see page 26) the chief p h a r m a c i s t s were asked to comment on the acce p t a b i l i t y and u s e -fulness of the drug monograph fo r m a t . Suggestions for changes and additions were reviewed i n addition to those that were id e n t i f i e d f r o m an anal y s i s of the l i t e r a t u r e and f r o m the comments of the m e m b e r s of the 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 , 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 who were involved i n the c u r r e n t r e v i s i o n s . A l l of these were noted and some of them were adopted for further evaluations i n the present study. 29 Canadian D r u g Identification Code The recent publication by the f e d e r a l Health P r o t e c t i o n B r a n c h of the Canadian D r u g Identification Code stimulated i n t e r e s t in adding to the drug monographs a drug code which was s p e c i f i c a l l y Canadian in nature. T h i s would supplement the existing 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 c l a s s i f i c a t i o n number. Since the Canadian D r u g Identification Code contains four unique drug codes, the Health P r o -tection B r a n c h publication was studied to determine which of the four codes would be most useful to the F o r m u l a r y u s e r s for drug i d e n t i f i c a t i o n as well as stock c o n t r o l and other p r o c e d u r e s . A m b u l a t o r y C o n s i d e r a t i o n s In recent y e a r s , hospitals and hospital p h a r m a c i s t s have become i n c r e a s i n g l y involved i n ambulatory and outpatient s e r v i c e s (60). In attempting to produce a D r u g F o r m u l a r y which might be useful to a l l health p r o f e s s i o n a l s of the p r o v i n c e , c o n s i d e r a t i o n was given to those a r e a s which deal with ambulatory patients in an outpatient c l i n i c as well as in the inpatient setting. F o r this r e a s o n an attempt was made to supply i n f o r m a t i o n on the drug monographs to a s s i s t the health c a r e p r o f e s s i o n a l s in i n s t r u c t i n g the ambulatory patients about the proper handling and use of their m e d i c a t i o n s . The m e c h a n i s m that is being evaluated as a means of updating the D r u g F o r m u l a r y monographs was adopted as the b a s i s for also a c c o m p l i s h i n g the objective of supplying i n s t r u c t i o n s to the patients. 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 present method of p r i n t i n g the D r u g F o r m u l a r y r e q u i r e s that the whole monograph be re-typed each time that it is up-dated, it was decided that another means of producing the F o r m u l a r y should be investigated. The 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 becoming m o r e common i n m e d i c a l and pharmacy p r a c t i c e and s e v e r a l drug f o r m u l a r i e s have been produced by these means. To i n v e s -tigate the p o s s i b i l i t y of c o m p u t e r i z e d production of the D r u g F o r m u l a r y i n future y e a r s , the recent l i t e r a t u r e on this subject was r e v i e w e d . A letter was also sent to M r . H. Smythe, D i r e c t o r of P h a r m a c y at the Ottawa C i v i c H o s p i t a l , (Ottawa, Ontario) requesting i n f o r m a t i o n on the c o s t s , storage of i n f o r m a t i o n , and the method used to update the monographs by E.D.P. The Ottawa C i v i c H o s p i t a l was chosen as the source of this i n f o r m a t i o n because it is a Canadian hospital using E.D.P. to produce a drug f o r m u l a r y and it was thought that the costs and p r o c e d u r e s at a Canadian hospital would 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 costs and methods also a v a i l a b l e 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 between 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 . Smythe and the costs of the conventional methods as used to produce the B r i t i s h C o l u m b i a D r u g F o r m u l a r y was done. 31 (d) Monograph U t i l i z a t i o n Survey-One of the l i m i t a t i o n s 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 s that the two-volume set i s too bulky for easy use (47, 65). S i m i l a r l y , the present D r u g F o r m u l a r y also i s awkward due to its s i z e . F o r this r e a s o n and because the content of the F o r m u l a r y may have to be further i n c r e a s e d to cover the drug i n f o r m a t i o n needs of the p r o v i n c e , an attempt was made to find a method(s) by which the wards of the hospitals could be supplied with u s e f u l , compact f o r m u l a r i e s through identifying the unique drug use patterns in each patient care a r e a . A study was conducted i n this r e g a r d in five p r o v i n c i a l hospitals to determine the frequency of use of the drugs and drug products l i s t e d i n the alphabetical index of the F o r m u l a r y a c c o r d i n g to spe c i a l t y w ards. The complete drug l i s t was typed ( f i r s t page e x e m p l i f i e d in F i g u r e 3) and d i s -tributed to Vancouver 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 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 . Information in this r e s p e c t was generated on the frequency of use of the l i s t e d drugs in the s p e c i f i c c a r e a r e a s of 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 Extended C a r e . T h e s e a r e a s were chosen to exemplify s p e c i a l t i e s because of the wide v a r i e t y of drugs that might be used in each of them. F o r each l i s t e d drug the frequency of use was determined as "frequently", " o c c a s i o n a l l y " or " r a r e l y " i n each of the four a r e a s . " F r e -quently Used D r u g s " were defined as those drugs which were supplied to 32 F i g u r e 3. Sample of Drug L i s t s used for Monograph U t i l i z a t i o n S urvey. 33 DRUG PEDIATRICS EMERGENCY PSYCHIATRIC EXTENDED i . CARE F 0 R F i 0 R F 0 i i R F I 0 I R Acetaminophen I Acetazolamide i 1 1 • Acetycholine j 1 i A cetylcysteine i 1 A c e t y l s a l i c y l i c acid i Achromycin 1 1 ACTH | Adephinine I Adrenalin 1 1 Aerosporin i Aerosporin (Ear) i • Agarol i i Airbron !• Alcohol 1 Alkeran i | A l l o p u r i n o l 1 Alpha-Chymotrypsin ! Alpha-Tocopherol Aluminum Hydroxide Americaine I Amesec 1 Amethopterin t ' Aminocaproic acid ii 1 t 1 Aminophyllin |j | 1 Aminophyllin Compounds|| i A m itriptyline ! Ammonium Carbonate .i i Mixture 1 ! Ammonium Chloride Ammonium Chloride • Mixture 1 Amobarbital Sodium 1 Amphotercin 1 Amphyl A m p i c i l l i n Amyl N i t r i t e Artectine A n i l e r i d i n e Annanase Antepar i ! Anusol i Apresoline Argyrol Ascorbic acid Atropine (eye) F I G U R E 3 34 an a r e a as ward stock, used dai l y or s e v e r a l times a week. " O c c a s i o n a l U s e d D r u g s " were those used in an a r e a only once or twice a month, and " R a r e l y U s e d D r u g s " were i n t e r p r e t e d as those drugs used in an a r e a only once or twice a y e a r , or n e v e r . To obtain this i n f o r m a t i o n , r e c o r d s were r e v i e w e d and p h a r m a c i s t s and n u r s e s were interviewed a c c o r d i n g to s p e c i f i c drug use patterns (see F i g u r e 4). The l i s t s f r o m each hospital were analysed a c c o r d i n g to the s p e c i f i c treatment areas to determine the number of drugs and the approximate percentage of the drugs used "frequently", " o c c a s i o n a l l y " and " r a r e l y " f o r each h o s p i t a l . It was anticipated that the r e s u l t s could then be u s e d to propose a s y s t e m whereby the monographs of the " F r e -quently U s e d D r u g s " could be made m o r e r e a d i l y available to the health p r o f e s s i o n a l s on the n u r s i n g w ard without 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 monographs for drugs used " O c c a s i o n a l l y " and " R a r e l y " in each a r e a . It was hoped also to keep the potential bulk of 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 and Updating the F o r m u l a r y F o r the past two y e a r s a l i m i t e d number of senior y e a r pharmacy students at the 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 , 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 in 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 c o u r s e in C l i n i c a l P h a r m a c y . It was r e c o g n i z e d that the work done by the students was valuable and that much of this work 35 F I G U R E 4 I N S T R U C T I O N S F O R 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 U R V E Y O F D R U G U S E F O R S P E C I A L T Y F O R M U L A R I E S Hos p i t a l Name Resident's Name INSTRUCTIONS: 1. Complete the following charts with r e g a r d to the frequency of drug use i n s p e c i a l i z e d care a r e a s in your hosp i t a l . 2. F = F r e q u e n t l y - floor stock to a r e a or used daily, s e v e r a l times a week? O = O c c a s i o n a l l y - used i n s p e c i f i c a r e a only once or twice a month. R = R a r e l y - used in s p e c i f i c a r e a only once or twice per year -or never.. Other than floo r stock, frequency of use i s to be determined by Resident's experience, p h a r m a c i s t s ' opinions and n u r s e s ' opinions. 3. A section on the last page is pr o v i d e d for evaluation of the frequency of use of drugs that are not l i s t e d here, but are used i n your hospital. 4. Drugs are l i s t e d by gener i c name only, to prevent confusion with brands that may not be used in a l l h o s p i t a l s . (Exception: those medications which are combination products). 5. P l e a s e complete and r e t u r n f o r m s before December 20, 1972. 36 could be further applied to a p r a c t i c a l use in f u l f i l l i n g the need of updating the present 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 was proposed to the M e d i c a l S e r v i c e s Foundation of B r i t i s h C o l u m b i a whereby the mono-graphs of the D r u g F o r m u l a r y could be updated as a c l i n i c a l l y r e l a t e d educational assignment to the senior year pharmacy c l a s s i n 1972-73. The proposed m e c h a n i s m of updating the drug monographs to be evaluated i n the present study r e p r e s e n t s a sequence of senior year C l i n i c a l P h a r m a c y student assignments and i n s t r u c t o r review, both as an "academic" r e s p o n s i b i l i t y and on a " s e r v i c e " b a s i s to ensure the a c c u r a c y of the student work. The 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 and condensing of the l i t e r a t u r e evaluation r e p o r t to suitable monograph fo r m a t . The above Foundation approved a one-year grant to enable the financing of this " s e r v i c e " component by the i n s t r u c t o r as we l l as some stenographic a s s i s t a n c e . The questions that were to be answered before a continuing p r o -gramme of this nature could be undertaken on an annual b a s i s include: 1. Is there a need for r e g u l a r updating of the drug monographs ? 2. What are the time r e q u i r e m e n t s of the students and what i s the extent of their contribution to the updating m e c h a n i s m ? 3. What is the time r e q u i r e m e n t of the i n s t r u c t o r s beyond their academic involvement? 4. What is the time r e q u i r e m e n t of; the stenographic staff to type the updated monographs on an annual b a s i s ? 