How can a DOP make some extra dough?

[PharmDstudent]

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may be a stupid question: why?

Many of the patients are very weak. Either their kidneys are shot, or they should be in hospice. We have a lot of repeats that keep coming back. The nursing homes send them over again and again with wounds and such. Neglect. Sad stuff.

Issues like this.

 

[Angryrooster]

so you worked for LTAC? may I ask how many beds at your place? normally should be about less than 30beds, right?

 

[PharmDstudent]

so you worked for LTAC? may I ask how many beds at your place? normally should be about less than 30beds, right?

Less than 30 beds at my place. I would say less than 100 beds is standard.

 

[Its Z]

Many of the patients are very weak. Either their kidneys are shot, or they should be in hospice. We have a lot of repeats that keep coming back. The nursing homes send them over again and again with wounds and such. Neglect. Sad stuff.

Issues like this.

That is absolutely the worst advice regarding aminoglycoide dosing. If if its CRF or completely shot kidneys who cares about nephrotixicity. If its acute yet physician feels AG is warranted then the worst thing you can do is give a lower dose. AG nephrotoxicity results from high sustained trough. so AG should be dosed according to patients proper VD and desired peak in which the dose should remain as but the regimen needs to be modified by the frequency of dosing to allow for a drug free period in the patient which allows for recovery of renal tissues and increased susceptibility of the bugs. In case of LTAC patient requiring AG its most likely MDRO like acinetobacter or ESBL producing gram negs those bugs require a higher Cmax Vs. MIC ratio which lower dosing wont hit without high sustained toxic trough. Of course if its endocarditis requiring AG synergy low dose regimen should be OK yet most of those patients are already on an established regimen by the time they enter LTAC.

 

[Its Z]

In the late 90s wheN the CMS allowed the LTAC model to get the patient out of acute care hospitals to free up the ICU and step down beds many thought the business would Las about 5 years. Its a pleasant surprise they're still around. Its a tough environment to work in. My second dop job was at an ltac. Then I did a several LTAC pharmacy start ups. Its a great opportunity for someone wanting to get into hospital pharm admin. You have to do it all.
With my last job I had 3 LTAC I managed. Its a neat operation still. I also did a full scale consult for an LTAC company who owns hospitals throughout the US last year. Its robust. But if I was xiphoid, I would opt to cuddle the baby on weekends rather than trying to make additional $500 per weekend after taxes.

 

[PharmDstudent]

That is absolutely the worst advice regarding aminoglycoide dosing. If if its CRF or completely shot kidneys who cares about nephrotixicity. If its acute yet physician feels AG is warranted then the worst thing you can do is give a lower dose. AG nephrotoxicity results from high sustained trough. so AG should be dosed according to patients proper VD and desired peak in which the dose should remain as but the regimen needs to be modified by the frequency of dosing to allow for a drug free period in the patient which allows for recovery of renal tissues and increased susceptibility of the bugs. In case of LTAC patient requiring AG its most likely MDRO like acinetobacter or ESBL producing gram negs those bugs require a higher Cmax Vs. MIC ratio which lower dosing wont hit without high sustained toxic trough. Of course if its endocarditis requiring AG synergy low dose regimen should be OK yet most of those patients are already on an established regimen by the time they enter LTAC.

I'm not getting in a fight with you. Not worth my time.

I've seen their levels skyhigh after they come back from inpatient or ICU settings.

No. Usually not. Most of the time we have to start regimens for them, and their labs are great.

Go play golf or something. 🙄

 

[type b pharmD]

That is absolutely the worst advice regarding aminoglycoide dosing. If if its CRF or completely shot kidneys who cares about nephrotixicity. If its acute yet physician feels AG is warranted then the worst thing you can do is give a lower dose. AG nephrotoxicity results from high sustained trough. so AG should be dosed according to patients proper VD and desired peak in which the dose should remain as but the regimen needs to be modified by the frequency of dosing to allow for a drug free period in the patient which allows for recovery of renal tissues and increased susceptibility of the bugs. In case of LTAC patient requiring AG its most likely MDRO like acinetobacter or ESBL producing gram negs those bugs require a higher Cmax Vs. MIC ratio which lower dosing wont hit without high sustained toxic trough. Of course if its endocarditis requiring AG synergy low dose regimen should be OK yet most of those patients are already on an established regimen by the time they enter LTAC.

