Article

Impact of a clinical pharmacist-enforced intensive care unit sedation protocol on duration of mechanical ventilation and hospital stay

February 2008
Critical Care Medicine 36(2):427-33

DOI:10.1097/01.CCM.0000300275.63811.B3

Source
PubMed

Authors:

Massachusetts General Hospital

While the use of a protocol to guide sedation and analgesia therapy in the intensive care unit has been shown to improve patient outcomes, compliance is often poor. We hypothesized that a formal, consistent intervention by pharmacists to promote adherence to our institution's sedation guidelines would improve clinical outcomes. The purpose of this study was to document the impact of daily pharmacist interventions on clinical outcomes of intensive care unit patients prescribed continuous sedative therapy. Before-after study. Two medical intensive care units (total of 18 beds) at a university medical center. Patients were 156 mechanically ventilated patients prescribed a continuous infusion of sedative medication while in the medical intensive care unit. In the retrospective group, data were collected on all mechanically ventilated patients receiving continuous sedative infusions over a 3-month period. In the prospective group, a pharmacist evaluated all mechanically ventilated patients on continuous sedation daily and made recommendations to adhere to the institution's previously approved sedation guidelines. Data were collected for 78 control and 78 intervention patients. The groups were well matched in terms of baseline demographics. The mean duration of mechanical ventilation was reduced from 338 +/- 348 hrs (14 days) in the pre-intervention group to 178 +/- 178 hrs (7.4 days) in the postintervention group (p < .001). Durations of both intensive care unit stay (380 +/- 325 hrs vs. 238 +/- 206 hrs, p = .001) and hospital stay (537 +/- 350 hrs vs. 369 +/- 274 hrs, p = .001) were also significantly reduced in the post intervention group. The institution of a daily pharmacist-enforced intervention directed at improving sedation guideline adherence resulted in a significant decrease in the duration of mechanical ventilation in patients receiving continuous sedation.

The Effect of Sedation Protocol Using Richmond Agitation- Sedation Scale (RASS) on Some Clinical Outcomes of Mechanically Ventilated Patients in Intensive Care Units: a Randomized Clinical Trial

Article

Full-text available

Dec 2019

Introduction: Providing for patients' comfort and reducing their pain is one of the important tasks of health care professionals in the Intensive Care Unit (ICU). The current study was conducted to determine the effect of a protocol using a Richmond Agitation-Sedation Scale (RASS) on some clinical outcomes of patients under mechanical ventilation (MV) in 2017. Methods: This single-blind clinical trial was conducted on 79 traumatic patients in the ICU who were randomly allocated into the intervention (N=40) and the control groups (N=39). The sedation was achieved, using a sedation protocol in the intervention group and the routine care in the control group. The clinical outcomes of the patients (duration of MV, length of staying in ICU, final outcome) were measured. As the participants had different lengths of MV and staying in ICU, the data were restructured, and were analyzed, using proper statistical methods. Results: The patients' level of sedation in the intervention group was significantly closer to the ideal score of RASS (-1 to +1). The duration of MV was significantly reduced in the intervention group, and the length of stay in the ICU was also significantly shorter. There was no difference in terms of final outcome. The ICU cost in the control group was twice as high as the cost in of the intervention group. Conclusion: The applied sedation protocol in this study would provide better sedation and could consequently lead to significantly better clinical outcomes, and the cost of caring as a result. Citation: Taran Z, Namadian M, Faghihzadeh S, Naghibi T. The effect of sedation protocol using Richmond agitation-sedation scale (RASS) on some clinical outcomes of mechanically ventilated patients in intensive care units.

Compliance with sedation analgesia protocols: Do clinical pharmacists have an impact?

Article

Full-text available

Oct 2019

What is known and objectives: The agreement between prescribed sedation objectives and sedation pump syringe rate adaptation is not optimal. Delays in adjustment of sedation doses are associated with an increased patient length of stay in the intensive care unit. Our objectives were to assess compliance with the approved sedation protocol and to evaluate the impact of a clinical pharmacist daily controlling sedation and analgesia scores and pump syringe rates on patients' outcomes in a critical care unit. Methods: Prospective before/after study involving 60 adult patients divided into two groups (non-intervention and intervention groups) who received mechanical ventilation and continuous infusions of sedative and analgesic drugs in an intensive care unit. In both groups, data were collected daily in 30 mechanically ventilated patients receiving a sedation/analgesia regimen during a 3-month period according to a standardized protocol. A pharmacist was in charge of intervening with physicians when the local sedation analgesia protocol was not followed. Results and discussion: There were no significant differences between the groups in terms of demographic characteristics except a higher proportion of men in the intervention group (70% vs 40%, P = .019). In the control group, sedation and analgesia objectives were not prescribed in more than half the cases. Pharmacist intervention reduced sedation duration (5 [2-11] vs 2 [1-5.5] days, P = .019). The cumulative delay in adaptation of the sedation analgesia electric syringe pump was significantly decreased in the intervention group (8 [0-29.5] vs 28.5 hours [11.1-68.4], P = .034). Total doses of sedatives (midazolam, propofol) and analgesics (sufentanil, remifentanil) per patient were decreased in the intervention group compared to the control group (respectively, P = .24, P = .0009, P = .0013 and P = .0007). Conclusions: Pharmacist intervention can decrease the sedation duration and the total dose of sedation medications and reinforce adherence to sedation/analgesia guidelines.

Quantifying Critical Care Pharmacist Interventions in COVID-19

Article

Full-text available

Jul 2023
J Intensive Care Med

Purpose/Background: Pharmacists have been shown to play an important role in the medication management of critically ill patients. Pharmacist interventions in the care of critically ill patients with coronavirus disease 2019 (COVID-19) have not been quantitatively described. Methodology: A single center, retrospective, observational study was conducted at Vanderbilt University Medical Center in Nashville, Tennessee. All adult patients admitted to the COVID-19 intensive care unit (ICU) or Medical ICU with a COVID-19 diagnosis between March 1, 2020, and June 30, 2021, were included. All interventions made by pharmacists were documented electronically, collected, categorized, and analyzed. The primary outcome of this study was the median number of interventions by pharmacists per patient. The secondary outcome was the number of different types of interventions performed. Results: A total of 768 patients were included in the analysis. The median age was 63 years old; 63% of patients were male and 71% were Caucasian. Median hospital length of stay (LOS) was 12 days (interquartile range (IQR) 7-21) and ICU LOS was 5 days (IQR 1-11). The median Sequential Organ Failure Assessment score was 4 (IQR 2-7) and Charlson Comorbidity Index was 3 (IQR 2-5). Mortality at 60 days occurred in 352 patients (46%). Pharmacists performed a total of 7027 interventions for 655 patients with a median number of pharmacist interventions per patient of 6 (IQR 3-14). The most common pharmacist interventions were medication discontinuation (24%), completion of components of the ICU liberation bundle (19%), medication dose adjustment (18%), therapeutic drug monitoring (15%), and medication initiation (10%). Conclusions: Pharmacists made multiple interventions related to medication use and management in critically ill patients with COVID-19. This study adds important information of the evolving role clinical pharmacists play in the care of critical illness, specifically during the COVID-19 pandemic.

A survey of current practices in sedation, analgesia, withdrawal, and delirium management in paediatric cardiac ICUs

Article

Full-text available

Jan 2023
CARDIOL YOUNG

Objective: To characterise the current approach to sedation, analgesia, iatrogenic withdrawal syndrome and delirium in paediatric cardiac ICUs. Design: A convenience sample survey of practitioners at institutions participating in the Pediatric Cardiac Critical Care Consortium conducted from September to December 2020. Setting: Paediatric cardiac ICUs. Measurements and main results: Survey responses were received from 33 of 42 institutions contacted. Screening for pain and agitation occurs commonly and frequently. A minority of responding centres (39%) have a written analgesia management protocol/guideline. A minority (42%) of centres have a written protocol for sedation. Screening for withdrawal occurs commonly, although triggers for withdrawal screening vary. Only 42% of respondents have written protocols for withdrawal management. Screening for delirium occurs "always" in 46% of responding centres, "sometimes" in 36% of centres and "never" 18%. Nine participating centres (27%) have written protocols for delirium management. Conclusions: Our survey identified that most responding paediatric cardiac ICUs lack a standardised approach to the management of analgesia, sedation, iatrogenic withdrawal, and delirium. Screening for pain and agitation occurs regularly, while screening for withdrawal occurs fairly frequently, and screening for delirium is notably less consistent. Only a minority of centres use written protocols or guidelines for the management of these problems. We believe that this represents an opportunity to significantly improve patient care within the paediatric cardiac ICU.

Comparing the efficacy of dexmedetomidine versus propofol for sedating mechanically ventilated patients after cardiovascular surgeries: Our experience in a tertiary hospital

Article

Jul 2021

Position Paper on Critical Care Pharmacy Services (Executive Summary): 2020 Update

Article

Sep 2020
CRIT CARE MED

Objectives: Provide a multiorganizational statement to update the statement from a paper in 2000 about critical care pharmacy practice and makes recommendations for future practice. Design: The Society of Critical Care Medicine, American College of Clinical Pharmacy Critical Care Practice and Research Network, and the American Society of Health-Systems Pharmacists convened a joint task force of 15 pharmacists representing a broad cross-section of critical care pharmacy practice and pharmacy administration, inclusive of geography, critical care practice setting, and roles. The Task Force chairs reviewed and organized primary literature, outlined topic domains, and prepared the methodology for group review and consensus. A modified Delphi method was used until consensus (> 66% agreement) was reached for each practice recommendation. Previous position statement recommendations were reviewed and voted to either retain, revise, or retire. Recommendations were categorized by level of ICU service to be applicable by setting, and grouped into five domains: patient care, quality improvement, research and scholarship, training and education, and professional development. Main results: There are 82 recommendation statements: forty-four original recommendations and 38 new recommendation statements. Thirty-four recommendations were made for patient care, primarily relating to critical care pharmacist duties and pharmacy services. In the quality improvement domain, 21 recommendations address the role of the critical care pharmacist in patient and medication safety, clinical quality programs, and analytics. Nine recommendations were made in the domain of research and scholarship. Ten recommendations are in the domain of training and education and eight recommendations regarding professional development. Conclusions: The statements recommended by this taskforce delineate the activities of a critical care pharmacist and the scope of pharmacy services within the ICU. Effort should be made from all stakeholders to implement the recommendations provided, with continuous effort toward improving the delivery of care for critically ill patients.

Position Paper on Critical Care Pharmacy Services: 2020 Update

Article

Sep 2020
CRIT CARE MED

Objectives: To provide a multiorganizational statement to update recommendations for critical care pharmacy practice and make recommendations for future practice. A position paper outlining critical care pharmacist activities was last published in 2000. Since that time, significant changes in healthcare and critical care have occurred. Design: The Society of Critical Care Medicine, American College of Clinical Pharmacy Critical Care Practice and Research Network, and the American Society of Health-Systems Pharmacists convened a joint task force of 15 pharmacists representing a broad cross-section of critical care pharmacy practice and pharmacy administration, inclusive of geography, critical care practice setting, and roles. The Task Force chairs reviewed and organized primary literature, outlined topic domains, and prepared the methodology for group review and consensus. A modified Delphi method was used until consensus (> 66% agreement) was reached for each practice recommendation. Previous position statement recommendations were reviewed and voted to either retain, revise, or retire. Recommendations were categorized by level of ICU service to be applicable by setting and grouped into five domains: patient care, quality improvement, research and scholarship, training and education, and professional development. Main results: There are 82 recommendation statements: 44 original recommendations and 38 new recommendation statements. Thirty-four recommendations represent the domain of patient care, primarily relating to critical care pharmacist duties and pharmacy services. In the quality improvement domain, 21 recommendations address the role of the critical care pharmacist in patient and medication safety, clinical quality programs, and analytics. Nine recommendations were made in the domain of research and scholarship. Ten recommendations were made in the domain of training and education and eight recommendations regarding professional development. Conclusions: Critical care pharmacists are essential members of the multiprofessional critical care team. The statements recommended by this taskforce delineate the activities of a critical care pharmacist and the scope of pharmacy services within the ICU. Effort should be made from all stakeholders to implement the recommendations provided, with continuous effort toward improving the delivery of care for critically ill patients.