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 student in the senior y e a r pharmacy c l a s s was assigned three drugs (see Appendix III) to completely evaluate the existing mono-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 l i t e r a t u r e a l l statements i n the monograph sections of "Drug Interactions" and "Intravenous I n c o m p a t i b i l i t i e s " . The students were supplied with a statement of the type of papers and r e f e r e n c e s which were acceptable l i t e r a t u r e s o urces and were i n s t r u c t e d to use only 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 update the monographs. In addition the section of the monograph concerning " A c t i o n " was to be expanded to include the m e c h a n i s m of action, a b s o r p -tion, d i s t r i b u t i o n , m e t a b o l i s m and e x c r e t i o n of the drug. A new section of "Instructions to the Pa t i e n t " was added also to f u l f i l l the o b j e c t i v e of supplying drug i n f o r m a t i o n to ambulatory c a r e a r e a s . Throughout the assignment the students were r e q u i r e d to add any new in f o r m a t i o n f r o m the l i t e r a t u r e of the past y e a r as we l l as to evaluate e x i s t i n g monograph inf o r m a t i o n f r o m e a r l i e r y e a r s . The students also were d i r e c t e d to r e c o r d any changes or c o r r e c t i o n s that were found f r o m the l i t e r a t u r e and to r e f e r e n c e these a l t e r a t i o n s on a Change Sheet (see F i g u r e 5) which were presented to the i n s t r u c t o r with both the o r i g i n a l and evaluated mono-g r a p h s . Throughout the assignment the students r e c o r d e d the time r e q u i r e d to update each monograph. The r e s u l t s of the time study were 38 F i g u r e 5 . Sample of a Change Sheet as d i s t r i b u t e d to the students, with sections for the updated i n f o r m a t i o n s i m i l a r to the monograph f o r m a t . 39 Pharmacy 403 Drug and Poison Information Centre Revisions and Updating of Drug Monograph GENERIC NAME OF 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 used to p r o j e c t the student involvement i n annual updating and a time schedule for future r e v i s i o n s . P h a r m a c i s t Involvement The r e q u i r e d i n s t r u c t o r involvement i n total r e v i s i o n of the drug monographs r e p r e s e n t s the p a r t i c i p a t i o n of the i n s t r u c t o r s beyond their " academic" r e s p o n s i b i l i t y . The "academic" r e s p o n s i b i l i t y included being present at the student presentations of the evaluated monographs and grading the work on the b a s i s of academic 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 then reviewed the r e v i s e d monographs for a l l changes, additions and c o r r e c t i o n s made by the students, and evaluated the work and cited r e f e r e n c e s for 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 had completed the evaluation of the r e v i s e d monographs they then edited and condensed the monographs into the standard format of the D r u g F o r m u l a r y . The i n s t r u c t o r s were requested to ma i n t a i n a r e c o r d of their 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 were used to project 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 for updating the monographs on a future annual b a s i s . Stenographic Requirements The 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 be typed i n a u n i f o r m format for duplication and di 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 sec-tions 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 From 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 A N D DISCUSSION The three b a s i c i s s u e s to be r e s o l v e d in the present study-included the definition of the drug monograph and F o r m u l a r y format changes r e q u i r e d to present a m o r e p r o v i n c i a l l y useful r e f e r e n c e , the p r o j e c t i o n of an evaluation m e c h a n i s m which could e f f e c t i v e l y update the F o r m u l a r y on a r e g u l a r b a s i s , and a d e s c r i p t i o n of the type and number of p e r s o n n e l r e q u i r e d to produce such updated drug monographs. I. Identifying the P r o v i n c i a l Needs T h r e e approaches were used to determine the n e c e s s a r y format changes and how to implement these changes to produce a m ore p r o v i n c i a l l y u s e f u l D r u g F o r m u l a r y . (1) A questionnaire was sent to the chief p h a r m a c i s t s of a l l B r i t i s h C o l u m b i a hospitals which l i s t e d a chief or d i r e c t o r of p h a rmacy in the 1971 edition of the Cana-dian H o s p i t a l D i r e c t o r y * . (2) A sample of four hospitals of the province were s u r -veyed to determine which, i f any, additional drug monographs were needed. (3) A n evaluation of the drug use patterns of the drugs l i s t e d in the alphabetical index of 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 of five p r o v i n c i a l hospitals was conducted to determine i f m o r e effective use could be made of the F o r m u l a r y at the ward l e v e l . * Canadian H o s p i t a l D i r e c t o r y , V o l . 19, The Canadian H o s p i t a l A s s o c i a t i o n , T o r o n t o , 1971. B y reviewing the r e s u l t s of these three approaches, some format and content changes that would make the D r u g F o r m u l a r y m o r e useful to a l l hospitals of the p r o v i n c e were i d e n t i f i e d . (a) P o p u l a r i t y of Use Of the 46 hospitals m o n i t o r e d i n the chief p h a r m a c i s t s questionnaire, 32 or approximately 70 percent r e p l i e d to the questionnaire and of these, 19 or approximately 60 percent r e p o r t e d using the Drug F o r -m u l a r y (see T a b l e I). The m a j o r reasons for not using the F o r m u l a r y and the incidence of these reasons a r e presente d in T a b l e II. - Since the majo-r i t y of the respondents appear to be using the F o r m u l a r y and since the lim i t a t i o n s forwarded can be o v e r c o m e , it would appear to be worthwhile to pursue an attempt to make 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 acceptable. Those hospitals u s i n g the D r u g F o r m u l a r y submitted some excellent recommendations for improvements and the following l i s t of recommended mo 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 of these as well as those f r o m the other sources mentioned on page 42: (1) that additional drug monographs, be added to the F o r m u l a r y to cover the drug i n f o r m a -tion needs of the p r o v i n c e ; (2) that the mode of action be included on the drug monographs and that m o r e extensive i n f o r m a -tion on some drugs be added; (3) that c o n s i d e r a t i o n be given to supplying i n f o r -m ation to those a r e a s of p r a c t i c e that deal with the ambulatory patient i n a hospital setting 44 TABLE I DRUG FORMULARY UTILIZATION As Determined By a Survey of Chief Pharmacists Number of Hospitals Percentage^ Hospitals in British Columbia 104 Hospitals Surveyed 46 44 Hospitals which replied 32 70 Hospitals which use the Provincial 2 Drug Formulary 19 60 1. Determined to the nearest percentage point. 2. Of those hospitals which replied. 45 TABLE II REASONS FOR NOT USING THE DRUG FORMULARY 1 Reason 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 13 Total 1. Acs determined from the survey of chief pharmacists. 46 such as the Outpatient C l i n i c , N u r s i n g Stations in remote a r e a s and the M e n t a l Health C l i n i c s ; (4) that r e f e r e n c e s of the drug monographs would a s s i s t the u s e r s in obtaining additional i n f o r -m ation as r e q u i r e d ; (5) that a Canadian D r u g Code be included on the monographs for drug i d e n t i f i c a t i o n ; (6) that the Drug F o r m u l a r y is too bulky and cumbersome for quick r e f e r e n c e ; (7) that e l e c t r o n i c data p r o c e s s i n g (E.D.P.) be c o n s i d e r e d as a means of producing the D r u g F o r m u l a r y which might be cheaper and fa c i l i t a t e quicker updating and editing; (8) that the F o r m u l a r y should be updated at r e g u l a r i n t e r v a l s so that it r e m a i n s an a c c u r a t e , up-to-date source of drug i n f o r m a t i o n to the u s e r s . • Some of the above recommendations were implemented in the c u r r e n t r e v i s i o n of the F o r m u l a r y . Others have been investigated in the present study for p o s s i b l e future adaptations. The r e s u l t s in each a r e a are c o n s i d e r e d as follows under the sub-headings of "Number of D r u g Monographs", " F o r m a t of D r u g Monographs", " F o r m a t of the F o r m u l a r y " and " E v a l u a t i o n and Updating of the F o r m u l a r y " . (b) Number of D r u g Monographs B e f o r e requesting which additional drug monographs might be needed by the p r o v i n c i a l h o s p i t a l s , the number of drug monographs included in the present D r u g F o r m u l a r y was d e t e r m i n e d . T h i s was done to enable a 47 pr o j e c t i o n of the p o s s i b l e si z e of the F o r m u l a r y i f additional drug mono-graphs are r e q u i r e d . The total number of drug monographs in the e x i s t -ing F o r m u l a r y is 306. The alphabetical index of the F o r m u l a r y , however, l i s t s 483 drugs and drug p r o d u c t s . The d i s c r e p a n c y that exists i s due to the fact that the latter number includes the v a r i o u s salts of the generic name drugs as well as some br a n d names of combination products which may be mono-graphed i n the F o r m u l a r y under a single generic name. In r e c o g n i t i o n of the fact that the present D r u g F o r m u l a r y con-tains monographs of only those drugs used at one h o s p i t a l , a survey was conducted in four additional p r o v i n c i a l hospitals of varying size to d e t e r -mine what additional drug monographs might be r e q u i r e d to supply com-prehensive drug i n f o r m a t i o n in the p r o v i n c e . The hospitals included i n this study (see Methodology, page 27) were requested to l i s t the drugs that they stock which are not included p r e s e n t l y i n the D r u g F o r m u l a r y It was felt that by c o r r e l a t i n g these l i s t s with those submitted by five chief p h a r m a c i s t s on the chief p h a r m a c i s t s questionnaire (see Methodology, page 24), the fi n a l r e s u l t would r e f l e c t most of the drug monographs needed by the p r o v i n c i a l h o s p i t a l s . Of a total of 904 drug monographs eventually requested in a d d i -tion to the existing monographs, 592 r e c e i v e d one request, 204 were r e -quested by two ho s p i t a l s , 71 were requested by three h o s p i t a l s , 32 others 48 were requested by four institutions and five drug monographs were r e -quested by five hospitals (see Appendix II). In t e r m s of p r i o r i t i e s for new drug monographs to be produced in the future, it is recommended that those drugs which r e c e i v e d two or m o r e requests should be c o n s i -d ered f i r s t l y . On 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 might be expected to contain in excess of 600 drug monographs; 306 existing monographs, plus approximately 300 new monographs requested by two or m o r e i n s t i t u t i o n s . (c) F o r m a t of the D r u g Monographs Among the many ways in which the format of the present drug monographs were recommended to be changed to obtain a more 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 of "Mode of A c t i o n " , ambulatory use 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 and the Canadian D r u g Identification C o d e were some which were adopted during 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 . F i g u r e 6 and F i g u r e 7 present copies of the monographs of E r y t h r o m y c i n , r e s -p e c t i v e l y , b efore and after r e v i s i o n featuring the above additions. Mode of A c t i o n Although the existing monographs have a section for i n f o r m a -tion on the action of the drug, it i s often only a statement of the therapeu-tic c l a s s i f i c a t i o n of the drug (see F i g u r e 6). In view of the request that the mode of action be included on the monographs, each r e v i s e d monograph now contains i n f o r m a t i o n on the m e c h a n i s m , absorption, d i s t r i b u t i o n . 