The effect of ICU sedation guidelines and pharmacist interventions on clinical outcomes and drug cost

Patterns of interactions among ICU interprofessional teams: A prospective patient-shift-level survey approach

BACKGROUND

The Awakening, Breathing Coordination, Delirium monitoring and Early mobility bundle (ABCDE) is associated with lower mortality for intensive care unit (ICU) patients. However, efforts to improve ABCDE are variably successful, possibly due to lack of clarity about who are the team members interacting when caring for each patient, each shift. Lack of patient shift-level information regarding who is interacting with whom limits the ability to tailor interventions to the specific ICU team to improve ABCDE.

OBJECTIVE

Determine the number and types of individuals (i.e., clinicians and family members) interacting in the care of mechanically ventilated (MV) patients, as reported by the patients' assigned physician, nurse, and respiratory therapist (RT) each shift, using a network science lens.

METHODS

We conducted a prospective, patient-shift-level survey in 2 medical ICUs. For each patient, we surveyed the assigned physician, nurse, and RT each day and night shift about who they interacted with when providing ABCDE for each patient-shift. We determined the number and types of interactions, reported by physicians, nurses, and RTs and day versus night shift.

RESULTS

From 1558 surveys from 404 clinicians who cared for 169 patients over 166 shifts (65% response rate), clinicians reported interacting with 2.6 individuals each shift (physicians: 2.65, nurses: 3.33, RTs: 1.86); this was fewer on night shift compared to day shift (1.99 versus 3.02). Most frequent interactions were with the bedside nurse, attending, resident, intern, and RT; family member interactions were reported in less than 1 in 5 surveys (12.2% of physician surveys, 19.7% of nurse surveys, 4.9% of RT surveys).

INTERPRETATION

Clinicians reported interacting with 3-4 clinicians each shift, and fewer on nights. Nurses interacted with the most clincians and family members. Interventions targeting shift-level teams, focusing on nurses and family members, may be a way to improve ABCDE delivery and ICU teamwork.

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.

Critical Care Pharmacists: A Focus on Horizons

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.

Position Paper on Critical Care Pharmacy Services: 2020 Update

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.

Impact on Patient Outcomes of Pharmacist Participation in Multidisciplinary Critical Care Teams: A Systematic Review and Meta-Analysis

OBJECTIVES

The objective of this systematic review and meta-analysis was to assess the effects of including critical care pharmacists in multidisciplinary ICU teams on clinical outcomes including mortality, ICU length of stay, and adverse drug events.

DATA SOURCES

PubMed, EMBASE, and references from previous relevant systematic studies.

STUDY SELECTION

We included randomized controlled trials and nonrandomized studies that reported clinical outcomes such as mortality, ICU length of stay, and adverse drug events in groups with and without critical care pharmacist interventions.

DATA EXTRACTION

We extracted study details, patient characteristics, and clinical outcomes.

DATA SYNTHESIS

From the 4,725 articles identified as potentially eligible, 14 were included in the analysis. Intervention of critical care pharmacists as part of the multidisciplinary ICU team care was significantly associated with the reduced likelihood of mortality (odds ratio, 0.78; 95% CI, 0.73-0.83; p < 0.00001) compared with no intervention. The mean difference in ICU length of stay was -1.33 days (95% CI, -1.75 to -0.90 d; p < 0.00001) for mixed ICUs. The reduction of adverse drug event prevalence was also significantly associated with multidisciplinary team care involving pharmacist intervention (odds ratio for preventable and nonpreventable adverse drug events, 0.26; 95% CI, 0.15-0.44; p < 0.00001 and odds ratio, 0.47; 95% CI, 0.28-0.77; p = 0.003, respectively).

CONCLUSIONS

Including critical care pharmacists in the multidisciplinary ICU team improved patient outcomes including mortality, ICU length of stay in mixed ICUs, and preventable/nonpreventable adverse drug events.

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

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.

Interprofessional Care and Teamwork in the ICU

OBJECTIVES

We describe the importance of interprofessional care in modern critical care medicine. This review highlights the essential roles played by specific members of the interprofessional care team, including patients and family members, and discusses quality improvement initiatives that require interprofessional collaboration for success.

DATA SOURCES

Studies were identified through MEDLINE search using a variety of search phrases related to interprofessional care, critical care provider types, and quality improvement initiatives. Additional articles were identified through a review of the reference lists of identified articles.

STUDY SELECTION

Original articles, review articles, and systematic reviews were considered.

DATA EXTRACTION

Manuscripts were selected for inclusion based on expert opinion of well-designed or key studies and review articles.

DATA SYNTHESIS

"Interprofessional care" refers to care provided by a team of healthcare professionals with overlapping expertise and an appreciation for the unique contribution of other team members as partners in achieving a common goal. A robust body of data supports improvement in patient-level outcomes when care is provided by an interprofessional team. Critical care nurses, advanced practice providers, pharmacists, respiratory care practitioners, rehabilitation specialists, dieticians, social workers, case managers, spiritual care providers, intensivists, and nonintensivist physicians each provide unique expertise and perspectives to patient care, and therefore play an important role in a team that must address the diverse needs of patients and families in the ICU. Engaging patients and families as partners in their healthcare is also critical. Many important ICU quality improvement initiatives require an interprofessional approach, including Awakening and Breathing Coordination, Delirium, Early Exercise/Mobility, and Family Empowerment bundle implementation, interprofessional rounding practices, unit-based quality improvement initiatives, Patient and Family Advisory Councils, end-of-life care, coordinated sedation awakening and spontaneous breathing trials, intrahospital transport, and transitions of care.

CONCLUSIONS

A robust body of evidence supports an interprofessional approach as a key component in the provision of high-quality critical care to patients of increasing complexity and with increasingly diverse needs.

Impact of Quality Bundle Enforcement by a Critical Care Pharmacist on Patient Outcome and Costs

OBJECTIVES

Surgical and medical ICU patients are at high risk of mortality and provide a significant cost to the healthcare system. The aim of this study is to describe the effect of pharmacist-led interventions on drug therapy and clinical strategies on ICU patient outcome and hospital costs.

DESIGN

Before and after study in two French ICUs (16 and 10 beds).

PATIENTS

ICU patients.

INTERVENTION

From January 1, 2013, to June 30, 2015, a pharmacist observation period was compared with an intervention period in which a critical care pharmacist provided recommendations to clinicians regarding sedative drugs and doses, choice of mechanical ventilation mode and related settings, antimicrobial de-escalation, and central venous and urinary catheters removal. Differences in ICU and hospital length of stay, duration of mechanical ventilation, mortality rate, and hospital costs per patient were quantified between groups with patients matched for severity of illness (Simplified Acute Physiology Score II) at admission.

