Topic: Quality Assurance & Improvement
Liu, Danny1,2; De Castro, Charisse1,2; Seto, Winnie1,2,3; Russell,Jennifer4,5; Steven Schwartz3; Lau, Elaine1,2
1 Department of Pharmacy, The Hospital for Sick Children, Toronto, ON, Canada
2 Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
3 Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
4 Department of Pediatrics, University of Toronto, Toronto, ON, Canada
5 The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
Introduction: Chlorothiazide (CTZ) is the only intravenous (IV) thiazide diuretic in Canada through the Health Canada Special Access Program (SAP) and has been used at the Hospital for Sick Children (SickKids) since 2011. Prescribing restrictions for SickKids formulary have been implemented due to limited published paediatric evidence and its high cost.
Objectives: Primary objectives are were to evaluate CTZ usage, cost, and adherence to formulary guidelines. Secondary objectives were to explore associations between:
- indication for diuresis with guideline adherence and effective diuresis
- prescribing service with guideline adherence
- use of other diuretics at time of CTZ initiation with effective diuresis
Methods: This was a single-center, retrospective observational study. Patients were included if they initiated at least one dose of CTZ between June 2, 2018, and May 31, 2019, as per electronic health records. Drug utilization data included dose, duration, indication, service, and costs. Patient data included demographics , NPO status, diuretic intolerance, urine output and fluid balance. Usage was considered adherent if used in post-op cardiac patients for sternal closure or in patients in which other diuretics were optimized. Effective diuresis was defined as an increase in urine output of >0.5 mL/kg/hr from CTZ initiation. Costs were assessed using data from all courses while adherence and effective diuresis were assessed using data from initial courses. Descriptive statistics were used due to small sample size.
Results: A total of 181 CTZ courses were included for 74 patients. Of the 100 initial CTZ courses, 92 met inclusion criteria. Median (range) age, weight, and sex were 110 days (7 days - 11 years), 4.25 kg (1.05- 32.5 kg) and 53.3% male respectively. Baseline urine output was <1 mL/kg/hr in 10.9% of initial courses and median fluid balance was 15.9 ml/kg (-85.7 - 128.3 ml/kg). Median dose, frequency and duration were 5 mg/kg/dose (1-5 mg/kg/dose), q12h (q6h-q24h) and 3.5 days (1-37 days) respectively. CTZ was most commonly prescribed for non-surgical cardiac indications (58.7%), sternal closure (27%), and respiratory indications (7.6%). Non- adherence to guidelines was 58.7% overall and was attributed to suboptimal use of enteral thiazides (28.3%), IV loop diuretics (20.7%) or both (50.9%). Non-adherence was most common in non-surgical cardiac indications (79.6%), then respiratory (12.9%) and other (non-cardiac/non-respiratory) (7.4%) indications. Effective diuresis was seen in 53.6% of initial CTZ orders with a decrease in diuretic effect in patients who previously received metolazone (25% effective), bumetanide (0%) or optimized enteral diuretics (20%). Diuresis was least effective in respiratory indications (37.5% effective) and highest in other indications (66.6%). The total CTZ cost during the study period was $134,000. Costs of non-adherent initial orders ($37,500) contributed to 56.8% of the total costs of initial orders ($64,000).
Conclusion:
Results indicate that there is room for improvement in adherence with approved guidelines for CTZ. Further efforts could be targeted at non-surgical patients who were not trialed or optimized on other diuretics. Cost savings may be realized with improved adherence and optimization of concurrent diuretics. Adherence to guidelines may be improved through clinical decision support systems such as computerized physician order entry order-sets and alerts, and ongoing audit and feedback.
Product Monograph (USA). Sodium Diuril (Chlorothiazide Sodium). Oak Pharmaceuticals, 2012.
Garin EH. A comparison of combinations of diuretics in nephrotic edema. Am J Dis Child 1987 Jul;141(7):769-71.
Green TP, Thompson TR, Johnson DE, Lock JE. Diuresis and pulmonary function in premature infants with respiratory distress syndrome. J Pediatr. 1983 Oct;103(4):618-23.
Thomas CA, Morris JL, Sinclair EA. Implementation of a diuretic stewardship program in a pediatric cardiovascular intensive care unit to reduce medication expenditures. Am J Health Syst Pharm. 2015 Jun 15;72(12):1047-51
Moffett BS, Tsang R, Kennedy C, Bronicki RA, Akcan-Arikan A, Checchia PA. Efficacy of sequential nephron blockade with intravenous chlorothiazide to promote diuresis in cardiac intensive care infants. Cardiol Young. 2017;27(6):1104-1109.