49 Figure 6. Sample monograph of Erythromycin from the existing Drug Formulary before revision. so E R Y T H R O M Y C I N I L O S O N E E R Y T H R O C I N 8:12:12 A C T I O N : 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 . Spectrum 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 . Du 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 . Serum 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 . B A C T E R I A L S P E C T R U M : Sta 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. diph-t h e r i a e , treponema, * M y c o p l a s m a pneumoniae (Eaton agent)., v i r u s e s causing trachoma and lymphogranuloma venereum. (^Generally c o n s i d e r e d a n t i b i o t i c of 1st choice.) Other p r i n c i p a l use i s against group A, beta-hemolytic s t r e p t o c o c c i and pneumococcal inf e c t i o n s i n patients 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 s t a p h y l o c c i , pneumococci, beta-hemolytic s t r e p t o c o c c i . U sed i n soft 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 . C O N T R A I N D I C A T I O N S : 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 estolate (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 jaundice or l i v e r d i s e a s e . Kidney disfunction 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 . D OSAGE: O R A L : A D U L T S AND C H I L D R E N over 23 kg: 250 mg. every 6 h o u r s . Severe i n f e c t i o n s : 500 mg. every 6 h o u r s . Taken 1-1-1/2 hours p r i o r to or after m e a l s . Dosage range 1-4 gm. d a i l y . C H I L D R E N 11. 5-23 kg: 125 mg. q.6.hl C H I L D R E N 4. 5-11. 5 kg: 11 mg./kg. q.6.h. . I. V. : A D U L T S : R e s e r v e d for severe i n f e c t i o n s : 1-4 gm. d a i l y i n d i v i d e d doses q. 6.h. C H I L D R E N : 1 2 - (24)- 48 mg./kg/24 hours d i v i d e d q. 8. h. M a x i m u m si n g l e dose: 0.5 gm. M a x i m u m d a i l y dose: 1.5 gm. 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 . /min. o r l e s s ) : N o r m a l i n i t i a l dose followed by half-doses at i n t e r v a l s of 8 h o u r s . SIDE E F F E C T S : Nausea, v o m i t i n g , d i a r r h e a , s k i n r a s h , jaundice, I.M. i n j e c t i o n of m o r e than 100 mg. produces 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. doses frequently causes p h l e b i t i s . D R U G I N T E R A C T I O N S : 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 . N U R SING I M P L I C A T I O N S : O r a l solutions must 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 with product. Injection stable 14 days under r e f r i g e r a t i o n . I.V. i n j e c t i o n must be m i x e d with water f o r i n j e c t i o n without p r e s e r v a t i v e o t h e r w i s e the drug p r e c i p i t a t e s . It i s advisable to give o r a l p r e p a r a t i o n s between meals unl 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 blood c e l l counts are a d v i s a b l e . L i v e r function tests are advisable i n prolonged therapy with the estolate 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 in solution i s r a p i d at a pH below 5. Compatible with most I.V. solutions but may be p r e c i p i t a t e d by addition of high concentrations of i n o r g a n i c s a l t s . Incompatible with B complex with 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 , Ceporan, Diphenylhydantoin ( D i l a n t i n ) . C h l o r a m p h e n i c o l , A m i n o p h y l l i n , S t r e p t o m y c i n . P R E S E N T A T I O N : Capsules or T a b l e t s : 250 mg. Drops: 100 mg./cc. Suspension: 1 2 5 m g . / 5 c c . V i a l : 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 E R Y T H R O C I N ( S T E A R A T E ) E R Y T H R O M Y C I N I L O S O N E ( E S T O L A T E ) A N D ITS E S T E R S E - M Y C I N (BA S E ) 8:14:12 A C T I O N : B a c t e r i o s t a t i c A n t i b i o t i c . 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 . Inhibits p r o t e i n synthesis at r i b o s o m a l l e v e l (1). A b s o r p t i o n : O r a l - r e a d i l y , p r i m a r i l y f r o m upper part of s m a l l i n t e s t i n e . The base and stearate salt a b s o r p t i o n d e c r e a s e s i f taken with food but the estolate s a l t i s unaffected (3). H i g h l y p r o t e i n bound, peak blood l e v e l s i n about two hours with estolate s a l t , i n about four h o u r s w i t h stearate salt o r with 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 twice as high (1), m o r e p r e d i c t a b l e and m o r e prolonged (3) when an equivalent dose of estolate given as compared w i t h base or 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 except b r a i n contain h i g h e r concentrations than i n blood (1); into 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 membrane of the t r a c h e o - b r o n c h i a l t r e e ; into 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 into s p i n a l f l u i d u n l e s s meninges 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 up to f i v e h ours ( l 1). E x c r e t i o n : The drug i s concentrated i n the l i v e r and 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 , feces and m i l k (3). S P E C T R U M O F A C T I V I T Y : ' 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 against Staphylo-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. d i p h t h e r i a e , treponema, ^ 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 a n t i b i o t i c 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 r e s i s t a n c e with c a r b o m y c i n , oleandomycin and s p i r a m y c i n . Staphylo-c 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). I NDICATIONS: ' P r i n c i p a l use i s i n group 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 a l and pneumococcal i n f e c t i o n s i n patients who are 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 of b a c t e r i a l endo-c a r d i t i s p r i o r to dental or other o p e r a t i v e p r o c e d u r e s on patients with a h i s t o r y of r h e u m a t i c r e fever o r congenital heart disease (2). U sed 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 . C O N T R A I N D I C A T I O N S : H y p e r s e n s i t i v i t y . E s t o l a t e s a l t 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 jaundice o r l i v e r d i s e a s e , and i n c h r o n i c d i s o r d e r s (e.g., acne and f u r u n c u l o s i s ) (3). K i dney dys 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 (1). C AUTIONS: 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 ysfunction (4). DOSAGE: O r a l : A d u l t s and c h i l d r e n o ver 23 K g . 250 mg e v e r y 6 h o u r s . Severe i n f e c t i o n - 500 mg e v e r y 6 h o u r s . T a k e n 1 hour p r i o r to o r 2 hours after m e a l s . Dosage range 1-4 G m d a i l y . C h i l d r e n : 11. 5 to 23 Kg: 125 mg q. 6. h.; 4. 5 to 11. 5 Kg: 11 mg/Kg q.6.h. I V . : R e s e r v e d f o r severe i n f e c t i o n s . A d u l t s : 1-4 Gm d a i l y i n d i v i d e d doses q. 6.h. M a x i m u m s i n g l e dose: 0.5 Gm. M a x i m u m d a i l y dosage: 1,5 Gm. 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 or l e s s ) : N o r m a l i n i t i a l dose followed by ha l f dose at i n t e r v a l s of 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 nausea, 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 , jaundice (only with estolate s a l t and extended therapy (3, 8)). I.M. i n j e c t i o n of more than 100 m g m produces severe 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 l G m doses f r e q u e n t l y causes p h l e b i t i s . 53 00431 - 2 - E R Y T H R O M Y C I N INTERACTIONS: Erythromycin 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 prior to fruit juice or other acid drink - activity of drug greatly decreases in acid solution (3). I.V. INCOMPATIBILITIES: Erythromycin is extremely pH dependent - most stable above pH 6-8. Loss of activity in solu-tion is rapid at a pH below 5 - avoid concurrent use of additives which will result in an ad-mixture pH below 5 (9). Compatible with most I.V. solutions but may be precipitated by addi-tion 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 IMPLICATIONS: Oral solutions must be refrigerated, store in a cool place, protected from light (4); stability varies. 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 irritating and too painful and should not exceed 100 mg. It is advisable to give oral prepara-tions between meals unless gastric irritation is too severe. Antacid may be given for gastric irritation. Periodic 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 infu-sion, stop flow before removing needle (4). Observe for symptoms of overgrowth of nonsus- . ceptible organisms (black furry tongue, enteritis) during prolonged therapy (4). The commer-cial I.M. product is not miscible with water, so only a dry syringe and needle should be used (2). INSTRUCTIONS TO PATIENT: Take one tablet one hour before meals (or two hours after) and at bedtime - 4 a day. Take antacid if 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 from light. PRESENTATION: ^ Capsules or Tablets 250 mgm Suspension 125 mgm/5 cc Drops 100 mgm/cc Vial 1 Gm Date Prepared: March, 1973 54 00431 E r y t h r o m y c i n R E F E R E N C E S : 1. Goodman, L . and G i l m a n , A.: The 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 - peu t i c s, 4th e d i t i o n . (1970) p. 1274-7. 2. Compendium 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 , 6th ed i t i o n . Canada, 1972 . 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. 3. 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 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 , Washington, D.C. (1971). 4. Govoni, L . E . and Hayes, J . : Drugs and N u r s i n g Imp l i c a t i o n s, 2nd ed i t i o n , p. 128. 5. A M A D r u g E v a l u a t i o n s , 1 st edition (1971). p. 402. 6. Savath, L.D., et a l . : E x c r e t i o n of e r y t h r o m y c i n and its enhanced ac t i v i t y i n u r i n e against g r a m negative b a c i l l i with a l k a l i n i z a t i o n . J . L a b . C l i n . M e d . 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 and a l k a l i n i z a t i o n i n therapy of b a c t e r i u r i a . A n t i m i c r o b . Agents Chemother. 9th conf. (1969) 36 A b s t . 85, 1969. 8. F D A R e p o r t s of suspected adverse r e a c t i o n s to drugs, 1967, No. 671103-002-00501. 9. Anon., C o m p a t i b i l i t y D i g e s t , A m e r . J . Hosp. P h a r m . 26:410, 1969. 10. Intravenous A d d i t i v e I n c o m p a t i b i l i t i e s . January (1970). U.S. Dept. . Health, E d u c a t i o n , W e l f a r e . 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 in C l i n i c a l P h a r m a c y . Drug Intelligence 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 . Ann. Rev. P h a r m a c o l . 