In-patient orders

In-patient medication is an item ordered for a specific patient for use during their stay on the ward. In-patient orders will be for medication not usually kept as stock on the patient s ward. 

Before these schemes were introduced, patients were asked to bring any medication they were taking into hospital so that doctors could gather an accurate patient medication history upon admission. This information was transferred to the patient s in-patient chart and subsequent administration of the medication in the hospital took place either via ward stock or patient-specific in-patient orders (see Section 4.2.1). Upon discharge, patients were given a standard 14-day supply of medication via a TTO. In many cases, the patient s original medication was not returned to them and was just discarded. 

In order for this system to work effectively, more than 14 days supply is usually supplied in the first place to allow for both the in-patient and TTO supply. This reduces the instances of items being dispensed twice for a patient (i.e. once as an in-patient order and once as a TTO) and therefore reduces both dispensing time and cost. 

In-patient orders will usually specify the name of the patient, the ward the patient is on and the name and strength of the drug required. 

In addition to the patient s name and details of the ward they are staying on, in-patient orders will usually only contain the name and strength of the drug required. Therefore, it is the responsibility of the ward pharmacist to perform the clinical check on the medication on the ward. This will involve checking the dose and frequency of administration (as details of the dose and frequency of administration will be detailed in the in-patient drug chart). 

Unless the item is being dispensed as part of a dispensing for discharge scheme (see Section 4.2.2, in-patient orders do not usually have an additional or individual patient specific labels added. In some hospitals, they may be labelled with the patient s name and ward (so that the ward staff can easily identify who the medication is for when it arrives on the ward and then place it in the correct section of the ward drugs trolley) but not usually the dose or frequency of the medication. 

This section contains examples of hospital medication orders (an in-patient order, a TTO and an out-patient prescription) for dispensing in a hospital pharmacy. 

In-patient orders check against in-patient chart TTOs check against in-patient chart... 

Once this change has been made, the ward pharmacist can order the amoxicillin sachets from the pharmacy via an in-patient order as follows ... 

The in-patient order would be sent to the pharmacy and the pharmacy technician would dispense two amoxicillin 3 g sachets and send to the ward (once checked), labelled with the patient s name. As the medication will be administered by the ward s nursing staff according to the directions on the in-patient chart, it is not necessary to include administration details on the label. 

Endorse prescription Endorse the in-patient order with the details of the medication supplied. 

Destination of paperwork File the in-patient order within the hospital according to local procedures. 

This chapter has covered the key points with which it is necessary to be familiar in order to supply medication to patients within a hospital setting. It is important that pharmacists and pharmacy technicians are familiar with the different types of hospital supply (in-patient orders, TTOs and out-patient prescriptions) and the new variants of these (for example, dispens-... 

Other Cardiovascular Agents Effecting Atherosclerosis. A large amount of clinical data is available concerning semm Upid profiles in patients subjected to dmg therapy for other cardiovascular diseases. Atheroma, for example, may be the underlying cause of hypertension and myocardial infarction. There are on the order of 1.5 million heart attacks pet year in the United States (155). 

The pretreatment of MH-susceptible patients with oral or intravenous dantrolene prior to surgery in order to avoid a crisis is controversial. Most physicians do not recommend prophylactic pretreatment except in patients who have had a previously documented episode. However, if pretreatment is desired, it is recommended that therapy be begun with intravenous dantrolene in a dose of 2 mg/Kg just prior to induction of anesthesia. This prevents the uncertainty of predictive blood values associated with the use of the oral route. The adverse effects of intravenous dantrolene prophylaxis include phlebitis and tissue necrosis. Patients who receive prophylactic treatment with oral dantrolene often complain of incapacitation, gastrointestinal irritation, prolonged drowsiness, and clinically significant respiratory muscle weakness. 

Self-expanding stents with a higher radial force (e.g., WingSpan, Boston Scientific Corp.) will probably play a key role in acute stroke cases related to intracranial atherosclerotic disease. Antegrade flow is essential for the maintenance of vascular patency, as particularly evident in patients with severe proximal stenoses who commonly develop rethrombosis after vessel recanalization. Furthermore, stenting of the proximal vessels may be required in order to gain access to the intracranial thrombus with other mechanical devices or catheters. In a recent series, 23 of 25 patients (92%) with acute n = 15) or subacute n = 10) ICA occlusions were successfully revascularized with this technique. " ... 

For acute symptomatic hypocalcemia, 200 to 300 mg of elemental calcium is administered IV and repeated until symptoms are fully controlled. This is achieved by infusing 1 g of calcium chloride or 2 to 3 grams of calcium at a rate no faster than 30 to 60 mg of elemental calcium per minute. More rapid administration is associated with hypotension, bradycardia, or cardiac asystole. Total calcium concentration is commonly monitored in critically ill patients. Under normal circumstances, about half of calcium is loosely bound to serum proteins while the other half is free. Total calcium concentration measures bound and free calcium. Ionized calcium measures free calcium only. Under usual circumstances, a normal calcium level implies a normal free ionized calcium level. Ionized calcium should be obtained in patients with comorbid conditions that would lead to inconsistency between total calcium and free serum calcium (abnormal albumin, protein, or immunoglobulin concentrations). For chronic asymptomatic hypocalcemia, oral calcium supplements are given at doses of 2 to 4 g/day of elemental calcium. Many patients with calcium deficiency have concurrent vitamin D deficiency that must also be corrected in order to restore calcium homeostasis.2,37,38... 

Lifestyle modifications are always in order in patients who have developed or those who are at increased risk of developing NODAT.74 Insulin therapy and oral hypoglycemic agents are used often (Table 52-8) in patients in whom lifestyle modifications alone have not controlled blood glucose levels. See Chapter 40 for appropriate treatment regimens for diabetes. 

FIGURE 69-3. Treatment algorithm3 for acute bacterial rhinosinusitis in patients with mild disease without recent antibiotic exposure.31 aAntibiotics are listed in order of predicted efficacy based on predicted clinical and bacteriologic efficacy rates, clinical studies, safety, and tolerability. Doses can be found in Table 69-4. 6Cephalosporins should be considered for patients with non-type I hypersensitivity to penicillins they are more likely to be effective than the alternative agents. cHigh doses (90 mg/kg per day) are recommended for most children, especially those with day-care contacts or frequent infections. 

Additionally, the patient needs to be counseled on the necessity of prophylactic antibiotics prior to any dental or surgical procedure in order to prevent recurrent infections. This is critical in patients with risk factors that predispose them to developing IE, such as prosthetic heart valves, other valvular defects, or previous IE. 

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