MEASUREMENTS AND MAIN RESULTS

From the 1,519 and 1,268 admitted patients during the observation and intervention periods, respectively, 1,164 patients were evaluable in both groups after matching for Simplified Acute Physiology Score II score. The intervention period was associated with mean (95% CI) reductions in patient hospital length of stay (3.7 d [5.2-2.3 d]; p < 0.001), ICU length of stay (1.4 d [2.3-0.5 d]; p < 0.005), duration of mechanical ventilation (1.2 d [2.1-0.3 d]; p < 0.01), and hospital costs per stay (2,560 euros [3,728-1,392 euros]; p < 0.001). The overall cost savings were 10,840 euros (10,727-10,952 euros) per month, mostly due to reduced consumption of sedatives and antimicrobials. No impact on mortality rate was identified.

CONCLUSIONS

Critical care pharmacist-led interventions were associated with decreases in ICU and hospital length of stays and ICU drug costs.

Pharmacists' interventions to reduce sedative/hypnotic use for insomnia in hospitalized patients

BACKGROUND

Hospitalization can contribute to insomnia in many patients and is usually treated symptomatically. However, sedative/hypnotic misuse is associated with complications in this population, especially in the elderly. Such complications include dizziness, falls and over-sedation. Due to the implicit dangers, widespread use of these drugs for insomnia, particularly in older patients, has been discouraged by many hospitals. The aim of this study was to review and evaluate prescribing patterns and to optimize the use of the sedative/hypnotic agents through daily pharmacy interventions at a community hospital.

METHODS

This was a biphasic before and after study. Data on sedative/hypnotic use was collected retrospectively for a 2-month period and a sample of 100 patients was randomly selected for analysis. A 2-month prospective phase followed, in which daily orders were reviewed by one pharmacy resident and recommendations made to discontinue any unnecessary, newly prescribed sedative/hypnotic orders when appropriate. Finally, results of both phases were compared for any differences in patient demographics, being prescribed more than one sedative/hypnotic, and complications documented.

RESULTS

During the prospective phase, pharmacist interventions led to the discontinuation of 25% of a total of 97 sedative/hypnotic orders in 97 patients. The number of patients receiving more than one sedative/hypnotic agents in the intervention group was significantly lower than the retrospective control group (15 Vs. 34, P = 0.0026). The incidence of complications was not significantly different between the control and intervention groups for the following: over-sedation, falls and delirium (p = 0.835, p = 0.185, p = 0.697, respectively).

CONCLUSION

This study suggests that the use of sedative/hypnotics in the inpatient units (excluding the critical care unit), is somewhat prevalent, and many patients may be on more than one sedative/hypnotic, which could potentially cause cumulative harm. During the intervention phase, 25% of the total in-hospital orders for sedative/hypnotics were discontinued following recommendations made by a pharmacist, and significantly lower number of patients receiving duplicate sedative/hypnotics was noted. Further efforts should be implemented to avoid unnecessary sedative/hypnotic initiation in hospitalized patients, and to ensure monitoring by pharmacists is optimized.

How to translate the new hospital-acquired and ventilator-associated pneumonia guideline to the bedside

PURPOSE OF REVIEW

Hospital-acquired pneumonia and ventilator-associated pneumonia remain significant causes of morbidity, mortality, and financial burden in the United States and around the globe. Although guidelines for the management of patients with these conditions have been available for several years, implementation remains challenging. Here, we review the most common barriers faced by clinicians in implementing the current guidelines and offer suggestions for improved adherence.

RECENT FINDINGS

Recent studies have identified barriers to the implementation of the guidelines regarding management of hospital-acquired and ventilator-associated pneumonia. The most common difficulties encountered are lack of awareness of the guidelines, practice variation among providers delivering care to affected patients, lack of antibiogram information, and lack of antibiotic stewardship programs.

SUMMARY

Translating the current hospital-acquired and ventilator-associated pneumonia guidelines to the bedside requires understanding of the current barriers affecting care of patients with these conditions. Adopting clinical guidelines facilitates the management of these patients and improves outcomes. Dissemination of the guidelines, provider education, antibiotic stewardship programs, access to local antibiogram information, audit and feedback, electronic tools and leadership commitment are likely to play important roles in guideline implementation. More studies on hospital-acquired and ventilator-associated pneumonia guideline implementation are necessary to identify the most effective interventions.

Advanced Modes of Mechanical Ventilation: Introduction for the Critical Care Pharmacist

Mechanical ventilation continues to be an evolving modality in the critical care environment. Technological advances in microprocessor-controlled ventilation integrated with the complexity of new ventilator modes has provided the multidisciplinary team opportunities to further improve the care of the critically ill ventilator patients. As members of the critical care multidisciplinary team, pharmacists require a basic understanding of both conventional and advanced modes of mechanical ventilation in order to assist in optimizing medication use and ultimately patient health-care outcomes. Pharmacists have a key responsibility to practice vigilance to maintain safe drug therapy use by preventing drug-drug or drug-disease interactions and optimal dose selection based upon pharmacokinetics and pharmacodynamics principles. Pharmacists also assist in the development of drug utilization guidelines and pharmacological ventilator-weaning protocols based upon evidence-based practice. The result of these responsibilities must include the continued longitudinal assessment and reporting of quality measures to assess ventilator weaning, time to liberation of mechanical ventilation, and length of care in intensive care unit. The purpose of this article is to provide the clinical pharmacist a guide to a basic understanding of advanced modes of mechanical ventilation in adults and to apply the knowledge gained to assist in the care of the critical care patients.

Impact of Multiple Daily Clinical Pharmacist-Enforced Assessments on Time in Target Sedation Range

OBJECTIVES

Incorporation of a single daily assessment by a clinical pharmacist to improve adherence with a sedation protocol is associated with reduced duration of mechanical ventilation and intensive care unit (ICU) length of stay (LOS). We test the feasibility of incorporating a clinical pharmacist into more frequent sedation assessments and observed whether there are any potential differences in the sedatives administered.

METHODS

Prospective, quasi-experimental, pilot study of patients admitted to the medical ICU. Patients were included in the analysis if ≥18 years of age within the first 24 hours of initiation of mechanical ventilation. Our primary intent was to test the clinical feasibility surrounding more frequent sedation assessments by a clinical pharmacist by evaluating potential differences in time in target sedation range and sedative administration. Exploratory efficacy end points included time in target sedation range (0 to -2) using the Richmond Agitation Sedation Scale (RASS) and sedative exposure. Patients were assigned to receive either 3 assessments with a clinical pharmacist per day (intervention) or a single assessment by a clinical pharmacist per day (standard of care). During the assessments, clinical pharmacists participated in the RASS administration and made dosing adjustments according to an established sedation protocol.