8:151 (1968). Date P r e p a r e d : M a r c h , 1973 55 m e t a b o l i s m and e x c r e t i o n of the drug where applicable (see F i g u r e 7) . A s well as adding the above i n f o r m a t i o n to the monographs, the r e v i s e d mono-graphs now also include m o r e extensive i n f o r m a t i o n in each of the other sections of the monograph on "Indications", "Side E f f e c t s " , C o n t r a i n d i -c a t i o n s " and "Intravenous I n c o m p a t i b i l i t i e s " . Such additional i n f o r m a t i o n contained in the drug monographs should better meet the needs of most u s e r s in the future. A m b u l a t o r y Use Instructions Since the D r u g F o r m u l a r y is i n use in hospitals i n a l l parts of the p r o v i n c e , and since some of these hospitals are active in many s e r v i c e s including outpatient c l i n i c s , it was d e t ermined that a section should be added to this year's r e v i s e d monographs on "Instructions to the P a t i e n t " (see F i g u r e 7). T h i s section also i s expected to be of use within the hospital setting i t s e l f to a s s i s t in the i n s t r u c t i o n of patients r e c e i v i n g d i s -charge m e d i c a t i o n s . The addition of this section may further prove useful i f an A m b u l a t o r y D r u g F o r m u l a r y is produced at some future date for use i n Community Health C e n t r e s . In an A m b u l a t o r y F o r m u l a r y the section on "Instructions to the P a t i e n t " could be used in place of the sections on "In-travenous I n c o m p a t i b i l i t i e s " and " N u r s i n g I m p l i c a t i o n s " which at present deal p r i m a r i l y with i n f o r m a t i o n r e q u i r e d i n the hospital setting. R e f e r e n c e s and B i b l i o g r a p h y F r o m previous experience with 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 . ) and other r e f e r e n c e s o u r c e s such as standard textbooks, d i f f i c u l t y is experienced frequently in conducting additional i n f o r -mation s e a r c h e s on the presented i n f o r m a t i o n because these sources contain no ind i c a t i o n of where the o r i g i n a l i n f o r m a t i o n was found. Although it is p o s s i b l e to obtain the r e f e r e n c e s to the A.H. F . S . by w r i t i n g to the 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 , experience dictates that this s y s t e m is too awkward and time consuming for efficient u t i l i z a t i o n . F o r these r e a s o n s , it was decided to r e f e r e n c e the contents of the drug monographs and to provide a complete b i b l i o g r a p h y for each monograph i n the D r u g F o r m u l a r y (see F i g u r e 7). The p r e s e n c e of the. r e f e r e n c e s and b i b l i o g r a p h y i s expected to enable the u s e r to further r e s e a r c h i n f o r m a t i o n and to identify the i n f o r m a -tion source q u i c k l y . Canadian D r u g Identification Code The Health P r o t e c t i o n B r a n c h of the Canadian government has r e c e n t l y p u b lished the Canadian D r u g Identification Code. The publication contains four sections of different codes - the Sequential Identifier; an alphabetical l i s t i n g by T r a d e names; the M a n u f a c t u r e r s ' A s s i g n e d Code and the A c t i v e Ingredient Group Number. A f t e r r e v i e w i n g the above four codes, it was decided to adopt the A c t i v e Ingredient Group Number for i n c l u s i o n in the drug monographs because it appeared to be the most useful code without l i m i t i n g i d e n t i f i c a t i o n to only one manufacturer's product (see F i g u r e 7, top l e f t ) . It was felt that as w e l l 57 as having the Canadian D r u g Identification Code A c t i v e Ingredient Group Number however, 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 number (8:12:12) should be retained on the monograph (see F i g u r e 7, top right) as a c o r r e l a t i o n to the A.H. F . S . and for those hospitals which wish to f i l e the monographs by the 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 s . (d) F o r m a t of the F o r m u l a r y The m a j o r c r i t i c i s m of the present D r u g F o r m u l a r y format as d e t e r m i n e d f r o m the chief p h a r m a c i s t s questionnaire, f r o m the m e m b e r s of the F a c u l t y of P h a r m a c e u t i c a l Sciences who were involved with the c u r r e n t r e v i s i o n s and f r o m the comments of the F o r m u l a r y u s e r s , i s that it is too bulky. The F o r m u l a r y , i f expanded i n its present format to approximately 600 monographs as anticipated (see page 48) would be further reduced in u s e f u l n e s s , p a r t i c u l a r l y on the n u r s i n g station where l i m i t e d time and space is a v a i l a b l e . . It would appear that the l a r g e r the r e f e r e n c e book, the l e s s it is l i k e l y to be u s e d . Monograph U t i l i z a t i o n Survey In an attempt to reduce the bulk and to i n c r e a s e the usefulness of the D r u g F o r m u l a r y , a survey was conducted to determine the frequency of use of the 483 drugs and drug products l i s t e d i n the F o r m u l a r y alphabe-t i c a l index (see pages 31-35). T h i s approach should r e f l e c t the frequency 58 of monograph r e q u i r e m e n t s in s p e c i a l t y a r e a s within the hospitals and a c c o r d i n g l y , the m i n i m u m number ^ r e q u i r e d in each/. The survey was conducted in five B r i t i s h C o l u m b i a hospitals (see Methodology, page 31 ). The study requested i n f o r m a t i o n on the frequency of use of the drugs and there f o r e drug monographs i n the following four s p e c i a l i z e d care areas: 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 Extended C a r e . The i n f o r m a t i o n evaluated at the five hospitals was c o m p i l e d into the following tables under the headings of " 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 " used d r u g s . It was a s s u m e d that should some format of the D r u g F o r m u l a r y eventually be designed for s p e c i f i c w ard a r e a s , only those drugs i d e n t i f i e d as " F r e q u e n t l y " and/or " O c c a s i o n a l l y " used might be included for use in those a r e a s . The anticipated advantage of such a s y s t e m would be to reduce the bulk of the F o r m u l a r y while supplying the r e q u i r e d drug i n f o r m a t i o n on the drugs most frequently used i n the ward a r e a . In the a r e a of P e d i a t r i c s , five hospitals r e p l i e d whereas in E x -tended C a r e and P s y c h i a t r y only three hospitals supplied the n e c e s s a r y i n f o r m a t i o n because the other two hospitals do not have f a c i l i t i e s for these s e r v i c e s . In r e g a r d to E m e r g e n c y c a r e , one institution,the R o y a l Jubilee H o s p i t a l , was unable to supply complete i n f o r m a t i o n on drug usage and there f o r e was not included in the r e s u l t s . T a b l e III shows the frequency of use of the 483 drugs l i s t e d i n the F o r m u l a r y alphabetical index on P e d i a t r i c w a r d s . The number of drugs 59 " F r e q u e n t l y " u s e d ranged f r o m 63 at L i o n s Gate H o s p i t a l to 111 at the Vancouver G e n e r a l H o s p i t a l . The di f f e r e n c e i n these fi g u r e s m a y b e a t t r i -butable to the la r g e teaching atmosphere of the latter h o s p i t a l . The average number of " F r e q u e n t l y " used drugs i n the five hospitals was 86 or a p p r o x i -m a t ely 18 percent of the total number of drugs l i s t e d . T h i s would seem to indicate that a F o r m u l a r y of 600 monographs would not only be cumbersome but of li t t l e value for use on P e d i a t r i c w a r d s . T a b l e IV shows s i m i l a r r e s u l t s for four hospitals on the study of E m e r g e n c y Ward drug use. L i o n s Gate H o s p i t a l again had the lowest number of " F r e q u e n t l y " used drugs at 68 while St. Paul's H o s p i t a l indicated that 178 drugs were " F r e q u e n t l y " u s e d . The r e a s o n for this d i f f e r e n c e was di f f i c u l t to determine but may have been due to the urban, c e n t r a l setting of the latter h o s p i t a l which might r e q u i r e a m o r e d i v e r s e pattern of emergency c a r e . In E m e r g e n c y Wards the average number of '".Frequently" used drugs in the four hospitals was 122 or approximately 25 percent of the total number of drugs 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 alphabetical index. A g a i n , the l i m i t e d number of monographs apparently used in this a r e a further supports the apparent n e e d l e s s n e s s of the complete D r u g F o r m u l a r y in any sp e c i a l t y a r e a . In Extended C a r e (Table V ) , Vancouver G e n e r a l H o s p i t a l r e c o r d e d the lowest number of " F r e q u e n t l y " used drugs at 43, and L i o n s Gate H o s p i -t a l had the highest number at 106. It i s thought that the Vancouver G e n e r a l H o s p i t a l had the lowest number in this category because they had just opened 60 TABLE III FREQUENCY OF USE OF PROVINCIAL FORMULARY DRUGS (483) IN PEDIATRIC WARDS OF VARIOUS HOSPITALS FREQUENTLY 1 OCCASIONALLY 2 RARELY 3 Hospital Number (%) 4 Number (%) 4 Number (%) 4 Vancouver General 93 (19) 111 (23) 279 (58) St. Paul's 75 (16) 88 (18) 320 (66) Lions Gate 63 (13) 40 (8) 387 (79) Victoria General 111 (23) 134 (27) 238 (50) Royal Jubilee 86 (18) 103 (21) 294 (61) 5 Average 86 (18) 93 (20) 304 (62) 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. 6 1 TABLE IV FREQUENCY OF USE OF PROVINCIAL FORMULARY DRUGS (483) IN EMERGENCY WARDS OF VARIOUS HOSPITALS FREQUENTLY 1 OCCASIONALLY 2 RARELY 3 Hospital Number (%) 4 Number (%) 4 Number (% 4 St. Paul's 178 (37) 53 (11) 252 (52) Vancouver General 137 (28) 112 (23) 234 (49) Lions Gate 68 (14) 65 (13) 350 (73) Victoria General 103 (21) 125 (26) 255 (53) Average^ 122 (25) 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. 62 their new f a c i l i t y and therefore m e d i c a t i o n r e q u i r e m e n t s were quite low. The average number of " F r e q u e n t l y " used drugs for the three hospitals with Extended C a r e f a c i l i t i e s was 83 or approximately 17 percent of the 483 drugs. Should a future D r u g F o r m u l a r y contain as many as 600 monographs, some m e c h a n i s m for separating those monographs " F r e q u e n t l y " used i n spe c i a l t y a r e a s , such as Extended C a r e , should be designed for ease of u s e . In the f i e l d of P s y c h i a t r y (Table VI), L i o n s Gate H o s p i t a l and the Vancouver G e n e r a l H o s p i t a l had s i m i l a r drug use needs with 50 and 53 drugs " F r e q u e n t l y " used r e s p e c t i v e l y . The R o y a l Jubilee H o s p i t a l l i s t e d 193 drugs " F r e q u e n t l y " u s e d . The l a r g e d i f f e r e n c e seen here may be due to the fact that the R o y a l Jubilee H o s p i t a l operates a v e r y large P s y c h i a t r i c f a c i l i t y while both L i o n s Gate H o s p i t a l and the Vancouver G e n e r a l H o s p i t a l operate c o n s i d e r a b l y s m a l l e r u n i t s . The average number of " F r e q u e n t l y " used drugs for the three hospitals was 98 or approximately 20 percent of the number of drugs l i s t e d i n the alphabetical index of the present D r u g F o r -m u l a r y . A g a i n , the complete D r u g F o r m u l a r y on p s y c h i a t r i c wards would appear to prove u n n e c e s s a r y and awkward as demonstrated throughout T a b l e s III to V I . The m a j o r c r i t i c i s m of the present F o r m u l a r y is that it is too bulky for convenient use at the ward l e v e l . Attempts to make 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 nature (see page 46 ) suggest that this p r o b l e m may be i n c r e a s e d with the addition of approximately 300 additional monographs in the future. The data p r e s e n t e d in T a b l e s III to VI, however, r e v e a l that 63 TABLE V FREQUENCY OF USE OF PROVINCIAL FORMULARY DRUGS (483) IN EXTENDED CARE WARDS OF VARIOUS HOSPITALS FREQUENTLY 1 OCCASIONALLY 2 RARELY 3 Hospital Number (%) 4 Number (%) 4 Number (%) 4 Vancouver General 43 (9) 73 (15) 367 (76) Lions Gate 106 (22) 67 (14) 310 (64) Victoria General 100 (20) 120 (25) 463 (55) Average^ 83 (17) 86 (18) 314 (65) 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. 64 TABLE VI FREQUENCY OF USE OF PROVINCIAL FORMULARY DRUGS (483) IN PSYCHIATRIC WARDS OF VARIOUS HOSPITALS FREQUENTLY 1 OCCASIONALLY 2 RARELY 3 Hospital Number (%) 4 Number (%) 4 Number (%) 4 Vancouver General 53 (11) 116 (24) 314 (65) Lions Gate 50 (10) 49 (10) 384 (80) Royal Jubilee 193 (40) 91 (19) 199 (41) 5 Average 98 (20) 85 (18) 300 (62) 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. 