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Zelenkov D, Hollins R, Mahoney EJ, Faugno AJ, Poyant J. The Impact of a Pharmacist-Driven Multicomponent Sleep-Promoting Protocol on Delirium in Critically Ill Patients. J Pharm Pract 2024; 37:578-586. [PMID: 36594245 DOI: 10.1177/08971900221148581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background: Sleep deprivation is reported in 80% of patients in the intensive care unit (ICU) and is associated with delirium. Guidelines recommend implementing a sleep-promoting protocol in critically ill patients which may increase the quantity and quality of sleep and may decrease delirium. Our objective was to implement a pharmacist-led interdisciplinary sleep-promoting protocol and analyze its impact on delirium in ICU patients receiving mechanical ventilation (MV). Methods: The study involved pre-implementation education, protocol development, and post-implementation analysis. ICU pharmacists completed prospective patient chart reviews to reduce exposure to deliriogenic medications and assess the need for a pharmacologic sleep aid. The primary outcome was the incidence of delirium and delirium-free days. Secondary outcomes included ICU length of stay (LOS), incidence of MV, and pharmacist medication interventions. Results: Post-protocol patients (n = 185) had a higher incidence of delirium compared to pre-protocol patients (n = 237) (51.3% vs 39.0%; P = .01). Post-protocol patients had a higher average APACHE III score (P = <.001). Delirium-free days were not significantly different between groups (P = .97). Difference in ICU LOS was not significant (P = .80). More patients received MV post-protocol implementation (55.7% vs 36.1%; P < .001). Pharmacists documented a total of 113 medication interventions. Conclusion and Relevance: A pharmacist-led, ICU sleep-promoting protocol was successfully implemented but did not reduce the incidence of delirium or the administration of insomnia agents. Post-protocol patients had higher disease severity and were more likely to receive MV. Incidence of delirium was consistent with the national reported prevalence of ICU delirium. ICU pharmacists on all shifts had an active role in optimizing sleep.
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Affiliation(s)
| | - Randy Hollins
- Department of Pharmacy, Melrose Wakefield Healthcare, Melrose, MA, USA
| | - Eric J Mahoney
- Department of Surgical Critical Care, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Anthony J Faugno
- Department of Critical Care, Sleep and Pulmonary Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Janelle Poyant
- Department of Pharmacy, Tufts Medical Center, Boston, MA, USA
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Shrestha S, Iqbal A, Teoh SL, Khanal S, Gan SH, Lee SWH, Paudyal V. Impact of pharmacist-delivered interventions on pain-related outcomes: An umbrella review of systematic reviews and meta-analyses. Res Social Adm Pharm 2024; 20:34-51. [PMID: 38514293 DOI: 10.1016/j.sapharm.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 03/09/2024] [Accepted: 03/12/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Pain is a significant healthcare challenge, impacting millions worldwide. Pharmacists have increasingly taken on expanded roles in managing pain, particularly in primary and ambulatory care contexts. This umbrella review aims to systematically evaluate evidence from published systematic reviews that explore the impact of pharmacist-delivered interventions on clinical, humanistic, and economic outcomes related to pain. METHODS A systematic search was conducted across six electronic databases, including Ovid Embase, MEDLINE, CINAHL, Scopus, CENTRAL, APA PsycINFO, and DARE, from inception until June 2023. Prior to inclusion, two independent reviewers assessed study titles and abstracts. Following inclusion, an assessment of the methodological quality of the included studies was conducted. AMSTAR 2 was used to evaluate the methodological quality of the included SRs. RESULTS From 2055 retrieved titles, 11 systematic reviews were included, with 5 out of 11 being meta-analyses. These SRs encompassed diverse pharmacist-led interventions such as education, medication reviews, and multi-component strategies targeting various facets of pain management. These findings showed favorable clinical outcomes, including reduced pain intensity, improved medication management, enhanced overall physical and mental well-being, and reduced hospitalization durations. Significant pain intensity reductions were found due to pharmacists' interventions, with standardized mean differences (SMDs) ranging from -0.76 to -0.22 across different studies and subgroups. Physical functioning improvements were observed, with SMDs ranging from -0.38 to 1.03. Positive humanistic outcomes were also reported, such as increased healthcare provider confidence, patient satisfaction, and quality of life (QoL). QoL improvements were reported, with SMDs ranging from 0.29 to 1.03. Three systematic reviews examined pharmacist interventions' impact on pain-related economic outcomes, highlighting varying cost implications and the need for robust research methodologies to capture costs and benefits. CONCLUSION This umbrella review highlights the effectiveness of pharmacist-delivered interventions in improving clinical, humanistic, and economic outcomes related to pain management. Existing evidence emphasises on the need to integrate pharamacists into multi-disciplinary pain management teams. Further research is needed to investigate innovative care models, such as pharmacist-independent prescribing initiatives within collaborative pain management clinics.
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Affiliation(s)
- Sunil Shrestha
- School of Pharmacy, Monash University Malaysia, Subang Jaya, Selangor, Malaysia.
| | - Ayesha Iqbal
- Office of Lifelong Learning and the Physician Learning Program, Faculty of Medicine and Dentistry, University of Alberta, AB, T6G1C9, Edmonton, Canada.
| | - Siew Li Teoh
- School of Pharmacy, Monash University Malaysia, Subang Jaya, Selangor, Malaysia.
| | - Saval Khanal
- Health Economics Consulting, Norwich Medical School, University of East Anglia, Bob Champion Research & Education Building, UEA Research Park Rosalind Franklin Rd, NR4 7UQ, Norwich, United Kingdom.
| | - Siew Hua Gan
- School of Pharmacy, Monash University Malaysia, Subang Jaya, Selangor, Malaysia.
| | - Shaun Wen Huey Lee
- School of Pharmacy, Monash University Malaysia, Subang Jaya, Selangor, Malaysia; School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya, Selangor, Malaysia; Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well Being Cluster, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia; Global Asia in the 21st Century (GA21) Platform, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia.
| | - Vibhu Paudyal
- School of Pharmacy, College of Medical and Dental Sciences, University of Birmingham Edgbaston, Birmingham, United Kingdom; Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom.
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Crosby A, Jennings JK, Mills AT, Silcock J, Bourne RS. Economic evaluations of adult critical care pharmacy services: a scoping review. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2023; 31:574-584. [PMID: 37607337 DOI: 10.1093/ijpp/riad049] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 07/05/2023] [Indexed: 08/24/2023]
Abstract
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.
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Affiliation(s)
- Alex Crosby
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jennifer K Jennings
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Anna T Mills
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Jonathan Silcock
- Faculty of Life Sciences, School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
| | - Richard S Bourne
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK
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4
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Dager WE. Developing precision-based multidisciplinary pharmacotherapy management plans in the critically ill. Pharmacotherapy 2023; 43:1102-1111. [PMID: 37772645 DOI: 10.1002/phar.2871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 07/16/2023] [Accepted: 07/27/2023] [Indexed: 09/30/2023]
Affiliation(s)
- William E Dager
- Davis Medical Center, University of California, Sacramento, California, USA
- University of California San Francisco School of Pharmacy, San Francisco, California, USA
- University of California Davis School of Medicine, Sacramento, California, USA
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Pluenneke JC, Semler MW, Casey JD, Qian ET, Rice TW, Stollings JL. Quantifying Critical Care Pharmacist Interventions in COVID-19. J Intensive Care Med 2023; 38:651-656. [PMID: 36755415 PMCID: PMC9912037 DOI: 10.1177/08850666231156551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 02/10/2023]
Abstract
Purpose/Background: Pharmacists have been shown to play an important role in the medication management of critically ill patients. Pharmacist interventions in the care of critically ill patients with coronavirus disease 2019 (COVID-19) have not been quantitatively described. Methodology: A single center, retrospective, observational study was conducted at Vanderbilt University Medical Center in Nashville, Tennessee. All adult patients admitted to the COVID-19 intensive care unit (ICU) or Medical ICU with a COVID-19 diagnosis between March 1, 2020, and June 30, 2021, were included. All interventions made by pharmacists were documented electronically, collected, categorized, and analyzed. The primary outcome of this study was the median number of interventions by pharmacists per patient. The secondary outcome was the number of different types of interventions performed. Results: A total of 768 patients were included in the analysis. The median age was 63 years old; 63% of patients were male and 71% were Caucasian. Median hospital length of stay (LOS) was 12 days (interquartile range (IQR) 7-21) and ICU LOS was 5 days (IQR 1-11). The median Sequential Organ Failure Assessment score was 4 (IQR 2-7) and Charlson Comorbidity Index was 3 (IQR 2-5). Mortality at 60 days occurred in 352 patients (46%). Pharmacists performed a total of 7027 interventions for 655 patients with a median number of pharmacist interventions per patient of 6 (IQR 3-14). The most common pharmacist interventions were medication discontinuation (24%), completion of components of the ICU liberation bundle (19%), medication dose adjustment (18%), therapeutic drug monitoring (15%), and medication initiation (10%). Conclusions: Pharmacists made multiple interventions related to medication use and management in critically ill patients with COVID-19. This study adds important information of the evolving role clinical pharmacists play in the care of critical illness, specifically during the COVID-19 pandemic.
