Pharmacists in Trauma: a randomised controlled trial of emergency medicine pharmacists in trauma response teams

BACKGROUND

Analgesia is an important component for patient well-being, but commonly delayed during trauma resuscitation. The Pharmacists in Trauma trial assessed the effects of integrating pharmacists into trauma response teams to improve analgesia delivery and medication management.

METHODS

This unblinded randomised trial compared emergency medicine (EM) pharmacist involvement in trauma callouts versus standard care at an Australian level 1 trauma centre. Randomisation was performed via an online single sequence randomisation service. Eligible patients included those managed with a trauma callout during working hours of an EM pharmacist. Pharmacists were able to prescribe medications using a Partnered Pharmacist Medication Charting model. The primary outcome was the proportion of patients who had first dose analgesia within 30 min compared using the χ2 test.

RESULTS

From 15 July 2021 until 31 January 2022, there were 119 patients randomised with 37 patients excluded as no analgesia was required. There were 82 patients included for analysis, 39 in the control arm and 43 in the intervention arm. The primary outcome was achieved in 25 (64.1%) patients in the control arm and 36 (83.7%) patients in the pharmacist arm (relative risk 1.31; 95% CI 1.0 to 1.71; p=0.042). Time to analgesia in the control arm was 28 (22-35) mins and 20 (15-26 mins) with pharmacist involvement; p=0.025. In the pharmacist arm, the initial dose of analgesia was prescribed by the pharmacist for 38 (88.4%) patients. There were 27 other medications prescribed by the pharmacist for the management of these patients. There were no differences in emergency and trauma centre or hospital length of stay.

CONCLUSION

Addition of the EM pharmacist in trauma response teams improved time to analgesia. Involvement of an EM pharmacist in trauma reception and resuscitation may assist by optimising medication management, with members of the team more available to focus on other life-saving interventions.

TRIAL REGISTRATION NUMBER

ACTRN12621000338864.

Implementation Strategies Addressing Stakeholder-Perceived Barriers and Enablers to the Establishment of a Beta-Lactam Antibiotic Therapeutic Drug Monitoring Program: A Qualitative Analysis

BACKGROUND

Therapeutic drug monitoring (TDM) of beta-lactam antibiotics (beta-lactams) is increasingly recommended for optimizing antibiotic exposure in intensive care patients with sepsis. However, limited data are available on the implementation of beta-lactam TDM in complex health care settings. Theory-based approaches were used to systematically explore barriers and enablers perceived by key stakeholders in the implementation of beta-lactam TDM in the intensive care unit.

METHODS

In this qualitative descriptive study, the authors interviewed key stakeholders (n = 40): infectious disease physicians, intensive care unit physicians, pharmacists, clinical leaders, scientists, and nurses. The data were thematically analyzed and coded using the theoretical domains framework, and the codes and themes were mapped to the relevant domains of the capability, opportunity, and motivation behavior-change wheel model.

RESULTS

Barriers included a lack of knowledge, experience, evidence, and confidence, which led to concerns about capability, lack of resources, and harm in straying from standard practice. Access to education and guidelines, on-site assays with short turnaround times, communication among teams, and workflow integration were identified as enablers. A focus on patient care, trust in colleagues, and endorsement by hospital leaders were strong motivators. Pharmacist and nursing stakeholder groups emerged as key targets in the implementation of strategies.

CONCLUSIONS

Using theory-based approaches, the authors identified the key barriers and enablers to establishing beta-lactam TDM. These data were used to identify strategies, policies, and key target groups for the implementation of interventions.

The clinical application of beta-lactam antibiotic therapeutic drug monitoring in the critical care setting

Critically ill patients have increased variability in beta-lactam antibiotic (beta-lactam) exposure due to alterations in their volume of distribution and elimination. Therapeutic drug monitoring (TDM) of beta-lactams, as a dose optimization and individualization tool, has been recommended to overcome this variability in exposure. Despite its potential benefit, only a few centres worldwide perform beta-lactam TDM. An important reason for the low uptake is that the evidence for clinical benefits of beta-lactam TDM is not well established. TDM also requires the availability of specific infrastructure, knowledge and expertise. Observational studies and systematic reviews have demonstrated that TDM leads to an improvement in achieving target concentrations, a reduction in potentially toxic concentrations and improvement of clinical and microbiological outcomes. However, a small number of randomized controlled trials have not shown a mortality benefit. Opportunities for improved study design are apparent, as existing studies are limited by their inclusion of heterogeneous patient populations, including patients that may not even have infection, small sample size, variability in the types of beta-lactams included, infections caused by highly susceptible bacteria, and varied sampling, analytical and dosing algorithm methods. Here we review the fundamentals of beta-lactam TDM in critically ill patients, the existing clinical evidence and the practical aspects involved in beta-lactam TDM implementation.