Financial impact of an analgosedation protocol for mechanically ventilated patients in a cardiovascular intensive care unit

Article

Dec 2019

Purpose The primary objective was to evaluate the impact of an analgosedation protocol in a cardiac intensive care unit (CICU) on daily doses and costs of analgesic, sedative, and antipsychotic medications. Methods We conducted a single-center quasi-experimental study in 363 mechanically ventilated patients admitted to our CICU from March 1, 2011, to April 13, 2013. On March 1, 2012, an analgosedation protocol was implemented. Patients in the pre-implementation group were managed at the cardiologist’s discretion, which consisted of a continuous sedative-hypnotic approach and opioids as needed. Patients in the implementation group were managed using this protocol. Results The mean ± S.D. per-patient doses (mg/day) of propofol, lorazepam, and clonazepam decreased with the use of an analgosedation protocol (propofol 132,265.7 ± 12,951 versus 87,980.5 ± 10,564 [p = 0.03]; lorazepam 10.5 ± 7.3 versus 3.3 ± 4.0 [p < 0.001]; clonazepam 9.9 ± 8.3 versus 1.1 ± 0.5 [p = 0.03]). The mean daily cost of propofol and lorazepam also significantly decreased (33.5% reduction in propofol cost [p = 0.03]; 69.0% reduction in lorazepam cost [p < 0.001]). The per-patient dose and cost of fentanyl (mcg/day) declined with analgosedation protocol use (fentanyl 2,274.2 ± 2317.4 versus 1,026.7 ± 981.4 [p < 0.001]; 54.8% decrease in fentanyl cost [p < 0.001]). Conclusion The implementation of an analgosedation protocol significantly decreased both the use and cost of propofol, lorazepam, and fentanyl. Further investigation of the clinical impact and cost-effectiveness of a critical care consultation service with implementation of an analgosedation protocol is warranted in the CICU.

Clinical Pharmacy Services in a Neurosurgical Intensive Care Unit in Iran: A Focus on a Comprehensive Medication Management Model

Article

Full-text available

Jul 2024

Background: Critically ill patients treated in the intensive care unit (ICU) are at risk of drug-related problems (DRPs), clinical pharmacists are specifically trained in pharmacotherapy evaluations with the abilities to identify and manage drug-related complications. This study aims to identify areas where clinical pharmacists can be effective in the ICU. The primary outcomes of this study were determining the clinical aspect of clinical pharmacists in the ICU, type, and number of clinical pharmacist interventions. Methods: This was a prospective, interventional study in a teaching hospital in Iran. A clinical pharmacist was dedicated to implement comprehensive medication management (CMM); All Pharmacotherapy Problems were categorized. Results: During the monitoring of 162 patients by the clinical pharmacist, 1524 interventions were conducted. The most frequent pharmacotherapy-related problems identified were drug selection (33.3%), dose adjustment (17.3%), and fluid and electrolyte management (12.9%). Conclusion: Clinical pharmacists’ interventions could reduce the rate of DRPs by pharmacotherapy evaluation and may have important role in many aspects of patient’s management.

Consensus Statement on Standards for Neurocritical Care Units in Low-Income and Middle-Income Countries (LMICs).

Preprint

Full-text available

Dec 2023

The disease burden of severe neurological and neurosurgical illnesses in low-income and middle-income countries (LMICs) is high. Management of these patients by a dedicated neurocritical care team can improve outcome. Globally, there is significant variation in organization, structure, and outcome of patients with neurocritical illnesses. This consensus statement aims to contextualize the standards for neurological critical care units (NCCUs) in LMICs. Recommendations were made about organization and infrastructure, personnel, logistics, training, education, and process for developing neurocritical care program appropriate for LMICs. Methods: The steering committee for the consensus statement was formed under the leadership of SNCC. With permission from NCS and the NCS guidelines committee, the previously published standards for NCCUs by NCS was used for a web-based survey. The Delphi method was used to gather consensus. A total of 30 experts from 21 regions, all from LMICs, participated in the survey. Feedback was formally collated, reviewed, and incorporated into the final document.

Avaliação da sedoanalgesia pelo monitoramento do índice bispectral em uma Unidade de Terapia Intensiva Covid: a importância das intervenções farmacêuticas

Article

Full-text available

Nov 2023

Introdução: O índice bispectral (BIS) é um monitor do nível de conciência com maior sensibilidade e objetividade para a avaliação da atividade cerebral em comparação às escalas subjetivas usuais, principalmente a RASS (Richmond Agitation-Sedation Scale), durante os estados comatosos. Objetivos: Avaliar a sedoanalgesia e os níveis de consciência dos pacientes em ventilação mecância por meio do monitoramento pelo BIS. Métodos: A pesquisa é exploratória, transversal e retrospectiva, conduzida em pacientes da UTI-Covid do Hospital Universitário da Federal do Piauí (HU-UFPI). Dados foram coletados de junho a dezembro de 2021, utilizando infrormações de prontuários e fichas próprias do BIS, após aprovação do comitê de ética (parecer 5.427.074). Análises foram feitas com estatística descritiva simples no Microsoft Excel. Resultados: Analisaram-se 121 avaliações em 47 pacientes, sendo 67% homens. Fentanil e midazolam foram os analgésicos e sedativos principais. Cerca de 60% dos pacientes estavam profundamente sedados e somente 31% apresentavam níveis adequados de sedoanalgesia pelo BIS. Comparando BIS e RASS, 67 análises tiveram BIS 0-39 e RASS -5. Cerca de 80% apresentavam sobredose de midazolam e 29% de fentanil. As intervenções farmacêuticas contribuíram para redução do uso de sedoanalgesia. Conclusão: O BIS mostrou ser uma ferramenta eficaz na avaliação da sedoanalgesia e permitiu uma melhor participação do farmacêutico na prática clínica. Seus benefícios incluíram melhor controle medicamentoso e adequação da sedação em pacientes sob ventilação mecânica na UTI-Covid do HU-UFPI.

Machine learning based prediction of prolonged duration of mechanical ventilation incorporating medication data

Article

Full-text available

Sep 2023

Rationale Duration of mechanical ventilation is associated with adverse outcomes in critically ill patients and increased use of resources. The increasing complexity of medication regimens has been associated with increased mortality, length of stay, and fluid overload but has never been studied specifically in the setting of mechanical ventilation. Objective The purpose of this analysis was to develop prediction models for mechanical ventilation duration to test the hypothesis that incorporating medication data may improve model performance. Methods This was a retrospective cohort study of adults admitted to the ICU and undergoing mechanical ventilation for longer than 24 hours from October 2015 to October 2020. Patients were excluded if it was not their index ICU admission or if the patient was placed on comfort care in the first 24 hours of admission. Relevant patient characteristics including age, sex, body mass index, admission diagnosis, morbidities, vital signs measurements, severity of illness, medication regimen complexity as measured by the MRC-ICU, and medical treatments before intubation were collected. The primary outcome was area under the receiver operating characteristic (AUROC) of prediction models for prolonged mechanical ventilation (defined as greater than 5 days). Both logistic regression and supervised learning techniques including XGBoost, Random Forest, and Support Vector Machine were used to develop prediction models. Results The 318 patients [age 59.9 (SD 16.9), female 39.3%, medical 28.6%] had mean 24-hour MRC-ICU score of 21.3 (10.5), mean APACHE II score of 21.0 (5.4), mean SOFA score of 9.9 (3.3), and ICU mortality rate of 22.6% (n=72). The strongest performing logistic model was the base model with MRC-ICU added, with AUROC of 0.72, positive predictive value (PPV) of 0.83, and negative prediction value (NPV) of 0.92. The strongest overall model was Random Forest with an AUROC of 0.78, a PPV of 0.53, and NPV of 0.90. Feature importance analysis using support vector machine and Random Forest revealed severity of illness scores and medication related data were the most important predictors. Conclusions Medication regimen complexity is significantly associated with prolonged duration of mechanical ventilation in critically ill patients, and prediction models incorporating medication information showed modest improvement in this prediction.

Intervenciones farmacéuticas y factores asociados a su aceptación en unidades de cuidados intensivos en Brasil

Article

Full-text available

Jun 2023

Objetivo: El propósito de este estudio es evaluar las intervenciones farmacéuticas (IF) realizadas sobre PRM y los factores asociados a su aceptación. Método: Se trata de un estudio descriptivo y transversal que analizó las IF realizadas a pacientes adultos de dos UCI de Fortaleza, Brasil, en 2019. Las IF se analizaron en las categorías cantidad de fármaco y estrategia farmacológica, utilizando la clasificación propuesta por Sabater et al. Los fármacos se clasificaron además por el Sistema de Clasificación Anatómica, Terapéutica, Química y por la clasificación de Fármacos de Alta Vigilancia (FAV). Resultados: Se incluyeron 305 pacientes, siendo la mayoría del sexo masculino (55,1 %), ancianos (52,8 %) y atendidos en la UCI quirúrgica (51,4 %). Se analizaron 1.317 IF y se aceptaron el 88,0 %, siendo la sustitución de uno o más fármacos (28,0 %) y la adición de uno o más fármacos (27,7 %) las más frecuentes. La clase terapéutica más prevalente fue antiinfeccioso de uso sistémico (24,1 %) y los FAV estuvieron implicados en el 21,7 % de las IF. Se observó asociación entre las IF aceptadas e ingreso en UCI clínica (p<0,0001), FAV (p=0,0013), sustitución de uno o más fármacos (p=0,0062) y la clase sustitutos sanguíneos y soluciones de perfusión (p= 0,0187). Conclusiones: Se realizaron y aceptaron un elevado número de IF, lo que refuerza la importancia del farmacéutico en la revisión de las prescripciones médicas en UCI.

Impact of Pharmacists to Improve Patient Care in the Critically Ill: A Large Multicenter Analysis Using Meaningful Metrics With the Medication Regimen Complexity-ICU (MRC-ICU) Score

Article

Sep 2022
CRIT CARE MED

Despite the established role of the critical care pharmacist on the ICU multiprofessional team, critical care pharmacist workloads are likely not opti- mized in the ICU. Medication regimen complexity (as measured by the Medication Regimen Complexity-ICU [MRC-ICU] scoring tool) has been proposed as a potential metric to optimize critical care pharmacist workload but has lacked robust external validation. The purpose of this study was to test the hypothesis that MRC-ICU is related to both patient outcomes and pharmacist interventions in a diverse ICU population.