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Affiliation(s)
- Jack C. Pluenneke
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew W. Semler
- Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan D. Casey
- Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward T. Qian
- Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W. Rice
- Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joanna L. Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, TN, USA
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6
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Sikora A. Critical Care Pharmacists: A Focus on Horizons. Crit Care Clin 2023; 39:503-527. [PMID: 37230553 DOI: 10.1016/j.ccc.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
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.
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Affiliation(s)
- Andrea Sikora
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, 120 15th Street, HM-118, Augusta, GA 30912, USA; Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA.
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7
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Alabsi H, Emerson K, Lin DJ. Neurorecovery after Critical COVID-19 Illness. Semin Neurol 2023. [PMID: 37168008 DOI: 10.1055/s-0043-1768714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
With the hundreds of millions of people worldwide who have been, and continue to be, affected by pandemic coronavirus disease (COVID-19) and its chronic sequelae, strategies to improve recovery and rehabilitation from COVID-19 are critical global public health priorities. Neurologic complications have been associated with acute COVID-19 infection, usually in the setting of critical COVID-19 illness. Neurologic complications are also a core feature of the symptom constellation of long COVID and portend poor outcomes. In this article, we review neurologic complications and their mechanisms in critical COVID-19 illness and long COVID. We focus on parallels with neurologic disease associated with non-COVID critical systemic illness. We conclude with a discussion of how recent findings can guide both neurologists working in post-acute neurologic rehabilitation facilities and policy makers who influence neurologic resource allocation.
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Affiliation(s)
- Haitham Alabsi
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Kristi Emerson
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David J Lin
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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8
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Surgical Pharmacy for Optimizing Medication Therapy Management Services within Enhanced Recovery after Surgery (ERAS ®) Programs. J Clin Med 2023; 12:jcm12020631. [PMID: 36675560 PMCID: PMC9861533 DOI: 10.3390/jcm12020631] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/16/2022] [Accepted: 01/06/2023] [Indexed: 01/15/2023] Open
Abstract
Drug-related problems (DRPs) are common among surgical patients, especially older patients with polypharmacy and underlying diseases. DRPs can potentially lead to morbidity, mortality, and increased treatment costs. The enhanced recovery after surgery (ERAS) system has shown great advantages in managing surgical patients. Medication therapy management for surgical patients (established as "surgical pharmacy" by Guangdong Province Pharmaceutical Association (GDPA)) is an important part of the ERAS system. Improper medication therapy management can lead to serious consequences and even death. In order to reduce DRPs further, and promote the rapid recovery of surgical patients, the need for pharmacists in the ERAS program is even more pressing. However, the medication therapy management services of surgical pharmacy and how surgical pharmacists should participate in ERAS programs are still unclear worldwide. Therefore, this article reviews the main perioperative medical management strategies and precautions from several aspects, including antimicrobial agents, antithrombotic agents, pain medication, nutritional therapy, blood glucose monitoring, blood pressure treatment, fluid management, treatment of nausea and vomiting, and management of postoperative delirium. Additionally, the way surgical pharmacists participate in perioperative medication management, and the relevant medication pathways are explored for optimizing medication therapy management services within the ERAS programs. This study will greatly assist surgical pharmacists' work, contributing to surgeons accepting that pharmacists have an important role in the multidisciplinary team, benefitting medical workers in treating, counseling, and advocating for their patients, and further improving the effectiveness, safety and economy of medication therapy for patients and promoting patient recovery.
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9
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Shaygan M, Hosseini FA. Comparison of the effect of psychosocial skills training on acute and chronic musculoskeletal pain intensity: The effectiveness of early intervention in the reduction of acute musculoskeletal pain. Musculoskeletal Care 2022; 20:839-847. [PMID: 35332994 DOI: 10.1002/msc.1635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Pain, as a psychological experience, is caused by complex interactions among sensory-discriminative, motivational-affective, and cognitive-evaluative dimensions. The psychosocial approach is one of the important approaches in managing musculoskeletal pain in patients. Therefore, this study aimed to determine and compare the effects of psychosocial skills training on pain intensity in patients with acute and chronic musculoskeletal pain. METHODS In this quasi-experimental study, 64 patients with acute and chronic musculoskeletal pain were selected using convenience sampling. Both groups received psychosocial training in pain management in groups of 8-10 people over six 1-h sessions. The data were collected at baseline, after the intervention, and 3 months later using a numerical rating scale (NRS). Then, the data were entered into the SPSS 22 software and were analysed using descriptive and inferential statistics. RESULTS In this study, the mean age of the participants was 50.10 ± 10.63 years and 60.9% of them were female. Based on the results, time had a significant effect on pain intensity (p < 0.001), but the effect of group on pain intensity was not statistically significant (p = 0.07). The group × time effect on pain intensity was also statistically significant (p < 0.001). CONCLUSION Psychosocial training had a positive impact on the reduction of pain among the patients with acute and chronic musculoskeletal pain. Additionally, the training was more effective in patients with acute pain due to early training. These findings can help healthcare providers in the field of musculoskeletal pain management, especially in patients with acute pain.
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Affiliation(s)
- Maryam Shaygan
- Community Based Psychiatric Care Research Center, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fahimeh A Hosseini
- Community Based Psychiatric Care Research Center, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
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The Pharmacist’s Role in the Implementation of FASTHUG-MAIDENS, a Mnemonic to Facilitate the Pharmacotherapy Assessment of Critically Ill Patients: A Cross-Sectional Study. PHARMACY 2022; 10:pharmacy10040074. [PMID: 35893712 PMCID: PMC9326553 DOI: 10.3390/pharmacy10040074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/23/2022] [Accepted: 06/26/2022] [Indexed: 02/01/2023] Open
Abstract
FASTHUG is a mnemonic used by intensive care physicians to ensure the proper management of patients admitted to an Intensive Care Unit (ICU). FASTHUG-MAIDENS is a modified version that incorporates key pharmacotherapeutic elements such as delirium management, drug dosing, and drug interactions for an appropriate medication assessment of critically ill patients. An analytical cross-sectional study of hospitalized patients was carried out to determine aspects related to the pharmacotherapeutic management of critically ill patients that required to be optimized, to design and implement a protocol based on the FASTHUG-MAIDENS mnemonic. A total of 435 evaluations were performed to assess the status of current critical patient management. The main parameters with opportunities to be improved were analgesia, feeding, and sedation. With the implementation of MAIDENS, the parameters of analgesia, sedation, and thromboprophylaxis showed an increase in the percentage of optimal management. Furthermore, 103 drug-related problems were detected, and most of them were associated with feeding (21.3%), glucose control (11.7%), and delirium (9.7%). The FASTHUG MAIDENS protocol implementation allows for the evaluation of more vital aspects in the management of critically ill patients. The daily review of patients admitted to the ICU by a clinical pharmacist (CP) using the FASTHUG-MAIDENS checklist instead of the FASTHUG mnemonic facilitates the identification of DRPs for the performance of possible interventions by the CP to improve the pharmacotherapeutic management.
