Phenytoin monitoring of patients in a long-term care facility

An interdisciplinary team of geriatric health care professionals evaluated the issue of frequent phenytoin sampling in a Veterans Administration long-term care facility. Few recommendations on the frequency of phenytoin monitoring in a stable nursing-home population already existed. Our team hypothesized that placing criteria-based restrictions on phenytoin monitoring would reduce the frequency of testing without worsening patient outcomes. Extensive education was performed to improve subjective clinical monitoring of phenytoin toxicity in an effort to reduce dependency on laboratory tests. When quarterly and criteria-based restrictions were placed on phenytoin sampling, the overall quantity of levels decreased by 45%, from a mean of 10.27 to 5.64 per patient in a 6-month period (p < 0.01). No increase in morbidity due to reduced intensity of phenytoin monitoring was detected by the team. As a result of the evaluation, a policy of routine quarterly sampling with additional criteria-based serum concentrations as necessary was developed.