Introduction of an emergency medicine pharmacist-led sepsis alert response system in the emergency department: A cohort study

OBJECTIVE

To determine effects of implementing a sepsis alert response system in the ED that included early intervention by emergency medicine (EM) pharmacists.

METHODS

A prospective cohort (8 February 2016 to 28 February 2018) of patients after implementation of a sepsis alert response system in an Australian ED was compared to a retrospective cohort (3 January 2015 to 7 February 2016) of patients with sepsis who presented during EM pharmacist working hours and were admitted to the ICU.

RESULTS

There were 184 patients, including 80 patients pre- and 104 patients post-implementation. The post-intervention cohort was triaged at a higher acuity, had higher quick Sepsis-related Organ Failure Assessment (qSOFA) scores and higher initial lactate measurements. After the intervention, antimicrobial agents were administered to patients within 60 min of presentation more often (21 [26.3%] to 85 [81.7%], P < 0.001). After adjusting for presenting triage category, admission lactate and presenting qSOFA scores, this association remained significant (adjusted odds ratio 9.99; 95% confidence interval 4.7-21.3). Significant improvements were observed for proportion of patients who had intravenous fluids initiated within 60 min (47.5% vs 72.1%); proportion of patients who had serum lactate measured within 60 min (50.0% vs 77.9%) and proportion of patients who had blood cultures performed within 60 min (52.5% vs 85.6%).

CONCLUSION

Implementation of a sepsis alert response that included early involvement of the EM pharmacist was associated with improvement in time to antimicrobials and other components of the sepsis bundle. An upfront, multidisciplinary approach to patients presenting to the ED with suspected sepsis should be considered more broadly.

Pharmacist-Managed Therapeutic Drug Monitoring Programs within Australian Hospital and Health Services—A National Survey of Current Practice

Pharmacist-managed therapeutic drug monitoring (TDM) services have demonstrated positive outcomes in the literature, including reduced duration of therapy and decreased incidence of the adverse effects of drug therapy. Although the evidence has demonstrated the benefits of these TDM services, this has predominately been within international healthcare systems. The extent to which pharmacist-managed TDM services exist within Australia, and the roles and responsibilities of the pharmacists involved compared to their counterparts in other countries, remains largely unknown. A cross-sectional online survey was conducted evaluating pharmacist-managed TDM programs within Australian hospital and healthcare settings. Pharmacist perceptions were also explored about the strengths, weaknesses, opportunities, and barriers associated with implementing a pharmacist-managed TDM service. A total of 92 surveys were returned, which represents a response rate of 38%. Pharmacist-managed TDM programs were present in 15% of respondents. It is only in the minority of hospitals where there is a pharmacist-managed service, with pharmacists involved in recommending pathology and medication doses. The programs highlighted improved patient outcomes but had difficulty maintaining the educational packages and training. For hospitals without a service, a lack of funding and time were highlighted as barriers. Based on the findings of this survey, there is minimal evidence of pharmacist-managed TDM models within Australian hospital and health services. A standardized national approach to pharmacist-managed TDM services and recognition of this specialist area for pharmacists could be a potential solution to this.

Consensus guidelines for optimising antifungal drug delivery and monitoring to avoid toxicity and improve outcomes in patients with haematological malignancy and haemopoietic stem cell transplant recipients, 2021

Antifungal agents can have complex dosing and the potential for drug interaction, both of which can lead to subtherapeutic antifungal drug concentrations and poorer clinical outcomes for patients with haematological malignancy and haemopoietic stem cell transplant recipients. Antifungal agents can also be associated with significant toxicities when drug concentrations are too high. Suboptimal dosing can be minimised by clinical assessment, laboratory monitoring, avoidance of interacting drugs, and dose modification. Therapeutic drug monitoring (TDM) plays an increasingly important role in antifungal therapy, particularly for antifungal agents that have an established exposure-response relationship with either a narrow therapeutic window, large dose-exposure variability, cytochrome P450 gene polymorphism affecting drug metabolism, the presence of antifungal drug interactions or unexpected toxicity, and/or concerns for non-compliance or inadequate absorption of oral antifungals. These guidelines provide recommendations on antifungal drug monitoring and TDM-guided dosing adjustment for selected antifungal agents, and include suggested resources for identifying and analysing antifungal drug interactions. Recommended competencies for optimal interpretation of antifungal TDM and dose recommendations are also provided.

Evaluating the Impact of Education on Pharmacist Tobramycin Dose Recommendations for Cystic Fibrosis and a Review of Perceptions on Pharmacist-Led Charting

BACKGROUND

Pharmacists routinely interpret and optimize tobramycin dosing for people with cystic fibrosis (PwCF).

OBJECTIVES

To determine the impact of tobramycin therapeutic drug monitoring (TDM) education on pharmacist dose recommendations, and to explore nurses' and medical doctors' perceptions toward pharmacist-led TDM charting.