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Moraes FDS, Marengo LL, Moura MDG, Bergamaschi CDC, de Sá Del Fiol F, Lopes LC, Silva MT, Barberato-Filho S. ABCDE and ABCDEF care bundles: A systematic review of the implementation process in intensive care units. Medicine (Baltimore) 2022; 101:e29499. [PMID: 35758388 PMCID: PMC9276239 DOI: 10.1097/md.0000000000029499] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 05/05/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The ABCDE (Awakening and Breathing Coordination of daily sedation and ventilator removal trials, Delirium monitoring and management, and Early mobility and exercise) and ABCDEF (Assessment, prevent and manage pain, Both spontaneous awakening and spontaneous breathing trials, Choice of analgesia and sedation, assess, prevent and manage Delirium, Early mobility and exercise, Family engagement) care bundles consist of small sets of evidence-based interventions and are part of the science behind Intensive Care Unit (ICU) liberation. This review sought to analyse the process of implementation of ABCDE and ABCDEF care bundles in ICUs, identifying barriers, facilitators and changes in perception and attitudes of healthcare professionals; and to estimate care bundle effectiveness and safety. METHODS We selected qualitative and quantitative studies addressing the implementation of ABCDE and ABCDEF bundles in the ICU, identified on MEDLINE, Embase, CINAHL, The Cochrane Library, Web of Science, Epistemonikos, PsycINFO, Virtual Health Library and Open Grey, without restriction on language or date of publication, up to June 2018. The outcomes measured were ICU and hospital length of stay; mechanical ventilation time; incidence and prevalence of delirium or coma; level of agitation and sedation; early mobilization; mortality in ICU and hospital; change in perception, attitude or behaviour of the stakeholders; and change in knowledge of health professionals. Two reviewers independently selected the studies, performed data extraction, and assessed risk of bias and methodological quality. A meta-analysis of random effects was performed. RESULTS Twenty studies were included, 13 of which had a predominantly qualitative and 7 a quantitative design (31,604 participants). The implementation strategies were categorized according to the taxonomy developed by the Cochrane Effective Practice and Organization of Care Group and eighty strategies were identified. The meta-analysis results showed that implementation of the bundles may reduce length of ICU stay, mechanical ventilation time, delirium, ICU and hospital mortality, and promoted early mobilization in critically-ill patients. CONCLUSIONS : This study can contribute to the planning and execution of the implementation process of ABCDE and ABCDEF care bundles in ICUs. However, the effectiveness and safety of these bundles need to be corroborated by further studies with greater methodological rigor. PROTOCOL REGISTRATION PROSPERO CRD42019121307.
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Luz M, Brandão Barreto B, de Castro REV, Salluh J, Dal-Pizzol F, Araujo C, De Jong A, Chanques G, Myatra SN, Tobar E, Gimenez-Esparza Vich C, Carini F, Ely EW, Stollings JL, Drumright K, Kress J, Povoa P, Shehabi Y, Mphandi W, Gusmao-Flores D. Practices in sedation, analgesia, mobilization, delirium, and sleep deprivation in adult intensive care units (SAMDS-ICU): an international survey before and during the COVID-19 pandemic. Ann Intensive Care 2022; 12:9. [PMID: 35122204 PMCID: PMC8815719 DOI: 10.1186/s13613-022-00985-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/16/2022] [Indexed: 12/16/2022] Open
Abstract
Background Since the publication of the 2018 Clinical Guidelines about sedation, analgesia, delirium, mobilization, and sleep deprivation in critically ill patients, no evaluation and adequacy assessment of these recommendations were studied in an international context. This survey aimed to investigate these current practices and if the COVID-19 pandemic has changed them. Methods This study was an open multinational electronic survey directed to physicians working in adult intensive care units (ICUs), which was performed in two steps: before and during the COVID-19 pandemic. Results We analyzed 1768 questionnaires and 1539 (87%) were complete. Before the COVID-19 pandemic, we received 1476 questionnaires and 292 were submitted later. The following practices were observed before the pandemic: the Visual Analog Scale (VAS) (61.5%), the Behavioral Pain Scale (BPS) (48.2%), the Richmond Agitation Sedation Scale (RASS) (76.6%), and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) (66.6%) were the most frequently tools used to assess pain, sedation level, and delirium, respectively; midazolam and fentanyl were the most frequently used drugs for inducing sedation and analgesia (84.8% and 78.3%, respectively), whereas haloperidol (68.8%) and atypical antipsychotics (69.4%) were the most prescribed drugs for delirium treatment; some physicians regularly prescribed drugs to induce sleep (19.1%) or ordered mechanical restraints as part of their routine (6.2%) for patients on mechanical ventilation; non-pharmacological strategies were frequently applied for pain, delirium, and sleep deprivation management. During the COVID-19 pandemic, the intensive care specialty was independently associated with best practices. Moreover, the mechanical ventilation rate was higher, patients received sedation more often (94% versus 86.1%, p < 0.001) and sedation goals were discussed more frequently in daily rounds. Morphine was the main drug used for analgesia (77.2%), and some sedative drugs, such as midazolam, propofol, ketamine and quetiapine, were used more frequently. Conclusions Most sedation, analgesia and delirium practices were comparable before and during the COVID-19 pandemic. During the pandemic, the intensive care specialty was a variable that was independently associated with the best practices. Although many findings are in accordance with evidence-based recommendations, some practices still need improvement. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-00985-y.
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Affiliation(s)
- Mariana Luz
- Intensive Care Unit of the Hospital da Mulher, Rua Barão de Cotegipe, 1153, Roma, Salvador, BA, CEP: 40411-900, Brazil. .,Programa de Pós-Graduação em Medicina e Saúde, Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Bahia, Brazil. .,Intensive Care Unit, Hospital Universitário Professor Edgard Santos, Salvador, Brazil.
| | - Bruna Brandão Barreto
- Intensive Care Unit of the Hospital da Mulher, Rua Barão de Cotegipe, 1153, Roma, Salvador, BA, CEP: 40411-900, Brazil.,Programa de Pós-Graduação em Medicina e Saúde, Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Bahia, Brazil
| | - Roberta Esteves Vieira de Castro
- Departamento de Pediatria, Hospital Universitário Pedro Ernesto, Universidade Do Estado Do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jorge Salluh
- Department of Critical Care and Postgraduate Program in Translational Medicine, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil.,Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Felipe Dal-Pizzol
- Laboratório de Fisiopatologia Experimental, Programa de Pós-Graduação em Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma, Santa Catarina, Brazil
| | - Caio Araujo
- Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, BA, Brazil
| | - Audrey De Jong
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214, Montpellier, CEDEX 5, France
| | - Gérald Chanques
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214, Montpellier, CEDEX 5, France
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Eduardo Tobar
- Internal Medicine Department, Critical Care Unit, Hospital Clínico Universidad de Chile, Santiago, Chile
| | | | - Federico Carini
- Intensive Care Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Eugene Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA.,Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA.,Geriatric Research Education and Clinical Center (GRECC) Service at the Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joanna L Stollings
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kelly Drumright
- Tennessee Valley Healthcare System VA Medical Center, Nashville, TN, USA
| | - John Kress
- Division of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL, USA
| | - Pedro Povoa
- Polyvalent Intensive Care Unit, Hospital de São Francisco Xavier, CHLO, Lisbon, Portugal.,CHRC, CEDOC, NOVA Medical School, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
| | - Yahya Shehabi
- Department of Critical Care and Perioperative Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Wilson Mphandi
- Intensive Care Unit, Hospital Américo Boavida, Luanda, Angola
| | - Dimitri Gusmao-Flores
- Intensive Care Unit of the Hospital da Mulher, Rua Barão de Cotegipe, 1153, Roma, Salvador, BA, CEP: 40411-900, Brazil.,Programa de Pós-Graduação em Medicina e Saúde, Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Bahia, Brazil
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13
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Adams CD, Brunetti L, Davidov L, Mujia J, Rodricks M. The impact of intensive care unit physician staffing change at a community hospital. SAGE Open Med 2022; 10:20503121211066471. [PMID: 35024141 PMCID: PMC8744200 DOI: 10.1177/20503121211066471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 11/25/2021] [Indexed: 11/16/2022] Open
Abstract
Objectives A high-intensity staffing model has been defined as either mandatory intensivist consultation or a closed intensive care unit in which intensivists manage all aspects of patient care. In the current climate of limited healthcare resources, transitioning to a closed intensive care unit model may lead to significant improvements in patient care and resource utilization. Methods This is a single-center, retrospective cohort study of all mechanically ventilated intensive care unit admissions in the pre-intensive care unit closure period of 1 October 2014 to 30 September 2015 as compared with the post-intensive care unit closure period of 1 November 2015 to 31 October 2016. Patient demographics as well as outcome data (duration of mechanical ventilation, length of stay, direct costs, complications, and mortality) were abstracted from the electronic health record. All data were analyzed using descriptive and inferential statistics. Regression analyses were used to adjust outcomes for potential confounders. Results A total of 549 mechanically ventilated patients were included in our analysis: 285 patients in the pre-closure cohort and 264 patients in the post-closure cohort. After adjusting for confounders, there was no significant difference in mortality rates between the pre-closure (40.7%) and post-closure (38.6%) groups (adjusted odds ratio = 0.82; 95% confidence interval = 0.56-1.18; p = 0.283). The post-closure cohort was found to have significant reductions in duration of mechanical ventilation (3.71-1.50 days; p < 0.01), intensive care unit length of stay (5.8-2.7 days; p < 0.01), hospital length of stay (10.9-7.3 days; p < 0.01), and direct hospital costs (US $16,197-US $12,731; p = 0.009). Patient complications were also significantly reduced post-intensive care unit closure. Conclusion Although a closed intensive care unit model in our analysis did not lead to a statistical difference in mortality, it did demonstrate multiple beneficial outcomes including reduced ventilator duration, decreased intensive care unit and hospital length of stay, fewer patient complications, and reduced direct hospital costs.
