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Ali Hussain Alsayed H, Saheb Sharif-Askari F, Saheb Sharif-Askari N, Halwani R. Clinical pharmacist interventions in an intensive care unit reduces ICU mortality at a tertiary hospital in Dubai, United Arab Emirates. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2024; 14:100431. [PMID: 38533449 PMCID: PMC10963309 DOI: 10.1016/j.rcsop.2024.100431] [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: 12/14/2023] [Revised: 02/22/2024] [Accepted: 03/07/2024] [Indexed: 03/28/2024] Open
Abstract
Background Drug-related problems (DRPs) are prevalent in critical care settings and can be life-threatening. Involving clinical pharmacists (CP) within the critical care team is recommended to optimize therapy and improve patient survival. Objective To classify DRPs identified by a CP in the Intensive Care Unit (ICU) and to assess the impact of CP interventions accepted by physicians on the length of ICU stay and in-hospital survival. Methods This study was conducted prospectively at the Medical ICU of Rashid Hospital, a tertiary hospital in Dubai, over a 16-month period from September 2021 to December 2022. The study included patients admitted to ICU during the study period. CP interventions were documented, and DRPs were classified using the modified Pharmaceutical Care Network Europe V.9.1. Results During the study period, 1004 interventions were recommended for 200 patients. The majority of these interventions, 92% (n = 922), received physician acceptance, and 82% (n = 820) were fully implemented by the physician. In total, 1033 drug-related problems (DRPs) were identified, with a median of 3 DRPs per patient. The most common DRPs was drug selection (61%), followed by dose selection (22%). There were 337 DRPs related to antimicrobial agents. Interestingly, we noted that when we adjusted for patients' demographic data and the Glasgow Coma Scale severity score, patients who received >4 implemented interventions exhibited lower cumulative hazard of death within 90 days of their ICU stay in comparison to their counterparts (adjusted Hazard Ratio: 0.10, 95% CI of 0.02-0.41; P = 0.027). Conclusion The study emphasizes the critical role of CP in the ICU, addressing DRPs, and enhancing overall patient care. Furthermore, it highlights the potential impact of pharmacist interventions in improving patient survival outcomes. This underscores the importance of implementing CP services in ICUs across the UAE.
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Affiliation(s)
- Hawra Ali Hussain Alsayed
- Department of Pharmacy, Rashid Hospital, Dubai Academic Health Corporation, Dubai, United Arab Emirates
| | - Fatemeh Saheb Sharif-Askari
- Research Institute for Medical and Health Science, University of Sharjah, Sharjah, United Arab Emirates
- Department of Pharmacy Practice and Pharmacotherapeutics, College of Pharmacy, University of Sharjah, Sharjah, United Arab Emirates
| | - Narjes Saheb Sharif-Askari
- Research Institute for Medical and Health Science, University of Sharjah, Sharjah, United Arab Emirates
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Rabih Halwani
- Research Institute for Medical and Health Science, University of Sharjah, Sharjah, United Arab Emirates
- Department of Pharmacy Practice and Pharmacotherapeutics, College of Pharmacy, University of Sharjah, Sharjah, United Arab Emirates
- Prince Abdullah Ben Khaled Celiac Disease Chair, Department of Pediatrics, Faculty of Medicine, King Saud University, Saudi Arabia
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Behal ML, Flannery AH, Barreto EF. Medication Management in the Critically Ill Patient with Acute Kidney Injury. Clin J Am Soc Nephrol 2023; 18:1080-1088. [PMID: 36723347 PMCID: PMC10564345 DOI: 10.2215/cjn.0000000000000101] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/20/2023] [Indexed: 02/02/2023]
Abstract
ABSTRACT AKI occurs frequently in critically ill patients. Patients with AKI, including those who require KRT, experience multiple pharmacokinetic and pharmacodynamic perturbations that dynamically influence medication effectiveness and safety. Patients with AKI may experience both subtherapeutic drug concentrations, which lead to ineffective therapy, and supratherapeutic drug concentrations, which increase the risk for toxicity. In critically ill patients with AKI not requiring KRT, conventional GFR estimation equations, especially those based on serum creatinine, have several limitations that can limit the accuracy when used for medication dosing. Alternative methods to estimate kidney function may be informative, including use of measured urinary creatinine clearance, kinetic eGFR, and equations that integrate novel kidney biomarkers. For critically ill patients with AKI requiring KRT, physicochemical properties of the drug, the KRT prescription and circuit configuration, and patient-specific factors each contribute to medication clearance. Evidence-based guidance for medication dosing during AKI requiring KRT is often limited. A working knowledge of the basic tenets of drug elimination during KRT can provide a framework for how to approach decision making when the literature is lacking. Iterative re-evaluation of a patient's progress toward therapeutic goals with a medication must occur over the arc of critical illness, including and especially in the setting of dynamic kidney function.