Evaluating the Medication Regimen Complexity Score as a Predictor of Clinical Outcomes in the Critically Ill

Article

Full-text available

Aug 2022

Background: Medication Regimen Complexity (MRC) refers to the combination of medication classes, dosages, and frequencies. The objective of this study was to examine the relationship between the scores of different MRC tools and the clinical outcomes. Methods: We conducted a retrospective cohort study at Roger William Medical Center, Providence, Rhode Island, which included 317 adult patients admitted to the intensive care unit (ICU) between 1 February 2020 and 30 August 2020. MRC was assessed using the MRC Index (MRCI) and MRC for the Intensive Care Unit (MRC-ICU). A multivariable logistic regression model was used to identify associations among MRC scores, clinical outcomes, and a logistic classifier to predict clinical outcomes. Results: Higher MRC scores were associated with increased mortality, a longer ICU length of stay (LOS), and the need for mechanical ventilation (MV). MRC-ICU scores at 24 h were significantly (p < 0.001) associated with increased ICU mortality, LOS, and MV, with ORs of 1.12 (95% CI: 1.06-1.19), 1.17 (1.1-1.24), and 1.21 (1.14-1.29), respectively. Mortality prediction was similar using both scoring tools (AUC: 0.88 [0.75-0.97] vs. 0.88 [0.76-0.97]. The model with 15 medication classes outperformed others in predicting the ICU LOS and the need for MV with AUCs of 0.82 (0.71-0.93) and 0.87 (0.77-0.96), respectively. Conclusion: Our results demonstrated that both MRC scores were associated with poorer clinical outcomes. The incorporation of MRC scores in real-time therapeutic decision making can aid clinicians to prescribe safer alternatives.

Impact of Pharmacists to Improve Patient Care in the Critically Ill: A Large Multicenter Analysis Using Meaningful Metrics With the Medication Regimen Complexity-ICU (MRC-ICU)

Article

Jun 2022

Objectives: Despite the established role of the critical care pharmacist on the ICU multiprofessional team, critical care pharmacist workloads are likely not optimized in the ICU. Medication regimen complexity (as measured by the Medication Regimen Complexity-ICU [MRC-ICU] scoring tool) has been proposed as a potential metric to optimize critical care pharmacist workload but has lacked robust external validation. The purpose of this study was to test the hypothesis that MRC-ICU is related to both patient outcomes and pharmacist interventions in a diverse ICU population. Design: This was a multicenter, observational cohort study. Setting: Twenty-eight ICUs in the United States. Patients: Adult ICU patients. Interventions: Critical care pharmacist interventions (quantity and type) on the medication regimens of critically ill patients over a 4-week period were prospectively captured. MRC-ICU and patient outcomes (i.e., mortality and length of stay [LOS]) were recorded retrospectively. Measurements and main results: A total of 3,908 patients at 28 centers were included. Following analysis of variance, MRC-ICU was significantly associated with mortality (odds ratio, 1.09; 95% CI, 1.08-1.11; p < 0.01), ICU LOS (β coefficient, 0.41; 95% CI, 00.37-0.45; p < 0.01), total pharmacist interventions (β coefficient, 0.07; 95% CI, 0.04-0.09; p < 0.01), and a composite intensity score of pharmacist interventions (β coefficient, 0.19; 95% CI, 0.11-0.28; p < 0.01). In multivariable regression analysis, increased patient: pharmacist ratio (indicating more patients per clinician) was significantly associated with increased ICU LOS (β coefficient, 0.02; 0.00-0.04; p = 0.02) and reduced quantity (β coefficient, -0.03; 95% CI, -0.04 to -0.02; p < 0.01) and intensity of interventions (β coefficient, -0.05; 95% CI, -0.09 to -0.01). Conclusions: Increased medication regimen complexity, defined by the MRC-ICU, is associated with increased mortality, LOS, intervention quantity, and intervention intensity. Further, these results suggest that increased pharmacist workload is associated with decreased care provided and worsened patient outcomes, which warrants further exploration into staffing models and patient outcomes.

Practices in sedation, analgesia, mobilization, delirium, and sleep deprivation in adult intensive care units (SAMDS-ICU): an international survey before and during the COVID-19 pandemic

Article

Full-text available

Feb 2022

Background: Since the publication of the 2018 Clinical Guidelines about sedation, analgesia, delirium, mobilization, and sleep deprivation in critically ill patients, no evaluation and adequacy assessment of these recommendations were studied in an international context. This survey aimed to investigate these current practices and if the COVID-19 pandemic has changed them. Methods: This study was an open multinational electronic survey directed to physicians working in adult intensive care units (ICUs), which was performed in two steps: before and during the COVID-19 pandemic. Results: We analyzed 1768 questionnaires and 1539 (87%) were complete. Before the COVID-19 pandemic, we received 1476 questionnaires and 292 were submitted later. The following practices were observed before the pandemic: the Visual Analog Scale (VAS) (61.5%), the Behavioral Pain Scale (BPS) (48.2%), the Richmond Agitation Sedation Scale (RASS) (76.6%), and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) (66.6%) were the most frequently tools used to assess pain, sedation level, and delirium, respectively; midazolam and fentanyl were the most frequently used drugs for inducing sedation and analgesia (84.8% and 78.3%, respectively), whereas haloperidol (68.8%) and atypical antipsychotics (69.4%) were the most prescribed drugs for delirium treatment; some physicians regularly prescribed drugs to induce sleep (19.1%) or ordered mechanical restraints as part of their routine (6.2%) for patients on mechanical ventilation; non-pharmacological strategies were frequently applied for pain, delirium, and sleep deprivation management. During the COVID-19 pandemic, the intensive care specialty was independently associated with best practices. Moreover, the mechanical ventilation rate was higher, patients received sedation more often (94% versus 86.1%, p < 0.001) and sedation goals were discussed more frequently in daily rounds. Morphine was the main drug used for analgesia (77.2%), and some sedative drugs, such as midazolam, propofol, ketamine and quetiapine, were used more frequently. Conclusions: Most sedation, analgesia and delirium practices were comparable before and during the COVID-19 pandemic. During the pandemic, the intensive care specialty was a variable that was independently associated with the best practices. Although many findings are in accordance with evidence-based recommendations, some practices still need improvement.

Quality Improvement Initiative to Increase Rate of and Time to Post-intubation Analgesia in the Emergency Department

Article

Full-text available

Jul 2021
West J Emerg Med

Introduction: Intubation and mechanical ventilation are common interventions performed in the emergency department (ED). These interventions cause pain and discomfort to patients and necessitate analgesia and sedation. Recent trends in the ED and intensive care unit focus on an analgesia-first model to improve patient outcomes. Initial data from our institution demonstrated an over-emphasis on sedation and an opportunity to improve analgesic administration. As a result of these findings, the ED undertook a quality improvement (QI) project aimed at improving analgesia administration and time to analgesia post-intubation. Methods: We performed a pre-post study between January 2017-February 2019 in the ED. Patients over the age of 18 who were intubated using rapid sequence intubation (RSI) were included in the study. The primary outcome was the rate of analgesia administration; a secondary outcome was time to analgesia administration. Quality improvement interventions occurred in two phases: an initial intervention focused on nursing education only, and a subsequent intervention that included nursing and physician education. Results: During the study period, 460 patients were intubated in the ED and met inclusion/exclusion criteria. Prior to the first intervention, the average rate of analgesia administration was 57.3%; after the second intervention, the rate was 94.9% (P <0.01). Prior to the first intervention, average time to analgesia administration was 36.0 minutes; after the second intervention, the time was 16.6 minutes (P value <0.01). Conclusion: This QI intervention demonstrates the ability of education interventions alone to increase the rate of analgesia administration and reduce the time to analgesia in post-intubation patients.

Productivity Tracking: A Survey of Critical Care Pharmacist Practices and Satisfaction

Article

Full-text available

Apr 2022
Hosp Pharm

Introduction: The position paper on critical care pharmacy services describes two tiers of responsibilities: essential and desirable activities. Activities are categorized into five domains: patient care, quality improvement, research and scholarship, training and education, and professional development. Documentation of these activities can be important for justifying pharmacist positions, comparing pharmacy practice models, conducting performance evaluations, and tracking individual workload; however, limited recommendations are provided for standardized productivity tracking, and national practices remain largely uncharacterized. Objectives: The purpose of this survey was to describe documentation practices of critical care pharmacist activities. Methods: A cross-sectional survey was distributed via email to 1694 members of the ACCP critical care practice research network. The survey asked respondents to describe the methods used to document productivity as it relates to the 5 domains. Results: Seventy-nine (4.7%) critical care pharmacists from 63 institutions completed the survey. Intervention documentation was used for position justification and annual reviews among 54.4% and 44.1% of pharmacists, respectively. Pharmacists were routinely expected to perform additional responsibilities beyond patient care that contribute to overall productivity, but the percentage of institutions that track these activities as a measure of pharmacist productivity was relatively low: quality improvement (46%), research/scholarship (29%), training/education (38%), and professional development (27%). Documentation of these additional responsibilities and activities was primarily used for annual evaluations, but the majority of respondents answered that no standardized method for tracking activities existed. In multivariate regression, dedicated ICU pharmacists was a significant predictor for increased satisfaction (Exp(ß) 4.498, 95% CI 1.054-19.187, P = .042). Conclusion: Practice variation exists in how and for what intent critical care pharmacists track productivity. Further evaluation and standardization of productivity tracking may aid in position justification and practice model evaluation for dedicated ICU pharmacists in today’s value-based era.

Optimization of critical care pharmacy clinical services: A gap analysis approach

Article

Jun 2021

What gets measured, gets improved. —Robert Sharma Every critically ill patient requires care by a critical care pharmacist (CCP) for best possible outcomes. Indeed, these highly trained professionals generate benefit through direct patient care (eg, pharmacist-driven protocols, medication monitoring, etc), participation on the intensive care unit (ICU) interprofessional team (eg, pharmacotherapy recommendations, team education, etc), and leadership in the development and implementation of quality improvement initiatives.¹ However, clinical CCP services are not provided for all ICU patients, and CCP staffing models often vary substantially across ICUs in a given hospital and among ICUs in the United States.²⁻⁴ In this narrative review, we use a gap analysis approach to define current levels of clinical CCP services, identify barriers to reaching an optimal level of these services, and propose strategies focused on expanding clinical CCP services and justifying those that currently exist. Current critical care pharmacy clinical services The broad scope of beneficial activities performed by the CCP has been extensively reviewed and supported by a position statement from the American Society of Health-System Pharmacists (ASHP), the American College of Clinical Pharmacy (ACCP), and the Society of Critical Care Medicine (SCCM): the CCP is an essential member of the healthcare team for delivery of patient-centered care in the ICU.

FCCM (Chair) 1,2 ; Yoanna Skrobik, MD, FRCP(c), MSc, FCCM (Vice-Chair) 3,4 ; Weinhouse, MD 10

Article

Jan 2018

Multicenter validation of a novel medication-regimen complexity scoring tool

Article

Mar 2020

Background The MRC-ICU, a novel regimen complexity scoring tool, provides an objective measure of medication regimen complexity in critically ill patients. The MRC-ICU may have the ability to evaluate the impact of critical care pharmacists on patient outcomes but requires further validation. The objective of this study was to confirm the external validity of the MRC-ICU scoring tool at multiple institutions and intensive care unit (ICU) settings. Methods This was a multicenter, prospective, observational study. The electronic medical record was reviewed to collect patient demographics and patient outcomes, and the medication administration record was reviewed to collect MRC-ICU scores at 24 hours, 48 hours, and ICU discharge. Validation was performed by assessing convergent and divergent validity of the score. Spearman rank-order correlation was used to determine correlation. Results A total of 230 patients were evaluated across both centers in both medical ICUs and surgical ICUs. Differences between the original center and the new site included that total number of orders (29 vs 126; P < 0.001) and total number of medication orders (17 vs 36; P < 0.001) were higher at the new site, whereas the original site had higher overall MRC-ICU scores (14 vs 11; P = 0.004). The MRC-ICU showed appropriate convergent validity with number of orders and medication orders (all P < 0.001) and appropriate divergent validity with no significant correlation found between age, weight, or gender (all P > 0.05). Conclusions External validity of the MRC-ICU has been confirmed through evaluation at an external site and in the surgical ICU population. The MRC-ICU scoring tool requires prospective evaluation to provide objective data regarding optimal pharmacist use.

mckenzieanddevlin

Article

Full-text available

Feb 2018
CRIT CARE MED

EDITORIAL IN CCM

Abdominal Compartment Syndrome

Chapter

Apr 2025

Abdominal compartment syndrome (ACS) is a rapidly progressive and potentially fatal condition. With appropriate understanding of the risk factors, prevention strategies, and multidisciplinary approaches to management, ACS can be successfully treated. In this chapter, we aim to familiarize pharmacist clinicians with the pathophysiology, diagnosis, and management of abdominal compartment syndrome as well as specific opportunities for their pivotal role in care for patients with this condition.