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Affiliation(s)
- Christopher D Adams
- Robert Wood Johnson University Hospital Somerset, Somerville, NJ, USA.,Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | - Luigi Brunetti
- Robert Wood Johnson University Hospital Somerset, Somerville, NJ, USA.,Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | - Liza Davidov
- Robert Wood Johnson University Hospital Somerset, Somerville, NJ, USA
| | - Jose Mujia
- Robert Wood Johnson University Hospital Somerset, Somerville, NJ, USA
| | - Michael Rodricks
- Robert Wood Johnson University Hospital Somerset, Somerville, NJ, USA.,Division of Acute Care Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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14
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Green S, Staffileno BA. Favorable Outcomes After Implementing a Nurse-Driven Sedation Protocol. Crit Care Nurse 2021; 41:29-35. [PMID: 34851385 DOI: 10.4037/ccn2021625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND In patients receiving mechanical ventilation, prolonged exposure to sedative and analgesic medications contributes to negative clinical outcomes. OBJECTIVE To reduce exposure to sedative and analgesic medications among patients receiving mechanical ventilation by implementing a nurse-driven sedation protocol. METHODS This quality improvement project followed a plan-do-study-act cycle. Nurses were educated on the protocol, and 30 patient medical records were reviewed both before and after protocol implementation. Data were extracted on intensive care unit length of stay, duration of mechanical ventilation, duration of continuous sedation, presence of delirium, pain, level of sedation, and performance and documentation of spontaneous awakening trials. Data were analyzed using descriptive statistics, the χ2 test, and calculated percent change. RESULTS Forty-four nurses completed protocol education. The mean (SD) duration of mechanical ventilation decreased by 26% (from 5 [3.7] days to 3.7 [3.2] days), and the mean (SD) intensive care unit length of stay decreased by 27% (from 6.3 [4.3] days to 4.6 [3.7] days). The mean (SD) duration of continuous sedation decreased by 35% (from 6419 [7241] minutes to 4178 [4507] minutes). Spontaneous awakening trials documented increased by 35% (from 57% to 77%), and spontaneous awakening trials performed increased by 92% (from 40% to 77%), a statistically significant change (P = .004). CONCLUSION These preliminary data suggest that implementation of a nurse-driven sedation protocol resulted in favorable outcomes by decreasing duration of mechanical ventilation, intensive care unit length of stay, and duration of continuous sedation and increasing the number of spontaneous awakening trials performed.
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Affiliation(s)
- Samantha Green
- Samantha Green is a registered nurse in the medical intensive care unit at Ascension St. John Hospital, Detroit, Michigan
| | - Beth A Staffileno
- Beth A. Staffileno is a professor in the College of Nursing and Co-Director for the Center for Clinical Research and Scholarship at Rush University Medical Center, Chicago, Illinois
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15
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Bondi DS, Alavandi P, Allen JM, Avery LM, Buatois E, Connor KA, Martello JL, Michienzi SM, Trujillo TC, Ybarra J, Chung AM. Addressing challenges of providing remote inpatient clinical pharmacy services. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
| | | | - John M. Allen
- American College of Clinical Pharmacy Lenexa Kansas USA
| | - Lisa M. Avery
- American College of Clinical Pharmacy Lenexa Kansas USA
| | - Emily Buatois
- American College of Clinical Pharmacy Lenexa Kansas USA
| | | | | | | | | | - Joseph Ybarra
- American College of Clinical Pharmacy Lenexa Kansas USA
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16
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Impact of a Real-Time, Pharmacist-Led, Intensive Care Unit-Based Feedback Intervention on Analgesia and Sedation Quality Among Mechanically Ventilated Patients. J Nurs Care Qual 2021; 36:242-248. [PMID: 33259465 DOI: 10.1097/ncq.0000000000000527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Consensus guidelines for pain, agitation, and delirium (PAD) in mechanically ventilated patients recommend maintaining a light level of sedation. LOCAL PROBLEM Consistent attainment of target PAD assessments in mechanically ventilated ICU patients is often challenging. METHODS This is a single-center, prospective study. INTERVENTIONS In the intervention group, a pharmacist provided weekly feedback to nurses on their success in achieving target PAD assessments compared with a historical cohort without feedback. RESULTS Overall, 478 patients and 205 nurses were included. The odds of having weekly Richmond Agitation-Sedation Scale (RASS) score, pain score goals, and Confusion Assessment Method for the ICU (CAM-ICU) negative assessments at goal between the intervention and control groups fluctuated over time without a discernible trend. CONCLUSION The provision of weekly feedback to nurses on PAD nursing assessments by a pharmacist did not impact the achievement of PAD goals among critically ill mechanically ventilated patients.
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17
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Schmidt LE, Patel S, Stollings JL. The pharmacist's role in implementation of the ABCDEF bundle into clinical practice. Am J Health Syst Pharm 2021; 77:1751-1762. [PMID: 32789461 DOI: 10.1093/ajhp/zxaa247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE To summarize published data regarding implementation of the ABCDEF bundle, a multicomponent process for avoidance of oversedation and prolonged ventilation in intensive care unit (ICU) patients; discuss pertinent literature to support each bundle element; and discuss the role of the pharmacist in coordinating bundle elements and implementation of the ABCDEF bundle into clinical practice. SUMMARY Neuromuscular weakness and ICU-acquired weakness are common among critically ill patients and associated with significant cost and societal burdens. Recent literature supporting early liberation from mechanical ventilation and early mobilization has demonstrated improved short- and long-term outcomes. With expanded use of pharmacy services in the ICU setting, pharmacists are well positioned to advocate for best care practices in ICUs. A dedicated, interprofessional team is necessary for the implementation of the ABCDEF bundle in inpatient clinical practice settings. As evidenced by a number of studies, successful implementation of the ABCDEF bundle derives from involvement by motivated and highly trained individuals, timely completion of individual patient care tasks, and effective leadership to ensure proper implementation and ongoing support. Factors commonly identified by clinicians as barriers to bundle implementation in clinical practice include patient instability and safety concerns, lack of knowledge, staff concerns, unclear protocol criteria, and lack of interprofessional team care coordination. This narrative review discusses research on bundle elements and recommendations for application by pharmacists in clinical practice. CONCLUSIONS Despite the benefits associated with implementation of the ABCDEF bundle, evidence suggests that the recommended interventions may not be routinely used within the ICU. The pharmacist provides the expertise and knowledge for adoption of the bundle into everyday clinical practice.
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Affiliation(s)
- Lauren E Schmidt
- Department of Pharmacy, Penn Presbyterian Medical Center, Philadelphia, PA
| | - Sneha Patel
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN.,Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
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18
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Abstract
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.