65 c o n s i d e r a b l y fewer drugs than those that might appear i n a future F o r m u l a r y are u s e d with any degree of frequency i n any given s p e c i a l t y ward. T h i s would suggest that there i s no need for the bulk of the complete F o r m u l a r y i n these a r e a s . It also suggests that "Specialty F o r m u l a r i e s " for s p e c i a l t y a r e a s may function well in 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 " for the entire h o s p i t a l . M a s t e r - " M i n i " F o r m u l a r y The p r e v i o u s r e s u l t s p r o j e c t that each hospital might have 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 drug monographs as well as " M i n i " F o r m u l a r i e s designed for and containing monographs for only those drugs " F r e q u e n t l y " used i n s p e c i a l t y ward a r e a s . These two types of F o r m u l a r i e s within a ho s p i t a l would be fu 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 monograph content. F o r example (see F i g u r e 7, page 51), the M a s t e r F o r m u l a r y would contain the complete monograph plus the b i b l i o g r a p h y whereas the " M i n i " F o r m u l a r y in use on the w ard would not be encumbered by the b i b l i o g r a p h y . Another feature that might be included in a future M a s t e r (but not "Mini") F o r m u l a r y is 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 number of different m a n u f a c t u r e r s and b r and names for each generic name drug or drug product, it i s suggested that a complete c r o s s - i n d e x of b r and to generic names be produced. In this index it is suggested also that the Canadian D r u g Identification Code A c t i v e Ingredient Group Number shown on the present r e v i s e d monographs be included to f a c i l i t a t e the use of national 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 systems when these are i n t r o -duced into the hospitals at some future date. It is recommended further that this c r o s s - i n d e x be produced as soon as p o s s i b l e and updated as new brand name drugs are introduced and as new monographs are produced for i n c l u s i o n i n the D r u g F o r m u l a r y . A s can be deduced f r o m the i n c r e a s e d amount of i n f o r m a t i o n p r oposed for addition to the F o r m u l a r y as well as a complete b i b l i o g r a p h y for each monograph and 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 could become a m a s s i v e volume. The value of such a volume for r e s o u r c e i n f o r -mation and r e s e a r c h , however, becomes apparent. On the other hand, it becomes apparent also that the M a s t e r F o r m u l a r y as d e s c r i b e d here would not be e f f e c t i v e l y used at the ward l e v e l due to its b u l k. F r o m this study there appear to be four ways to reduce the b u l k i -ness of the D r u g F o r m u l a r y on the ward by using a " M a s t e r " - " M i n i " F o r -m u l a r y arrangement. F i r s t l y , by 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 located at the ward l e v e l the bulk should be d e c r e a s e d by one-t h i r d to one-half. In this r e s p e c t , it is proposed that the monographs with the r e f e r e n c e numbers be kept on the ward while the b i b l i o g r a p h i e s be m a i n -tained in the M a s t e r F o r m u l a r y in the C e n t r a l P h a r m a c y or D r u g Informa-tion C e n t r e . T h i s would enable the reduction of the D r u g F o r m u l a r y on the w ard while s t i l l allowing 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 when n e c e s s a r y by contacting the p h a r m a c y . 67 A second approach to r e d u c i n g the.bulk of the F o r m u l a r y would be to produce " M i n i " F o r m u l a r i e s for each s p e c i f i c ward, including only those drugs which are " F r e q u e n t l y " used i n each a r e a . Unfortunately, this solution i f undertaken by the p r o d u c e r s of the D r u g F o r m u l a r y would probably be too c o s t l y to become f e a s i b l e . If a s p e c i f i c " M i n i " F o r m u l a r y was to be produced for each ward of each hospital of the p r o v i n c e (100 p r o v i n c i a l hospitals with an average of 8 to 10 wards each) there could 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 collate s e p a r a t e l y . T h i s would gre 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 produce the D r u g F o r m u l a r y and i n c r e a s e the costs p o s s i b l y beyond the present c o s t s . A t h i r d approach to producing a " M i n i " F o r m u l a r y could o v e r -come this p r o b l e m by having the p h a r m a c i s t s of each hospital conduct s u r -veys s i m i l a r to the Monograph U t i l i z a t i o n Survey (see pages 31-34) on the wards of the i r hospital to determine those drugs most frequently used in each patient c a r e a r e a . Once this has been determined, it is suggested that the monographs for these drugs (without the bibliography) could be removed f r o m a complete F o r m u l a r y and be p l a c e d i n c l e a r p l a s t i c envelopes and i n s e r t e d i n a t h r e e - r i n g binder which could be permanently affixed to either a counter or wa l l at the location of greatest u s e . In this manner, the mono-graphs would be available to the u s e r s but could not be r e m o v e d f r o m the place of use, 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 of the monographs being l o s t . The r e m a i n i n g monographs could be maintained i n the o r i g i n a l binder and stored on the n u r s i n g station i n a drawer or cupboard. T h e s e monographs should be kept on the n u r s i n g station so that they are av a i l a b l e when o c c a s i o n a l l y 68 or r a r e l y used drugs are being 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 medications i s r e q u i r e d by the m e d i c a l or n u r s i n g staff. The above proposed s y s t e m might be expected to cost a p p r o x i -mately $10. 00 per ward beyond the cost of the b a s i c Drug F o r m u l a r y . (This i s based on $2. 50 for a h a r d c o v e r , t h r e e - r i n g binder and $0. 15 x 50 = $7. 50 for 50 p l a s t i c envelopes). T h i s s y s t e m would allow between 50 and 100 monographs to be p l a c e d in the " M i n i " F o r m u l a r y . Another s y s t e m along s i m i l a r lines was investigated u s i n g K a r d e x f r a m e s of 8-1/2 x 11 inch s i z e to contain the monographs. The cost of this type of s y s t e m was approximately 40 times gr e a t e r than the above syste m and ther e f o r e was thought to be p r o h i b i t i v e for w i d e s p r e a d use. The fourth suggestion for r e d u c i n g the bulk of the F o r m u l a r y i s to p r i n t the monographs of two pages or m o r e in length on both sides of a page (see F i g u r e 7, page 51 ). The b i b l i o g r a p h i e s of two or m o r e pages also could be p r i n t e d on both sides of a page. T h i s suggestion could have the p o s s i b l e effect of reducing the siz e of the F o r m u l a r y by up to one-half. Under the p r o p o s e d conditions, the M a s t e r F o r m u l a r y would be maintained in the p h a rmacy (containing the monographs of a l l drugs used in the h o s p i t a l , the b i b l i o g r a p h i e s for each monograph and the complete c r o s s -index of the F o r m u l a r y ) . The " M i n i " F o r m u l a r y would contain only the drug monographs of the drugs frequently used on the ward with the r e m a i n i n g monographs being s t o r e d in the o r i g i n a l binder in a drawer or cupboard on the ward. 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 Data P r o c e s s i n g . As 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 the use of Cathode Ray Tube (C.R. T.) r e a d e r - p r i n t e r s become m o r e acceptable in h o s p i t a l s , another means of reducing the bulk of the present D r u g F o r m u l a r y w i l l become f e a s i b l e . 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 completely f r o m the ward ar e a s and the maintenance of a l l drug i n f o r m a t i o n in a c e n t r a l data bank which would be connected to each a r e a by a C.R.T. r e a d e r - p r i n t e r . The present cost of this s y s t e m i s p r o h i b i t i v e , but as the s y s t e m becomes m o r e available and l e s s expensive, the use of C.R.T. r e a d e r - p r i n t e r s may become a m o r e fe a s i b l e means of supplying drug i n f o r m a t i o n to health p r a c t i t i o n e r s . Another approach to E . D . P . however, might reduce the present cost of F o r m u l a r y p r o d u c t i o n . The production of the D r u g F o r m u l a r y p r e s e n t l y i s being undertaken by 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 cost to the hospitals of about $15. 00 per copy or approximately four cents a page. T h i s cost r e p r e s e n t s only the duplication and d i s t r i b u t i o n costs and does not include p e r s o n n e l and stenographic expenses in r e s e a r c h -ing and p r e p a r i n g the i n f o r m a t i o n for each monograph. The Ottawa C i v i c H o s p i t a l was contacted in r e g a r d to the production costs of E.D.P. F o r m u -l a r y p r i n t i n g . The cost of producing each F o r m u l a r y at the Ottawa C i v i c H o s p i t a l was $5. 00 or about two cents per page. T h i s cost r e p r e s e n t s approximately one-half the cost of p r i n t i n g the D r u g F o r m u l a r y by a conven-tional method. It i s felt that the cost d i f f e r e n c e can be attributed to three 70 f a c t o r s : the method of production; the number of pages; and f i n a l l y , the number 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 H o s p i t a l F o r m u l a r y i s p r i n t e d by E.D.P. methods which, f r o m the l i t e r a t u r e (27, 38) were noted to be l e s s expensive for l o n g - t e r m p r i n t i n g , while 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. The Ottawa C i v i c H o s p i t a l p r i n t s about 600 copies of approximately 270 pages each, whereas the c u r r e n t D r u g F o r m u l a r y contains 400 pages and the number of F o r m u -l a r i e s p r i n t e d i s about 250. A c c o r d i n g l y , the adoption of E .D.P. pr i n t i n g for the P r o v i n c i a l F o r m u l a r y should not be c o n s i d e r e d before the m a j o r r e v i s i o n s are made and the r e g u l a t i o n publication is decided upon. The above studies 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 of the present D r u g F o r m u l a r y should be c o n s i d e r e d in addition to updating, i n making it m o r e use f u l on a p r o v i n c i a l b a s i s . The future number of mono-graphs, additional i n f o r m a t i o n in each, an extensive b i b l i o g r a p h y , a M a s t e r - " M i n i " format for m o r e effective hospital use and production aids such as e l e c t r o n i c data p r o c e s s i n g , a l l would a s s i s t in producing 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 Updating the F o r m u l a r y P e r h a p s the greatest l i m i t a t i o n of the present D r u g F o r m u l a r y is that no m e c h a n i s m exists for updating and evaluating the drug monographs or for r e v i e w i n g the s c i e n t i f i c and c l i n i c a l v a l i d i t y of the i n f o r m a t i o n con-71 tained t h e r e i n . The pr o p o s e d method that was evaluated in the present study is the one which was used to produce 100 existing monograph r e v i s i o n s based on a senior p h a r macy student assignment (see Methodology, page 37 ) during 1972-73. To evaluate the proposed m e c h a n i s m , two points were studied: (1) The number and nature of changes i n the mono-graphs as suggested f r o m the student updating assignment (see Methodology, page 37 ); (2) The time r e q u i r e m e n t for student, i n s t r u c t o r and stenographer input for monograph updating (see Methodology, page 41 ), F r o m the r e s u l t s of these studies, p r o j e c t i o n s were made r e g a r d i n g a schedule for updating the monographs on an annual combined education and " s e r v i c e " b a s i s and r e g a r d i n g the person n e l which might be r e q u i r e d to con-tinue the annual updating of the F o r m u l a r y . (a) Nature and F r e q u e n c y of Changes F o r each updated monograph the students completed a Change Sheet (see Methodology, page 39) which indicated a l l additions, c o r r e c t i o n s and changes to the o r i g i n a l monograph. One hundred of these Change Sheets were analyzed to determine the need for annual updating of the existing monographs. The r e s u l t s of this study are presented in Table VII. Because i n some ca s e s , three to five y e a r s had elapsed since the o r i g i n a l monograph was produced, a great deal of new i n f o r m a t i o n and, I 72 T A B L E VII 1 M O N O G R A P H C H A N G E S B a s e d on Information F r o m the L i t e r a t u r e i n 1969-73 2 Average Range T o t a l Changes 13.26 3-30 Changes in sections on D r u g Interactions and - „ „ „ T 4. T .,. 