Topic: Quality Assurance & Improvement
Liu, Danny1,2; De Castro, Charisse1,2; Seto, Winnie1,2,3; Russell,Jennifer4,5; Steven Schwartz3; Lau, Elaine1,2
1 Department of Pharmacy, The Hospital for Sick Children, Toronto, ON, Canada
2 Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
3 Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
4 Department of Pediatrics, University of Toronto, Toronto, ON, Canada
5 The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
Introduction: Chlorothiazide (CTZ) is the only intravenous (IV) thiazide diuretic in Canada through the Health Canada Special Access Program (SAP) and has been used at the Hospital for Sick Children (SickKids) since 2011. Prescribing restrictions for SickKids formulary have been implemented due to limited published paediatric evidence and its high cost.
Objectives: Primary objectives are were to evaluate CTZ usage, cost, and adherence to formulary guidelines. Secondary objectives were to explore associations between:
- indication for diuresis with guideline adherence and effective diuresis
- prescribing service with guideline adherence
- use of other diuretics at time of CTZ initiation with effective diuresis
Methods: This was a single-center, retrospective observational study. Patients were included if they initiated at least one dose of CTZ between June 2, 2018, and May 31, 2019, as per electronic health records. Drug utilization data included dose, duration, indication, service, and costs. Patient data included demographics , NPO status, diuretic intolerance, urine output and fluid balance. Usage was considered adherent if used in post-op cardiac patients for sternal closure or in patients in which other diuretics were optimized. Effective diuresis was defined as an increase in urine output of >0.5 mL/kg/hr from CTZ initiation. Costs were assessed using data from all courses while adherence and effective diuresis were assessed using data from initial courses. Descriptive statistics were used due to small sample size.
Results: A total of 181 CTZ courses were included for 74 patients. Of the 100 initial CTZ courses, 92 met inclusion criteria. Median (range) age, weight, and sex were 110 days (7 days - 11 years), 4.25 kg (1.05- 32.5 kg) and 53.3% male respectively. Baseline urine output was <1 mL/kg/hr in 10.9% of initial courses and median fluid balance was 15.9 ml/kg (-85.7 - 128.3 ml/kg). Median dose, frequency and duration were 5 mg/kg/dose (1-5 mg/kg/dose), q12h (q6h-q24h) and 3.5 days (1-37 days) respectively. CTZ was most commonly prescribed for non-surgical cardiac indications (58.7%), sternal closure (27%), and respiratory indications (7.6%). Non- adherence to guidelines was 58.7% overall and was attributed to suboptimal use of enteral thiazides (28.3%), IV loop diuretics (20.7%) or both (50.9%). Non-adherence was most common in non-surgical cardiac indications (79.6%), then respiratory (12.9%) and other (non-cardiac/non-respiratory) (7.4%) indications. Effective diuresis was seen in 53.6% of initial CTZ orders with a decrease in diuretic effect in patients who previously received metolazone (25% effective), bumetanide (0%) or optimized enteral diuretics (20%). Diuresis was least effective in respiratory indications (37.5% effective) and highest in other indications (66.6%). The total CTZ cost during the study period was $134,000. Costs of non-adherent initial orders ($37,500) contributed to 56.8% of the total costs of initial orders ($64,000).
Conclusion:
Results indicate that there is room for improvement in adherence with approved guidelines for CTZ. Further efforts could be targeted at non-surgical patients who were not trialed or optimized on other diuretics. Cost savings may be realized with improved adherence and optimization of concurrent diuretics. Adherence to guidelines may be improved through clinical decision support systems such as computerized physician order entry order-sets and alerts, and ongoing audit and feedback.
Product Monograph (USA). Sodium Diuril (Chlorothiazide Sodium). Oak Pharmaceuticals, 2012.
Garin EH. A comparison of combinations of diuretics in nephrotic edema. Am J Dis Child 1987 Jul;141(7):769-71.
Green TP, Thompson TR, Johnson DE, Lock JE. Diuresis and pulmonary function in premature infants with respiratory distress syndrome. J Pediatr. 1983 Oct;103(4):618-23.
Thomas CA, Morris JL, Sinclair EA. Implementation of a diuretic stewardship program in a pediatric cardiovascular intensive care unit to reduce medication expenditures. Am J Health Syst Pharm. 2015 Jun 15;72(12):1047-51
Moffett BS, Tsang R, Kennedy C, Bronicki RA, Akcan-Arikan A, Checchia PA. Efficacy of sequential nephron blockade with intravenous chlorothiazide to promote diuresis in cardiac intensive care infants. Cardiol Young. 2017;27(6):1104-1109.