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19
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Andrews JL, Louzon PR, Torres X, Pyles E, Ali MH, Du Y, Devlin JW. Impact of a Pharmacist-Led Intensive Care Unit Sleep Improvement Protocol on Sleep Duration and Quality. Ann Pharmacother 2020; 55:863-869. [PMID: 33166192 DOI: 10.1177/1060028020973198] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Sleep improvement protocols are recommended for use in the intensive care unit (ICU) despite questions regarding which interventions to include, whether sleep quality or duration will improve, and the role of pharmacists in their development and implementation. OBJECTIVE To characterize the impact of a pharmacist-led, ICU sleep improvement protocol on sleep duration and quality as evaluated by a commercially available activity tracker and patient perception. METHODS Critical care pharmacists from a 40-bed, mixed ICU at a large community hospital led the development and implementation of an interprofessional sleep improvement protocol. It included daily pharmacist medication review to reduce use of medications known to disrupt sleep or increase delirium and guideline-based recommendations on both environmental and nonpharmacological sleep-focused interventions. Sleep duration and quality were compared before (December 2018 to December 2019) and after (January to June 2019) protocol implementation in non-mechanically ventilated adults using both objective (total nocturnal sleep time [TST] measured by an activity tracker (Fitbit Charge 2) and subjective (patient-perceived sleep quality using the Richards-Campbell Sleep Questionnaire [RCSQ]) measures. RESULTS Groups before (n = 48) and after (n = 29) sleep protocol implementation were well matched. After protocol implementation, patients had a longer TST (389 ± 123 vs 310 ± 147 minutes; P = 0.02) and better RCSQ-perceived sleep quality (63 ± 18 vs 42 ± 24 mm; P = 0.0003) compared with before implementation. CONCLUSION AND RELEVANCE A sleep protocol that incorporated novel elements led to objective and subjective improvements in ICU sleep duration and quality. Application of this study may result in increased utilization of sleep protocols and pharmacist involvement.
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Affiliation(s)
| | | | - Xavier Torres
- University of Chicago Medical Center, Chicago, IL, USA
| | | | | | - Yuan Du
- AdventHealth Orlando, Orlando, FL, USA
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20
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Werremeyer A, Bostwick J, Cobb C, Moore TD, Park SH, Price C, McKee J. Impact of pharmacists on outcomes for patients with psychiatric or neurologic disorders. Ment Health Clin 2020; 10:358-380. [PMID: 33224694 PMCID: PMC7653731 DOI: 10.9740/mhc.2020.11.358] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Psychiatric and neurologic illnesses are highly prevalent and are often suboptimally treated. A 2015 review highlighted the value of psychiatric pharmacists in improving medication-related outcomes. There is a need to describe areas of expansion and strengthened evidence regarding pharmacist practice and patient care impact in psychiatric and neurologic settings since 2015. METHODS A systematic search of literature published from January 2014 to June 2019 was conducted. Publications describing patient-level outcome results associated with pharmacist provision of care in a psychiatric/neurologic setting and/or in relation to central nervous system (CNS) medications were included. RESULTS A total of 64 publications were included. There was significant heterogeneity of published study methods and data, prohibiting meta-analysis. Pharmacists practicing across a wide variety of health care settings with focus on CNS medication management significantly improved patient-level outcomes, such as medication adherence, disease control, and avoidance of hospitalization. The most common practice approach associated with significant improvement in patient-level outcomes was incorporation of psychiatric pharmacist input into the interprofessional health care team. DISCUSSION Pharmacists who focus on psychiatric and neurologic disease improve outcomes for patients with these conditions. This is important in the current health care environment as most patients with psychiatric or neurologic conditions continue to have unmet needs. Additional studies designed to measure pharmacists' impact on patient-level outcomes are encouraged to strengthen these findings.
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Affiliation(s)
- Amy Werremeyer
- Associate Professor, School of Pharmacy, North Dakota State University, Fargo, North Dakota,
| | - Jolene Bostwick
- Clinical Professor and Associate Chair, University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | - Carla Cobb
- Owner and Consultant, Capita Consulting, Billings, Montana
| | - Tera D Moore
- National Pharmacy Benefits Management Program Manager, Clinical Practice Integration and Model Advancement, Clinical Pharmacy Practice Office, Pharmacy Benefits Management Services, US Department of Veterans Affairs, Washington, DC
| | - Susie H Park
- Associate Professor, School of Pharmacy, University of Southern California, Los Angeles, California
| | - Cristofer Price
- Clinical Pharmacy Program Manager - Mental Health, Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | - Jerry McKee
- CEO and Lead Consultant, Psychopharm Solutions LLC, Morganton, North Carolina
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21
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Mohammad RA, Betthauser KD, Korona RB, Coe AB, Kolpek JH, Fritschle AC, Jagow B, Kenes M, MacTavish P, Slampak‐Cindric AA, Whitten JA, Jones C, Simonelli R, Rowlands I, Stollings JL. Clinical pharmacist services within intensive care unit recovery clinics: An opinion of the critical care practice and research network of the American College of Clinical Pharmacy. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Rima A. Mohammad
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor Michigan USA
| | - Kevin D. Betthauser
- Department of Pharmacy Services Barnes‐Jewish Hospital Saint Louis Missouri USA
| | | | - Antoinette B. Coe
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor Michigan USA
| | | | | | - Benjamin Jagow
- Department of Pharmacy MercyOne Des Moines Medical Center Des Moines Iowa USA
| | - Michael Kenes
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor Michigan USA
| | | | | | | | - Carol Jones
- Department of Pharmacy Guy's and St. Thomas' NHS Foundation Trust London UK
| | | | - Ian Rowlands
- Department of Pharmacy Barts Health NHS Trust London UK
| | - Joanna L. Stollings
- Department of Pharmacy and Critical Illness Brain Dysfunction, Survivorship (CIBS) Center, Vanderbilt University Medical Center Nashville Tennessee USA
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22
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Souza TLD, Azzolin KDO, Souza END. Validation of a multidisciplinary care protocol for critically ill patients with delirium. ACTA ACUST UNITED AC 2020; 41:e20190165. [PMID: 32491148 DOI: 10.1590/1983-1447.2020.20190165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 12/18/2019] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To validate a multiprofessional protocol for the care of patients with delirium admitted to an intensive care unit. METHOD Methodological study with the purpose of confirming with experts the care recommendations proposed in the protocol. For the content validation process, the content validity index of ≥ 0.90 was considered. RESULTS Of the 48 recommendations submitted to content validation, only four did not reach consensus through the content validity index. The multiprofessional protocol for patients with delirium in the intensive care unit included care related to the diagnosis of delirium, pause in sedation, early mobilization, pain management, agitation and delirium, cognitive guidance, sleep promotion, environmental interventions, and family participation. CONCLUSION The multiprofessional protocol qualifies the care provided to critically ill patients with delirium, improving clinical outcomes.
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Affiliation(s)
| | - Karina de Oliveira Azzolin
- Escola de Enfermagem, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brasil
| | - Emiliane Nogueira de Souza
- Programa de Pós-Graduação em Enfermagem, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brasil
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23
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Kane-Gill SL, Dzierba AL. Contemporary Topics in Critical Care With Evolving Medication Management Considerations. J Pharm Pract 2020; 32:254-255. [PMID: 31291841 DOI: 10.1177/0897190019857822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Sandra L Kane-Gill
- 1 Associate Professor of Pharmacy and Therapeutics, Biomedical Informatics, Critical Care Medicine and Clinical Translational Science Institute at the University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Amy L Dzierba
- 2 Clinical Pharmacy Manager, Adult Critical Care NewYork-Presbyterian Hospital, NY, USA
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24
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Impact on Patient Outcomes of Pharmacist Participation in Multidisciplinary Critical Care Teams: A Systematic Review and Meta-Analysis. Crit Care Med 2020; 47:1243-1250. [PMID: 31135496 DOI: 10.1097/ccm.0000000000003830] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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25
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Stollings JL, Devlin JW, Lin JC, Pun BT, Byrum D, Barr J. Best Practices for Conducting Interprofessional Team Rounds to Facilitate Performance of the ICU Liberation (ABCDEF) Bundle. Crit Care Med 2020; 48:562-570. [PMID: 32205603 DOI: 10.1097/ccm.0000000000004197] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Daily ICU interprofessional team rounds, which incorporate the ICU Liberation ("A" for Assessment, Prevention, and Manage Pain; "B" for Both Spontaneous Awakening Trials and Spontaneous Breathing Trials; "C" for Choice of Analgesia and Sedation; "D" for Delirium Assess, Prevent, and Manage; "E" for Early Mobility and Exercise; "F" for Family Engagement and Empowerment [ABCDEF]) Bundle, support both the care coordination and regular provider communication necessary for Bundle execution. This article describes evidence-based practices for conducting effective interprofessional team rounds in the ICU to improve Bundle performance. DESIGN Best practice synthesis. METHODS The authors, each extensively involved in the Society of Critical Care Medicine's ICU Liberation Campaign, reviewed the pertinent literature to identify how ICU interprofessional team rounds can be optimized to increase ICU Liberation adherence. RESULTS Daily ICU interprofessional team rounds that foster ICU Liberation Bundle use support both care coordination and regular provider communication within and between teams. Evidence-based best practices for conducting effective interprofessional team rounds in the ICU include the optimal structure for ICU interprofessional team rounds; the importance of conducting rounds at patients' bedside; essential participants in rounds; the inclusion of ICU patients and their families in rounds-based discussions; and incorporation of the Bundle into the Electronic Health Record. Interprofessional team rounds in the ICU ideally employ communication strategies to foster inclusive and supportive behaviors consistent with interprofessional collaboration in the ICU. Patient care discussions during interprofessional team rounds benefit from being patient-centered and goal-oriented. Documentation of ICU Liberation Bundle elements in the Electronic Health Record may help facilitate team communication and decision-making. CONCLUSIONS Conducting high-quality interprofessional team rounds in the ICU is a key strategy to support ICU Liberation Bundle use.