👍👍 Great advice!!! I have a lot of LTAC experience including an antibiotic focused internship, and AG use in these patients is a tricky issue! It really pisses me off when doctors use low dose AG's without regard to the time spent above toxic threshhold.

One other point to make though is -- a LOT of patients are NOT on an established regimen when they enter LTAC in my experience (****ty LTAC CEO/admins who try to recruit hospitals' 'gomers' or basically unmanageable patients.. a lot of patients come in on regimens that consist of "just keep them on vanco/zosyn permanantly and turf them to LTAC" ..

Edit: by 'regimen' i mean, something that makes some damn sense.

Some days I really feel like LTAC is short for long term antibiotic care. It is fun straightening everything out though to the extent possible. 🙂

 

[Its Z]

I'm not getting in a fight with you. Not worth my time.

I've seen their levels skyhigh after they come back from inpatient or ICU settings.

No. Usually not. Most of the time we have to start regimens for them, and their labs are great.

Go play golf or something. 🙄

You as a part time and probably the only LTAC practitioner on SDN can debate the clinical issues of your aminoglycoside recommendation without the ad hominem. You can choose to not argue with me vice versa. But if my AG statement is incorrect then feel free to correct me. Skyhigh high levels of AG from inpatient are usually the random levels usedd to plot into nomograms since troughs are typically not done unless its a traditional dosing. If so then the frequency needs to be extended not round ing down of dose.

 

[Its Z]

👍👍 Great advice!!! I have a lot of LTAC experience including an antibiotic focused internship, and AG use in these patients is a tricky issue! It really pisses me off when doctors use low dose AG's without regard to the time spent above toxic threshhold.

One other point to make though is -- a LOT of patients are NOT on an established regimen when they enter LTAC in my experience (****ty LTAC CEO/admins who try to recruit hospitals' 'gomers' or basically unmanageable patients.. a lot of patients come in on regimens that consist of "just keep them on vanco/zosyn permanantly and turf them to LTAC" ..

Edit: by 'regimen' i mean, something that makes some damn sense.

Some days I really feel like LTAC is short for long term antibiotic care. It is fun straightening everything out though to the extent possible. 🙂

Y'all not cherry picking your patients??

 

[type b pharmD]

Y'all not cherry picking your patients??

Well, the administrator responsible ended up being fired . More like scavenging rathr than cherry picking. >.<

 

[PharmDstudent]

👍👍 Great advice!!! I have a lot of LTAC experience including an antibiotic focused internship, and AG use in these patients is a tricky issue! It really pisses me off when doctors use low dose AG's without regard to the time spent above toxic threshhold.

One other point to make though is -- a LOT of patients are NOT on an established regimen when they enter LTAC in my experience (****ty LTAC CEO/admins who try to recruit hospitals' 'gomers' or basically unmanageable patients.. a lot of patients come in on regimens that consist of "just keep them on vanco/zosyn permanantly and turf them to LTAC" ..

Edit: by 'regimen' i mean, something that makes some damn sense.

Some days I really feel like LTAC is short for long term antibiotic care. It is fun straightening everything out though to the extent possible. 🙂

That sounds strange. Whatever it is, we don't have it. Pharmacy monitors everything unless the doctor requests to on the order.

Basically, we keep their trough under 2 for gent or tobra and under 6 or 8 for amikacin. For vanco, we keep it under 20. Normal stuff.

But it can easily get away from you if you aren't monitoring or are too aggressive.

 

[PharmDstudent]

You as a part time and probably the only LTAC practitioner on SDN can debate the clinical issues of your aminoglycoside recommendation without the ad hominem. You can choose to not argue with me vice versa. But if my AG statement is incorrect then feel free to correct me. Skyhigh high levels of AG from inpatient are usually the random levels usedd to plot into nomograms since troughs are typically not done unless its a traditional dosing. If so then the frequency needs to be extended not round ing down of dose.

Did you keep back-up kidneys or something? How do these patients metabolize a true dose? They can't.

Sure, the patients walking around will be fine. But the "gomers" that type b referred to can't.

Well, the administrator responsible ended up being fired . More like scavenging rathr than cherry picking. >.<

That's terrible. I'm sorry to hear that.



