Integrating a pharmacist into an anaesthesiology and critical care department: Is this worthwhile?

Pharmacoeconomic and clinical impact of pharmaceutical service in the intensive care unit: a systematic review

Clinical pharmacy is a fast-growing discipline in Europe, ensuring optimisation and a guarantee of safety in therapeutic management. Within a hospital the intensive care unit (ICU) typically admits the most severely ill patients who require expensive medications. These patients may be at risk for potentially serious adverse events, especially when medication errors occur. This study aims to evaluate the pharmacoeconomic and clinical impact of pharmaceutical care and service within ICUs. A systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 methodology was conducted to identify pharmacoeconomic studies published from 2017 to 2021 in Pubmed, Web of Science, and Science Direct. A qualitative methodological assessment of the studies was made using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) grid. Among the 525 articles identified from the databases, 11 were selected. Clinical benefits were mostly measured in terms of a reduction in the risk of adverse events related to care and reductions in the duration of mechanical ventilation and in-ICU and in-hospital length-of-stays. No impact on the mortality rate was demonstrated. All studies reported cost-benefit ratios ranging from €2.48 to €24.20 per €1 invested. The avoided costs per patient ranged from €29.73 to €194.24 per day of hospitalisation. The mean CHEERS compliance score was 63%±17%, demonstrating the heterogeneous quality of these analyses. International pharmacoeconomic evaluations on the impact of the clinical pharmacist operating in the ICU revealed both economic and clinical benefits for the patient. Larger randomised studies are required to confirm the major role of the pharmacist in the ICU.

[Implementing an operating room pharmacy satellite in an university hospital]

OBJECTIVES

An operating room pharmaceutical unit centralizes medical devices and drugs for various surgical specialities. The aim of this work is to present the methodology used in our establishment to set up the operating room pharmaceutical unit.

METHODS

This approach involved the formation of multi-professional working groups. The needs of operating theatres were defined based on an analysis of healthcare product consumption and stock inventories. Material sheets were defined for each procedure. On the basis of simulations, material supply arrangements were selected, specifying material flows, equipment, workstations and information systems.

RESULTS

Over 3200 healthcare product references were identified and 862 equipment files were created. Local stocks have been limited to medical trolleys for nursing staff. Emergency operating packs have been deployed for unforeseen operations. Cabinets have been dedicated to transporting re-sterilizable medical devices, and carts have been purchased for programmed operating packs. The equipment is made available by logistics agents and pharmacy assistants under pharmaceutical responsibility.

CONCLUSIONS

This innovative approach is a model for facilities desiring to centralize and secure the logistics of healthcare products in the operating room. Ongoing adjustments will be required to meet new operating rooms needs.

Whole blood thiamine, intravenous thiamine supplementation and delirium occurrence in the intensive care unit: retrospective cohort analyses

BACKGROUND

Thiamine di-phosphate is an essential cofactor in glucose metabolism, glutamate transformation and acetylcholinesterase activity, pathways associated with delirium occurrence. We hypothesised that a deficiency in whole blood thiamine and intravenous thiamine supplementation could impact delirium occurrence.

AIM

To establish whether a deficiency in whole blood thiamine and/or intravenous thiamine supplementation within 72 h of intensive care admission is associated with delirium occurrence.

METHOD

The first dataset was secondary analysis of a previous study in an intensive care unit in the Netherlands, reported in 2017. The second dataset contained consecutive intensive care admissions 2 years before (period 1: October 2014 to October 2016) and after (period 2: April 2017 to April 2019) routine thiamine supplementation was introduced within 72 h of admission. Delirium was defined as a positive Confusion Assessment Method-Intensive Care Unit score(s) in 24 h.

RESULTS

Analysis of the first dataset (n = 57) using logistic regression showed no relationship between delirium and sepsis or whole blood thiamine, but a significant association with age (p = 0.014). In the second dataset (n = 3074), 15.1% received IV thiamine in period 1 and 62.6% during period 2. Hierarchical regression analysis reported reduction in delirium occurrence in the second period; this did not reach statistical significance, OR = 0.81 (95% CI 0.652-1.002); p = 0.052.

CONCLUSION

No relationship was detected between whole blood thiamine and delirium occurrence on admission, at 24 and 48 h. It remains unclear whether routine intravenous thiamine supplementation during intensive care admission impacts delirium occurrence. Further prospective randomised clinical trials are needed.