The Role of the Pharmacist in Family Engagement in the Intensive Care Unit and During Transitions of Care

Chapter

Mar 2025

Joanna L Stollings

Utilization of the ABCDEF Bundle (Assess, prevent, and manage pain, both spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs), Choice of Analgesia and sedation, Delirium-assess, prevent, and manage, Early mobility and exercise, and Family engagement and empowerment) in the intensive care unit (ICU) promotes interprofessional care and improves patient outcomes. The pharmacist has a unique role engaging the family and assisting with implementation of the ABCDEF Bundle. Pharmacists conducted medication histories when compared to other health care practitioners have been shown to have a lower rate of errors. Having the family in addition to the patient present during medication reconciliation is key to obtaining the most accurate medication history. Deprescribing medications used temporarily in the ICU such as antipsychotics, stress ulcer prophylaxis, or sedatives is an important role of the pharmacist. The family can serve as a resource to clarify home medications and allow clinicians to feel more comfortable with deprescribing medications. Confirmation of a patient’s home medications with the family prior to reinitiation of important home medications is another way that the pharmacist interacts with the family. Having the family in addition to the patient present during discharge counseling by the pharmacist is imperative and has been reported to be helpful by pharmacists. Utilization of a pharmacist in a post-intensive care syndrome (PICS) or Post Acute COVID-19 Syndrome (PACS) is key as the medication reconciliation process including the family member can alleviate symptoms of PICS-F. This chapter describes the role of the pharmacist with family engagement and empowerment or post-intensive care syndrome-family (PICS-F).

Use of a drug-related problem oriented medical record in the medication review of critically ill patients – Randomized clinical trial

Article

Jan 2025
RES SOC ADMIN PHARM

The role of the pharmacist in the ICU: Current status and for the futureICUにおける薬剤師の役割：現状と未来に向けて

Article

Jan 2024

Shodai Yoshihiro

Pharmacists are crucial members of the multidisciplinary team caring for critically ill patients. Patient management by pharmacists in the ICU involves ensuring the quality of both direct and indirect care as well as honing professionalism as critical care pharmacists. “Position paper on critical care pharmacists in Japan” aptly outlines balanced behavioral objectives across these three domains. However, there is concern that the heterogeneity of processes for assessing patients and managing the workforce in clinical practice may lead to variability in patient outcomes. In addition, education for pharmacists to provide pharmacological care in the ICU is not widespread among all pharmacists. Demonstrating and continually refining appropriate indicators, along with providing systematic education on intensive care medicine not only to pharmacists but also to pharmacy students, may contribute to the continued evolution of critical care pharmacists in the ICU. The anticipated evolution of patient management by critical care pharmacists in the ICU is expected not only to deliver appropriate pharmacotherapy but also to contribute to further enhance patient outcomes further.

Role of Clinical Pharmacists in Intensive Care Unit

Chapter

Sep 2024

Yunus Emre Ayhan

The Roles and Responsibilities of Clinical Pharmacists in Hospital Settings is a comprehensive textbook designed to equip graduate pharmacy students and residents with the essential skills and knowledge needed for effective clinical pharmacy practice in hospitals. This book emphasizes the multidisciplinary nature of clinical pharmacy and the importance of adhering to international guidelines and standards. The book provides an overview of hospital pharmacy practice with an introduction to the essential requirements of a hospital environment, followed by a detailed exploration of clinical pharmacist roles across major medical subspecialties, including internal medicine, infectious diseases, intensive care, pediatrics, cardiology, and oncology. Key Features General and specialized Roles: Comprehensively covers different aspects of clinical pharmacology from basics to medical subspecialties Practical Insights: Offers practical tools, reference resources, and strategies for clinical pharmacy practice across different hospital departments. Advanced Practice: Guides readers from foundational knowledge to advanced clinical pharmacy practices, preparing them for specialized roles within hospital settings. Global Standards: Highlights the importance of multidisciplinary education and adherence to global clinical pharmacy standards. This textbook is an essential resource for pharmacy students, specialist assistants, and anyone pursuing a career in clinical pharmacy.

Board of Pharmacy Specialties 2022 recertification data: Characteristics and perceptions of pharmacists successfully recertified

Article

Oct 2024

Purpose The purpose of this retrospective study was to utilize existing data to (1) compare the characteristics of Board of Pharmacy Specialties (BPS) credentials successfully recertified vs those that were not successfully recertified in 2022 and (2) compare survey responses about maintaining board certification by continuing pharmacy education (CPE) vs examination among those who successfully recertified. Summary The characteristics of BPS credentials eligible for recertification in 2022 (n = 4,812) and survey responses from board-certified pharmacists who successfully recertified in 2022 (n = 3,629) were retrieved from the MyBPS database. Across all specialties, 75.4% of credentials were successfully recertified in 2022. Most credentials were recertified by CPE (92.1%). Successfully recertified credentials were predominately held by pharmacists practicing within the US (96.7%), those between the ages of 31 and 40 years (51.9%), and those completing the first 7-year certification cycle (73.9%). A significant difference was found between recertified credentials and those that were not recertified based on specialty, recertification pathway, credential holder practice location, and credential holder age. Over 89% of respondents reported that a primary benefit of maintaining board certification is to “expand knowledge and skills in pharmacy.” Conclusion Several factors influence the decision and/or ability of board-certified pharmacists to recertify and maintain their credentials. Successfully recertified board-certified pharmacists report expanded competency, credibility, personal gratification, and increased confidence among the primary benefits of maintaining board certification. Board-certified pharmacists who successfully recertify also report a preference for a recertification process that is temporally and financially efficient.

A pharmacist's guide to mitigating sleep dysfunction and promoting good sleep in the intensive care unit

Article

Aug 2024
AM J HEALTH-SYST PH

Purpose To review causes, risk factors, and consequences of sleep disruption in critically ill patients; evaluate the role of nonpharmacological and pharmacological therapies for management of sleep in the intensive care unit (ICU); and discuss the role of pharmacists in implementation of sleep bundles. Summary Critically ill patients often have disrupted sleep and circadian rhythm alterations that cause anxiety, stress, and traumatic memories. This can be caused by factors such as critical illness, environmental factors, mechanical ventilation, and medications. Methods to evaluate sleep, including polysomnography and questionnaires, have limitations that should be considered. Multicomponent sleep bundles with a focus on nonpharmacological therapy aiming to reduce nocturnal noise, light, and unnecessary patient care may improve sleep disorders in critically ill patients. While pharmacological agents are often used to facilitate sleep in critically ill patients, evidence supporting their use is often of low quality, which limits use to patients who have sleep disruption refractory to nonpharmacological therapy. Dedicated interprofessional teams are needed for implementation of sleep bundles in the ICU. Extensive pharmacotherapeutic training and participation in daily patient care rounds make pharmacists vital members of the team who can help with all components of the bundle. This narrative review discusses evidence for elements of the multicomponent sleep bundle and provides guidance on how pharmacists can help with implementation of nonpharmacological therapies and management of neuroactive medications to facilitate sleep. Conclusion Sleep bundles are necessary for patients in the ICU, and dedicated interprofessional teams that include pharmacists are vital for successful creation and implementation.

Next generation of critical care pharmacist practice studies: Beyond essential

Article

May 2024

Mojdeh Heavner

Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Early Deep Sedation Practices Worsened During the Pandemic Among Adult Patients Without COVID-19: A Retrospective Cohort Study

Article

Jan 2024
CHEST

Prevalence and Value of Board Certification Among Pharmacy Practice Faculty in the United States

Article

Nov 2023
AM J PHARM EDUC

Critical Care Pharmacists: A Focus on Horizons

Article

Jul 2023

Andrea Sikora

Critical care pharmacy has evolved rapidly over the last 50 years to keep pace with the rapid technological and knowledge advances that have characterized critical care medicine. The modern-day critical care pharmacist is a highly trained individual well suited for the interprofessional team-based care that critical illness necessitates. Critical care pharmacists improve patient-centered outcomes and reduce health care costs through three domains: direct patient care, indirect patient care, and professional service. Optimizing workload of critical care pharmacists, similar to the professions of medicine and nursing, is a key next step for using evidence-based medicine to improve patient-centered outcomes.

Medication Use Optimization in Critical Care Through a Pharmacy Morbidity, Mortality, and Improvement Program

Article

May 2023

Pharmacy‐led morbidity, mortality, and improvement (MMI) programs enhance practitioner education and improve patient‐safety culture. The impact of MMI programs on process improvement (PI) outcomes is lacking, particularly within critical care. The purpose of this retrospective report was to describe PI interventions from critical care medication errors evaluated through a pharmacy MMI program. Medication errors reported between June 2013 and August 2022 that occurred in an intensive care unit, emergency department, or procedural area were included. Error severity and potential were assessed using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Medication Error Index and Harm Associated with Medication Error Classification (HAMEC), respectively. The primary outcome of PI interventions was classified as clinical update, operations change, pharmacy or hospital administration change, and/or informatics and technology (IT) updates. Electronic medical record (EMR) were further classified as best practice advisory, medication order build/change, order set build/change, dose limit/alert, or infusion smart pump change. Institute for Healthcare Improvement (IHI) reliability level was evaluated as a secondary outcome. A total of 54 errors were included. Most errors were classified as NCC MERP category D (13 [24.1%]) and C (12 [22.2%]) with severe harm potential (HAMEC 4, 26 [48.1%]; median score 3 [interquartile range, IQR, 3–4]) error potential. A total of 88 PI interventions were identified (median 1.5 [IQR 1–2] per error); clinical (30 [34.1%]) and IT (26 [29.5%]) updates were the most common. Order set build or change (20 [45.5%]) was the most common EMR enhancement. PI interventions were a median IHI level 1 reliability (IQR, 1–2). EMR enhancements had a median IHI level of reliability of 2 (IQR, 1–2). Critical care medication errors addressed through a formal Pharmacy MMI program have high harm potential and often involve multiple PI interventions. EMR interventions generally had higher levels of empiric reliability.

Optimizing Pharmacotherapy Regimens in Adult Patients Receiving Extracorporeal Membrane Oxygenation: A Narrative Review for Clinical Pharmacists

Article

Mar 2023

Extracorporeal membrane oxygenation (ECMO) is a complex therapy aimed at providing mechanical support for patients with severe, life‐threating cardiac and/or respiratory failure. Research has demonstrated variability in pharmacokinetic changes in the critically ill patient population receiving ECMO. There is a need to understand the complexity of these pharmacokinetic changes to provide optimal pharmacotherapeutic regimens thereby maximizing effectiveness and mitigating harm. However, the number of pharmacokinetic studies in patients receiving ECMO remains small, and very few prospective studies have been published addressing optimal analgesic, sedative, or antimicrobial therapy. Anticoagulation is an additional important component of ECMO therapy but the preferred agent as well as dosing and monitoring strategy are unclear. The purpose of this narrative review is to discuss analgesia and sedation, antimicrobial, and anticoagulation management strategies in adult patients receiving ECMO.