MAIN RESULTS

Seventeen patients were enrolled (n = 6 intervention group, n = 11 standard of care). Duration of mechanical ventilation was similar in the 2 groups (intervention 100.0 hours [52.5-197.5] vs control 76.0 hours [46.0-201.0], P = .95), but patients in the intervention group exhibited a greater percentage time in the target RASS range (intervention 76.0% [53.7-81.5%] vs control 45.2% [35.3-67.0], P = .11) that was not statistically significant. Patients in the intervention group received less fentanyl per day (820.9 µg [227.3-1579.4] vs 1997 µg [1648.2-2477.2], P = .02) than in the control group.

CONCLUSION

Incorporating a clinical pharmacist into more frequent daily sedation assessments was associated with a reduction in fentanyl administration. There were no observed differences in time in target sedation range or reduction in duration of mechanical ventilation.

Propofol Associated with a Shorter Duration of Mechanical Ventilation than Scheduled Intermittent Lorazepam: A Database Analysis Using Project Impact

Background:

While one prospective controlled study in medical intensive care unit (ICU) patients demonstrated that sedation with propofol leads to a shorter duration of mechanical ventilation compared with scheduled intermittent intravenous lorazepam, its conclusions may not be applicable to surgical ICU patients and institutions not using daily sedation interruption.

Objective:

To compare the duration of mechanical ventilation between medical and surgical ICU patients receiving propofol versus scheduled intermittent lorazepam in routine clinical practice.

Methods:

Retrospective data (January 2001–December 2005) were obtained from the Project IMPACT database for medical and surgical ICU patients at Tufts-New England Medical Center, a 450 bed academic hospital. These patients had been mechanically ventilated for 24 hours or more and had received 24 hours or more of either propofol or scheduled intermittent lorazepam as the sole sedative. Clinically relevant variables were identified a priori, and their influence on duration of mechanical ventilation was evaluated. Differences in these variables between propofol and scheduled intermittent lorazepam groups within the ICU cohorts were then measured.

Results:

Of 4608 database patients, 287 met criteria. Factors associated with a prolonged duration of mechanical ventilation for the medical ICU cohort included sedation use for 5 or more days (OR 13.8; 95% CI 8.3 to 19.4), narcotic use (OR 7.6; 95% CI 2.3 to 13), and scheduled intermittent lorazepam use (OR 7.0; 95% CI 0.4 to 13.7). For the surgical ICU cohort, these factors included sedation use for 5 or more days (OR 15; 95% CI 11.4 to 19.4), APACHE II (Acute Physiology and Chronic Health Evaluation II) score equal to or greater than 18 (OR 4.1; 95% CI 0.4 to 7.8), and scheduled intermittent lorazepam use (OR 4.0; 95% CI 0.2 to 7.7). Duration of mechanical ventilation was the only variable that differed significantly between propofol and scheduled intermittent lorazepam in both the medical ICU, with a median (range) of 6 (3–12) versus 11 (5–25; p = 0.03), and surgical ICU, with a median of 4 (2–15) versus 9 (4–20; p = 0.001), groups.

Conclusions:

Sedation with propofol in the naturalistic setting appears to be associated with a shorter duration of mechanical ventilation compared with scheduled intermittent lorazepam in both medial and surgical ICU patients when only one sedative drug is used. Data from this uncontrolled observational study are consistent with findings from a randomized clinical trial.

Pharmacy-Driven Dexmedetomidine Stewardship and Appropriate Use Guidelines in a Community Hospital Setting

BACKGROUND

Dexmedetomidine is a widely utilized agent in the intensive care unit (ICU) because it does not suppress respiratory drive and may be associated with less delirium than midazolam or propofol. Cost of dexmedetomidine therapy and debate as to the proper duration of use has brought its use to the forefront of discussion.

OBJECTIVE

To validate the efficacy and cost savings associated with pharmacy-driven dexmedetomidine appropriate use guidelines and stewardship in mechanically ventilated patients.

METHODS

This was a retrospective cohort study of adult patients who received dexmedetomidine for ICU sedation while on mechanical ventilation at a 433-bed not-for-profit community hospital. Included patients were divided into pre-enactment (PRE) and postenactment (POST) of dexmedetomidine guideline groups.

RESULTS

A total of 100 patients (50 PRE and 50 POST) were included in the analysis. A significant difference in duration of mechanical ventilation (11.1 vs 6.2 days, P = 0.006) and incidence of reintubation (36% vs 18% of patients, P = 0.043) was seen in the POST group. Aggregate use of dexmedetomidine 200-µg vials (37.1 vs 18.4 vials, P = 0.010) and infusion days (5.4 vs 2.5 days, P = 0.006) were significantly lower in the POST group. Dexmedetomidine acquisition cost savings were calculated at $374 456.15 in the POST group. There was no difference between the PRE and POST groups with regard to ICU length of stay, expected mortality, and observed mortality.

CONCLUSIONS

Pharmacy-driven dexmedetomidine appropriate use guidelines decreased the use of dexmedetomidine and increased cost savings at a community hospital without adversely affecting clinical outcomes.

Implementation of Pharmaceutical Practice Guidelines by a Project Model Based: Clinical and Economic Impact

All around the world a few studies have been found on the effect of guideline implementation on direct medications' expenditure. The goal of this study was to evaluate cost savings of guideline implementation among patients who had to receive 3 costly medications including albumin, enoxaparin, and pantoprazole in a tertiary hospital in Shiraz, Iran.An 8-month prospective study was performed in 2 groups; group 1 as an observational group (control group) in 4 months from June to September 2014 and group 2 as an interventional group from October 2014 to January 2015.For group 1 the pattern of costly medications usage was determined without any intervention. For group 2, after guideline implementation, the economic impact was evaluated by making comparisons between the data achieved from the 2 groups.A total of 12,680 patients were evaluated during this study (6470 in group 1; 6210 in group 2). The reduction in the total value of costly administered drugs was 56% after guideline implementation. Such reduction in inappropriate prescribing accounts for the saving of 85,625 United States dollars (USD) monthly and estimated 1,027,500 USD annually.Guideline implementation could improve the adherence of evidence-based drug utilization and resulted in significant cost savings in a major teaching medical center via a decrease in inappropriate prescribing of costly medications.

Outcomes of expanded use of clinical pharmacist practitioners in addition to team-based care in a community health system intensive care unit

PURPOSE

Clinical and cost benefits achieved through expanded use of state-licensed clinical pharmacist practitioners (CPPs) with prescribing authority on a critical care team are reported.