Topic: Quality Assurance & Improvement
Liu, Danny1,2; De Castro, Charisse1,2; Seto, Winnie1,2,3; Russell,Jennifer4,5; Steven Schwartz3; Lau, Elaine1,2
1 Department of Pharmacy, The Hospital for Sick Children, Toronto, ON, Canada
2 Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
3 Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
4 Department of Pediatrics, University of Toronto, Toronto, ON, Canada
5 The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
Introduction: Chlorothiazide (CTZ) is the only intravenous (IV) thiazide diuretic in Canada through the Health Canada Special Access Program (SAP) and has been used at the Hospital for Sick Children (SickKids) since 2011. Prescribing restrictions for SickKids formulary have been implemented due to limited published paediatric evidence and its high cost.
Objectives: Primary objectives are were to evaluate CTZ usage, cost, and adherence to formulary guidelines. Secondary objectives were to explore associations between:
- indication for diuresis with guideline adherence and effective diuresis
- prescribing service with guideline adherence
- use of other diuretics at time of CTZ initiation with effective diuresis
Methods: This was a single-center, retrospective observational study. Patients were included if they initiated at least one dose of CTZ between June 2, 2018, and May 31, 2019, as per electronic health records. Drug utilization data included dose, duration, indication, service, and costs. Patient data included demographics , NPO status, diuretic intolerance, urine output and fluid balance. Usage was considered adherent if used in post-op cardiac patients for sternal closure or in patients in which other diuretics were optimized. Effective diuresis was defined as an increase in urine output of >0.5 mL/kg/hr from CTZ initiation. Costs were assessed using data from all courses while adherence and effective diuresis were assessed using data from initial courses. Descriptive statistics were used due to small sample size.
Results: A total of 181 CTZ courses were included for 74 patients. Of the 100 initial CTZ courses, 92 met inclusion criteria. Median (range) age, weight, and sex were 110 days (7 days - 11 years), 4.25 kg (1.05- 32.5 kg) and 53.3% male respectively. Baseline urine output was <1 mL/kg/hr in 10.9% of initial courses and median fluid balance was 15.9 ml/kg (-85.7 - 128.3 ml/kg). Median dose, frequency and duration were 5 mg/kg/dose (1-5 mg/kg/dose), q12h (q6h-q24h) and 3.5 days (1-37 days) respectively. CTZ was most commonly prescribed for non-surgical cardiac indications (58.7%), sternal closure (27%), and respiratory indications (7.6%). Non- adherence to guidelines was 58.7% overall and was attributed to suboptimal use of enteral thiazides (28.3%), IV loop diuretics (20.7%) or both (50.9%). Non-adherence was most common in non-surgical cardiac indications (79.6%), then respiratory (12.9%) and other (non-cardiac/non-respiratory) (7.4%) indications. Effective diuresis was seen in 53.6% of initial CTZ orders with a decrease in diuretic effect in patients who previously received metolazone (25% effective), bumetanide (0%) or optimized enteral diuretics (20%). Diuresis was least effective in respiratory indications (37.5% effective) and highest in other indications (66.6%). The total CTZ cost during the study period was $134,000. Costs of non-adherent initial orders ($37,500) contributed to 56.8% of the total costs of initial orders ($64,000).
Conclusion:
Results indicate that there is room for improvement in adherence with approved guidelines for CTZ. Further efforts could be targeted at non-surgical patients who were not trialed or optimized on other diuretics. Cost savings may be realized with improved adherence and optimization of concurrent diuretics. Adherence to guidelines may be improved through clinical decision support systems such as computerized physician order entry order-sets and alerts, and ongoing audit and feedback.
Product Monograph (USA). Sodium Diuril (Chlorothiazide Sodium). Oak Pharmaceuticals, 2012.
Garin EH. A comparison of combinations of diuretics in nephrotic edema. Am J Dis Child 1987 Jul;141(7):769-71.
Green TP, Thompson TR, Johnson DE, Lock JE. Diuresis and pulmonary function in premature infants with respiratory distress syndrome. J Pediatr. 1983 Oct;103(4):618-23.
Thomas CA, Morris JL, Sinclair EA. Implementation of a diuretic stewardship program in a pediatric cardiovascular intensive care unit to reduce medication expenditures. Am J Health Syst Pharm. 2015 Jun 15;72(12):1047-51
Moffett BS, Tsang R, Kennedy C, Bronicki RA, Akcan-Arikan A, Checchia PA. Efficacy of sequential nephron blockade with intravenous chlorothiazide to promote diuresis in cardiac intensive care infants. Cardiol Young. 2017;27(6):1104-1109.