Impact of Critical Care Pharmacist‐Led Interventions on Pain, Agitation, and Delirium in Mechanically‐Ventilated Adults: A Systematic Review

Article

Mar 2023

Best practices of pain, agitation, and delirium (PAD) management require coordinated, bundled care among an interprofessional intensive care unit (ICU) team. Clinical pharmacists are essential health care team members in optimizing sedation and analgesia management in critically ill patients. The purpose of this systematic review is to summarize the clinical impact of pharmacist‐led interventions targeting pain, agitation, and delirium in mechanically‐ventilated adult ICU patients. A literature search was conducted using MEDLINE, EMBASE, CINAHL, SCOPUS, and the Cochrane Central Register of Controlled Trials between January 1, 2000 and September 1, 2022. Randomized controlled trials, quasi‐experimental, or observational studies comparing pharmacist‐led interventions aimed at PAD management best practices and usual care in adult (≥18 years) ICU patients were included. Clinical (mechanical ventilation, length of stay, mortality) and economic outcomes as well as sedation and analgesia utilization were evaluated. A total of 1418 citations were identified with 9 studies (n=3769 patients) meeting eligibility. The type of pharmacist‐led intervention strategy was inconsistent among included studies. Four of the 9 studies showed that pharmacist‐led interventions were associated with a significant reduction in mechanical ventilation duration ranging from 4 to 8.5 days compared with approximately 5.6 to 14.0 days in the control groups. Three (50%) of 6 studies evaluating length of stay showed significant reductions with the intervention group compared with controls. No impact on mortality and ICU‐acquired delirium/coma rates was shown. The pharmacist‐led intervention group was also associated with significant reductions in opioid analgesia and sedative utilization. Only two studies evaluated the financial impact of the intervention group with one study finding a positive benefit attributed to decreased drug utilization, while the other report failed to find an impact on total hospital stay costs. Pharmacist‐led interventions promote PAD best practices in the ICU, although the impact on patient‐centered outcomes remains controversial.

New and Persistent Sedative Prescriptions Among Older Adults After Critical Illness: A Population-Based Cohort Study

Article

Jan 2023
CHEST

Background: ICU survivors often have complex care needs and can experience insufficient medication reconciliation and polypharmacy. It is unknown which ICU survivors are at risk of new sedative use post-hospitalization. Research question: For sedative-naïve older adult ICU survivors, how common is receipt of new and persistent sedative prescriptions, and what factors are associated with receipt? Study design and methods: Population-based cohort study of ICU survivors ≥66 years who had not filled sedative prescriptions ≤6 months pre-hospitalization (sedative-naïve) in Ontario, Canada (2003 - 2019). Using multilevel logistic regression, we described demographic, clinical, and hospital characteristics and their association with new sedative prescription ≤7 days of discharge. We quantified variation between hospitals using the adjusted median odds ratio (aMOR). Factors associated with persistent prescriptions (≤6 months) were examined with multivariable proportional hazards model. Results: 250,428 patients were included (mean age 76, 61% male). 15,277 (6.1%) filled a new sedative prescription with variation across hospitals (2% (95% CI 1-3) to 44% (3-57)); 8,458 (3.4%) filled persistent sedative prescriptions. Adjusted factors associated with a new sedative included: discharge to long-term care facility (aOR 4.00, 3.72-4.31); receipt of inpatient geriatric (aOR 1.95, 1.80-2.10) or psychiatry (aOR 2.76, 2.62-2.91) consultation, invasive ventilation (aOR 1.59, 1.53-1.66), and ICU length of stay ≥7 days (aOR 1.50, 1.42-1.58). The residual heterogeneity between hospitals (aMOR 1.43, 1.35-1.49) had a stronger association with new sedative prescriptions than Charlson comorbidity score or sepsis. Factors associated with persistent sedative use were similar with the addition of females (sHR 1.07, 1.02-1.13) and pre-existing polypharmacy (sHR 0.88, 0.80-0.93). Interpretation: One in 15 sedative-naïve older adult ICU survivors filled a new sedative ≤7 days of discharge, of whom more than half filled persistent prescriptions. New prescriptions at discharge varied widely across hospitals and represent the potential value of modifying prescription practices, including medication review and reconciliation.

The Impact of a Pharmacist-Driven Multicomponent Sleep-Promoting Protocol on Delirium in Critically Ill Patients

Article

Jan 2023
J Pharm Pract

Background: Sleep deprivation is reported in 80% of patients in the intensive care unit (ICU) and is associated with delirium. Guidelines recommend implementing a sleep-promoting protocol in critically ill patients which may increase the quantity and quality of sleep and may decrease delirium. Our objective was to implement a pharmacist-led interdisciplinary sleep-promoting protocol and analyze its impact on delirium in ICU patients receiving mechanical ventilation (MV). Methods: The study involved pre-implementation education, protocol development, and post-implementation analysis. ICU pharmacists completed prospective patient chart reviews to reduce exposure to deliriogenic medications and assess the need for a pharmacologic sleep aid. The primary outcome was the incidence of delirium and delirium-free days. Secondary outcomes included ICU length of stay (LOS), incidence of MV, and pharmacist medication interventions. Results: Post-protocol patients (n = 185) had a higher incidence of delirium compared to pre-protocol patients (n = 237) (51.3% vs 39.0%; P = .01). Post-protocol patients had a higher average APACHE III score (P = <.001). Delirium-free days were not significantly different between groups (P = .97). Difference in ICU LOS was not significant (P = .80). More patients received MV post-protocol implementation (55.7% vs 36.1%; P < .001). Pharmacists documented a total of 113 medication interventions. Conclusion and Relevance: A pharmacist-led, ICU sleep-promoting protocol was successfully implemented but did not reduce the incidence of delirium or the administration of insomnia agents. Post-protocol patients had higher disease severity and were more likely to receive MV. Incidence of delirium was consistent with the national reported prevalence of ICU delirium. ICU pharmacists on all shifts had an active role in optimizing sleep.

Evaluating the Association and Predictability of Complex Medication Regimen Scores with Clinical Outcomes Among the Critically Ill

Preprint

Full-text available

Feb 2022

Introduction Medication Regimen Complexity (MRC) refers to the combination of medication classes, dosages, and frequencies. The relationship between MRC and clinical outcomes in the intensive care unit (ICU) has not been examined. The objective of this study is to examine the association between MRC scoring tools and their utility in predicting clinical outcomes. Methods We conducted a retrospective cohort study that includes 322 adult patients admitted and stayed (>24 hours) to the ICU between February 1, 2020, and August 30, 2020 in a community-based, teaching hospital in Rhode Island. Medication complexity was assessed using two MRC scoring tools: MRC Index (MRCI) and the MRC in ICU (MRCICU). We used a multivariable logistic regression model to identify the association between MRC scores and clinical outcomes and to predict the clinical outcomes. RESULTS Among the 317 patients included in the study (55.2% men with a median age of 62 [IQR: 51-75] years). Higher MRC scores (i.e., > 63 MRCI or > 6 MRCICU) were associated with increased mortality (14% and 15%), longer ICU length of stay (LOS)(30% and 34%), and need for MV (24% and 28%). MRCICU scores at 24 hours were found to be a significant risk factor in all clinical outcomes (ICU mortality, LOS, and MV) with Odds Ratio (ORs) of 1.12 (95% CI: 1.06-1.19), 1.17 (1.1-1.24), and 1.21 (1.14-1.29), respectively. In the prediction models, both MRCI and MRCICU models performed similarly (AUC: 0.88 [0.75-0.97] and 0.88 [0.76-0.97] in predicting mortality. The Medication Model included 15 medication classes outperformed others (AUC: 0.82 [0.71-0.93] in predicting ICU LOS and the MRCICU model outperformed others (AUC: 0.87 [0.77-0.96]) in predicting the need for MV. CONCLUSION MRC scores are associated with poorer clinical outcomes and improves the prediction of poorer clinical outcomes which will support clinicians to prescribe safer therapies.

Impact of a Real-Time, Pharmacist-Led, Intensive Care Unit–Based Feedback Intervention on Analgesia and Sedation Quality Among Mechanically Ventilated Patients

Article

Nov 2020
J NURS CARE QUAL

Background: Consensus guidelines for pain, agitation, and delirium (PAD) in mechanically ventilated patients recommend maintaining a light level of sedation. Local problem: Consistent attainment of target PAD assessments in mechanically ventilated ICU patients is often challenging. Methods: This is a single-center, prospective study. Interventions: In the intervention group, a pharmacist provided weekly feedback to nurses on their success in achieving target PAD assessments compared with a historical cohort without feedback. Results: Overall, 478 patients and 205 nurses were included. The odds of having weekly Richmond Agitation-Sedation Scale (RASS) score, pain score goals, and Confusion Assessment Method for the ICU (CAM-ICU) negative assessments at goal between the intervention and control groups fluctuated over time without a discernible trend. Conclusion: The provision of weekly feedback to nurses on PAD nursing assessments by a pharmacist did not impact the achievement of PAD goals among critically ill mechanically ventilated patients.

Intensive Care Unit Organization and Interdisciplinary Care for Critically Ill Patients with Cancer

Article

Jan 2021
CRIT CARE CLIN

Alexander Shimabukuro-Vornhagen

Patients with cancer are at high risk of developing acute critical illness requiring intensive care unit (ICU) admission. Critically ill patients with cancer have complex medical needs that can best be served by a multidisciplinary ICU care team. This article provides an overview of the current state-of-the-art in multidisciplinary care for critically ill patients with cancer. Better integration of multidisciplinary critical care into the continuum of care for patients with cancer offers the prospect of further improvements in the outcomes of patients with cancer.

The pharmacist’s role in implementation of the ABCDEF bundle into clinical practice

Article

Aug 2020

Purpose To summarize published data regarding implementation of the ABCDEF bundle, a multicomponent process for avoidance of oversedation and prolonged ventilation in intensive care unit (ICU) patients; discuss pertinent literature to support each bundle element; and discuss the role of the pharmacist in coordinating bundle elements and implementation of the ABCDEF bundle into clinical practice. Summary Neuromuscular weakness and ICU-acquired weakness are common among critically ill patients and associated with significant cost and societal burdens. Recent literature supporting early liberation from mechanical ventilation and early mobilization has demonstrated improved short- and long-term outcomes. With expanded use of pharmacy services in the ICU setting, pharmacists are well positioned to advocate for best care practices in ICUs. A dedicated, interprofessional team is necessary for the implementation of the ABCDEF bundle in inpatient clinical practice settings. As evidenced by a number of studies, successful implementation of the ABCDEF bundle derives from involvement by motivated and highly trained individuals, timely completion of individual patient care tasks, and effective leadership to ensure proper implementation and ongoing support. Factors commonly identified by clinicians as barriers to bundle implementation in clinical practice include patient instability and safety concerns, lack of knowledge, staff concerns, unclear protocol criteria, and lack of interprofessional team care coordination. This narrative review discusses research on bundle elements and recommendations for application by pharmacists in clinical practice. Conclusions Despite the benefits associated with implementation of the ABCDEF bundle, evidence suggests that the recommended interventions may not be routinely used within the ICU. The pharmacist provides the expertise and knowledge for adoption of the bundle into everyday clinical practice.