We just usually end up doing favors for the host. 🙁

 

[type b pharmD]

That sounds strange. Whatever it is, we don't have it. Pharmacy monitors everything unless the doctor requests to on the order.

Basically, we keep their trough under 2 for gent or tobra and under 6 or 8 for amikacin. For vanco, we keep it under 20. Normal stuff.

But it can easily get away from you if you aren't monitoring or are too aggressive.

Im sorry im only on one hour of sleep atm and its been a while since working in that setting. Not referring to any specific product or regimen. I was just thinking of a memory of poorly managed antibiotic regimens, with regard to the gut feeling of going with lower dose AG's , for renal function. All it's going to do is result in a sustained period above the toxicity trough while they wait for it to eliminate, but is not going to get to therapeutic efficacy. The resistance in these long term pts with multiple healthcare associated infections that have not responded to antibiotics necessitates getting the high peak. The kidney functon just means to wait longer , not to reduce the dose .

edit: I just realized my LTAC experience is probably out of the ordinary, since the person who was running it didnt have a clue as to how to recruit a profitable and curable patient base. The individual was basically going out begging for patients with anticipated long lengths of stays. They were disliked and a newcomer, so all the local docs just ended up recognizing the desperation and stupidity and dumping all of the long term healthcare associated infections on us which the ceo gladly accepted. I remember some days where >50% of our patients would be on IV vanc, AGs, zosyn, tygacil, or cubicin. Just to make an example of how poorly managed it was

 

[Its Z]

Did you keep back-up kidneys or something? How do these patients metabolize a true dose? They can't.

Considering most aminoglycosides are cleared renally unchanged, I would say metabolism is whole another topic. As far as backup kidneys...for those patients with no renal function we call it dialysis. At that point we are not worried about nephrotoxicity rather oto is the issue. For those with arf, aminoglycoside nephrotoxicity is reversible unlike oto.

 

[PharmDstudent]

Im sorry im only on one hour of sleep atm and its been a while since working in that setting.

Oh, it's ok. Maybe you should some sleep? 🙂

Not referring to any specific product or regimen. I was just thinking of a memory of poorly managed antibiotic regimens, with regard to the gut feeling of going with lower dose AG's , for renal function. All it's going to do is result in a sustained period above the toxicity trough while they wait for it to eliminate, but is not going to get to therapeutic efficacy. The resistance in these long term pts with multiple healthcare associated infections that have not responded to antibiotics necessitates getting the high peak. The kidney functon just means to wait longer , not to reduce the dose.

Sure... but upping the dose and then having to hold it for 5 days is a problem, too. So I usually round down from what I initially calculate, and things work out fine.

 

[PharmDstudent]

Considering most aminoglycosides are cleared renally unchanged, I would say metabolism is whole another topic. As far as backup kidneys...for those patients with no renal function we call it dialysis. At that point we are not worried about nephrotoxicity rather oto is the issue. For those with arf, aminoglycoside nephrotoxicity is reversible unlike oto.

And then what happens when they're too weak for dialysis?

 

[Its Z]

And then what happens when they're too weak for dialysis?

OK if you want to keep digging and play the if game.

If pt requires dialysis yet not able to to tolerate the procedure then patient has very little or no renalrenal function hence why would this warrant a lower dose? If this patient has a residual level requiring another dose on admission, then the right process is to draw a level and calculate the dose to get the level up to the desired peak which has nothing to do with rounding down the dose. If this patient has arf not requiring dialysis then the right process is to first provide the drug free period to let the renal function recover while PAE does its thing before the next dose is warranted. If its a new start on the arf patient, you would still dose aggressively but with an extended frequency. 5 or 7 mg/kg regimen which results in an extrapolated peak of 25 to 30ug/rml may not be warranted but a high enough peak and a significant time of trough below 1 is the right thing to do.

 

[PharmDstudent]

OK if you want to keep digging and play the if game.

It's not a game. It happens.

 

[Angryrooster]

it's really fun watching you guys play this game or whatever you want to call it. But at least, this sounds "professional" and "clinical", better than lots of crap most people post here. Thanks

 

[xiphoid2010]

Did my first per diem shift. It was pretty easy. Process some orders, make some IVs, a TPN. Meh. Doesn't seem very fast paced or very clinical. $500 for a pretty relaxed day's work. Relaxation AND getting paid? I like it!