3 5. 77 2-18 Intravenous In c o m p a t i b i l i t i e s 1. A s determined by re v i e w i n g the Change Sheets for 100 randomly sel e c t e d existing monographs during the updating assignment. 2. The average number of r e q u i r e d changes found on one monograph. 3. The number of changes found on the monograph sections thought to be most r e q u i r e d i n annual updatings. 73 t h e r e f o r e , changes appeared i n the updated monographs. T h i s became apparent when the Change Sheets were studied. Due to the significant number of changes r e q u i r e d , two f o r m s of updating should be i d e n t i f i e d in the total r e v i s i o n r e q u i r e m e n t s - complete evaluation and annual updating. Complete evaluation includes r e f e r e n c i n g of the existing monograph i n f o r m a t i o n , addition of the new sections on "Mode of A c t i o n " and "Instructions to the P a t i e n t " , and the addition of any-additional i n f o r m a t i o n f r o m previous and c u r r e n t l i t e r a t u r e to the existing monograph (see Methodology, pages 37-38). T h i s definition of complete evaluation is consistent with the assignment completed by the senior p harmacy students i n 1972-73. Once this complete evaluation has been done on a l l monographs, only annual updating f r o m c u r r e n t l i t e r a t u r e would be r e q u i r e d in future y e a r s . The p roposed annual updating, a part of the total r e v i s i o n , con-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 monograph against standard r e f e r e n c e s o urces such 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 , textbooks and the Compendium 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 , as w e l l as updating the monograph f r o m the l i t e r a t u r e of the p r e v i o u s year only, with emphasis on the sections of "Drug Interact i o n s " and "Intravenous I n c o m p a t i b i l i t i e s " . The determination to place the emphasis on these sections was made because the number of changes which o c c u r r e d in these two sections was greater than o n e - t h i r d of the total number of changes per monograph in most cases (see T a b l e VII). 74 (b) T i m e E v a l u a t i o n The purpose of studying the time r e q u i r e m e n t s of the students, i n s t r u c t o r s and stenographers for updating and typing the drug monographs was to determine an approximate p e r s o n n e l r e q u i r e m e n t for updating the D r u g F o r m u l a r y on a continuing " s e r v i c e " b a s i s i n the future. The i n d i v i -dual as well as c o l l e c t i v e times were analyzed to enable f l e x i b i l i t y i n any suggested s y s t e m . One hundred time sheets again were analyzed for each of the three groups (students, i n s t r u c t o r s , and stenographers) for i n c l u s i o n i n the time evaluations. The r e s u l t s of this study are presente d in T a b l e VIII. 75 TABLE VIII REVISION TIMES A. STUDENTS 1. Total Revision 2. Annual Updating B. INSTRUCTORS' REVIEW 1. Review and Evaluate 2. Edit and Condense for monograph format C. . SECRETARIAL WORK Typing 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. AVERAGE TIME FOR MONOGRAPHS - Standard Deviation (Hours)  13.13 - 9.09 4.50 t 3. 72 2 3.26 t l . 06 0.84 t 0.31 0.68 t 0.443 76 A s can be seen f r o m the T a b l e of R e v i s i o n T i m e s , approximately 13 hours per monograph was r e q u i r e d by the students to evaluate the comp-lete monograph. To update only the sections on "Drug Interact i o n s " and "Intravenous I n c o m p a t i b i l i t i e s " , the students r e q u i r e d between four and five h o u r s . B y c o r r e l a t i n g these r e s u l t s with the definitions of complete evaluation and annual updating on page 73 , it seems reasonable to estimate that the annual updating would r e q u i r e d approximately one-third of the time r e q u i r e d for the i n i t i a l complete evaluation of the monograph. The determination of i n s t r u c t o r time r e q u i r e d concerns only the time n e c e s s a r y to complete the " s e r v i c e " p o r t i o n of their work and does not c o n s i d e r their academic input to the updating assignment (see Methodology, page 37). T h i s " s e r v i c e " part includes the evaluation of the o r i g i n a l r e f e r e n c e as cited by the student for s c i e n t i f i c v a l i d i t y , editing and condensing the updated monograph for typing. It can be seen that this p o r t i o n of the i n s t r u c t o r s ' c ommitment r e q u i r e d about four hours per monograph. Once a l l of the F o r m u l a r y monographs have been completely evaluated however, it can be expected that a p p r oximately one hour w i l l be r e q u i r e d to r e v i e w the annual updating done by the students. The time r e q u i r e d by the stenographic staff to type each monograph in the standard format (see F i g u r e 7, page 51), with its 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 approximately 40 minutes. T h i s figure does not include the time n e c e s s a r y to c o r r e c t any typographical e r r o r s which were d i s c o v e r e d while p r o o f r e a d i n g the evaluated monographs. 77. In t o t a l , the time r e q u i r e d for student, i n s t r u c t o r , and stenographer input was about 18 hours for each monograph based on the 1972-73 complete evaluation f o r m a t . 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 using the r e s u l t s of the time evaluation, a schedule of complete evaluation and annual updating of the r e m a i n i n g and future monographs might be made on a combined education and " s e r v i c e " b a s i s . T h i s p r o p o s a l is made on the assumption that the educational time and c r e d i t value of the student assignment w i l l be continued. It i s made also on the assumption that a " s e r v i c e " component of i n s t r u c t o r time w i l l be made a v a i l a b l e . The prop o s e d schedule i s presented in T a b l e IX. A s s u m i n g that the educational assignment w i l l be s i m i l a r i n 1973-74, it is proposed that the senior year pharmacy students be assi g n e d complete evaluations (and annual updating) of the r e m a i n i n g 88 monographs not done in 1972-73 as wel l as the annual updating of the 218 monographs evaluated i n 1972-73. On this p r oposed schedule, the r e v i s i o n of the existing monographs w i l l r e a c h a maintenance l e v e l by the end of the academic t e r m 1973-74. T h e r e a f t e r , the student assignment would con s i s t only of annual updating of the existing drug monographs and perhaps the complete evaluation of new monographs. In 1972-73, the i n s t r u c t o r s reviewed, edited and condensed 100 of the 218 evaluated monographs. It is proposed that in 1973-74, the i n s t r u c t o r s 78 T A B L E IX F U T U R E R E V I S I O N S C H E D U L E for D r u g F o r m u l a r y Monographs A c a d e m i c T e r m s Number of R e v i s e d Monographs 1972-73 1973-74 T o t a l Complete E v a l u a t i o n 7 Annual Updating Instructor Review and C o n d e n s e3 218 218 100 88 (306) 306 206 (306) 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 student assignment i n 1972-73 and as defined on page 73 . 3. Instructor committment on a " s e r v i c e " b a s i s only. 4. The total number of drug monographs in the present F o r m u l a r y . 79 complete the r e m a i n i n g 118 monographs evaluated in 1972-73 and review and condense the 88 monographs evaluated in 1973-74. A s with the student assignments, the " s e r v i c e " commitment of the i n s t r u c t o r s would r e a c h a maintenance l e v e l by the end of the academic t e r m 1973-74 should no additional monographs be added. However, it is pr o p o s e d that the i n s t r u c t o r s ' c ommitment thereafter should be to produce new monographs as requested i n the Ad d i t i o n a l Drugs Survey (see Methodology, pages 27 , 28 and Appendix II). F u t u r e P e r s o n n e l Requirements T o continue the updating of the F o r m u l a r y on a " s e r v i c e " b a s i s for d i s t r i b u t i o n to the hospitals of B r i t i s h C o l u m b i a , c e r t a i n p e r s o n n e l r e q u i r e -ments must be quantitated. T h i s p r o j e c t i o n is ba s e d on a continued student involvement and, t h e r e f o r e , no p r o f e s s i o n a l staff r e q u i r e m e n t w i l l be assi g n e d to the por t i o n of evaluation p r e s e n t l y undertaken by the students. However, " s e r v i c e " staff w i l l be needed to continue the i n s t r u c t o r s ' review and condensing of the updated monographs as we l l as the typing of the same. F r o m the T i m e E v a l u a t i o n studies, it was noted that the i n s t r u c t o r s r e q u i r e d an average of four hours to review and condense each monograph (see T a b l e VIII). T h e r e f o r e , it might be expected that a p p r oximately 800 hours would be r e q u i r e d for the i n s t r u c t o r s to review and condense the r e m a i n i n g 206 monographs (four hours times 206 monographs). On this b a s i s it is expected that about one to one and one-half additional hours per monograph w i l l be n e c e s s a r y to r e v i e w the 218 monographs which w i l l r e q u i r e 8G annual updating i n 1973-74. T h i s r e p r e s e n t s approximately an additional 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 " committment as pr o j e c t e d , a total of approximately 1100 i n s t r u c t o r " s e r v i c e " hours w i l l be needed in 1973-74. F o r this r e a s o n , it is anticipated that one-half of a pharmacist's time w i l l be r e q u i r e d i n 1973-74 for this committment. R e c o g n i z i n g that there might be 206 additional monographs p r e p a r e d for typing i n 1973-74 (see T a b l e IX), and that each monograph took a p p r o x i -mately 40 minutes to type during 1972-73 (see T a b l e VIII), it is pr o j e c t e d that about 140 hours of stenographic time might be r e q u i r e d i n 1973-74. Since this extrapolation does not account for c o r r e c t i o n s of typographical e r r o r s , it i s r e c o g n i z e d that this time estimate is a v e r y m i n i m u m . The r e s u l t s of the above studies identify that the monographs of the exi 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 complete evaluation of the present i n f o r -m ation as w e l l as annual updating of new i n f o r m a t i o n . Student, i n s t r u c t o r and stenographic time r e q u i r e d to evaluate and update 100 monographs during the 1972-73 academic t e r m were r e c o r d e d and analyzed. Such analyses are used to p r o j e c t a continued evaluation and up-dating r e v i s i o n of the r e m a i n i n g monographs during 1973-74. On this b a s i s , it is expected that at least one-half of a pharmacist's time w i l l have to be made available other than for academic i n s t r u c t i o n , and that about 140-150 hours of stenographic time, s i m i l a r l y , w i l l be r e q u i r e d to complete the 81 r e v i s i o n of 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 d u r i n g the next y e a r . It c a n be e x p e c t e d that a n n u a l u p d a t i n g t h e r e a f t e r , w i l l r e q u i r e a s i m i l a r c o m m i t t m e n t . 