METHODS

A retrospective pre-post analysis was conducted to evaluate patient care outcomes and cost savings during one-year periods before and after the number of CPPs on a North Carolina community health system's neurotrauma intensive care unit (NTICU) team was increased from one to three. Outcomes assessed included the number and types of medication management encounters, estimated cost savings, and the rate of preventable adverse drug events (ADEs) with expanded use of CPPs.

RESULTS

During the two-year study period, CPPs conducted 13,386 documented medication encounters involving 2,198 patients; associated cost savings totaled an estimated $2,118,426. During the 12 months after CPP involvement on the NTICU team was increased, there was a 182% increase in encounters for therapeutic optimization (p = 0.01), with an associated 29% increase in cost savings and an improved return on investment. The CPP service expansion was also associated with a reduction in preventable ADEs, including a 75% reduction in prescribing-related ADEs (risk ratio [RR], 0.25; 95% confidence interval [CI], 0.05-1.2; p = 0.09) and a 37% reduction in higher-severity ADEs (RR, 0.63; 95% CI, 0.25-1.57; p = 0.36).

CONCLUSION

With expanded CPP involvement on the NTICU team, there was a substantial increase in therapeutic optimization interventions and a clinically notable reduction in preventable ADEs, as well as an estimated 30% increase in associated cost savings.

Practice guidelines for sedation and analgesia management of critically ill children: a pilot study evaluating guideline impact and feasibility in the PICU

AIMS

The aim of this study was to develop and implement guidelines for sedation and analgesia management in the paediatric intensive care unit (PICU) and evaluate the impact, feasibility and acceptability of these as part of a programme of research in this area and as a prelude to future trial work.

METHOD

This pilot study used a pre-post design using a historical control.

SETTING

Two PICUs at different hospitals in an Australian metropolitan city.

PARTICIPANTS

Patients admitted to the PICU and ventilated for ≥24 h, aged more than 1 month and not admitted for seizure management or terminal care.

INTERVENTION

Guidelines for sedation and analgesia management for critically ill children including algorithm and assessment tools.

OUTCOME VARIABLES

In addition to key outcome variables (ventilation time, medication dose and duration, length of stay), feasibility outcomes data (recruitment, data collection, safety) were evaluated. Guideline adherence was assessed through chart audit and staff were surveyed about merit and the use of guidelines.

RESULTS

The guidelines were trialled for a total of 12 months on 63 patients and variables compared with the historical control group (n=75). Analysis revealed differences in median Morphine infusion duration between groups (pretest 3.63 days (87 h) vs post-test 2.83 days (68 h), p=0.05) and maximum doses (pretest 120 μg/kg/h vs post-test 97.5 μg/kg/h) with no apparent change to ventilation duration. Chart audit revealed varied use of tools, but staff were positive about the guidelines and their use in practice.

CONCLUSIONS

The sedation guidelines impacted on the duration and dosage of agents without any apparent impact on ventilation duration or length of stay. Furthermore, the guidelines appeared to be feasible and acceptable in clinical practice. The results of the study have laid the foundation for follow-up studies in withdrawal from sedation, point prevalence and longitudinal studies of sedation practices as well as drug trial work.

Expected net benefit of clinical pharmacy in intensive care medicine: a randomized interventional comparative trial with matched before-and-after groups

RATIONALE, AIMS AND OBJECTIVES

This study evaluated clinical pharmacy costs against drug costs.

METHOD

We conducted a randomized interventional comparative trial at the surgical intensive care unit (ICU) of Ghent University Hospital, Belgium (period B: group B1 with pharmacist consultation; control group B0). We obtained before (period A) and after (period C) control groups using 1:1 propensity score matching with B1 and B0. Mean daily ICU drug costs with standard error of the mean (SEM) were compared between B1 and B0 (primary analysis) and between matched pairs (AB1, AB0, CB1 and CB0; secondary analysis). For B, we performed a 1000 bootstrapping (by resampling B1 and B0), calculated the benefit-cost ratio using pharmacy time (gross salary) as cost (euros) and drug cost savings as benefit. We performed sensitivity analysis with and without outlier drug costs (i.e. twice the standard deviation).

PERSPECTIVE

Belgian health care payer.

RESULTS

In period B, 135 patients were randomized: B0, n = 60; B1, n = 75. Pharmacists provided recommendations in 148/706 (21.0%) therapies with 83.1% acceptance. Mean drug cost difference between B0 (430.6 euros, SEM 406.0) and B1 (221.2 euros, SEM 58.7) (P = 0.870) became significant after excluding outlier drug costs (B0, 184.4 euros, SEM 42.5; B1, 90.5 euros, SEM 17.7; P < 0.001). Recommendations were cost-beneficial (break-even drug costs or savings) in 53.8% of patients with a benefit-cost ratio of 25:1 (confidence interval -5:1 to 94:1). In sensitivity analysis excluding outlier drug costs, B0 costs were significantly higher than both A and C, indicating high baseline expenses in B0.

CONCLUSIONS

The randomized interventional comparative trial in a small ICU patient group suggested the potential cost-benefit of clinical pharmacy on daily ICU drug costs. However, after matching, this benefit was attenuated. A final conclusion demands a larger randomized trial adopting a similar design with matched controls. Future research should include clinical impact of recommendations.

Current practices of mobilization, analgesia, relaxants and sedation in Indian ICUs: A survey conducted by the Indian Society of Critical Care Medicine

Background and Aim:

Use of sedation, analgesia and neuromuscular blocking agents is widely practiced in Intensive Care Units (ICUs). Our aim is to study the current practice patterns related to mobilization, analgesia, relaxants and sedation (MARS) to help in standardizing best practices in these areas in the ICU.

Materials and Methods:

A web-based nationwide survey involving physicians of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Society of Anesthesiologists (ISA) was carried out. A questionnaire included questions on demographics, assessment scales for delirium, sedation and pain, as also the pharmacological agents and the practice methods.

Results:

Most ICUs function in a semi-closed model. Midazolam (94.99%) and Fentanyl (47.04%) were the most common sedative and analgesic agents used, respectively. Vecuronium was the preferred neuromuscular agent. Monitoring of sedation, analgesia and delirium in the ICU. Ramsay's Sedation Scale (56.1%) and Visual Analogue Scale (48.07%) were the preferred sedation and pain scales, respectively. CAM (Confusion Assessment Method)-ICU was the most preferred method of delirium assessment. Haloperidol was the most commonly used agent for delirium. Majority of the respondents were aware of the benefit of early mobilization, but lack of support staff and safety concerns were the main obstacles to its implementation.