Enhancing Drug Management, Cost Savings, and Staff Satisfaction in Anesthesiology: A Quality Improvement Project in a Chinese Tertiary Hospital

INTRODUCTION

In alignment with China's national directive for improved drug management in anesthesiology, the Affiliated Hospital of Qingdao University initiated a quality improvement project, aiming to tackle the prevailing challenges of inefficiencies in drug administration, escalating drug costs, and the notable communication gap between pharmacists and anesthesiologists.

METHODS

We employed a Plan-Do-Study-Act methodology to establish a pharmacy team and execute a multidimensional pharmaceutical intervention. The interventions included the formulation of standard procedures, guidelines and regulations, assistance from an information system (including automatic dispensing cabinets and prospective prescription review system), communication feedback (via WeChat groups), and education for anesthesiology staff. The intervention spanned from April to September 2023, focusing on optimizing medication management, achieving cost savings, and enhancing the satisfaction of anesthesia team members, with an additional observation from October to December 2023.

RESULTS

Following the interventions, improvements were observed in drug management practices. These enhancements included increased compliance with accounting procedures, more rigorous registration of controlled substances, and more effective disposal of liquid residues. There was no adverse events related to high-alert medications or look-alike drug usage errors. The introduction of automatic dispensing cabinets and a prospective prescription review system markedly improved work efficiency. The utilization of a WeChat group facilitated effective communication about unreasonable prescriptions and drug-related issues. Among the 29,061 patients who underwent surgery both before and after the interventions, significant reductions were observed both in the drug proportion and the per capita drug costs (P = 0.03, P = 0.014, respectively). The per capita drug cost decreased by 20.82%, from ¥723.43 to ¥572.78, consistently remaining below ¥600 throughout the 9-month observation period. The per capita cost of monitoring drugs including dezocine, butorphanol, haemocoagulase agkistrodon, penehyclidine, and ulinastatin experienced a significant reduction (P < 0.05). Additionally, in the satisfaction questionnaires returned, a remarkable 94.44% of anesthesiology staff expressed high satisfaction with the comprehensive pharmaceutical interventions.

CONCLUSION

The quality improvement project has yielded remarkable positive outcomes, serving as a model worthy of reference and replication in similar healthcare settings.

Economic evaluations of adult critical care pharmacy services: a scoping review

OBJECTIVES

To summarise the extent and type of evidence available regarding economic evaluations of adult critical care pharmacy services in the context of UK practice.

METHODS

A literature search was conducted in eight electronic databases and hand searching of full-text reference lists. Of 2409 journal articles initially identified, 38 were included in the final review. Independent literature review was undertaken by two investigators in a two-step process against the inclusion and exclusion criteria; title and abstract screening were followed by full-text screening. Included studies were taken from high-income economy countries that contained economic data evaluating any key aspect of adult critical care pharmacy services. Grey literature and studies that could not be translated into the English language were excluded.

RESULTS

The majority were before-and-after studies (18, 47%) or other observational studies (17, 45%), and conducted in North America (25, 66%). None of the included studies were undertaken in the UK. Seven studies (18%) included cost-benefit analysis; all demonstrated positive cost-benefit values for clinical pharmacist activities.

CONCLUSIONS

Further high-quality primary research focussing on the economic evaluation of UK adult critical care pharmacy services is needed, before undertaking a future systematic review. There is an indication of a cost-benefit value for critical care pharmacist activities. The lack of UK-based economic evaluations is a limitation to further development and standardisation of critical care pharmacy services nationally.

A bibliometric analysis of global trends in the research field of pharmaceutical care over the past 20 years

