Adjustment of Desirable Body Weight for Amputees using MS Excel

Transcription

1 Adjustment of Desirable Body Weight for Amputees using MS Excel Dave Andersen, RPh, MPA andersen-computing.com 6/11/2016

2 Table of Contents Creatinine Clearance Overview...1 Installation Instructions...1 Populating the Provider Pharmacist Workbook...2 Changing the Hospital Data...3 Data entry...4 Printing the Report...7 Saving the Data...8 Changing the Report Title Image...8 Final Notes...10 License...11 Report Sample

3 Creatinine Clearance Overview Creatinine clearance (CrCl) calculations in patients with amputations can be problematic. Especially when you consider that many of these patients have lost their limbs due to complications of diabetes and that their renal function is probably compromised. This loss of limbs will affect the determination of lean body weight (LBW). Using References from John Murphy's Clinical Pharmacokinetics, 2nd ed and Brunnstrom, S. Clinical Kinesiology. 4th ed. 1983, a chart was developed to account for the loss of limbs in determining LBW. That chart was the basis for this workbook. First, a couple of notes about this workbook. Its purpose is to ease the calculation burden, but also to provide a report that can be printed and archived. Once the new creatinine clearance has been determined, this will in turn lead to adjustments in doses, dosing intervals, and when antibiotic (e.g. vancomycin and aminoglycosides) levels will need to be drawn. This workbook provides an estimate of CrCl and will likely only affect the first couple of doses, as levels drawn will provide a better method for adjustments as therapy continues. In other words, this tool is only designed to give you a good start for your therapeutic monitoring. Next, lets discuss what a Macro Enabled workbook is. Unlike regular, non-macro enabled spreadsheets, these workbooks contain macros (Visual Basic code) that allow some complex functions to manipulate data with just a click of a button. You will know macro enabled workbooks by their extension,.xlsm. For these macros to work, the user must configure MS Excel to allow their use. Set the Macro Security Settings to Medium. This allows you to pick and choose which macro to run. Depending on the Windows Version (sorry Mac users, but I don t know if this will work on an Apple product), choose Options, Trust /Center, and choose Trust Center Settings from the menu. Click on Macro Settings and set to Disable w/notification. This version was developed with Office 365-Excel (on Windows 10), but has been tested on Windows 7 and 8 systems. Requirements are simple, a system with MS Office/Excel and a printer (color would be nice). Again, this workbook only gives an estimate of Creatinine Clearance. You must use your clinical judgment whenever using any automated system. I hope this will make at least part of your clinical job easier. Installation Instructions To get the latest version, visit the Andersen-computing website. No real registration is required, just a form from the site filled out. I ask only for a valid address. Support will only be provided to those with valid addresses on file. Two zip files are required: AC_CrCl.zip (This file includes this manual and some sample images, see page 8). AC_Provider_Pharmacist.zip This manual is also available to download from site individually (it s also a great way to get more information about the workbook s function before its used). Unzip these files to the location of your choice. If this is to be used in health care organizations on a network, have your IT department install it to a shared location. Ideally it will be placed in a Pharmacy 1

4 folder that each of the pharmacists could access (a shortcut on every pharmacist s desktop would be ideal). Same for this PDF manual. One caveat, you MUST place these workbooks into the same folder. That is the only way you can update provider/pharmacist/ward information on the template. Populating the Provider Pharmacist Workbook. Many of the workbooks available for download from my website will have need for Providers, Pharmacists, and Clinic/Ward information. The workbooks are not linked directly, but as you update the information on this workbook, one of the macros discussed earlier will transfer the information to each of the templates provided (the reason they must be in the same folder). First open the Provider_Pharmacist.xlsm workbook. It should open to the Providers_Pharmacist tab, if not click the tab title. The following screen should appear. FIGURE 1-PROVIDERS_PHARMACIST DATA To replace the fictional characters above, (anybody guess I was a DC fan???), click the Unlock Page button. This macro will unlock the pages, make the cells shaded in green and blue editable. Enter the providers from your facility. You do not have to include every provider who has ever set foot in your hospital/clinic, but you should include those that regularly provide you with consults for renal dosing, antibiotic monitoring, and everyone in the surgical wards, recovery rooms, and post-op units, as these are most likely to have patients with amputated appendages. Next, enter the pharmacists in your facility. Enter both the pharmacists names (Last Name, First Name format), and the initials for each pharmacist used within the hospital computer system, usually all caps 2