Conclusion:

The results of the survey suggest that compliance with existing guidelines is low. Benzodiazepines still remain the predominant ICU sedative. The recommended practice of giving analgesia before sedation is almost non-existent. Delirium remains an underrecognized entity. Monitoring of sedation levels, analgesia and delirium is low and validated and recommended scales for the same are rarely used. Although awareness of the benefits of early mobilization are high, the implementation is low.

Improving Antibiotic De-Escalation in Suspected Ventilator-Associated Pneumonia: An Observational Study With a Pharmacist-Driven Intervention

BACKGROUND

Recommendations for treatment of ventilator-associated pneumonia (VAP) emphasize early empiric broad-spectrum antibiotics. However, appropriate antibiotic de-escalation is also critical for optimal patient care.

MATERIALS AND METHODS

We examined how often intensivists in our institution appropriately de-escalated antibiotics in cases of suspected VAP, and whether decision support by intensive care unit pharmacists could improve rates of antibiotic targeting and early antibiotic discontinuation in low-risk patients.

MAIN RESULTS

A total of 92 (observation phase = 50; intervention phase = 42) patients with suspected VAP were identified. During the observation phase, 39 cases yielded positive sputum cultures, but in only 23 (59%) were antibiotics targeted to culture results. This rate improved during the intervention phase when 29 (91%) of 32 cases with positive cultures were targeted (P value .003). There were 48 cases in which the risk of pneumonia was considered low. Of the 26 low-risk cases in the observation phase, 5 (19%) had antibiotics discontinued early versus 5 (23%) of the 22 cases in the intervention phase.

CONCLUSIONS

Decision support by clinical pharmacists significantly improved rates of appropriate antibiotic targeting in cases of culture-positive suspected VAP but did not have a significant effect on early antibiotic discontinuation in patients at low risk of true pneumonia.

Development of clinical pharmacy services for intensive care units in Korea

OBJECTIVE

To be utilized for the development of pharmacists' intervention service by determining factors which affect pharmacists' prescription interventions.

SETTING

Patients who were admitted to intensive care units (ICUs) in internal medicine departments in Korea.

METHODS

Data including age, gender, clinical departments, length of hospital stay, status of organ dysfunction, intervention status, frequently intervened drugs, and health care providers' questions were prospectively collected in ICUs in the department of internal medicine in a tertiary teaching hospital from January to December, 2012.

MAIN OUTCOME MEASURE

Primary outcome was factors which affect pharmacists' prescription interventions. Secondary outcomes included frequencies of the intervention, intervention acceptance rates, intervention issues, and frequently intervened drugs.

RESULTS

A total of 1,213 prescription interventions were made for 445 patients (33.1%) of the 1,344 patients that were analyzed. Length of hospital stay was significantly longer for the group that needed pharmacists' interventions (p < 0.001). Pharmacists' intervention requirements were significantly higher in patients with kidney dysfunction (p < 0.001). The percentage of intervention accepted was 96.8%, and interventions that were common were as follows (in order): clinical pharmacokinetic service, dosage or dosing interval changes, dosing time changes or dose changes, and total parenteral nutrition consultation. The five medications with the highest intervened frequency were (in order) vancomycin, famotidine, ranitidine, meropenem, and theophylline.

CONCLUSION

The need for pharmacists' prescription interventions was highest among patients with longer length of stay and patients with kidney dysfunction. Based on these findings, prescription intervention activities could be initiated with severely ill patients. The results could be utilized in countries which are planning to develop pharmacists' intervention service.

Intensive care units in Turkish hospitals: do they meet the minimum standards?

BACKGROUND

International and national standards for ICUs have been developed to ensure patient safety and provide effective and efficient service in these units. However, global economic crises along with shortages in professional health care staff affect the ability of ICUs to meet and maintain these standards.

AIMS AND OBJECTIVES

The aim of this study was to ascertain whether the equipment and workforce in intensive care units (ICUs) in Turkish hospitals meet current ICU standards.

DESIGN

This is a descriptive study based on the results of a survey questionnaire.

METHODS

In total, 145 ICUs in university and private hospitals in Turkey participated in this survey. Data collection was done by means of a survey questionnaire that assessed the current equipment and workforce in these ICUs.

RESULTS

We found that 97·0% of the occupied beds in the ICUs had a cardiac monitor. Crash-carts were present in every ICU. Transport monitors and transport ventilators were available in two of three and in one of two ICUs, respectively. In 82·8% of the ICUs, a physician (as a trainee level) was present at all times, while only a few ICUs had ICU-care team members such as respiratory- and physiotherapist, clinical pharmacists and dieticians available. There was a general shortage of nursing staff in ICUs.

CONCLUSION

Currently, ICUs in Turkish hospitals meet the majority of standards for ICU equipment, but they fail to meet both the international and national standards for ICU workforce requirement.

CLINICAL RELEVANCE

Hospital and ICU managers could use our findings to compare their facilities with others or to identify areas in need of improvement.

Pharmacist contributions as members of the multidisciplinary ICU team

Critical care pharmacy services in the ICU have expanded from traditional dispensing responsibilities to being recognized as an essential component of multidisciplinary care for critically ill patients. Augmented by technology and resource utilization, this shift in roles has allowed pharmacists to provide valuable services in the form of assisting physicians and clinicians with pharmacotherapy decision-making, reducing medication errors, and improving medication safety systems to optimize patient outcomes. Documented improvements in the management of infections, anticoagulation therapy, sedation, and analgesia for patients receiving mechanical ventilation and in emergency response help to justify the need for clinical pharmacy services for critically ill patients. Contributions to quality improvement initiatives, scholarly and research activities, and the education and training of interdisciplinary personnel are also valued services offered by clinical pharmacists. Partnering with physician and nursing champions can garner support from hospital administrators for the addition of clinical pharmacy critical care services. The addition of a pharmacist to an interprofessional critical care team should be encouraged as health-care systems focus on improving the quality and efficiency of care delivered to improve patient outcomes.

A clinical trial comparing physician prompting with an unprompted automated electronic checklist to reduce empirical antibiotic utilization

OBJECTIVES

To determine whether face-to-face prompting of critical care physicians reduces empirical antibiotic utilization compared to an unprompted electronic checklist embedded within the electronic health record.

DESIGN

Random allocation design.

SETTING

Medical ICU with high-intensity intensivist coverage at a tertiary care urban medical center.

PATIENTS

Two hundred ninety-six critically ill patients treated with at least 1 day of empirical antibiotics.

INTERVENTIONS

For one medical ICU team, face-to-face prompting of critical care physicians if they did not address empirical antibiotic utilization during a patient's daily rounds. On a separate medical ICU team, attendings and fellows were trained once to complete an electronic health record-embedded checklist daily for each patient, including a question asking whether listed empirical antibiotics could be discontinued.