Pharmaceutical care is essential in building up the basics of public health and clinical care. A comprehensive understanding of global status in the field of pharmaceutical care is necessary for directing its research frontiers and future trends. Therefore, this study aims to make a bibliometric analysis to track the development of pharmaceutical care research worldwide during the past two decades. The publications regarding pharmaceutical care were culled from the Web of Science Core Collection (WoSCC). Countries, institutions, authors, journals, references, and keywords in this field were visually analyzed by using VOSviewer (version 1.6.17) and CiteSpace (Version 5.8.R3). As a result, 3,597 publications (3,177 articles and 420 reviews) were obtained. The annual yields grew more than three times in the past two decades, from 54 records in 2002 to 379 papers in 2021. The United States played the leading role in this research from multiple aspects, including publication (n = 1,208), citations (n = 28,759), funding agencies, and collaboration worldwide. The University of Sydney in Australia was the most contributed institution with the greatest number of publications (n = 112) in pharmaceutical care research. Hersberger KE from the University of Basel was the most productive author (n = 40). Chen TF from the University of Sydney was the author who owed the highest H-index of 19 and most citations (n = 1,501). They both significantly impacted this field. American Journal of Health System Pharmacy produced the most publications, while Pharmacotherapy had the highest IF (IF2020 = 4.705) in this field. Clusters networks of co-cited references and keywords suggested that clinical pharmacy is an essential theme in pharmaceutical care. Terms of medication safety and critical care recognized by burst analysis of keywords also hint at the recent attention on clinical pharmacy. The present bibliometrics analysis may provide a comprehensive overview and valuable reference for future researchers and practitioners in the research field of pharmaceutical care.

Off-label Medication Use: A Double-edged Sword

Agarwal V. Off-label Medication Use: A Double-edged Sword. Indian J Crit Care Med 2021;25(8):845-846.

The role of the critical care pharmacist during the COVID-19 pandemic

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The COPIL allowed the restructuring of the ICU in record time to double its capacity.

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The CCP, integrated in the COPIL and already a member of the ICU team for a few years, provided an essential link between the ICU and the pharmacy during the COVID-19 pandemic.

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The CCP implemented actions to avoid health products shortages, to secure practices and played a key role in the critical analysis of emerging published data in COVID-19 potential treatments.

On January 4 2020, the World Health Organization (WHO) reported the emergence of a cluster of pneumonia cases in Wuhan, China due to a new coronavirus, the SARS-CoV-2. A few weeks later, hospitals had to put in place a series of drastic measures to deal with the massive influx of suspected COVID-19 (COronaroVIrus Disease) patients while securing regular patient care, in particular in the intensive care units (ICU). Since March 12th, 77 of the 685 COVID-19 patients admitted to our hospital required hospitalization in the ICU. What are the roles and the added-value of the critical care pharmacist during this period? His missions have evolved although they have remained focused on providing health services for the patients. Indeed, integrated into a steering committee created to organize the crisis in the intensive care units, the role of the clinical pharmacist was focused on the organization and coordination between ICU and the pharmacy, the implementation of actions to secure practices, to train new professionals and the adaptation of therapeutic strategies. He participated to literature monitoring and increased his involvement in the clinical research team. He provided a link between the ICU and the pharmacy thanks to his knowledges of practices and needs.

Physicians' acceptance of pharmacists' interventions in daily hospital practice

Background The physicians' acceptance rate of pharmacists' interventions to improve pharmacotherapy can vary depending on the setting. The acceptance rate of interventions proposed by pharmacists located in the hospital pharmacy over the telephone and factors associated with acceptance are largely unknown. Objective To determine the physicians' acceptance rate of pharmacists' interventions proposed over the telephone in daily hospital practice and to identify factors associated with acceptance. Setting A retrospective case-control study was performed concerning adult patients admitted to a university hospital in the Netherlands. Method Pharmacists' interventions, based on alerts for drug-drug interactions and drug dosing in patients with renal impairment, recorded between January 2012 and June 2013 that were communicated over the telephone were included. Factors associated with physicians' acceptance were identified with the use of a mixed-effects logistic model. Main outcome measure The primary outcome was the proportion of accepted interventions. Results A total of 841 interventions were included. Physicians accepted 599 interventions, resulting in an acceptance rate of 71.2%. The mixed-effects logistic model showed that acceptance was significantly associated with the number of prescribed drugs (16 to ≤ 20 drugs ORadj 1.88; 95% CI 1.05-3.35, > 20 drugs ORadj 2.90; 95% CI 1.41-5.96, compared to ≤ 10 drugs) and the severity of the drug-related problem (problem without potential harm ORadj 6.36; 95% CI 1.89-21.38; problem with potential harm OR 6.78; 95% CI 2.09-21.99, compared to clinically irrelevant problems), and inversely associated with continuation of pre-admission treatment (ORadj 0.55; 95% CI 0.35-0.87). Conclusion Over the study period, the majority of pharmacists' interventions proposed over the telephone were accepted by physicians. The probability for acceptance increased for patients with an increasing number of medication orders, for clinically relevant problems and for problems related to treatment initiated during admission.