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Affiliation(s)
- Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA
| | - John C Lin
- Division of Pediatrics and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Brenda T Pun
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
- Department of Medicine, Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN
| | - Diane Byrum
- Innovative Solutions for Healthcare Education, LLC, Charlotte, NC
| | - Juliana Barr
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
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26
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Coe AB, Bookstaver RE, Fritschle AC, Kenes MT, MacTavish P, Mohammad RA, Simonelli RJ, Whitten JA, Stollings JL. Pharmacists' Perceptions on Their Role, Activities, Facilitators, and Barriers to Practicing in a Post-Intensive Care Recovery Clinic. Hosp Pharm 2020; 55:119-125. [PMID: 32214446 PMCID: PMC7081480 DOI: 10.1177/0018578718823740] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: Complex medication regimen changes burden intensive care unit (ICU) survivors and their caregivers during the transition to home. Intensive care unit recovery clinics are a prime setting for pharmacists to address patients' and their caregivers' medication-related needs. The purpose of this study was to describe ICU recovery clinic pharmacists' activities, roles, and perceived barriers and facilitators to practicing in ICU recovery clinics across different institutions. Methods: An expert panel of ICU recovery clinic pharmacists completed a 15-item survey. Survey items addressed the pharmacists' years in practice, education and training, activities performed, their perceptions of facilitators and barriers to practicing in an ICU recovery clinic setting, and general ICU recovery clinic characteristics. Descriptive statistics were used. Results: Nine ICU recovery clinic pharmacists participated. The average number of years in practice was 16.5 years (SD = 13.5, range = 2-38). All pharmacists practiced in an interprofessional ICU recovery clinic affiliated with an academic medical center. Seven (78%) pharmacists always performed medication reconciliation and a comprehensive medication review in each patient visit. Need for medication education was the most prevalent item found in patient comprehensive medication reviews. The main facilitators for pharmacists' successful participation in an ICU recovery clinic were incorporation into clinic workflow, support from other health care providers, and adequate space to see patients. The ICU recovery clinic pharmacists perceived the top barriers to be lack of dedicated time and inadequate billing for services. Conclusions: The ICU recovery clinic pharmacists address ICU survivors' medication needs by providing direct patient care in the clinic. Strategies to mitigate pharmacists' barriers to practicing in ICU recovery clinics, such as lack of dedicated time and adequate billing for pharmacist services, warrant a multifaceted solution, potentially including advocacy and policy work by national pharmacy professional organizations.
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Affiliation(s)
- Antoinette B. Coe
- University of Michigan College of Pharmacy, Ann Arbor MI, USA,Antoinette B. Coe, PharmD, PhD, Department of Clinical Pharmacy, College of Pharmacy, University of Michigan College of Pharmacy, 428 Church Street, Ann Arbor, MI 48109, USA.
| | | | | | | | | | - Rima A. Mohammad
- University of Michigan College of Pharmacy, Ann Arbor MI, USA,Michigan Medicine, Ann Arbor, MI, USA
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Sedighie L, Bolourchifard F, Rassouli M, Zayeri F. Effect of Comprehensive Pain Management Training Program on Awareness and Attitude of ICU Nurses. Anesth Pain Med 2020; 10:e98679. [PMID: 32754429 PMCID: PMC7341110 DOI: 10.5812/aapm.98679] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 02/03/2020] [Accepted: 02/25/2020] [Indexed: 01/08/2023] Open
Abstract
Background Pain is one of the main complaints of many patients in intensive care units. However, most nurses and physicians are unable to properly monitor and relieve pain in these patients. Factors such as patients' inability to describe their pain and insufficient knowledge of nurses and physicians have made pain management difficult. Given that the knowledge and attitude of nurses play an important role in the effective implementation of the pain management process, this study aimed to investigate the effect of comprehensive pain management training program on the awareness and attitude of intensive care unit nurses. Methods This quasi-experimental single-group study was conducted in two phases (pre and post-intervention) to investigate the awareness and attitude of all nurses employed in the intensive care unit of Tehran Modarres Hospital, based on the determined inclusion and exclusion criteria. In the pre-intervention phase, the awareness and attitudes of the nurses were assessed using a questionnaire. After conducting the pain management training course, an executive program and algorithm were implemented for pain management in ICUs. Then, the nurses’ awareness and attitude toward pain management were assessed again. Finally, changes in the scores of the nurses’ awareness and attitude were analyzed by SPSS V. 22 software in two phases before and after applying the interventions using the Wilcoxon test. The relationship between some demographic variables and the level of awareness and attitude of nurses was also investigated using the Kruskal-Wallis and Mann-Whitney tests. Results The results of this study indicated that the mean score of the nurses’ awareness was significantly different in pre- and post-intervention phases (P < 0.05). Despite an increase in the post-intervention mean score of the nurses’ attitude (71.03), no statistically significant change was observed. Additionally, among the demographic variables, there was only a significant relationship between the nurses' job experience in ICUs and their attitudes. Conclusions Based on the results of this study, teaching and implementing a comprehensive program for pain management can play an effective role in promoting the nurses’ awareness. Therefore, it is proposed to use pain management models to improve the nurses' knowledge and attitude toward pain management in ICU patients.
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Affiliation(s)
- Ladan Sedighie
- Department of Nursing, Student Research Committee, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fariba Bolourchifard
- Department of Nursing, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Corresponding Author: Ph.D. in Nursing, Assistant Professor, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Maryam Rassouli
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farid Zayeri
- Department of Biostatistics, Proteomics Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Ducatman BS, Ducatman AM, Crawford JM, Laposata M, Sanfilippo F. The Value Proposition for Pathologists: A Population Health Approach. Acad Pathol 2020; 7:2374289519898857. [PMID: 31984223 PMCID: PMC6961144 DOI: 10.1177/2374289519898857] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/11/2019] [Accepted: 12/04/2019] [Indexed: 01/09/2023] Open
Abstract
The transition to a value-based payment system offers pathologists the opportunity to play an increased role in population health by improving outcomes and safety as well as reducing costs. Although laboratory testing itself accounts for a small portion of health-care spending, laboratory data have significant downstream effects in patient management as well as diagnosis. Pathologists currently are heavily engaged in precision medicine, use of laboratory and pathology test results (including autopsy data) to reduce diagnostic errors, and play leading roles in diagnostic management teams. Additionally, pathologists can use aggregate laboratory data to monitor the health of populations and improve health-care outcomes for both individual patients and populations. For the profession to thrive, pathologists will need to focus on extending their roles outside the laboratory beyond the traditional role in the analytic phase of testing. This should include leadership in ensuring correct ordering and interpretation of laboratory testing and leadership in population health programs. Pathologists in training will need to learn key concepts in informatics and data analytics, health-care economics, public health, implementation science, and health systems science. While these changes may reduce reimbursement for the traditional activities of pathologists, new opportunities arise for value creation and new compensation models. This report reviews these opportunities for pathologist leadership in utilization management, precision medicine, reducing diagnostic errors, and improving health-care outcomes.
