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Use of workload and work-flow documentation in two pharmacy satellites to evaluate pharmacists' productivity is described. Workload was evaluated during 14 consecutive days in May 1983 and 7 consecutive days in May 1984. All pharmacists and technicians working in the satellites recorded times for their activities on a form that listed every possible activity; interruptions such as answering the telephone, responding to walking requests, replacing stock, and lunches and break times were also recorded. Concurrently, the clinical coordinator observed and evaluated work performed for four-hour time blocks at least once each day. Analysis of workload and work-flow information identified problems with scheduling, priorities, interruptions, and pharmacists' knowledge of clinical pharmacy practice. Based on these observations, the following changes were implemented: pharmacists were scheduled to work either inside or outside the satellites for two-week or one-month time periods, priorities were assigned to certain tasks performed inside or outside the satellites, job assignments were made based on the pharmacist's capabilities and the needs of the patient-care areas, a form for documenting potential problem orders was created, and pharmacists were evaluated monthly and given one-on-one instruction by the clinical coordinator. Documentation of time use identified problems and led to changes in assignments that better integrated clinical, educational, and distributive responsibilities for the purpose of providing more efficient and effective services.

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How individual pharmacists can improve patient-oriented services is described. Pharmacists practicing on patient-care units should assess how they can, by meeting the needs of other health-care providers, contribute to better drug therapy. They should examine how changes in the drug distribution system can allow more flexibility for providing services on the patient-care unit. They should promote appropriate drug use by identifying problems and bringing these to the attention of the providers involved. Individual pharmacists can be assigned to patient-care units to coordinate drug therapy and patient education. They should document their activities. Individual pharmacists can take responsibility not only for their own actions but also for the actions of other health-care professionals associated with drug therapy.

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A panel discussed ways to improve patient-oriented pharmacy services, drawing on the proceedings of a recent conference on directions for clinical practice in pharmacy. Clinical pharmacy should be defined in terms of responsibility rather than by a list of specific functions. Pharmacists are responsible for drug use, not just for dispensing; this implies responsibility for educating physicians and nurses to ensure optimal patient outcomes. Clinical practice cannot be separated from pharmacy practice; although pharmacy practice requires different kinds of tasks, all have the goal of patient care. Pharmacists can exercise their responsibility for control of drug use without prescriptive authority or mandated review of physician prescribing. Pharmacists can increase their influence on drug therapy through the formulary system and through their physical presence on patient-care units. A mission statement that recognizes responsibility for patient outcomes can serve as the basis for a management system that supports clinical practice. The panel members believed that pharmacy leaders at the conference were unified by a commitment to increase the profession's clinical orientation.

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Pneumocystis carinii pneumonia is a devastating disease state that is almost always fatal without appropriate therapy. The offending organism is difficult to culture, and the diagnosis is best confirmed by performing an open-lung biopsy. Drug therapy includes pentamidine in doses of 4 mg/kg/d im and/or trimethoprim/sulfamethoxazole (TMP/SMX) in doses of 20 mg/Kg/d of the former and 100 mg/kg/d of the latter in four divided doses. Of these two agents, TMP/SMX appears to be most effective, although pentamidine may be of benefit if the combination product fails. Adverse effects associated with pentamidine are greater in number and more severe than those associated with TMP/SMX. A case report is presented to demonstrate drug therapy and the severity of the disease.

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The importance of the effect of gentamicin on heparin activity was investigated. Heparin activity was assessed using the activated partial thromboplastin time (APTT), thrombin clotting time (TCT), and Factor X heparin assay. Drug concentrations used were 0.1, 0.2, 0.3, and 0.4 units/ml heparin with 40, 80, and 400 microgram/ml gentamicin, in vitro in human plasma. The drugs were precipitated at concentrations of 10, 20, 30, and 40 units/ml heparin with 4 and 40 mg/ml gentamicin. After centrifuging, the supernate was diluted to 0.1-0.4 units/ml heparin for assay. There was no change in heparin activity in the presence of gentamicin (in the unprecipitated solutions) as measured by the TCT, Factor X assay, and the APTT; however, APTT was prolonged by gentamicin. In the precipitated samples, heparin activity was lost in the precipitate. No significant clinical interaction that would affect the therapeutic efficacy of heparin was demonstrated except for a pharmaceutical incompatibility between gentamicin and heparin. The APTT, performed with ellagic acid as an activator, is prolonged by gentamicin.

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Two case reports describing the treatment of digitoxin toxicity with cholestyramine resin are presented. Both female patients were receiving 100 microgram/day of digitoxin when toxicity occurred. In both patients, digitoxin was discontinued and hypokalemia was corrected. In patient 1, lidocaine hydrochloride and phenytoin sodium also were administered. Serum digitoxin levels were decreased from 43 ng/ml to 21.8 ng/ml and from 42 ng/ml to 29 ng/ml in patients 1 and 2, respectively, following administration of three 4-g doses of cholestyramine resin over a one-day period. Previous studies on the treatment of digitoxin intoxication with potassium chloride, phenytoin sodium, lidocaine hydrochloride, digitoxin-specific antibodies, colestipol hydrochloride and cholestyramine resin are discussed. Ion-exchange resins may be valuable adjuncts in the treatment of digitoxin intoxication but further studies of their utility are needed.

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