MEASUREMENTS AND MAIN RESULTS

Prompting led to a more than four-fold increase in discontinuing or narrowing of empirical antibiotics compared to use of the electronic checklist. Prompted group patients had a lower proportion of patient-days on which empirical antibiotics were administered compared to electronic checklist group patients (63.1% vs 70.0%, p = 0.002). Mean proportion of antibiotic-days on which empirical antibiotics were used was also lower in the prompted group, although not statistically significant (0.78 [0.27] vs 0.83 [0.27], p = 0.093). Each additional day of empirical antibiotics predicted higher risk-adjusted mortality (odds ratio, 1.14; 95% CI, 1.05-1.23). Risk-adjusted ICU length of stay and hospital mortality were not significantly different between the two groups.

CONCLUSIONS

Face-to-face prompting was superior to an unprompted electronic health record-based checklist at reducing empirical antibiotic utilization. Sustained culture change may have contributed to the electronic checklist having similar empirical antibiotic utilization to a prompted group in the same medical ICU 2 years prior. Future studies should investigate the integration of an automated prompting mechanism with a more generalizable electronic health record-based checklist.

Knowledge translation interventions for critically ill patients: a systematic review*

OBJECTIVE

We systematically reviewed ICU-based knowledge translation studies to assess the impact of knowledge translation interventions on processes and outcomes of care.

DATA SOURCES

We searched electronic databases (to July, 2010) without language restrictions and hand-searched reference lists of relevant studies and reviews.

STUDY SELECTION

Two reviewers independently identified randomized controlled trials and observational studies comparing any ICU-based knowledge translation intervention (e.g., protocols, guidelines, and audit and feedback) to management without a knowledge translation intervention. We focused on clinical topics that were addressed in greater than or equal to five studies.

DATA EXTRACTION

Pairs of reviewers abstracted data on the clinical topic, knowledge translation intervention(s), process of care measures, and patient outcomes. For each individual or combination of knowledge translation intervention(s) addressed in greater than or equal to three studies, we summarized each study using median risk ratio for dichotomous and standardized mean difference for continuous process measures. We used random-effects models. Anticipating a small number of randomized controlled trials, our primary meta-analyses included randomized controlled trials and observational studies. In separate sensitivity analyses, we excluded randomized controlled trials and collapsed protocols, guidelines, and bundles into one category of intervention. We conducted meta-analyses for clinical outcomes (ICU and hospital mortality, ventilator-associated pneumonia, duration of mechanical ventilation, and ICU length of stay) related to interventions that were associated with improvements in processes of care.

DATA SYNTHESIS

From 11,742 publications, we included 119 investigations (seven randomized controlled trials, 112 observational studies) on nine clinical topics. Interventions that included protocols with or without education improved continuous process measures (seven observational studies and one randomized controlled trial; standardized mean difference [95% CI]: 0.26 [0.1, 0.42]; p = 0.001 and four observational studies and one randomized controlled trial; 0.83 [0.37, 1.29]; p = 0.0004, respectively). Heterogeneity among studies within topics ranged from low to extreme. The exclusion of randomized controlled trials did not change our results. Single-intervention and lower-quality studies had higher standardized mean differences compared to multiple-intervention and higher-quality studies (p = 0.013 and 0.016, respectively). There were no associated improvements in clinical outcomes.

CONCLUSIONS

Knowledge translation interventions in the ICU that include protocols with or without education are associated with the greatest improvements in processes of critical care.

Daily sedation interruption versus targeted light sedation strategies in ICU patients

OBJECTIVE

The updated clinical practice guidelines for the management of pain, agitation, and delirium recommend either daily sedation interruption or maintaining light levels of sedation as methods to improve outcomes for patients who are sedated in the ICU. We review the evidence supporting both methods and discuss whether one method is preferable or if they should be used concurrently.

DATA SOURCE

Original research articles identified using the electronic PubMed database.

STUDY SELECTION AND DATA EXTRACTION

Randomized controlled trials and large prospective cohort studies of mechanically ventilated ICU patients requiring sedation were selected.

DATA SYNTHESIS

The methods of daily sedation interruption and targeting light sedation levels (including avoidance of deep sedation) are safe in critically ill patients with no increase, and a potential decrease, in long-term psychiatric disturbances. Randomized trials comparing these methods with standard care, which has traditionally involved moderate to heavy sedation, found that both methods reduced duration of mechanical ventilation and ICU length of stay. Additionally, one trial noted that daily sedation interruption paired with spontaneous breathing trials improved 1-year survival, whereas a large observational study found that deep sedation was associated with decreased 180-day survival. Two common characteristics of these interventions in trials showing benefits were avoidance of deep levels of sedation and significant reductions in sedative doses, especially benzodiazepines. Thus, combining targeted light sedation with daily sedation interruption may be more beneficial than either method alone if sedative doses are reduced and arousal and mobility are facilitated during the ICU stay.

CONCLUSION

Daily sedation interruption and targeting light sedation levels are safe and proven to improve outcomes for sedated ICU patients when these approaches result in reduced sedative exposure and facilitate arousal. It remains unclear as to whether one approach is superior, and further studies are needed to evaluate which patients benefit most from either or both techniques.

Delirium in the intensive care unit

Delirium is a serious complication that commonly occurs in critically ill patients in the intensive care unit (ICU). Delirium is frequently unrecognized or missed despite its high incidence and prevalence, and leads to poor clinical outcomes and an increased cost by increasing morbidity, mortality, and hospital and ICU length of stay. Although its pathophysiology is poorly understood, numerous risk factors for delirium have been suggested. To improve clinical outcomes, it is crucial to perform preventive measures against delirium, to detect delirium early using valid and reliable screening tools, and to treat the underlying causes or hazard symptoms of delirium in a timely manner.

Proactive clinical pharmacist interventions in critical care: effect of unit speciality and other factors

BACKGROUND

Clinical pharmacists working in critical-care areas have a beneficial effect on a range of medication-related therapies including improving medication safety, patient outcomes and reducing medicines' expenditure. However, there remains a lack of data on specific factors that affect the reason for and type of interventions made by clinical pharmacists, such as unit speciality.

OBJECTIVE

To compare the type of proactive medicines-related interventions made by clinical pharmacists on different critical-care units within the same institution.

METHODS

A retrospective evaluation of proactive clinical pharmacist recommendations, made in three separate critical-care areas. Intervention data were analysed over 18 months (general units) and 2 weeks for the cardiac and neurological units. Assessment of potential patient harm related to the medication interventions were made in the neurological and cardiac units.