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Affiliation(s)
- Barbara S. Ducatman
- Department of Pathology, Beaumont Health, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI,
USA
| | - Alan M. Ducatman
- Department of Occupational and Environmental Health Sciences, West Virginia
University School of Public Health, Morgantown, WV, USA
| | - James M. Crawford
- Department of Pathology and Laboratory Medicine, Donald and Barbara Zucker
School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Michael Laposata
- Department of Pathology, University of Texas Medical Branch, Galveston, TX,
USA
| | - Fred Sanfilippo
- Department of Pathology and Laboratory Medicine, Emory University School of
Medicine, Atlanta, GA, USA
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Talon B, Perez A, Yan C, Alobaidi A, Zhang KH, Schultz BG, Suda KJ, Touchette DR. Economic evaluations of clinical pharmacy services in the United States: 2011-2017. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1199] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Brian Talon
- Department of Pharmacy Systems, Outcomes & Policy; University of Illinois at Chicago; Chicago Illinois
| | - Alexandra Perez
- Department of Sociobehavioral and Administrative Pharmacy; Nova Southeastern University; Fort Lauderdale Florida
| | - Connie Yan
- Department of Pharmacy Systems, Outcomes & Policy; University of Illinois at Chicago; Chicago Illinois
| | - Ali Alobaidi
- Department of Pharmacy Systems, Outcomes & Policy; University of Illinois at Chicago; Chicago Illinois
| | - Katherine H. Zhang
- Department of Pharmacy Systems, Outcomes & Policy; University of Illinois at Chicago; Chicago Illinois
| | - Bob G. Schultz
- Department of Pharmacy Systems, Outcomes & Policy; University of Illinois at Chicago; Chicago Illinois
| | - Katie J. Suda
- Department of Medicine, Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System; University of Pittsburgh School of Medicine; Pittsburgh PA
| | - Daniel R. Touchette
- Department of Pharmacy Systems, Outcomes & Policy; University of Illinois at Chicago; Chicago Illinois
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Zoremba N, Coburn M, Schälte G. [Delirium in intensive care patients : A multiprofessional challenge]. Anaesthesist 2019; 67:811-820. [PMID: 30298270 DOI: 10.1007/s00101-018-0497-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Delirium is the most common form of cerebral dysfunction in intensive care patients and is a medical emergency that must be avoided or promptly diagnosed and treated. According to current knowledge the development of delirium seems to be caused by an interplay between increased vulnerability (predisposition) and simultaneous exposure to delirogenic factors. Since delirium is often overlooked in the clinical routine, a continuous screening for delirium should be performed. Due to the close connection between delirium, agitation and pain, sedation and analgesia must be evaluated at least every 8 h analogous to delirium screening. According to current knowledge, a multifactorial and multiprofessional approach is favored in the prevention and treatment of delirium. Non-pharmaceutical interventions through early mobilization, reorientation, sleep improvement, adequate pain therapy and avoidance of polypharmacy are of great importance. Depending on the clinical picture, different substances are used in symptom-oriented drug treatment of delirium. In order to achieve these diagnostic and therapeutic goals, an interdisciplinary treatment team consisting of intensive care, intensive care physicians, ward pharmacists, physiotherapists, nutrition specialists and psychiatrists is necessary in order to meet the requirements of the patient and their relatives.
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Affiliation(s)
- N Zoremba
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Sankt Elisabeth Hospital Gütersloh, Stadtring Kattenstroth 130, 33332, Gütersloh, Deutschland.
| | - M Coburn
- Klinik für Anästhesiologie, Universitätsklinikum der RWTH Aachen, Aachen, Deutschland
| | - G Schälte
- Klinik für Anästhesiologie, Universitätsklinikum der RWTH Aachen, Aachen, Deutschland
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Abstract
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.
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Zhang J, Liu G, Zhang F, Fang H, Zhang D, Liu S, Chen B, Xiao H. Analysis of postoperative cognitive dysfunction and influencing factors of dexmedetomidine anesthesia in elderly patients with colorectal cancer. Oncol Lett 2019; 18:3058-3064. [PMID: 31402961 PMCID: PMC6676718 DOI: 10.3892/ol.2019.10611] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/28/2019] [Indexed: 11/24/2022] Open
Abstract
Effect of dexmedetomidine-assisted general anesthesia on early postoperative cognitive dysfunctions in elderly patients with colorectal cancer was explored. In total, 140 patients with radical colorectal cancer under general anesthesia from March 2012 to June 2015 were enrolled in the Guizhou Provincial People's Hospital, including 80 patients in the dexmedetomidine group and 60 patients in the saline group. Surgery conditions were recorded, and the incidence of postoperative cognitive dysfunction (POCD) and cognitive function score (MMSE score) were compared between the two groups. Serum levels of S-100β protein (S-100β) and interleukin-6 (IL-6) were measured by enzyme-linked immunosorbent assay. The anesthesia time and intraoperative blood loss in the experiment group were significantly lower than those in the control group (P<0.05). The MMSE scores of the two groups on the 1st and 3rd day after surgery were lower than those before surgery (P<0.05). The incidence rates of the experiment group were significantly lower than that of the control group (P<0.05). The levels of serum IL-6 and S-100β were increased on the 1st and 3rd day after surgery compared with those before surgery (P<0.05). The levels of serum IL-6 and S-100β in the control group were significantly higher than those in the experiment group on the 1st and 3rd day after surgery (P<0.05). Age, duration of anesthesia, intraoperative blood loss, expression of IL-6 and S-100β were the influencing factors of POCD. Age ≥70 years, anesthesia duration ≥3 h, intraoperative blood loss ≥350 ml, and high expression of IL-6 and S-100β was an important factor related to the occurrence (P<0.05). Dexmedetomidine can significantly improve postoperative cognitive dysfunction in elderly patients with colorectal cancer, and the occurrence of cognitive dysfunction can be affected by age, duration of anesthesia, intraoperative blood loss and the high expression of IL-6 and S-100β.
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Affiliation(s)
- Jingchao Zhang
- Department of Anesthesiology, Guizhou Provincial People's Hospital, Guiyang, Guizhou 550002, P.R. China
| | - Guoqing Liu
- Department of Anesthesiology, Jinan Zhangqiu District Hospital of TCM, Jinan, Shandong 250200, P.R. China
| | - Fangxiang Zhang
- Department of Anesthesiology, Guizhou Provincial People's Hospital, Guiyang, Guizhou 550002, P.R. China
| | - Hua Fang
- Department of Anesthesiology, Guizhou Provincial People's Hospital, Guiyang, Guizhou 550002, P.R. China
| | - Duwen Zhang
- Department of Anesthesiology, Guizhou Provincial People's Hospital, Guiyang, Guizhou 550002, P.R. China
| | - Shuchun Liu
- Department of Anesthesiology, Guizhou Provincial People's Hospital, Guiyang, Guizhou 550002, P.R. China
| | - Bingning Chen
- Department of Anesthesiology, Guizhou Provincial People's Hospital, Guiyang, Guizhou 550002, P.R. China
| | - Hong Xiao
- Department of Anesthesiology, Xiamen Hospital of Traditional Chinese Medicine, Xiamen, Fujian 361001, P.R. China
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Smithburger PL, Patel MK. Pharmacologic Considerations Surrounding Sedation, Delirium, and Sleep in Critically Ill Adults: A Narrative Review. J Pharm Pract 2019; 32:271-291. [PMID: 30955461 DOI: 10.1177/0897190019840120] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Agitation, delirium, and sleep dysfunction in the intensive care unit (ICU) are common occurrences that result in negative patient outcomes. With the recent publication of the 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PAD-IS), several areas are of particular interest due to emerging literature or conflicting results of research. OBJECTIVE To highlight areas where emerging literature or variable study results exist and to provide the clinician with recommendations regarding patient management. METHODS The 2018 PAD-IS guidelines were reviewed, and areas of emerging literature or lack of consensus of included investigations surrounding pharmacologic management of sedation, delirium, and sleep in the ICU were identified. A review and appraisal of the literature was conducted specifically to address the identified areas. Prospective, randomized trials were included in this narrative review. RESULTS Four areas with emerging data or conflicting evidence were identified and included: use of propofol or dexmedetomidine for sedation, pharmacologic prevention of delirium, treatment of delirium, and pharmacologic strategies to improve sleep. CONCLUSION A comprehensive approach to the prevention and management of delirium, sedation, and sleep in the ICU is necessary to optimize patient outcomes.