82 R E C O M M E N D A T I O N S If the present D r u g F o r m u l a r y d i s t r i b u t e d for use in B r i t i s h C o l u m b i a hospitals is to r e t a i n its present value, and perhaps r e a l i z e a greater potential, s e v e r a l changes in format and a r e g u l a r updating m e c h a n i s m should be effected. B a s e d on the present study, these include: 1. The addition of a p proximately another 300 drug monograph en t r i e s to make the F o r m u l a r y m o r e useful 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 monograph, s p e c i f i c a l l y i n the "Mode of A c t i o n " and "Instructions to the Patient"; 3. The evaluation and r e f e r e n c i n g of the existing i n f o r m a t i o n and the annual updating of the same; 4. The adoption of a M a s t e r F o r m u l a r y containing a l l p r o v i n c i a l l y used drugs, a complete b i b l i o -graphy for each monograph and a c r o s s - i n d e x of g e n e r i c to m a n u f a c t u r e r s ' brand names; 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 and containing only the monographs for those drugs frequently used in the i n d i v i d u a l h o s p i t a l w ard a r e a s ; 6. The arrangement for a p r i n t i n g rather than typing production of the F o r m u l a r y ; 7. The p r o v i s i o n of at least one-half time p h a r m a c i s t on a " s e r v i c e " b a s i s to edit, r e v i s e and condense student drug l i t e r a t u r e evaluation p r o j e c t s to F o r m u l a r y format; 8. The p r o v i s i o n of a m i n i m u m of 200 hours per y e a r stenographer time; 83 9. The arrangement for a M e d i c a l Review B o a r d to judge the c l i n i c a l s i g n i f i c a n c e of proposed new i n f o r m a t i o n to be added; 1 0 . The establishment of a c e n t r a l D r u g Informa-tion Centre in the p r o v i n c e to coordinate the above functions and to serve as a r e s o u r c e centre for additional i n f o r m a t i o n r e q u i r e d on a da i l y b a s i s for the ef f e c t i v e use of the F o r m u l a r y . 84' B I B L I O G R A P H Y 1. Anon., D r u g I n t e l l . C l i n . P h a r m . , 4, 109 (1970). 2. R eport P r e p a r e d for the Study of 'Interagency 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 and R e g u l a t i o n s ' by the Subcommittee on R e o r g a n i z a t i o n and International O r g a n i z a t i o n of the Senate Committee on Government Op e r a t i o n s . U. S.. Government P r i n t i n g O f f i c e , August 30, 1963. Appendix C. 3. Report P r e p a r e d for the Study of 'Interagency Coordination in D r u g R e s e a r c h and Regulations' by the Subcomittee on R e o r g a n i z a t i o n and International O r g a n i z a t i o n of the Senate Committee on Government O p e r a t i o n s . U.S. Government P r i n t i n g O f f i c e , August 30, 1963. pp. 1-3. 4. R e port P r e p a r e d for the Study of 'Interagency C o o r d i n a t i o n in D r u g , R e s e a r c h and R e g u l a t i o n s ' by the Subcommittee on R e o r g a n i z a t i o n and International O r g a n i z a t i o n of the Senate Committee on Government Ope r a t i o n s , U. S.. 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J . , and D i c k , R.W., A m . J . Hosp. 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 . J . Hosp. P h a r m . , 24, 5 (1967). 29. B u r k h o l d e r , D., A m . J . Hosp. P h a r m . , 22, 48 (1965). 30. R o s e n b e r g , J.M. Hosp. P h a r m . , 3, 5 (1968). 86-31. L i g u o r i , S i s t e r M., Drug Information S e r v i c e s , presented at St. Michael's H o s p i t a l , T o r o n t o , August 20, 1968. (unpublished). 32. F r a n c k e , D.E., JLatiolais, C.S., F r a n c k e , G. N., Ho, N. F . H., M i r r o r T o H o s p i t a l P h a r m a c y , 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 , Washington, 1964, pp. 140-150. 33. Statement of Guidelines for the Use of the H o s p i t a l F o r m u l a r y System, Canadian Society of 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 , August, 1968. 34. Anon., A m . J . Hosp. P h a r m . , 21_, pp. 40-41 (1964). 35. Guide to H o s p i t a l A c c r e d i t a t i o n , 1972, Canadian 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 , T o r o n t o , 97. 36. Sonnedecker, G., D r u g I n t e l l . C l i n . P h a r m . , 6, pp. 425-432 (1972). 37. Hlynka, J.M., "To Develop the F i r s t Stage of a D r u g Information S e r v i c e for B r i t i s h C o l u m b i a " , Appendix I, July 20, 1972. 38. Smythe, H. A., Can. J . Hosp. P h a r m . , X X I V , pp. 169-171 (Sept. /Oct. 1971). 39. T o b e r , T.W., Am. J . Hosp. P h a r m . , _21, pp. 105-111 (1964). 40. L a m y , P.P., B o u r n , I. F . and F l a c k , H. L . , A m . J . Hosp. P h a r m . , 18, pp. 641-649 (1961). 41. D a n i e l s o n , F . , Hosp. P h a r m . , 5, pp. 21-24 (1970). 42. Anon., A m . J . Hosp. P h a r m . , 23, pp. 293-303 (1966). 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>, pp. 448-455 (1972). 44. M i l l e r , A.B., Drug Information B u l l . , _5, 157 ( J u l y / D e c . 1970). 45. Hetherington, C , The J o u r n a l of H o s p i t a l P h a r m a c y , 28, pp. 152-155 (1970). 46. H e l l e r , W.M., A m . J . Hosp. P h a r m . , _l€>, pp. 519-523 (1959). 47. S eim, H. C , and Kabat, H. F . , A m . J . Hosp. P h a r m . , _23, 241 (1966). 48. . B u r k h o l d e r , D., A m . J . Hosp. P h a r m . , 22, 50 (1965). 49. A n d e r s o n , R.D., and L a t i o l a i s , C. J . , A m . J . Hosp. P h a r m . , 22, 55 (1965). 87-: 50. P a r k e r , P . F . , A m . J . Hosp. P h a r m . , _22, pp. 42-47 (1965). 51. V i s c o n t i , J . , D r u g Information S e r v i c e s P o l i c y , Ohio State U n i v e r s i t y H o s p i t a l , Department of P h a r m a c y , 14 (1962, r e v i s e d 1968). 52. Munro, F . J . , J r . , A m . J . Hosp. P h a r m . , 24, 574 (1967). 53. R o s e n b e r g , J.M., and P e r i t o r e , S.P., A m . J . Hosp. P h a r m . , 28, 270 (1971). 54. P e a r s o n , R. E . , S a l t e r , F . J . , B o h l , J . C., Thudium, V . F . , and P h i l l i p s , G. L . , A m . J . Hosp. P h a r m . , 29, 229 (1972). 55. - A m e r s o n , A.B., and Walton, C.A., A m . J . Hosp. P h a r m . , 28, 267 (1971). 56. B a u m g a r t e r , R.P., Am.. J . Hosp. P h a r m . , 28, 670 (1971). 57. P e a r s o n , R. E . , S a l t e r , F . J . , B o h l , J . C., Thudium, V. F . , and P h i l l i p s , G.L., A m . J . Hosp. P h a r m . , _29, 312 (1972). 58. P e a r s o n , R. E . , P h i l l i p s , G. L . , and Thudium, V . F . , " P r o j e c t to Develop, Evaluate and Demonstrate a P i l o t Drug Information and D r u g T h e r a p y A n a l y s i s and Reporting System". A project of the U n i v e r s i t y of M i c h i g a n College of P h a r m a c y , pp. 8-12 (1971). 59. P e a r s o n , R. E . , P h i l l i p s , G. L . , and Thudium, V . F . , " P r o j e c t to Develop, Evaluate and Demonstrate a P i l o t D r u g Information and D r u g T h e r a p y A n a l y s i s and Reporting System". A p r o j e c t of the U n i v e r s i t y of M i c h i g a n College of P h a r m a c y , 17 (1971).-60. Couper, I. A., The J o u r n a l of H o s p i t a l P h a r m a c y , 30, 125 (1972). 61. Anon., The P h a r m a c e u t i c a l J o u r n a l , 209, 159 (1972). 62. Duront, W.J., The H o s p i t a l P h a r m a c i s t , X X I , 213 (Sept./Oct. 1968). 63. R e i l l y , M.J., D r u g Information B u l l . , _5, 154 ( J u l y / D e c . , 1970). 64. Wittrup, R.D., A m . J . Hosp. P h a r m . , 22, 59 (1965). 65. Rapport, H., Hosp. P h a r m . , 4, 17 (1969). 66. B u r k h o l d e r , D., D r u g I n t e l l . , 1, 321 (1967). 67. W i l s o n , C O . , and Jones, T . E . , ed. A m e r i c a n D r u g Index 1967, J . B. L i p p i n c o t t Co., P h i l a d e l p h i a , 174. .88 68. Rotenberg, G. N., D r u g Information B u l l . , _5, 181 ( J u l y / D e c . 1970). 69. Welt, I.D., ed. Drug Information II F o r the Health P r o f e s s i o n s , Gordon 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, pp. 336-341. 70. Rotenberg, G.N., and Hughes, F.N., ed. Compendium of P h a r m a c e u t i - cals and S p e c i a l t i e s 7th edition, The Canadian P h a r m a c e u t i c a l A s s o c i a -tion, T o r o n t o , 1972. 71. Z a c h a r i s , E . , P e r s o n a l C o m m u n i c a t i o n . 72. d u P l e s s i s , D., P e r s o n a l C o m m u n i c a t i o n . 89 A P P E N D I X I C O S T O F T H R E E 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 1. deHaen S e r v i c e s , P a u l deHaen Inc., 11 West 42nd Street, New Y o r k , N. Y., 10036. A. "Drugs in Use and Combination" $700.00/year B. "Drugs in R e s e a r c h " $150.00/year C. "Drugs in Use P r o d u c t P r o f i l e Index" $100.00/year D. "Drugs in P r o s p e c t " $450.00/year 2. 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 Hos p i t a l P h a r m a c i s t s , 4630 Montgomery Ave., Washington, D.C., 20014. $150.00/year 3. Iowa D r u g Information S e r v i c e s , College of 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 , Iowa. 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) $900. 00/year* B. R e t r o s p e c t i v e F i l e (1966-1972) $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 Information S e r v i c e s , College of 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 , Iowa, F e b r u a r y , 1973. APPENDIX II LISTS OF DRUGS RECEIVING TWO OR MORE REQUESTS FOR INCLUSION IN THE DRUG FORMULARY 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 (Continued) D r u gs r e c e i v i n g 4 requests (Continued) O x y t e t r a c y c l i n e P h e n e l z i n e Pseudoephedrine H y d r o c h l o r i d e T e r p i n Hydrate T r i e t h y l e n e t h i o P hosphoramide (Thio-tep T r i m e t h a d i o n e V a n c o m y c i n Drugs r e c e i v i n g 3 requests A c e n o c o u m a r o l Alphaprodine H y d r o c h l o r i d e A l u m i n u m Acetate Ambenonium C h l o r i d e A m m o n i a t e d M e r c u r y Bend r o f l u m e t h i a z i d e B l o o d and B l o o d Components Bu t a b a r b i t a l Sodium Carbinoxamine C a r i s o p r o d o l C h l o r c y c l i z i n e C hlo r me zanone Chlorphenoxamine Maleate Chlo r p r o t h i x e n e C h l o r t h a l i d o n e C h l o r o t r ianis ene C l i n d a m y c i n Cyclahdelate C y c l i z i n e H y d r o c h l o r i d e Cyclopentolate D a c t i n o m y c i n Dapsone Dex t r o s e Dextrothyroxine D i c h l o r p h e n i r amine D i c l o x a c i l l i n D i c y c l o m i n e D i m e t h y l p o l y s i l o x a n e D i o x y l i n e Phosphate D o x y c y c l i n e E s t r a d i o l V a l e r a t e E t h a m i v a l . A P P E N D I X II (Continued) Drugs r e c e i v i n g 3 requests (Continued) E t h i n y l E s t r a d i o l E t h i s t e r o n e F l u d r o c o r t i s o n e G i t a l i n G l y c e r i n E n e m a Hydroxyprogesterone Caproate Indomethacin Influenza V a c c i n e (Polyvalent) Inositol N i a c inate Isopropamide Isoproterenol Sulphate L i o thyronine M e t h d i l a z i n e H y d r o c h l o r i d e M e t h o c a r b a m o l Me t h y l p r e d n i s o l o n e M e t h y s e r g i d e B i m a l a t e Metapryone Nandrolone Phenpropionate Nicot i n a m i d e N o v o b i a c i n Oxymetholone Paramethadione P h e n m e t r a z i n e P r e d n i s o l o n e P r o c a r b a z i n e P y r i m e t h a m i n e Q u i n a c r i