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Affiliation(s)
- Michael L. Behal
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky
| | - Alexander H. Flannery
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky
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Wang C, Chen J, Yang B, Li S, Zhang Y, Chen L, Wang T, Dong Y. Determination of vancomycin exposure target and individualized dosing recommendations for critically ill patients undergoing continuous renal replacement therapy. Pharmacotherapy 2023; 43:180-188. [PMID: 36714991 DOI: 10.1002/phar.2771] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/18/2022] [Accepted: 12/25/2022] [Indexed: 01/31/2023]
Abstract
STUDY OBJECTIVE Few studies have been conducted to quantify the exposure target of vancomycin in intensive care unit (ICU) patients undergoing continuous renal replacement therapy (CRRT) and provide optimized dosage regimens. We aimed to determine vancomycin exposure target and dosing recommendations using data from an open database in critically ill patients undergoing CRRT. DESIGN A retrospective observational cohort study. DATA SOURCE A large public database. PATIENTS The adult patients who received intravenous vancomycin and CRRT treatment in the database between 2017 and 2019 were reviewed to determine eligibility. A total of 180 patients with 1186 observations were included in the population pharmacokinetic (PPK) model development. The clinical efficacy of vancomycin was analyzed in 159 eligible patients. METHODS A PPK model was developed to estimate individual pharmacokinetic (PK) parameters. The area under the concentration-time curve (AUC) was estimated by a Bayesian approach based on individual vancomycin concentrations. Multivariate logistic regression analyses were performed to identify the factors of clinical outcomes. Threshold of vancomycin exposure in predicting efficacy was identified via receiver operating characteristic (ROC) curve. Dosing recommendations were designed using Monte Carlo Simulations (MCS) based on the optimized exposure target. MEASUREMENTS AND MAIN RESULTS On covariate analysis, CRRT intensity significantly affected vancomycin PK. The AUC above 427 mg*h/L was the only significant predictor of clinical efficacy (adjusted odds ratio (aOR): 1.008, 95% confidence interval (CI): 1.004-1.011, p = 0.000). MCS indicated that vancomycin dosage regimens of 5 mg/kg q12h or 7.5 mg/kg q12h were recommended for patients with CRRT intensities of 20-25 mL/kg/h or 25.1-45 mL/kg/h, respectively. CONCLUSIONS An AUC threshold of 427 mg*h/L (assuming the minimal inhibitory concentration (MIC) = 1 mg/L) was a recommended efficacy exposure target of vancomycin for critically ill patients undergoing CRRT. Vancomycin 5-7.5 mg/kg q12h is recommended as the initial dosage regimens for ICU patients undergoing CRRT.