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Affiliation(s)
- Pamela L Smithburger
- 1 Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Mona K Patel
- 2 Department of Pharmacy, Surgical Intensive Care Unit, New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
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Lovely JK, Hyland SJ, Smith AN, Nelson G, Ljungqvist O, Parrish RH. Clinical pharmacist perspectives for optimizing pharmacotherapy within Enhanced Recovery After Surgery (ERAS ®) programs. Int J Surg 2019; 63:58-62. [PMID: 30665004 DOI: 10.1016/j.ijsu.2019.01.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/02/2019] [Accepted: 01/11/2019] [Indexed: 12/15/2022]
Abstract
One of the most durable approaches to perioperative enhanced recovery programming has culminated in the formation of perioperative organizations devoted to improvements in the quality of the surgical patient experience, such as the Enhanced Recovery After Surgery (ERAS®) Society. Members of the American College of Clinical Pharmacy (ACCP) Perioperative Care Practice and Research Network (PRN) and officials from the ERAS® Society present an opinion that: (1) identifies therapeutic options within each pharmacotherapy-intensive area of ERAS®; (2) generates applied research questions that would allow for comparative analyses of pharmacotherapy options within ERAS® programs; (3) proposes collaborative practice opportunities between key stakeholders in the surgical journey and clinical pharmacists to manage drug therapy problems and research questions; and (4) highlights examples of pharmacist-led cost savings attributed to ERAS® implementation. Clinical pharmacists, working in this manner with the perioperative team across the care continuum, have optimized pharmacotherapy towards measurable outcomes improvements, and stand ready to partner with inter-professional stakeholders and organizations to advance the care of our mutual patients.
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Affiliation(s)
| | | | - April N Smith
- Creighton University School of Pharmacy and Health Professions, Omaha, NE, 68178, USA.
| | - Gregg Nelson
- Departments of Obstetrics & Gynecology and Oncology, Section Chief, Gynecologic Oncology, Secretary, ERAS(®) Society, Tom Baker Cancer Centre, Cumming School of Medicine, University of Calgary, Calgary, Alberta, T2N 4N2, Canada.
| | - Olle Ljungqvist
- ERAS Society, Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden.
| | - Richard H Parrish
- St. Christopher's Hospital for Children, Philadelphia, PA, 19134, USA; Virginia Commonwealth University School of Pharmacy, Richmond, VA, 23298, USA.
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Newsome AS, Chastain DB, Watkins P, Hawkins WA. Complications and Pharmacologic Interventions of Invasive Positive Pressure Ventilation During Critical Illness. J Pharm Technol 2018; 34:153-170. [PMID: 34860978 DOI: 10.1177/8755122518766594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To review the fundamentals of invasive positive pressure ventilation (IPPV) and the common complications and associated pharmacotherapeutic management in order to provide opportunities for pharmacists to improve patient outcomes. Data Sources: A MEDLINE literature search (1950-December 2017) was performed using the key search terms invasive positive pressure ventilation, mechanical ventilation, pharmacist, respiratory failure, ventilator associated organ dysfunction, ventilator associated pneumonia, ventilator bundles, and ventilator liberation. Additional references were identified from a review of literature citations. Study Selection and Data Extraction: All English-language original research and review reports were evaluated. Data Synthesis: IPPV is a common supportive care measure for critically ill patients. While lifesaving, IPPV is associated with significant complications including ventilator-associated pneumonia, sinusitis, organ dysfunction, and hemodynamic alterations. Optimization of pain and sedation management provides an opportunity for pharmacists to directly affect IPPV exposure. A number of pharmacotherapeutic interventions are related directly to prophylaxis against IPPV-associated adverse events or aimed at reduction of duration of IPPV. Conclusions: Enhanced knowledge of the common complications, associated pharmacotherapy, and monitoring strategies facilitate the pharmacist's ability to provide increased pharmacotherapeutic insight in a multidisciplinary intensive care unit setting.
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Affiliation(s)
- Andrea Sikora Newsome
- The University of Georgia, Augusta, GA, USA.,Augusta University Medical Center, Augusta, GA, USA
| | | | | | - W Anthony Hawkins
- The University of Georgia, Augusta, GA, USA.,The University of Georgia-Albany, GA, USA
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36
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Abstract
The use of medication to support patients and optimise outcomes is a fundamental strand of care. Pharmacists provide a key role managing medication within the complexity of various routes of administration, severe and rapidly shifting pharmacokinetic and dynamic parameters, and extremes of physiology in critical illness. Pharmacists intercept and resolve medication errors, optimise medication therapy and undertake broader professional activities within the job role that contribute to the smooth running of ICU. These activities are associated with improved quality, reduced mortality and reduced costs.
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Affiliation(s)
- Mark Borthwick
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, UK
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37
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Stollings JL, Bloom SL, Wang L, Ely EW, Jackson JC, Sevin CM. Critical Care Pharmacists and Medication Management in an ICU Recovery Center. Ann Pharmacother 2018; 52:713-723. [PMID: 29457491 DOI: 10.1177/1060028018759343] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Many patients experience complications following critical illness; these are now widely referred to as post-intensive care syndrome (PICS). An interprofessional intensive care unit (ICU) recovery center (ICU-RC), also known as a PICS clinic, is one potential approach to promoting patient and family recovery following critical illness. OBJECTIVES To describe the role of an ICU-RC critical care pharmacist in identifying and treating medication-related problems among ICU survivors. METHODS A prospective, observational cohort study was conducted of all outpatient appointments of a tertiary care hospital's ICU-RC between July 2012 and December 2015. The pharmacist completed a full medication review, including medication reconciliation, interview, counseling, and resultant interventions, during the ICU-RC appointment. RESULTS Data from all completed ICU-RC visits were analyzed (n = 62). A full medication review was performed in 56 (90%) of these patients by the pharmacist. The median number of pharmacy interventions per patient was 4 (interquartile range = 2, 5). All 56 patients had at least 1 pharmacy intervention; 22 (39%) patients had medication(s) stopped at the clinic appointment, and 18 (32%) patients had new medication(s) started. The pharmacist identified 9 (16%) patients who had an adverse drug event (ADE); 18 (32%) patients had ADE preventive measures instituted. An influenza vaccination was administered to 13 (23%) patients despite an inpatient protocol to ensure influenza vaccination prior to discharge. A pneumococcal vaccination was administered to 2 (4%) patients. CONCLUSIONS Use of a critical care pharmacist resulted in the identification and treatment of multiple medication-related problems in an ICU-RC as well as implementation of preventive measures.
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Affiliation(s)
| | - Sarah L Bloom
- 1 Vanderbilt University Medical Center, Nashville, TN, USA
| | - Li Wang
- 1 Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wesley Ely
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,2 Department of Veterans Affairs Medical Center Tennessee Valley Healthcare System, Nashville, TN, USA
| | - James C Jackson
- 2 Department of Veterans Affairs Medical Center Tennessee Valley Healthcare System, Nashville, TN, USA.,3 Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Carla M Sevin
- 1 Vanderbilt University Medical Center, Nashville, TN, USA
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Impact of pharmaceutical care on pain and agitation in a medical intensive care unit in Thailand. Int J Clin Pharm 2017; 39:573-581. [PMID: 28357623 DOI: 10.1007/s11096-017-0456-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 03/21/2017] [Indexed: 10/19/2022]
Abstract
Background Currently, a lack of pharmaceutical care exists concerning pain and agitation in medical intensive care units (MICU) in Thailand. Pharmaceutical care focusing on analgesics/sedatives would improve clinical outcomes. Objective To investigate the impact of pharmaceutical care of pain and agitation on ICU length of stay (LOS), hospital LOS, ventilator days and mortality. Setting The MICU of a university hospital. Method A before/after study was conducted on mechanically ventilated patients receiving analgesics/sedatives. Medical chart reviews and data collection were conducted in the retrospective group (no pharmacists involved). In the prospective group, pharmacists involved with the critical care team helped select analgesics/sedatives for individual patients. Main outcome measure ICU LOS Results In total, 90 and 66 patients were enrolled in retrospective and prospective groups, respectively. The median duration of ICU LOS was reduced from 10.00 (2.00-72.00) in the retrospective group to 6.50 days (2.00-30.00) in the prospective group (p = 0.002). The median hospital stay was reduced from 30.50 days (2.00-119.00) in the retrospective group to 17.50 days (2.00-110.00) in the prospective group (p < 0.001). Also, the median ventilator days was reduced from 14.00 days (2.00-90.00) to 8.50 days (1.00-45.00), p = 0.008. Mortality was 53.03% in the prospective group and 46.67% in the retrospective group (p = 0.432). Conclusion Pharmacist participation in a critical care team resulted in a significant reduction in the duration of ICU LOS, hospital LOS and ventilator days, but not mortality.
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