Topic: Quality Assurance & Improvement
Liu, Danny1,2; De Castro, Charisse1,2; Seto, Winnie1,2,3; Russell,Jennifer4,5; Steven Schwartz3; Lau, Elaine1,2
1 Department of Pharmacy, The Hospital for Sick Children, Toronto, ON, Canada
2 Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
3 Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
4 Department of Pediatrics, University of Toronto, Toronto, ON, Canada
5 The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
Introduction: Chlorothiazide (CTZ) is the only intravenous (IV) thiazide diuretic in Canada through the Health Canada Special Access Program (SAP) and has been used at the Hospital for Sick Children (SickKids) since 2011. Prescribing restrictions for SickKids formulary have been implemented due to limited published paediatric evidence and its high cost.
Objectives: Primary objectives are were to evaluate CTZ usage, cost, and adherence to formulary guidelines. Secondary objectives were to explore associations between:
- indication for diuresis with guideline adherence and effective diuresis
- prescribing service with guideline adherence
- use of other diuretics at time of CTZ initiation with effective diuresis
Methods: This was a single-center, retrospective observational study. Patients were included if they initiated at least one dose of CTZ between June 2, 2018, and May 31, 2019, as per electronic health records. Drug utilization data included dose, duration, indication, service, and costs. Patient data included demographics , NPO status, diuretic intolerance, urine output and fluid balance. Usage was considered adherent if used in post-op cardiac patients for sternal closure or in patients in which other diuretics were optimized. Effective diuresis was defined as an increase in urine output of >0.5 mL/kg/hr from CTZ initiation. Costs were assessed using data from all courses while adherence and effective diuresis were assessed using data from initial courses. Descriptive statistics were used due to small sample size.
Results: A total of 181 CTZ courses were included for 74 patients. Of the 100 initial CTZ courses, 92 met inclusion criteria. Median (range) age, weight, and sex were 110 days (7 days - 11 years), 4.25 kg (1.05- 32.5 kg) and 53.3% male respectively. Baseline urine output was <1 mL/kg/hr in 10.9% of initial courses and median fluid balance was 15.9 ml/kg (-85.7 - 128.3 ml/kg). Median dose, frequency and duration were 5 mg/kg/dose (1-5 mg/kg/dose), q12h (q6h-q24h) and 3.5 days (1-37 days) respectively. CTZ was most commonly prescribed for non-surgical cardiac indications (58.7%), sternal closure (27%), and respiratory indications (7.6%). Non- adherence to guidelines was 58.7% overall and was attributed to suboptimal use of enteral thiazides (28.3%), IV loop diuretics (20.7%) or both (50.9%). Non-adherence was most common in non-surgical cardiac indications (79.6%), then respiratory (12.9%) and other (non-cardiac/non-respiratory) (7.4%) indications. Effective diuresis was seen in 53.6% of initial CTZ orders with a decrease in diuretic effect in patients who previously received metolazone (25% effective), bumetanide (0%) or optimized enteral diuretics (20%). Diuresis was least effective in respiratory indications (37.5% effective) and highest in other indications (66.6%). The total CTZ cost during the study period was $134,000. Costs of non-adherent initial orders ($37,500) contributed to 56.8% of the total costs of initial orders ($64,000).
Conclusion:
Results indicate that there is room for improvement in adherence with approved guidelines for CTZ. Further efforts could be targeted at non-surgical patients who were not trialed or optimized on other diuretics. Cost savings may be realized with improved adherence and optimization of concurrent diuretics. Adherence to guidelines may be improved through clinical decision support systems such as computerized physician order entry order-sets and alerts, and ongoing audit and feedback.
Product Monograph (USA). Sodium Diuril (Chlorothiazide Sodium). Oak Pharmaceuticals, 2012.
Garin EH. A comparison of combinations of diuretics in nephrotic edema. Am J Dis Child 1987 Jul;141(7):769-71.
Green TP, Thompson TR, Johnson DE, Lock JE. Diuresis and pulmonary function in premature infants with respiratory distress syndrome. J Pediatr. 1983 Oct;103(4):618-23.
Thomas CA, Morris JL, Sinclair EA. Implementation of a diuretic stewardship program in a pediatric cardiovascular intensive care unit to reduce medication expenditures. Am J Health Syst Pharm. 2015 Jun 15;72(12):1047-51
Moffett BS, Tsang R, Kennedy C, Bronicki RA, Akcan-Arikan A, Checchia PA. Efficacy of sequential nephron blockade with intravenous chlorothiazide to promote diuresis in cardiac intensive care infants. Cardiol Young. 2017;27(6):1104-1109.