KEY FINDINGS

Overall, 5623, 211 and 156 proactive recommendations were made; on average 2.2, 3.8 and 4.6 per patient from the general, neurological and cardiac units respectively. The recommendations acceptance rate by medical staff was approximately 90% for each unit. The median potential severity of patient harm averted by the interventions were 3.6 (3; 4.2) and 4 (3.2; 4.4) for the neurological and cardiac units (P = 0.059). The reasons for, types and drug classification of the medication recommendations demonstrated some significant differences between the units.

CONCLUSIONS

Clinical pharmacists with critical-care training make important medication recommendations across general and specialist critical-care units. The patient case mix and admitting speciality have some bearing on the types of medication interventions made. Moreover, severity of patient illness, scope of regular/routine specialist pharmacist service and support systems provided also probably affect the reason for these interventions.

Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit

OBJECTIVE

To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002.

METHODS

The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend …" is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest …" is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding.

CONCLUSION

These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.

Sedation for critically ill or injured adults in the intensive care unit: a shifting paradigm

As most critically ill or injured patients will require some degree of sedation, the goal of this paper was to comprehensively review the literature associated with use of sedative agents in the intensive care unit (ICU). The first and selected latter portions of this article present a narrative overview of the shifting paradigm in ICU sedation practices, indications for uninterrupted or prolonged ICU sedation, and the pharmacology of sedative agents. In the second portion, we conducted a structured, although not entirely systematic, review of the available evidence associated with use of alternative sedative agents in critically ill or injured adults. Data sources for this review were derived by searching OVID MEDLINE and PubMed from their first available date until May 2012 for relevant randomized controlled trials (RCTs), systematic reviews and/or meta-analyses and economic evaluations. Advances in the technology of mechanical ventilation have permitted clinicians to limit the use of sedation among the critically ill through daily sedative interruptions or other means. These practices have been reported to result in improved mortality, a decreased length of ICU and hospital stay and a lower risk of drug-associated delirium. However, in some cases, prolonged or uninterrupted sedation may still be indicated, such as when patients develop intracranial hypertension following traumatic brain injury. The pharmacokinetics of sedative agents have clinical importance and may be altered by critical illness or injury, co-morbid conditions and/or drug-drug interactions. Although use of validated sedation scales to monitor depth of sedation is likely to reduce adverse events, they have no utility for patients receiving neuromuscular receptor blocking agents. Depth of sedation monitoring devices such as the Bispectral Index (BIS©) also have limitations. Among existing RCTs, no sedative agent has been reported to improve the risk of mortality among the critically ill or injured. Moreover, although propofol may be associated with a shorter time to tracheal extubation and recovery from sedation than midazolam, the risk of hypertriglyceridaemia and hypotension is higher with propofol. Despite dexmedetomidine being linked with a lower risk of drug-associated delirium than alternative sedative agents, this drug increases risk of bradycardia and hypotension. Among adults with severe traumatic brain injury, there are insufficient data to suggest that any single sedative agent decreases the risk of subsequent poor neurological outcomes or mortality. The lack of examination of confounders, including the type of healthcare system in which the investigation was conducted, is a major limitation of existing pharmacoeconomic analyses, which likely limits generalizability of their results.

Critical care nurses' role in implementing the "ABCDE bundle" into practice

Imagine working in an environment where all patients undergoing mechanical ventilation are alert, calm, and delirium free. Envision practicing in an environment where nonvocal patients can effectively express their need for better pain control, repositioning, or emotional reassurance. Picture an intensive care unit where a nurse-led, interprofessional team practices evidence-based, patient-centered care focused on preserving and/or restoring their clients' physical, functional, and neurocognitive abilities. A recently proposed bundle of practices for the intensive care unit could advance the current practice environment toward this idealized environment. The Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility (ABCDE) bundle incorporates the best available evidence related to delirium, immobility, sedation/analgesia, and ventilator management in the intensive care unit for adoption into everyday clinical practice.

Association between hospital volume and network membership and an analgesia, sedation and delirium order set quality score: a cohort study

Introduction

Protocols for the delivery of analgesia, sedation and delirium care of the critically ill, mechanically ventilated patient have been shown to improve outcomes but are not uniformly used. The extent to which elements of analgesia, sedation and delirium guidelines are incorporated into order sets at hospitals across a geographic area is not known. We hypothesized that both greater hospital volume and membership in a hospital network are associated with greater adherence of order sets to sedation guidelines.

Methods

Sedation order sets from all nonfederal hospitals without pediatric designation in Washington State that provided ongoing care to mechanically ventilated patients were collected and their content systematically abstracted. Hospital data were collected from Washington State sources and interviews with ICU leadership in each hospital. An expert-validated score of order set quality was created based on the 2002 four-society guidelines. Clustered multivariable linear regression was used to assess the relationship between hospital characteristics and the order set quality score.

Results

Fifty-one Washington State hospitals met the inclusion criteria and all provided order sets. Based on expert consensus, 21 elements were included in the analgesia, sedation and delirium order set quality score. Each element was equally weighted and contributed one point to the score. Hospital order set quality scores ranged from 0 to 19 (median = 8, interquartile range 6 to 14). In multivariable analysis, a greater number of acute care days (P = 0.01) and membership in a larger hospital network (P = 0.01) were independently associated with a greater quality score.

Conclusions

Hospital volume and membership in a larger hospital network were independently associated with a higher quality score for ICU analgesia, sedation and delirium order sets. Further research is needed to determine whether greater order-set quality is associated with improved outcomes in the critically ill. The development of critical care networks might be one strategy to improve order set quality scores.

Pharmacist proactive medication recommendations using electronic documentation in a UK general critical care unit

BACKGROUND

Specific data on the actual clinical practice of United Kingdom pharmacists in Critical Care are limited. Within the general critical care units of Sheffield Teaching Hospitals, clinical pharmacists have the facility to electronically document, communicate and follow-up proactive recommendations using a Pharmacy Review Form via the Clinical Information System, MetaVision(®).

OBJECTIVE

The objective of the service evaluation was to describe the acceptance rate by medical staff of pharmacist proactive medication recommendations; including data on the types of recommendations and reasons thereof, for general intensive care patients of a UK teaching hospital trust.

SETTING

Sheffield Teaching Hospitals National Health Service Foundation Trust with 20 intensive care beds located on two hospital sites admitting Level 3 and 2 mixed general medical, surgical, trauma, burns and haematology/ oncology patients.

METHOD

Retrospective analysis of pharmacist proactive recommendations recorded electronically from January 2009 to July 2011 in general intensive care unit patients. Main outcome 5,623 electronic medication recommendations were documented, providing an average of 2.2 proactive recommendations per patient admitted to intensive care from January 2009 to July 2011. 5,101 (90.7%) of the recommendations were accepted and acted upon by medical staff.