Clinical Pharmacist Services within Intensive Care Unit Recovery Clinics: An Opinion of the Critical Care Practice and Research Network of the American College of Clinical Pharmacy

Article

Full-text available

Aug 2020

Intensive care unit recovery clinics (ICU‐RCs) have been proposed as a potential mechanism to address the multifaceted unmet needs of intensive care unit (ICU) survivors and caregivers. The needs of this population include, but are not limited to, medication optimization, addressing physical function and psychological needs, coordination of care, and other interventions that may help in improving patient recovery and reducing the rate of preventable readmissions. The objective of this opinion paper is to identify and describe clinical pharmacy services for the management of ICU survivors and their caregivers in an ICU‐RC. The goals are to guide the establishment and development of clinical pharmacist involvement in ICU‐RCs and to highlight ICU recovery research and educational opportunities. Recommendations provided in this paper are based on the following: a review of published data on clinical pharmacist involvement in the ICU‐RCs; a consensus of clinical pharmacists who provide direct patient care to ICU survivors and caregivers; and a review of published guidelines and literature focusing on the management of ICU survivors and caregivers. These recommendations define areas of clinical pharmacist involvement in ICU‐RCs. Consequently, clinical pharmacists can promote education on Post Intensive Care Syndrome and Post Intensive Care Syndrome‐Family; improve medication adherence; facilitate appropriate referrals to primary care providers and specialists; ensure comprehensive medication management and medication reconciliation; provide assessment of inappropriate and appropriate medications after hospitalization; address adverse drug events, medication errors, and drug interactions; promote preventive measures; and facilitate medication acquisition with the goal of improving patient outcomes and reducing health care system costs. This article is protected by copyright. All rights reserved.

Clinical Pharmacist–Led Impact on Inappropriate Albumin Utilization and Associated Costs in General Ward Patients

Article

Jun 2020

Background Inappropriate albumin use in clinical practice remains problematic. Health-systems face continued challenges in promoting cost-appropriate use. Objective To evaluate the clinical and economic impact of a clinical pharmacist–led intervention strategy targeting inappropriate albumin use in general ward patients. Methods A retrospective cohort study evaluated all adult (≥18 years) general ward patients administered ≥1 dose of albumin at a university medical center over a 2-year period. The intervention consisted of a clinical pharmacist–led strategy intervening on all albumin orders not in accordance with institutional guidelines. The primary end point was to compare inappropriate albumin utilization before and after implementation. Secondary end points compared the rates of inappropriate albumin use adjusted for hospital admission and patient-days as well as associated costs by appropriateness between study periods. Results A total of 4420 patients were screened, with 1971 (44.6%) patients meeting inclusion criteria. The clinical pharmacist strategy significantly reduced inappropriate albumin (grams) utilization by 86.0% ( P < 0.001). A 7-fold reduction of inappropriate albumin administered adjusted for the number of patient admissions was found from the preimplementation period following clinical pharmacist intervention strategy implementation (415.3 ± 83.2 vs 57.5 ± 34.2 g per 100 general ward hospital admissions, respectively; P < 0.001). Also, the adjusted inappropriate albumin rate was reduced from 62.2 ± 12.3 to 8.6 ± 5.2 g per 100 patient-days in the preimplementation and postimplementation periods, respectively ( P < 0.001). Annual cost savings were

421 455 overall, with

341 930 resulting from mitigation of inappropriate use. Conclusion and Relevance Clinical pharmacist–led interventions significantly reduced inappropriate albumin use and costs in hospitalized patients.

Benefit of Incorporating Clinical Pharmacists in an Adult Intensive Care Unit: A Cost‐saving Study

Article

Jun 2020

What is known and objective A framework to evaluate the impact of clinical pharmacists in intensive care units (ICUs) in Chile has not yet been established. This study evaluates the cost avoidance and cost‐benefit ratios of clinical pharmacist interventions in terms of treatment optimization in an adult ICU in southern Chile. Methods Clinical pharmacist interventions in a multidisciplinary adult ICU were assessed between January and December 2019. Only interventions suggested by pharmacists and accepted by the healthcare team were included in the analysis. Interventions were classified into six categories, and cost avoidance (in US dollars) was calculated for each category using a systematic validated approach. A cost‐benefit ratio for clinical pharmacy services in the adult ICU was also calculated. Results and discussion Over the 12‐month period, 505 interventions were performed in 169 patients, of whom 62% were male. Interventions were classified into the following six categories: adverse drug event prevention (18%), which led to

87 882 in savings; resource utilization (ie change in medication route) (10%), which led to

50 525 in savings; individualization of patient care (ie dose adjustment) (36%), which led to

57 089 in savings; prophylaxis (ie initiation of stress ulcer prophylaxis) (<1%), which led to

167 in savings; hands‐on care (ie bedside monitoring) (23%), which led to

57 846 in savings; and administrative and supportive tasks (ie patient own medication evaluation) (13%), which led to

9988 in savings. The total cost savings over the year‐long period were $263 500, resulting in a cost‐benefit ratio of 1:24.2. What is new and conclusion The participation of a clinical pharmacist in a multidisciplinary ICU team reduces healthcare expenditures through treatment optimization translated into cost avoidance. This study has corroborated prior evidence that clinical pharmacist involvement in ICUs provides economic value and quality assurance in healthcare settings.

A multisite study of nurse-reported perceptions and practice of ABCDEF bundle components

Article

May 2020
Intensive Crit Care Nurs

Objectives ABCDEF bundle implementation in the Intensive Care Unit (ICU) is associated with dose dependent improvements in patient outcomes. The objective was to compare nurse attitudes about the ABCDEF bundle to self-reported adherence to bundle components. Research methodology/design Cross-sectional study. Setting Nurses providing direct patient care in 28 ICUs within 18 hospitals across the United States. Main outcome measures 53-item survey of attitudes and practice of the ABCDEF bundle components was administered between November 2011 and August 2015 (n = 1661). Results We did not find clinically significant correlations between nurse attitudes and adherence to Awakening trials, Breathing trials, and sedation protocol adherence (rs = 0.05–0.28) or sedation plan discussion during rounds and Awakening and Breathing trial Coordination (rs = 0.19). Delirium is more likely to be discussed during rounds when ICU physicians and nurse managers facilitate delirium reduction (rs = 0.27–0.36). Early mobilization is more likely to occur when ICU physicians, nurse managers, staffing, equipment, and the ICU environment facilitate early mobility (rs = 0.36–0.47). Physician leadership had the strongest correlation with reporting an ICU environment that facilitates ABCDEF bundle implementation (rs = 0.63–0.74). Conclusions Nurse attitudes about bundle implementation did not predict bundle adherence. Nurse manager and physician leadership played a large role in creating a supportive ICU environment.

Prophylaxe des postoperativen DelirsPrevention of postoperative delirium: Anästhesie / Neurologie

Article

Apr 2020

Das postoperative Delir tritt bei rund einem Drittel der älteren Patienten auf. Es handelt sich um eine schwere Komplikation, die für die betroffenen Patienten und ihre Angehörigen sehr belastend ist. Der Hausarzt, der zumindest bei elektiven Operationen für die Operationsvorbereitung verantwortlich ist, kann Maßnahmen treffen, um das Risiko für ein postoperatives Delir so gering wie möglich zu halten.

Sedation and delirium

Chapter

Dec 2019

This chapter is centred on a case study of sedation and delirium. This topic is one of the key challenging areas in critical care medicine and one that all intensive care staff will encounter. The chapter is based on a detailed case history, ensuring clinical relevance, together with relevant images, making this easily relatable to daily practice in the critical care unit. The chapter is punctuated by evidence-based, up-to-date learning points, which highlight key information for the reader. Throughout the chapter, a topic expert provides contextual advice and commentary, adding practical expertise to the standard textbook approach and reinforcing key messages.

Compliance With Evidence-Based Processes of Care After Transitions Between Staff Intensivists

Article

Jan 2020
CRIT CARE MED

Objectives: We sought to evaluate the impact of transitions of care among staff intensivists on the compliance with evidence-based processes of care. Design: Cohort study using data from the Toronto Intensive Care Observational Registry. Setting: Seven academic ICUs in Toronto, Ontario. Patients: Critically ill mechanically ventilated adult patients. Interventions: We explored the effects of the weekly transition of care among staff intensivists on compliance with three evidence-based processes of care (spontaneous breathing trials, lung-protective ventilation, and neuromuscular blocking agents). Two practices that are less guided by evidence (early discontinuation of antibiotics and extubation attempts) served as positive controls. We conducted the analysis using generalized estimating equations to account for clustering at the patient level. Measurements and main results: The cohort consisted of 10,570 patients admitted between June 2014 and August 2018. Compliance varied for each practice (63.6%, 42.5%, and 21.1% for lung-protective ventilation, spontaneous breathing trials, and neuromuscular blockade, respectively). There was no effect of transitions of care on compliance with spontaneous breathing trials (odds ratio, 1.00; 95% CI, 0.95-1.07), lung-protective ventilation (odds ratio, 1.07, 95% CI, 0.90-1.26), or neuromuscular blockade use (odds ratio, 0.95; 95% CI, 0.75-1.20). However, early antibiotic discontinuation was more likely (odds ratio, 1.23; 95% CI, 1.06-1.42) and extubation attempts were less frequent (odds ratio, 0.77; 95% CI, 0.65-0.93) after a transition of care. Conclusions: We observed no significant impact of transitions of care between individual staff physicians on evidence-based processes of care for mechanically ventilated adult patients. However, transitions were associated with a lower likelihood of extubation and higher odds of earlier discontinuation of antibiotics.

APACHE II

Article

Full-text available

Oct 1985
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This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases.When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.

APACHE II: a severity of disease classification system

Article

Full-text available

Nov 1985
CRIT CARE MED

This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases. When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.

Kollef MH, Levy NT, Ahrens TS, et al: The use of continuous IV sedation is associated with prolongation of mechanical ventilation. Chest 114: 541-548

Article

Full-text available

Aug 1998

To determine whether the use of continuous i.v. sedation is associated with prolongation of the duration of mechanical ventilation. Prospective observational cohort study. The medical ICU of Barnes-Jewish Hospital, a university-affiliated urban teaching hospital. Two hundred forty-two consecutive ICU patients requiring mechanical ventilation. Patient surveillance and data collection. The primary outcome measure was the duration of mechanical ventilation. Secondary outcome measures included ICU and hospital lengths of stay, hospital mortality, and acquired organ system derangements. A total of 93 (38.4%) mechanically ventilated patients received continuous i.v. sedation while 149 (61.6%) patients received either bolus administration of i.v. sedation (n=64) or no i.v. sedation (n=85) following intubation. The duration of mechanical ventilation was significantly longer for patients receiving continuous i.v. sedation compared with patients not receiving continuous i.v. sedation (185+/-190 h vs 55.6+/-75.6 h; p<0.001). Similarly, the lengths of intensive care (13.5+/-33.7 days vs 4.8+/-4.1 days; p<0.001) and hospitalization (21.0+/-25.1 days vs 12.8+/-14.1 days; p<0.001) were statistically longer among patients receiving continuous i.v. sedation. Multiple linear regression analysis, adjusting for age, gender, severity of illness, mortality, indication for mechanical ventilation, use of chemical paralysis, presence of a tracheostomy, and the number of acquired organ system derangements, found the adjusted duration of mechanical ventilation to be significantly longer for patients receiving continuous i.v. sedation compared with patients who did not receive continuous i.v. sedation (148 h [95% confidence interval: 121, 175 h] vs 78.7 h [95% confidence interval: 68.9, 88.6 h]; p<0.001). We conclude from these preliminary observational data that the use of continuous i.v. sedation may be associated with the prolongation of mechanical ventilation. This study suggests that strategies targeted at reducing the use of continuous i.v. sedation could shorten the duration of mechanical ventilation for some patients. Prospective randomized clinical trials, using well-designed sedation guidelines and protocols, are required to determine whether patient-specific outcomes (eg, duration of mechanical ventilation, patient comfort) can be improved compared with conventional sedation practices.