METHODS

This study involved 3 phases: a 12-month retrospective audit of PwCF prescribed tobramycin to identify the appropriateness of pharmacists' dose recommendations, a pharmacist tobramycin educational intervention utilizing a voiceover presentation with pre- and post-online tobramycin TDM assessment (involving multiple choice pharmacokinetics and case-based scenario questions), and a cross-sectional survey of respiratory nurses' and doctors' perceptions toward pharmacist-led TDM charting. The pharmacists' dose recommendations, in the audit and case-based questions, were considered appropriate if subsequent levels achieved the targeted area under the curve (AUC).

RESULTS

Audit results revealed that 44.4% of the 277 pharmacist dose recommendations identified were appropriate. The pre- and post-interventional assessments were completed by 51 and 52 pharmacists, respectively. Post intervention, correct scores were significantly higher than pre-intervention, evident in both the pharmacokinetics (median score 75% vs 100%; P = 0.048) and case-based scenario (median score 60% vs 90%; P < 0.0001) questions. Of the 54 nurses and medical doctors surveyed, 92.6% supported the implementation of pharmacist-led tobramycin charting.

CONCLUSION

The study demonstrated an increased accuracy and appropriateness of pharmacists' tobramycin pharmacokinetics knowledge and TDM dose recommendations post-educational intervention and highlighted nurses' and medical doctors' support of pharmacist-led tobramycin TDM charting.

Are vancomycin dosing guidelines followed? A mixed methods study of vancomycin prescribing practices

AIMS

Despite the availability of international consensus guidelines, vancomycin dosing and therapeutic drug monitoring (TDM) remain suboptimal. This study aimed to assess concordance of vancomycin dosing and TDM with institutional guidelines and to identify factors taken into consideration by clinicians when prescribing vancomycin.

METHODS

A retrospective audit of 163 patients receiving vancomycin therapy (≥48 hours) was undertaken. Data collected included patient characteristics, dosing history and plasma vancomycin and creatinine concentrations. Concordance of dosing and TDM with institutional guidelines was evaluated. Semi-structured interviews, including simulated prescribing scenarios, were undertaken with prescribers (n = 17) and transcripts analysed.

RESULTS

Plasma vancomycin concentrations (n = 1043) were collected during 179 courses of therapy. Only 24% of courses commenced with a loading dose with 72% lower than recommended. The initial maintenance dose was concordant in 42% of courses with 34% lower than recommended. Only 14% of TDM samples were trough vancomycin concentrations. Dose was not adjusted for 60% (21/35) of subtherapeutic and 43% (18/42) of supratherapeutic trough vancomycin concentrations, respectively. Interview participants reported that patient characteristics (including renal function), vancomycin concentrations, guidelines and expert advice influenced vancomycin prescribing decisions. Despite referring to guidelines when completing simulated prescribing scenarios, only 37% of prescribing decisions aligned with guideline recommendations.

CONCLUSION

Poor compliance with institutional vancomycin guidelines was observed, despite prescriber awareness of available guidelines. Multifaceted strategies to support prescriber decision-making are required to improve vancomycin dosing and monitoring.

Therapeutic drug monitoring of commonly used anti-infective agents: A nationwide cross-sectional survey of Australian hospital practices

When performed according to best-practice principles, therapeutic drug monitoring (TDM) can optimise anti-infective treatment and directly benefit clinical outcomes. We evaluated TDM performance and clinical decision-making for established anti-infective agents amongst Australian hospitals. A nationwide cross-sectional survey was conducted between August and September 2019. The survey consisted of multiple-choice questions regarding TDM of anti-infective agents in general as well as clinical vignettes specific to vancomycin, gentamicin and voriconazole. We sought to survey all Australian hospitals operating both in the public and private health sectors. Responses were captured from 85 unique institutions, from all Australian states and territories. Regarding guidelines, 26% of hospitals did not have endorsed guidelines to advise on the ordering, sampling and interpretation of TDM for any anti-infective agent. Admitting teams were predominantly responsible for ordering TDM (85%) and interpreting results (76%). Only 51% of hospitals had access to dose prediction software, with access generally better amongst principal referral (69%) (P = 0.01) and children's hospitals (100%) (P = 0.04). Whenever a laboratory-derived minimum inhibitory concentration (MIC) was not available to guide dosing decisions, a surrogate target MIC was assumed in 77% of hospitals. This was based on a 'worst-case' scenario infection in 11% of hospitals. The rates of clinical practice consistent with current guideline recommendations across all aspects of TDM were demonstrated to be 0% for vancomycin, 4% for gentamicin and 35% for voriconazole. At present, there is significant institutional variability in the clinical practice of TDM for anti-infective agents in Australia for established TDM drugs.