RESULTS

The most common recommendations were Add Drug 1,862 (28.2%); Dose Review 1,707 (25.8%); Discontinue Drug 1,185 (17.9%); Alternative Drug 903 (13.7%); Alternative Route 770 (11.7%). The most common reasons for the proactive medication recommendations were related to changes in gastrointestinal absorption 951 (15.6%); compliance with medication guidelines 857 (14.1%); sedation/delirium/agitation management 764 (12.6%); dose adjustment for renal dysfunction or continuous renal replacement therapies 756 (12.4%); and medication reconciliation 612 (10.1%). The majority of medication recommendations involved drugs in Gastrointestinal, Central Nervous System, Cardiovascular, Infection, Nutrition and Blood classes (British National Formulary).

CONCLUSION

There was a high acceptance rate for proactive medication-related recommendations made by critical care pharmacists via the electronic review form. The majority of pharmacist recommendations were related to adding or refining currently prescribed medication. Ten percent of recommendations related to medication reconciliation of patients' pre-admission medication.

I-SAVE Study: Impact of Sedation, Analgesia, and Delirium Protocols Evaluated in the Intensive Care Unit: An Economic Evaluation

BACKGROUND:

Intensive care units (ICUs) account for considerable health care costs. Adequate pain and sedation management is important to clinical care.

OBJECTIVE:

To determine whether implementing a protocol for management of analgesia, sedation, and delirium in the ICU would save costs.

METHODS:

With data from the I-SAVE (Impact of Sedation, Analgesia and Delirium Protocols Evaluated in the Intensive Care Unit: an Economic Evaluation) study, a prospective pre- and postprotocol design was used. Between the 2 periods, protocols for systematic management of sedation, analgesia, and delirium were implemented. Cost-effectiveness was calculated by associating the variation of cost and effectiveness measures (proportion of patients within targeted pain, sedation, and delirium goals). Total costs (in 2004 Canadian dollars), by patient, consisted of the sum of sedation, analgesia, and delirium drug acquisition costs during the ICU stay and the cost of the ICU stay.

RESULTS:

A total of 1214 patients, 604 in the preprotocol group and 610 in the postprotocol group, were included. The mean (SD) ICU length of stay and the duration of mechanical ventilation were shorter among patients of the postprotocol group compared with those of the preprotocol group (5.43 [6.43] and 6.39 [8.05] days, respectively; p = 0.004 and 5.95 [6.80] and 7.27 [9.09] days, respectively; p < 0.009). The incidence of delirium remained the same. The proportion of patients with Richmond Agitation and Sedation (RASS) scores between −1 and +1 increased from 57.0% to 66.2% (p = 0.001), whereas the proportion of patients with a numeric rating scale (NRS) score of 1 or less increased from 56.3% to 66.6% (p < 0.001). The mean total cost of ICU hospitalization decreased from $6212.64 (7846.86) in the preprotocol group to $5279.90 (6263.91) in the postprotocol group (p = 0.022). The cost analyses for pain and agitation management improved; the proportion of patients with RASS scores between −1 and +1 or NRS scores of 1 or less increased significantly in the postprotocol group while costing, on average, $932.74 less per hospitalization.

CONCLUSIONS:

Establishing protocols for patient-driven management of sedation, analgesia, and delirium is a cost-effective practice and allows savings of nearly $1000 per hospitalization.

Analytic reviews: managing the agitated patient in the ICU: sedation, analgesia, and neuromuscular blockade

Physical and psychological distress is exceedingly common among critically ill patients and manifests generically as agitation. The dangers of over- and undertreatment of agitation have been well described, and the intensive care unit (ICU) physician must strike a balance in the fast-paced, dynamic ICU environment. Identification of common reversible etiologies for distress may obviate the need for pharmacologic therapy, but most patients receive some combination of sedative, analgesic, and neuroleptic medications during the course of their critical illness. As such, understanding key pharmacologic features of commonly used agents is critical. Structured protocols and objective assessment tools can optimize drug delivery and may ultimately improve patient outcomes by reducing ventilator days, ICU length of stay, and by reducing cognitive dysfunction.

Systematic review of practice guideline dissemination and implementation strategies for healthcare teams and team-based practice

AIM

To synthesis the literature relevant to guideline dissemination and implementation strategies for healthcare teams and team-based practice.

METHODS

Systematic approach utilising Joanna Briggs Institute methods. Two reviewers screened all articles and where there was disagreement, a third reviewer determined inclusion.

RESULTS

Initial search revealed 12,083 of which 88 met the inclusion criteria. Ten dissemination and implementation strategies identified with distribution of educational materials the most common. Studies were assessed for patient or practitioner outcomes and changes in practice, knowledge and economic outcomes. A descriptive analysis revealed multiple approaches using teams of healthcare providers were reported to have statistically significant results in knowledge, practice and/or outcomes for 72.7% of the studies.

CONCLUSION

Team-based care using practice guidelines locally adapted can affect positively patient and provider outcomes.

A systematic review of the impact of sedation practice in the ICU on resource use, costs and patient safety

Introduction

Patients in intensive care units (ICUs) often receive sedation for prolonged periods. In order to better understand the impact of sub-optimal sedation practice on outcomes, we performed a systematic review, including observational studies and controlled trials which were conducted in sedated patients in the ICU and which compared the impact of changes in or different protocols for sedation management on economic and patient safety outcomes.

Methods

We searched Medline, Embase and CINAHL online literature databases from 1988 to 15^th May 2008 and hand searched conferences. English-language studies set in the ICU, in sedated adult humans on mechanical ventilation, which reported the impact of sedation practice on cost and resource use and patient safety outcomes, were included. All abstracts were reviewed twice by two independent reviewers, with all conflicts resolved by a third reviewer, to check that they met the review inclusion criteria. Full-text papers of all included studies were retrieved and again reviewed twice against inclusion criteria. Data were doubly extracted from studies. Study aims, design, population, and outcomes including duration of mechanical ventilation, length of stay in ICU and hospital, costs and rates of mortality and adverse events were extracted. Due to heterogeneity between study designs and outcomes reported, no quantitative data synthesis such as meta-analysis was possible.

Results

Included studies varied in design, patient population and aim, with the majority being before-after studies. Overall, studies showed that improvements in sedation practice, such as the introduction of guidelines and protocols, or daily interruption of sedation, were associated with improvements in outcomes including ICU and hospital length of stay, duration of mechanical ventilation, and costs. Mortality and the incidence of nosocomial infections were also reduced.

Conclusions

Systematic interventions to improve sedation practice and maintain patients at an optimal sedation level in the ICU may improve patient outcomes and optimize resource usage.