Pharmacist Participation on Physician Rounds and Adverse Drug Events in the Intensive Care Unit

Article

Full-text available

Aug 1999

Pharmacist review of medication orders in the intensive care unit (ICU) has been shown to prevent errors, and pharmacist consultation has reduced drug costs. However, whether pharmacist participation in the ICU at the time of drug prescribing reduces adverse events has not been studied. To measure the effect of pharmacist participation on medical rounds in the ICU on the rate of preventable adverse drug events (ADEs) caused by ordering errors. Before-after comparison between phase 1 (baseline) and phase 2 (after intervention implemented) and phase 2 comparison with a control unit that did not receive the intervention. A medical ICU (study unit) and a coronary care unit (control unit) in a large urban teaching hospital. Seventy-five patients randomly selected from each of 3 groups: all admissions to the study unit from February 1, 1993, through July 31, 1993 (baseline) and all admissions to the study unit (postintervention) and control unit from October 1, 1994, through July 7, 1995. In addition, 50 patients were selected at random from the control unit during the baseline period. A senior pharmacist made rounds with the ICU team and remained in the ICU for consultation in the morning, and was available on call throughout the day. Preventable ADEs due to ordering (prescribing) errors and the number, type, and acceptance of interventions made by the pharmacist. Preventable ADEs were identified by review of medical records of the randomly selected patients during both preintervention and postintervention phases. Pharmacists recorded all recommendations, which were then analyzed by type and acceptance. The rate of preventable ordering ADEs decreased by 66% from 10.4 per 1000 patient-days (95% confidence interval [CI], 7-14) before the intervention to 3.5 (95% CI, 1-5; P<.001) after the intervention. In the control unit, the rate was essentially unchanged during the same time periods: 10.9 (95% CI, 6-16) and 12.4 (95% CI, 8-17) per 1000 patient-days. The pharmacist made 366 recommendations related to drug ordering, of which 362 (99%) were accepted by physicians. The presence of a pharmacist on rounds as a full member of the patient care team in a medical ICU was associated with a substantially lower rate of ADEs caused by prescribing errors. Nearly all the changes were readily accepted by physicians.

Delirium in Mechanically Ventilated PatientsValidity and Reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)

Article

Full-text available

Dec 2001

Delirium is a common problem in the intensive care unit (ICU). Accurate diagnosis is limited by the difficulty of communicating with mechanically ventilated patients and by lack of a validated delirium instrument for use in the ICU. To validate a delirium assessment instrument that uses standardized nonverbal assessments for mechanically ventilated patients and to determine the occurrence rate of delirium in such patients. Prospective cohort study testing the Confusion Assessment Method for ICU Patients (CAM-ICU) in the adult medical and coronary ICUs of a US university-based medical center. A total of 111 consecutive patients who were mechanically ventilated were enrolled from February 1, 2000, to July 15, 2000, of whom 96 (86.5%) were evaluable for the development of delirium and 15 (13.5%) were excluded because they remained comatose throughout the investigation. Occurrence rate of delirium and sensitivity, specificity, and interrater reliability of delirium assessments using the CAM-ICU, made daily by 2 critical care study nurses, compared with assessments by delirium experts using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. A total of 471 daily paired evaluations were completed. Compared with the reference standard for diagnosing delirium, 2 study nurses using the CAM-ICU had sensitivities of 100% and 93%, specificities of 98% and 100%, and high interrater reliability (kappa = 0.96; 95% confidence interval, 0.92-0.99). Interrater reliability measures across subgroup comparisons showed kappa values of 0.92 for those aged 65 years or older, 0.99 for those with suspected dementia, or 0.94 for those with Acute Physiology and Chronic Health Evaluation II scores at or above the median value of 23 (all P<.001). Comparing sensitivity and specificity between patient subgroups according to age, suspected dementia, or severity of illness showed no significant differences. The mean (SD) CAM-ICU administration time was 2 (1) minutes. Reference standard diagnoses of delirium, stupor, and coma occurred in 25.2%, 21.3%, and 28.5% of all observations, respectively. Delirium occurred in 80 (83.3%) patients during their ICU stay for a mean (SD) of 2.4 (1.6) days. Delirium was even present in 39.5% of alert or easily aroused patient observations by the reference standard and persisted in 10.4% of patients at hospital discharge. Delirium, a complication not currently monitored in the ICU setting, is extremely common in mechanically ventilated patients. The CAM-ICU appears to be rapid, valid, and reliable for diagnosing delirium in the ICU setting and may be a useful instrument for both clinical and research purposes.

Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult

Article

Full-text available

Feb 2002
CRIT CARE MED

An abstract is unavailable. This article is available as HTML full text and PDF.

Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients

Article

Full-text available

Mar 2006
CRIT CARE MED

To characterize the perceived utilization of sedative, analgesic, and neuromuscular blocking agents, the use of sedation scales, algorithms, and daily sedative interruption in mechanically ventilated adults, and to define clinical factors that influence these practices. Cross-sectional mail survey. Canadian critical care practitioners. A total of 273 of 448 eligible physicians (60%) responded. Respondents were well distributed with regard to age, years of practice, specialist certification, size of intensive care unit and hospital, and location of practice. Twenty-nine percent responded that a protocol/care pathway/guideline for the use of sedatives or analgesics is currently in use in their intensive care unit. Daily interruption of continuous infusions of sedatives or analgesics is practiced by 40% of intensivists. A sedation scoring system is used by 49% of respondents. Of these, 67% use the Ramsay scale, 10% use the Sedation-Agitation Scale, 9% use the Glasgow Coma Scale, and 8% use the Motor Activity Assessment Scale. Only 3.7% of intensivists use a delirium scoring system in their intensive care units. Only 22% of respondents currently have a protocol for the use of neuromuscular blocking agents in their intensive care unit, and 84% of respondents use peripheral nerve stimulation for monitoring. In patients receiving neuromuscular blocking agents for >24 hrs, 63.7% of respondents discontinue the neuromuscular blocking agent daily. Intensivists working in university-affiliated hospitals are more likely to employ a sedation protocol and scale (p < .0001), as are intensivists working in larger intensive care units (>or=15 beds, p < .01). Intensivists with anesthesiology training (and no formal critical care training) are more likely to use a protocol and sedation scale, and critical care-trained intensivists are more likely to use daily interruption. Younger physicians (<40 yrs) are more likely to practice daily interruption (p = .0092). There is significant variation in critical care sedation, analgesia, and neuromuscular blockade practice. Given the potential effect of practices regarding these medications on patient outcome, future research and educational efforts related to evidence-based protocols for the use of these agents in mechanically ventilated patients might be worthwhile.

The use of continuous intravenous sedation is associated with prolongation of mechanical ventilation

Article

Oct 1998

Purpose: To determine whether the use of continuous intravenous sedation is associated with prolongation of the duration of mechanical ventilation. Methods: Prospective cohort study. The medical intensive care unit (ICU) of Barnes-Jewish Hospital, a university-affiliated urban teaching hospital. Two hundred forty two consecutive ICU patients requiring mechanical ventilation. Results: A total of 93 (38.4%) mechanically ventilated patients recieved continuous intravenous sedation while 149 (61.6%) patients received either bolus administration of intravenous sedation (n=64) or no intravenous sedation (n=85) following intubation. The duration of mechanical ventilation was significantly longer for patients receiving continuous intravenous sedation compared to patients not receiving continuous intravenous sedation (185± 190 hours versus 55.6 ±75.6 hours; P < 0.001) Similarly, the lengths of intensive care (13.5 ± 33.7 days versus 4.8 ± 4.1 days; P < 0.0001) and hospitalization (21.0 ± 25.1 days versus 12.8 ± 14.1 days; P < 0.001) were statistically longer among patients receiving continuous intravenous sedation. Multiple linear regression analysis, adjusting for age, gender, severity of illness, mortality, indication for mechanical ventilation, use of chemical paralysis, presence of a tracheostomy, and the number of acquired organ system derangements, found the adjusted duration of mechanical ventilation to be significantly longer for patients receiving continuous intravenous sedation compared to patients who did not receive continous intravenous sedation (148 hours [95% confidence interval: 121, 175 hours] versus 78.7 hours [95% confidence interval: 68.9, 88.6 hours]; P < 0.001). Conclusions: We conclude that the use of continuous intravenous sedation may be associated with the prolongation of mechanical ventilation. Clinical Implications: These data suggest that strategies targeted at reducing the use of continuous intravenous sedation could shorten the duration of mechanical ventilation for some patients.

Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients

Article

Jan 1999
CRIT CARE MED

Delirium in Mechanically Ventilated Patients

Article

Dec 2001

Context Delirium is a common problem in the intensive care unit (ICU). Accurate diagnosis is limited by the difficulty of communicating with mechanically ventilated patients and by lack of a validated delirium instrument for use in the ICU.Objectives To validate a delirium assessment instrument that uses standardized nonverbal assessments for mechanically ventilated patients and to determine the occurrence rate of delirium in such patients.Design and Setting Prospective cohort study testing the Confusion Assessment Method for ICU Patients (CAM-ICU) in the adult medical and coronary ICUs of a US university-based medical center.Participants A total of 111 consecutive patients who were mechanically ventilated were enrolled from February 1, 2000, to July 15, 2000, of whom 96 (86.5%) were evaluable for the development of delirium and 15 (13.5%) were excluded because they remained comatose throughout the investigation.Main Outcome Measures Occurrence rate of delirium and sensitivity, specificity, and interrater reliability of delirium assessments using the CAM-ICU, made daily by 2 critical care study nurses, compared with assessments by delirium experts using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria.Results A total of 471 daily paired evaluations were completed. Compared with the reference standard for diagnosing delirium, 2 study nurses using the CAM-ICU had sensitivities of 100% and 93%, specificities of 98% and 100%, and high interrater reliability (κ = 0.96; 95% confidence interval, 0.92-0.99). Interrater reliability measures across subgroup comparisons showed κ values of 0.92 for those aged 65 years or older, 0.99 for those with suspected dementia, or 0.94 for those with Acute Physiology and Chronic Health Evaluation II scores at or above the median value of 23 (all P<.001). Comparing sensitivity and specificity between patient subgroups according to age, suspected dementia, or severity of illness showed no significant differences. The mean (SD) CAM-ICU administration time was 2 (1) minutes. Reference standard diagnoses of delirium, stupor, and coma occurred in 25.2%, 21.3%, and 28.5% of all observations, respectively. Delirium occurred in 80 (83.3%) patients during their ICU stay for a mean (SD) of 2.4 (1.6) days. Delirium was even present in 39.5% of alert or easily aroused patient observations by the reference standard and persisted in 10.4% of patients at hospital discharge.Conclusions Delirium, a complication not currently monitored in the ICU setting, is extremely common in mechanically ventilated patients. The CAM-ICU appears to be rapid, valid, and reliable for diagnosing delirium in the ICU setting and may be a useful instrument for both clinical and research purposes.