5 and limited to 4-6 characters. Names may change in the hospital system, but usually the initials remain the same (unique computer user names?). It does not matter if the names are in order; that s what the sort buttons are for. Sort each of the lists now and each time you add a name to the lists. Locking the page not only protects it from inadvertent deleting of information, but it also transfers this information to each of the workbook templates you add to the folder. Click on the Wards tab and repeat the same steps. Locking the page also updates the information on the templates. Rather than link information from this workbook to all others, this allows Excel to see the data and not have that annoying link warning each time you open the workbook. Click on the Close button when done. Not only does it close the file, but saves the file changes as well. Do NOT close the form by using the X at the top right of the Excel menu. You will close the form, but it will not guarantee that the data will be saved Changing the Hospital Data. Click the Pharmacy Information tab and click the Unlock Page button. Enter your facility information into the yellow shaded cells. Lock the page. If you choose the transparent report image (see later in this manual), this information will display and print on your report. FIGURE 2-CHANGING HOSPITAL AND PHARMACY INFORMATION 3

6 Data entry Click on Patient Info. & Reports tab. The user must enter the information into the yellow shaded cells located at the top of the screen. The clinic/ward, provider and pharmacist data is accessed using drop-down menus. You cannot see the result, as it is placed behind the drop-down. The menus are not printed, and the information changed is shown on reports. Next, click on the Creatinine Cl. tab. If the amputee is missing at least part of each leg, enter the patient s before amputation height. If at least one full extremity is left, enter the patient s current height. Notes can be entered within the large yellow shaded area. This next form is the heart of the program. The best way to explain this form is to perform an exercise. Before we get to this form, click on the Patient Info. & Reports tab. Enter a fictitious name, choose a provider, pharmacist, and ward from the drop-down menus. Enter a date of birth that would put the patient s age at 73 y/o. Enter a bed #, height (48 inches) and weight (150 lbs.), choose the patient s sex as F, and finally enter a SrCr of 1.0. FIGURE 7-DATA ENTRY ON REPORT SCREEN USING DROP DOWN MENU Move to the Creatinine Cl. tab and enter the patient s pre-amputation height as 67 inches. Click the checkbox above the pre-amputation height to open the CrCl clearance dialog box (see below). Click the checkbox (Cell A9) to use Adjusted Body Weight (ADJ_BW) for patients whose actual weight is 20%, or more, greater than the estimated Lean Body Weight (a common practice in hospitals today) near the top of the screen. This will be the weight used in CrCl calculations. I ll call it Creatinine Clearance weight. FIGURE 3-CREATININE CLEARANCE CALCULATIONS 4

7 Click the check box in cell G21. This opens the Adjustment to Body Weight form. For this patient simulation, assume she is missing both legs below the knee. Select the radio button 2, next to the Below the Knee label (almost color coordinated with the image). Now, click the Calculate button. This calculates the new estimated lean body weight, LBW, as 58.2 kg, based on the percentage of lean body mass (12%) missing. It then calculates CrCl as 46. (Adjusted body weight is not used because her actual weight is only 17% above the new calculated LBW). FIGURE 5-AMPUTATION CALCULATION FORM To view the changes for a bilateral above the knee amputation, click the radio button (2) next to Above Knee. Change the height before amputation to 70, click Calculate (Note: pt s actual weight is now more than 20% over the calculated IBW of 51.1 kg). Next, deselect the Adjusted Body Weight check box. Note the change in CrCl weight (now uses ADJ Wt) and CrCl. All changes made, to include pre- amputation height, on this form are transferred to the corresponding data cells on the Creatinine Cl. page. Clicking Accept will save these changes and calculations and close the form; while Cancel returns to the original workbook values and closes the form, each returning the user to the workbook page. For this exercise, click Accept. FIGURE 6-NEW CALCULATION VALUES FOR CRCL 5