n e Quinidine P h e n y l e t h y l B a r b a t u r i c A c i d S a c c h a r i n Sodium Sodium T e t r a d e c t y l Sulphate Stanozolol S u c c i n y l s u l f a t h i a z i d e Sulfamethiazole Sulfinpyrazone Tetanus A n t i t o x i n T h i o m e r sol T r i a m c i n o l o n e T r i f l u o p r o m a z i n e T r i m e p r amine T r i m e t h o b e n z a m i n e T r i m i p r amine T r i p l e Sulfa C r e a m (equivalent) T r o l n i t r a t e Phosphate Witch H a z e l APPENDIX 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 (Continued) Drugs r e c e i v i n g 2 requests (Continued) C y c l o b a r b i t o n e C y c l o m e t h y l c a i n e Cyclopentamine Dextromethorphan D i a s o l Diatroate Sodium D i h e x y l v e r i n e H y d r o c h l o r i d e D i h y d r o t a c h y s t e r o l D i l l O i l D i p e r i d o l a t e D i p e r i d o n Dipianone D i m e t h i s o q u i n Dime thy Is ter one D i s o d i u m Hydrogen C i t r a t e D o xylamine D r o m o r a n Duo-C V P E n t o r a l E o s i n e E s t r a d i o l L i p r o p i o n a t e E t r a f e d r i n e Ethopropazine Ethylenediamine T e t r a - a c e t a t e E t h y l e n e G l y c o l E t r a f o n E u c a l y p t u s O i l E u f l a v i n e E vans Blue F a t E m u l s i o n F e s t o l F i b r i n o g e n F l u c i n o n i d e F l u o e s c i t e F i u r a n d r e n o l o n e F o l i n i c A c i d F r a m y c e t i n Sulphate F u r a z a l i d o n e G a l l and Opium Ointment Glauber Salts G l y c o t hmoline G o l d Salts A P P E N D I X II (Continued ) Drugs r e c e i v i n g 2 requests (Continued) H e m o c e b r i n Heptobarbital H e t a c i l l i n H i s t a m i n e A z o p r o t e i n H i s t o p l a s m i n Hydromorphone Hy g r o t o n - R e s e r p i n e Ichthyl Immune Se r u m G l o b u l i n Imuvac Iodoform Compounds Iopanoic A c i d Iophendylate Isoflurophate Isometheptene Itramine T o s y l a t e Ketamine L a c t a t e d P e p s i n E l i x i r L a c t o s t a t ( T e s t o s t e r o n e E s t r a d i o l ) Lanatoside C L e v o p r o m a z i n e Magenta M a g n e s i u m T r i s i l i c a t e M e f e n a m i c A c i d Menadione Mepenzolate Mephenytoil M e p h o b a r b i t a l M e p i v a c a i n e M e r c u r i c Oxide M e r c u r y B i c h l o r i d e Ointment Metaxalone Methacholine Methanthe line M e t h y c e l l u l o s e M e t i m y d M y o c r y s i n e Nandrolone Decanoate N e o m e d r o l N i f u r o x i m e Norethandrolone N o r i s o d r i n e O i l of Cajaput O r a l P r o t e o l y t i c s A P P E N D I X II (Continued ) 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 A c i d P a r a - a m i n o B e n z o i c A c i d P a p a i n P u l v u l e s P e n i c i l l a m i n e Penthienate Methobrorriide P e n t y l e n e t e t r a z o l e P e r i c y a z i n e P e r t u s s i s Immune G l o b u l i n P h e n aglycodol P h enol P h e n o x y m e t h y l p e n i c i l l i n P i m a c r i n Compound P i p e r o x a n P o d o p h y l l i n P o t a s s i u m B r o m i d e P o t a s s i u m Phosphate P r o f l a v i n e P r o g f e s t e r o n e P r o g u a n i l P r o t a m i d e P r o t e i n H y d r o l y s a t e P y r i m e t h a m i n e P y r i t h e n P y r r o b u t a m i n e Compound Quandrinal Quinidine Compound Rau d i x i n R a u t r a c t y l #2 #4 R e s o r c i n o l Monoacetate R e s t e c l i n R e s t r o p i n R e s t r o p i n a l R imactane R o n i a c o l Salbutamol S a l i c y l a m i d e S e r - A p - E s S i l v e r N i t r a t e Sodium C i t r a t e Sodium Iodide Sodium F r e e Salt Sulfa suxidine Sodium Oxychlorosene A P P E N D I X II (Continued) D r u gs r e c e i v i n g 2 requests (Continued) Sodium P a r a - a m i n o Hippurate Staphlococcus A n t i t o x i n S t i l b o e s t r o l Diphosphate Sodium Sulf a m e r a z i n e Surfacaine T e s t o l a c t o n e T etrahydr azoline T h e o b r o m i n e C a l c i u m S a l i c y l a t e T h e o p h y l l i n e T hy r o g l o b u l i n T h y r o t r o p i n T r i c h l o r o a c e t i c A c i d T r ifluoper azine T r i p r o l i d i n e and Compounds Tr o x i d o n e T r y p s i n T u b e r c u l i n P P D T y p h o i d , P a r a t y p h o i d and Tetanus T y r o t h r i c i n U r e t h a n V a g i s e c V a l e r i a n Root V i t a m i n A and D Ointment V i o m y c i n White P i n e Syrup Xanthinol Niacinate Zeobarb Z i n c a f r i n Z ylene 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 Information Centre Monograph A s s i g n m e n t P h a r m a c y 403 1. E a c h student w i l l be a s s i g n e d to p r e p a r e three drug monographs and one poison monograph. 2. The completed monographs w i l l be typewritten (double-spaced - including r e f e r e n c e s ) on 8-1/2" x 11" white bond paper. 3. E a c h page of the monograph s h a l l have the name of the drug or poison and the name of the student. 4. D R U G M O N O G R A P H S (a) Update the Lion's Gate H o s p i t a l F o r m u l a r y monograph using the most recent monograph 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 . 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 for 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 drug or poison which has been published during the previous 12 months. R e f e r e n c e a l l new i n f o r m a t i o n with 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 pertinent c l i n i c a l data (do N O T include animal data) - deHaen i n f o r m a t i o n c a r d s may be used but not quoted as r e f e r e n c e s o u r c e . (c) The following sections must be completely r e f e r e n c e d with o r i g i n a l r e f e r e n c e s o u r c e s : Section IX: D r u g Interactions Section X: I.V. I n c o m p a t i b i l i t i e s Only c l i n i c a l l y s i g n i f i c a n t drug i n t e r a c t i o n s should be included in the monograph. ("Drug I n t e r a c t i o n s " by Hansten 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 of the v a r i o u s drug i n t e r a c t i o n s quite 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 In t e r a c t i o n s " by Hansten ar 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 and the student must review the o r i g i n a l a r t i c l e and use 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 s o u r c e . (d) Section 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 statement should be r e f e r e n c e d . 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 and/or r e f e r e n c e s u s e d i n p r e p a r i n g Sections I - X may be repeated. (e) Section XII: Instructions to Patient E v e r y statement should be r e f e r e n c e d . A useful r e f e r e n c e is "Drugs and N u r s i n g Implications1 1 by Govoni and Hayes. The r e f e r e n c e sources may be either 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) Section XIII: P r e s e n t a t i o n A. Dosage F o r m s A v a i l a b l e - "CPS" i s recommended r e f e r e n c e . B . Identi-Code Number - i f a p p l i c a b l e . C. C o s t - the cost to the community p h a r m a c i s t for 100 tablets or capsules is obtained f r o m the Drug Benefit L i s t i n the Student Health S e r v i c e P h a r m a c y , Cunningham B u i l d i n g , U.B.C. 6. G e n e r a l (a) The m e t r i c and centigrade s c a l e s should be u s e d . (b) The following format should be used for the b i b l i o g r a p h y : J O U R N A L : B i l l i g , N., Propoxyphene H y d r o c h l o r i d e (Darvon) P o i s o n i n g i n a T h r e e Y e a r O l d C h i l d , A m e r . J . P i s . C h i l d . 116: 187-189 (August). T E X T B O O K : Goodman, L.S. and G i l m a n , A., The P h a r m a c o l o g i c a l B a s i s  T h e r a p e u t i c s , 4th edi t i o n , M a c M i l l a n Co. : New Y o r k , 1970. 10*0 The abbreviations of j o u r n a l names should c o n f o r m to that of Index M e d i c u s . In r e viewing c l i n i c a l case r e p o r t s , the study should have a random-i z e d double-blind t r i a l with a sample siz e of a p p r o ximately Z 0 patients before the r e s u l t s can be c o n s i d e r e d s t a t i s t i c a l l y s i g n i f i c a n t . One exception is adverse drug re a c t i o n s in which case, the sample si z e can be r educed to only one patient. In c l i n i c a l case r e p o r t s , it is important to co n s i d e r pertinent patient f a c t o r s : i) kidney function ii) l i v e r function i i i ) age, weight, sex iv) other c o i n c i d i n g d i s e a s e s v) placebo effect vi) spontaneous r e m i s s i o n of the d i s e a s e (if applicable) i . e . , rheumatoid a r t h r i t i s vii) seasonal v a r i a t i o n of the disease (if applicable) i . e . , hay fever 101 P H A R M A C Y 403 D R U G A N D POISON I N F O R M A T I O N C E N T R E (DPIC) F o r m a t for D R U G M O N O G R A P H 1. G e n e r a l Information: A. Heading: A H F S P h a r m a c o l o g i c - 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 Number. B. N o n - p r o p r i a t o r y name. C. T r a d e name or synonyms. II. A c t i o n : A. A b s o r p t i o n - includes absorption by usual routes of a d m i n i s t r a -tion but should not be confined only to routes used for com-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 l e v e l s following v a r i o u s routes; f a c t o r s affecting a b s o r p t i o n . B . D i s t r i b u t i o n - usual d i s t r i b u t i o n in body ti s s u e s and f l u i d s ; indicate p r o t e i n binding, penetration of b l o o d - b r a i n b a r r i e r , t r a n s f e r a c r o s s placental b a r r i e r . C. M e t a b o l i s m - h a l f - l i f e and fa c t o r s affecting; sites of b i o t r a n s f o r -mation; met a b o l i c products and their a c t i v i t y . D. E x c r e t i o n - route(s) of e l i m i n a t i o n f r o m the body; f a c t o r s affecting e l i m i n a t i o n ; f o r m i n which e l i m i n a t e d . III. S p e ctrum 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, e t c . ) . IV. Indications: Statement of indications and use (Indicate p r o p h y l a c t i c , therapeutic, p a l l i a t i v e , c u r a t i v e , supportive use, etc. ). V. C o n t r a i n d i c a t i o n s : (include pregnancy if i n f o r m a t i o n known). VI. Cautions: e.g. use in patients with c e r t a i n d i s e a s e s or under c e r t a i n conditions. 102 VII. Dosage: A. Include m i n i m u m , m a x i m u m and maintenance dosage. B. State routes of a d m i n i s t r a t i o n and dose schedule. C. . Give adult and children's dosage. VIII. . Side E f f e c t s A. Include incidence (if a v a i l a b l e ) . B. Group a c c o r d i n g to body s y s t e m (e.g., G. 1.). C. Report changes i n r e n a l or hepatic changes - function, blood d y s c r a s i n s , etc. IX. D r u g Interactions: (include OTC's) A. D r u g - d r u g . B. D r u g - food. C. D r u g - l a b . test. X. I.V. I n c o m p a t i b i l i t i e s : (if applicable) XI. N u r s i n g I m p l i c a t i o n s : (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. O b s e r v a t i o n for a d v e r s e r e a c t i o n s , h y p e r s e n s i t i v i t y r e a c t i o n s , t o x i c i t y . 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 status. C. L a b . tests for r e n a l , and/or hepatic function, blood counts, blood c h e m i s t r y , etc. D. O b s e r v a t i o n for p h y s i c a l changes i n drug - e.g., d i s c o l o u r a t i o n . E . Method, route, time of a d m i n i s t r a t i o n . F . Storage. 103 XII. Instructions to Patient: A. C o r r e c t methods of a d m i n i s t r a t i o n . B. Drug-food and drug-drug (including O T C ) i n t e r a c t i o n s , C. "Selected" side e f f e c t s . D. C o n t r a i n d i c a t i o n s for continued u s e . E . S p e c i f i c storage i n s t r u c t i o n s . XIII. P r e s e n t a t i o n : A. Dosage f o r m s a v a i l a b l e . B. Identi-code number. C. C o s t . X I V . R e f e r e n c e s : X V . Date P r e p a r e d : 

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