The Effect of ICU Sedation Guidelines and Pharmacist Interventions on Clinical Outcomes and Drug Cost

Article

Jul 1997

To measure the effect of evidence-based intensive care unit (ICU) sedation guidelines and interventions by a pharmacist to promote these guidelines on the weaning time from mechanical ventilation and sedation drug cost. Before-after study. A 15-bed medical-surgical ICU at a tertiary-care teaching hospital. 100 patients (2 groups of 50 consecutive patients) on mechanical ventilation (assist or pressure control mode for > or = 6 h) who were successfully discharged from the ICU. ICU sedation guidelines were developed through physician, nursing, and pharmacy consensus using a physician survey and literature overview as points of reference and were implemented into practice. Prospectively, data on the time required to wean patients from mechanical ventilation (successful trial of T-piece, pressure support, or intermittent mandatory ventilation leading to extubation) and total drug costs for sedation were measured and compared between groups. All prospective ICU pharmacist interventions pertaining to sedation were documented. New sedation guidelines promoted lorazepam use in preference to midazolam and suggested propofol for patients not successfully sedated with high-dose lorazepam, haloperidol, or morphine. Over the 2-month collection periods, there was no difference in the median weaning time between the pre- (16 h, range 2-607) and post- (18 h, range 1-284) guideline groups. Total sedation drug costs decreased from

4515 to

1152 (

US) (p = 0.081). Median sedation drug costs decreased from

11.27 (range

0-1340) to

3.55 (range $0-250), with the amount (mg) of midazolam and propofol used decreasing by 86% and 100%, respectively. The ICU pharmacist successfully recommended a change from midazolam to lorazepam in 12 of 50 patients, 5 of whom had received midazolam for more than 24 hours. High compliance with ICU sedation guidelines promoting lorazepam rather than midazolam or propofol in mechanically ventilated patients led to a 75% decrease in sedation drug costs and did not adversely affect the clinicians' ability to wean patients from mechanical ventilation.

Acute withdrawal syndrome related to the administration of analgesic and sedative medications in adult intensive care unit patients

Article

May 1998
CRIT CARE MED

To estimate the frequency of acute withdrawal syndrome related to the administration of analgesic and sedative medications in mechanically ventilated adult intensive care unit (ICU) patients; to identify associated clinical factors. Retrospective review of medical records. An adult trauma/surgical ICU in an urban Level I trauma center. Twenty-eight mechanically ventilated adult trauma/ surgical ICU patients requiring >7 days of ICU care. None. Daily doses of all opioid, sedative, hypnotic, and major tranquilizer drugs administered to each patient were measured, as was duration of ICU stay, duration of mechanical ventilation, and duration of the administration of analgesic, sedative, and neuromuscular blocking agents (NMBAs) for each patient. All opioids and benzodiazepines were converted to their respective fentanyl and lorazepam equivalent units based on potency and bioavailability. Calculation of the weaning rate for each patient during tapering from opioid and benzodiazepine medications was performed. The presence or absence of acute withdrawal syndrome was identified for each patient. Nine (32.1%) patients developed acute withdrawal syndrome potentially related to the administration of analgesic or sedative medications. Patients in the withdrawal group received significantly higher mean daily (p = .049) and peak (p = .032) doses of fentanyl equivalents, as well as higher mean daily lorazepam equivalents (p = .049) compared with patients not experiencing withdrawal. Patients in the withdrawal group were also significantly more likely to have received neuromuscular blocking agents (p = .004) or propofol (p =.026) for >1 day during ICU admission compared with patients not experiencing withdrawal. Duration of mechanical ventilation (p = .049), benzodiazepine therapy (p = .048), and propofol therapy (p = .049) was also significantly longer in the group experiencing withdrawal. Withdrawal patients received a significantly lower mean daily dose of haloperidol (p = .026). There was a significant association between the development of withdrawal syndrome and the presence of ARDS (p = .017). Finally, the slopes of the lines representing opioid and benzodiazepine drug weaning were more steep for the withdrawal group, although these results did not achieve statistical significance. These results suggest that mechanically ventilated adult patients with extended ICU care (> or =7 days) who receive large doses of analgesic and sedative medications are at risk for acute withdrawal syndromes during drug weaning. The association between ARDS and withdrawal syndrome, combined with the observation that withdrawal syndromes were also associated with the use of neuromuscular blocking agents and prolonged mechanical ventilation, suggests that patients with ARDS may be more likely to receive high doses of analgesic and sedative medications, and are therefore at increased risk for withdrawal syndrome.

Riker RR, Picard JT, Fraser GL: Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med 27: 1325-1329

Article

Aug 1999
CRIT CARE MED

Subjective scales to assess agitation and sedation in adult intensive care unit (ICU) patients have rarely been tested for validity or reliability. We revised and prospectively tested the Sedation-Agitation Scale (SAS) for interrater reliability and compared it with the Ramsay scale and the Harris scale to test construct validity. A convenience sample of ICU patients was simultaneously and independently examined by pairs of trained evaluators by using the revised SAS, Ramsay, and Harris Scales. Multidisciplinary 34-bed ICU in a nonuniversity, academic medical center. Forty-five ICU patients (surgical and medical) were examined a total of 69 times by evaluator pairs. The mean patient age was 63.2 yrs, 36% were female, and 71% were intubated. When classified by using SAS, 45% were anxious or agitated (SAS 5 to 7), 26% were calm (SAS 4), and 29% were sedated (SAS 1 to 3). Interrater correlation was high for SAS (r2 = .83; p < .001) and the weighted kappa score for interrater agreement was 0.92 (p < .001). Of 41 assessments scored as Ramsay 1, 49% scored SAS 6, 41% were SAS 5, 5% were SAS 4, and 2% each were SAS 3 or 7. SAS was highly correlated with the Ramsay (r2 = .83; p < .001) and Harris (r2 = .86; p < .001) scales. SAS is both reliable (high interrater agreement) and valid (high correlation with the Harris and Ramsay scales) in assessing agitation and sedation in adult ICU patients. SAS provides additional information by stratifying agitation into three categories (compared with one for the Ramsay scale) without sacrificing validity or reliability.

Brook AD, Ahrens TS, Schaiff R, et al: Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med 27: 2609-2615

Article

Jan 2000
CRIT CARE MED

To compare a practice of protocol-directed sedation during mechanical ventilation implemented by nurses with traditional non-protocol-directed sedation administration. Randomized, controlled clinical trial. Medical intensive care unit (19 beds) in an urban teaching hospital. Patients requiring mechanical ventilation (n = 321). Patients were randomly assigned to receive either protocol-directed sedation (n = 162) or non-protocol-directed sedation (n = 159). The median duration of mechanical ventilation was 55.9 hrs (95% confidence interval, 41.0-90.0 hrs) for patients managed with protocol-directed sedation and 117.0 hrs (95% confidence interval, 96.0-155.6 hrs) for patients receiving non-protocol-directed sedation. Kaplan-Meier analysis demonstrated that patients in the protocol-directed sedation group had statistically shorter durations of mechanical ventilation than patients in the non-protocol-directed sedation group (chi-square = 7.00, p = .008, log rank test; chi-square = 8.54, p = .004, Wilcoxon's test; chi-square = 9.18, p = .003, -2 log test). Lengths of stay in the intensive care unit (5.7+/-5.9 days vs. 7.5+/-6.5 days; p = .013) and hospital (14.0+/-17.3 days vs. 19.9+/-24.2 days; p < .001) were also significantly shorter among patients in the protocol-directed sedation group. Among the 132 patients (41.1%) receiving continuous intravenous sedation, those in the protocol-directed sedation group (n = 66) had a significantly shorter duration of continuous intravenous sedation than those in the non-protocol-directed sedation group (n = 66) (3.5+/-4.0 days vs. 5.6+/-6.4 days; p = .003). Patients in the protocol-directed sedation group also had a significantly lower tracheostomy rate compared with patients in the non-protocol-directed sedation group (10 of 162 patients [6.2%] vs. 21 of 159 patients [13.2%], p = .038). The use of protocol-directed sedation can reduce the duration of mechanical ventilation, the intensive care unit and hospital lengths of stay, and the need for tracheostomy among critically ill patients with acute respiratory failure.

Kress JP, Pohlman AS, O’Connor MF, et al: Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 342: 1471-1477

Article

Jun 2000

Conous infusions of sedative drugs in the intensive care unit may prolong the duration of mechanical ventilation, prolong the length of stay in the intensive care unit and the hospital, impede efforts to perform daily neurologic examinations, and increase the need for tests to assess alterations in mental status. Whether regular interruption of such infusions might accelerate recovery is not known. We conducted a randomized, controlled trial involving 128 adult patients who were receiving mechanical ventilation and continuous infusions of sedative drugs in a medical intensive care unit. In the intervention group, the sedative infusions were interrupted until the patients were awake, on a daily basis; in the control group, the infusions were interrupted only at the discretion of the clinicians in the intensive care unit. The median duration of mechanical ventilation was 4.9 days in the intervention group, as compared with 7.3 days in the control group (P=0.004), and the median length of stay in the intensive care unit was 6.4 days as compared with 9.9 days, respectively (P=0.02). Six of the patients in the intervention group (9 percent) underwent diagnostic testing to assess changes in mental status, as compared with 16 of the patients in the control group (27 percent, P=0.02). Complications (e.g., removal of the endotracheal tube by the patient) occurred in three of the patients in the intervention group (4 percent) and four of the patients in the control group (7 percent, P=0.88). In patients who are receiving mechanical ventilation, daily interruption of sedative-drug infusions decreases the duration of mechanical ventilation and the length of stay in the intensive care unit.

A nursing–implemented sedation protocol and the duration of mechanical ventilation

Article

Jun 2000
Aust Crit Care

S McKinley

The impact of critical care pharmacists on enhancing patient outcomes

Article

Jun 2003

The highly specialized knowledge and skills needed to care for critically ill patients requires a multidisciplinary team approach. Pharmacists are integral members of this team. They make valuable contributions to improve clinical, economic, and humanistic outcomes of patients. The purpose of this article is to review the literature pertaining to pharmacists' contributions within a multidisciplinary intensivist-led intensive care unit (ICU) team. Pharmacist interventions include correcting/clarifying orders, providing drug information, suggesting alternative therapies, identifying drug interactions, and therapeutic drug monitoring. Pharmacist involvement in improving clinical outcomes of critically ill patients is associated with optimal fluid management and substantial reductions in the rates of adverse drug events, medication administration errors, and ventilator-associated pneumonia. Furthermore, economic evaluations of clinical pharmacy services in the ICU consistently reveal the potential for considerable cost savings.

APACHE II: A severity of disease classification system Acute withdrawal syndrome related to the administration of analgesic and sedative medications in adult intensive care unit patients

Jan 1985
818-829676

Wa Knaus
Ea Draper
Dp Wagner

Knaus WA, Draper EA, Wagner DP, et al: APACHE II: A severity of disease classification system. Crit Care Med 1985; 311:818–829 [Context Link] 11. Cammarano WB, Pittet JF, Weitz S, et al: Acute withdrawal syndrome related to the administration of analgesic and sedative medications in adult intensive care unit patients. Crit Care Med 1998; 26:676–668 [Context Link]

Impact of a clinical pharmacist-enforced intensive care unit sedation protocol on duration of mechanical ventilation and hospital stay *

Ovid

Ovid: Impact of a clinical pharmacist-enforced intensive care unit sedation protocol on duration of mechanical ventilation and hospital stay *.

Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation

Jp Kress
As Pohlman
O Connor

Kress JP, Pohlman AS, O'Connor MF, et al: Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N

Highlights of Boston Medical Center Sedation Guidelines APPENDIX 2

Figure

Figure. Highlights of Boston Medical Center Sedation Guidelines APPENDIX 2. [Context Link]

Impact of a clinical pharmacist-enforced intensive care unit sedation protocol on duration of mechanical ventilation and hospital stay

Abstract

No full-text available

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