8 Notice, the new Height before Amputation, calculated CrCl weight, and new CrCl values have replaced the previous values in the workbook. At this point, review your data and, if needed, deselect the creatinine check box, select again and repeat the process. As you can see, by manipulating the variables, the estimated CrCl can change significantly. By not accounting for lost LBW, you can underestimate the patient s renal function, leading to a greater dosing interval that could lead to lower antibiotic levels than required. 6

9 Printing the Report Return to the Patient Info. & Reports page. Click the Report button. A report is generated to the screen. Click the printer Icon, choose your printer and it should print to one page. If not, close the print preview, try again and select the Selection radio button, and reprint. FIGURE 7-PRINT PREVIEW See the resulting sample report at the end of the manual. 7

10 Saving the Data When you are satisfied with the data entered, Save and Close this form. Initially, this process creates a new file based on the patient s account number, the date, and the template s original file name. Before you save the file, you may wish to take a mulligan (a little golf humor), or start over. Click the Clear Templates button. All data fields will be returned to the original (null) values. Changing the Report Title Image If you peeked ahead at the sample report generated, you will notice that the hospital header image was for a fictitious hospital in Kansas (another DC reference). Obviously this would be inappropriate for your facilities. If you have a readily available image for your reports that prints in greater than or equal to 300 dpi, you could use that. However, this report works best with an image that is 500 X 100 pixels in size. You may have to resize using a graphics program such as Paint Shop Pro (my favorite). Don t have access to a quality report image? I have provided several blank colored images (everyone has access to color printing these days, don t we??) within a folder called Report Title Images. Use the graphics program, put a color image of the facility in the middle (may have to resize the image) and text to the right and the left of the centered photo. Color background not right? Change the image color at the start and repeat the steps. Save to the Report Title Images folder. Open the AC_CrCl_Amputee.xlsm workbook and move to the Patient Info. & Reports tab. Click on the Replace Header button. Enter the master password, 57Chevy, in the dialog box. You will have 5 tries to get it right, or the dialog box closes. Relax, you can start over. FIGURE 8-PASSSWORD PROTECTION FOR REPORT IMAGE 8

11 Once the password is entered correctly, the following instructions appear as a dialog box. Click OK. Follow the directions, Right click on the title image. And choose Change Picture. FIGURE 5-DIALOG BOX INSTRUCTIONS TO CHANGE IMAGE Select From a file to locate a new title image from a file location. FIGURE 6-SELECTING IMAGE FROM FILE LOCATION The following window opens. Follow the files to your image folder (I have included a folder with blank image backgrounds, where you should place your title image). Select the image from the file location and click Insert. 9

12 FIGURE 6-SELECTING IMAGE FROM FILE LOCATION After the image is placed within the report, click the Replace Image button a second time. This will align and lock the image in place. There is a transparent image available, Title00.png. Use only if you wish to use a text header (hospital information is centered behind the image). This is the default image used in this workbook. Save and close the form to have the replacement image remain for future reports, or until you change hospital names, phone # s, etc. Final Notes This is the first published version. In my next update, this workbook will be linked to a workbook index to access these files by file name. This report is considered protected health information and should be secured. I did not include an opening password, but that, too, will be included in the next update. As such, this data and printed reports should be secured and only accessible by pharmacy staff and providers. Remember, this workbook only gives an estimate of Creatinine Clearance. You must use your clinical judgment whenever using any automated system. I hope this will make at least part of your clinical job easier. 10

13 License June 2016 Software License Agreement The following Software License Agreement is between Andersen Computing (herein after known as "Licensor") and you, the user (herein after known as "Licensee") for the use of Licensor's program(s): AC CrCl_Amputee MS Excel workbook (all versions). By installing the enclosed programs, you indicate that you accept all the terms and conditions of this agreement as written without modification. If you do NOT so agree, DO NOT INSTALL the program but, instead, immediately remove it from your computer. BY INSTALLING THE PROGRAM, LICENSEE AGREES THAT THIS LICENSE IS THE COMPLETE AND EXCLUSIVE STATEMENT OF THE AGREEMENT BETWEEN LICENSOR AND LICENSEE. GRANT OF MULTIPLE MACHINE USE LICENSE: All Andersen Computing Programs are free to health care organizations for unlimited use, provided the organizations register the software (at Andersen-Computing.com). Otherwise, all terms apply to the Licensee. RESTRICTIONS ON USE, TRANSFER, AND COPYING: AC CrCl_Amputee MS Excel workbook and the accompanying manuals are copyrighted by Licensor and are protected under the Copyright Act of the United States. Under this Act, LICENSEE MAY NOT, OR ALLOW ANOTHER TO: USE, COPY, MODIFY, SUBLICENSE, RENT, LEASE, CONVEY, TRANSLATE, OR TRANSFER THE PROGRAMS OR DOCUMENTATION, OR ANY COPY EXCEPT AS EXPRESSLY PROVIDED IN THIS AGREEMENT. LICENSEE MAY NOT, OR ALLOW ANOTHER TO: CONVERT THE SOFTWARE TO ANY PROGRAMMING LANGUAGE OR FORMAT, DECOMPILE OR DISASSEMBLE THE SOFTWARE, OR ANY COPY, MODIFICATION, OR MERGED PORTION, IN WHOLE OR IN PART. The above shall prevail in whole except as permitted by Title 17, United States Code and subparagraph (c)(i)(ii) of the Rights in Technical Data and Computer Software clause of DFARS or subparagraphs (c)(1) and (2) of the Commercial Computer Software - Restricted Rights at 48 CRF , as applicable. If this program was acquired in the United States, this Agreement is governed by the laws of the State of South Carolina. If this program was acquired outside the United States, then local law may apply. LIMITED WARRANTY AND DISCLAIMER Technical Support will be provided via to Licensee at no charge for a period of 360 days from date of download provided that Licensee registered the product. Licensor shall bear no responsibility for telephone or other charges incurred by Licensee in obtaining Technical Support. Licensor shall bear no responsibility to provide Technical Support to non-registered users. 11

14 Report Sample Adjustment of Desirable Body Weight for Amputees Patient Report Date: 6/13/2016 Filename: AC_CrCl_Amputee.xlsm Physician Luthor,Alexander Date 06/10/2016 DOB: 03/01/1943 Pharmacist Grayson,Richard Given: Location ICU Bed: 10 Account # becomes part of the filename upon saving initial da Age= 73 y/o Unit #: M Account #: A Height= 48 in cm Weight= 150 lb kg Sex (M or F) F Factor= 0.85 SrCr (Day one) = Smallville Medical Center 101 North Luther Lane, Smallville, KS Inpatient Pharmacy - (555) Quinn,Harley 1.0 mg/dl Estimated Pre-Amputation Height: 70 inches 1. Estimate Creatinine Clearance (est.)* Cockroft-Gault formula Cr Cl=((140-age)*(LBWt in kg)/(72*srcr))*sex factor Cr Cl = ml/min** *Using estimated LBW for amputee rather than calculated value. Check if using Adjusted Body Weight for patients > 120% of Lean Body Weight to calculate CrCl **Note how changes in LBWt from male to female affect CrCl (in addition to change in Sex factor) 2. Estimated CrCl Weight)* Actual BW= 68.2 Kg LBW=45+(2.3* inches in excess of 60) for Females For patients 20% over LBW LBW=50+(2.3* inches in excess of 60) for Males Adj BW = =LBW +0.4*(actual body wt-lbw) LBW= 51.1 kg Adj BW = 57.9 kg *For patients with Actual BW < LBW, use Actual BW Percent ABW/LBW 133.4% Use CrCl Weight Wt -> 51.1 Kg 3. Results of amputee Lean Body Weight analysis: Bilateral above the knee amputation: 30 % decrease in LBW. Lean Body Weight is estimated at 70% of preamputation LBW. Notes: Signature: Subtract noted percent of body weight for amputees Pharmacist: Grayson,Richard QUINN,HARLEY References 1.John Murphy's Clinical Pharmacokinetics, 2nd ed Acct: A LUTHOR,ALEXANDER M Brunnstrom, S. Clinical Kinesiology. 4th ed ICU Bed: 10 Version: 1.3 (06/091/2016) F 03/01/ _A _CrCl_Amputee.xlsm Admit Age: 73 12

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