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Affiliation(s)
- Chuhui Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jiaojiao Chen
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Bo Yang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Sihan Li
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yiran Zhang
- School of Pharmacy, Xi'an Jiaotong University, Xi'an, China
| | - Lei Chen
- Department of Hemodialysis, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Taotao Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Samaan F, Aoike D, Pagrion-Neto R, Cesar Pons T, Bracci Lisboa R, Burdmann EA. Medical students’ and health professionals’ knowledge regarding acute kidney injury: a cross-sectional study in the city of São Paulo, Brazil. Ren Fail 2022; 44:1660-1668. [DOI: 10.1080/0886022x.2022.2131575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Farid Samaan
- Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
- LIM 12, Disciplina de Nefrologia, Universidade de São Paulo, São Paulo, Brazil
| | - Danilo Aoike
- Disciplina de Nefrologia, Universidade Federal de São Paulo, Brazil
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Albayrak A, Başgut B, Bıkmaz GA, Karahalil B. Clinical pharmacist assessment of drug-related problems among intensive care unit patients in a Turkish university hospital. BMC Health Serv Res 2022; 22:79. [PMID: 35033079 PMCID: PMC8761343 DOI: 10.1186/s12913-022-07494-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Critically ill patients treated in the intensive care units (ICUs) often suffer from side effects and drug-related problems (DRPs) that can be life-threatening. A way to prevent DRPs and improve drug safety and efficacy is to include clinical pharmacists in the clinical team. This study aims to evaluate the classification of drug-related problems and the implementation of clinical pharmacy services by a clinical pharmacist in the ICU of a university hospital in Turkey. METHODS This study was carried out prospectively between December 2020 and July 2021 in Gazi University Medical Faculty Hospital Internal Diseases ICU. All patients hospitalized in the intensive care unit for more than 24 h were included in the study. During the study, the clinical pharmacist's interventions and other clinical services for patients were recorded. DRPs were classed according to the Pharmaceutical Care Network Europe V.8.02. RESULTS A total of 151 patients were included during the study period corresponding to 2264 patient-days. Patients with DRPs had a longer hospital stay and a higher mortality rate (p < 0.05). 108 patients had at least one DRP and the total number of DRPs was 206. There was an average of 1.36 DRPs per patient, 71.5% of patients experienced DRP and 89.22 DRPs per 1000 patient-days. A total of 35 ADEs were observed in 32 patients. ADE incidence was per 1000 patient-days 15.45. ADEs were caused by nephrotoxicity (48.57%), electrolyte disorders (17.14%), drug-induced thrombocytopenia (17.14%), liver enzyme increase (8.57%) and other causes (8.57%). Drug selection (40.29%) and dose selection (54.36%) constituted most of the causes of DRPs. Dose change was the highest percentage of planned interventions with a rate of 56.79%. Intervention was accepted at a rate of 90.8% and it was fully implemented. CONCLUSION In this study, the importance of the clinical pharmacist in the determination and analysis of DRPs was emphasized. Clinical pharmacy services like the one described should be implemented widely to increase patient safety.
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Affiliation(s)
- Aslınur Albayrak
- Department of Clinical Pharmacy, FacultyofPharmacy, Gazi University, Ankara, Turkey.
| | - Bilgen Başgut
- Department of Pharmacology, Faculty of Pharmacy, Baskent University, Ankara, Turkey
| | | | - Bensu Karahalil
- Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Gazi University, Ankara, Turkey
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Aghili M, Kasturirangan MN. Management of Drug-Drug Interactions among Critically Ill Patients with Chronic Kidney Disease: Impact of Clinical Pharmacist's Interventions. Indian J Crit Care Med 2021; 25:1226-1231. [PMID: 34866818 PMCID: PMC8608633 DOI: 10.5005/jp-journals-10071-23919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Drug-drug interactions (DDIs) can create a burden on prescribers to preserve patient safety. This study aimed to identify common DDIs in critically ill patients with chronic kidney disease (CKD) and to evaluate clinical pharmacist's interventions in managing DDIs among these patients. METHODS A prospective observational study was conducted from October 2018 to March 2019. The clinical pharmacist performed a medication chart review; DDIs were identified by using Lexicomp® drug interaction. Based on the occurrence of DDIs, patients were divided into group A: patients with DDI (n = 76) and group B: patients without DDI (n = 15). Clinical pharmacist's interventions were classified according to Pharmaceutical Care Network Europe. The National Coordinating Council for Medication Error Reporting and Prevention was used to categorize the severity outcomes of DDIs and the degree of patient harm. RESULTS A total of 273 DDIs were identified. The majority of DDIs (63.7%) required close monitoring of the therapeutic outcome to ensure maintaining patient safety. DDIs that needed to be managed by considering therapy modification and avoiding drug combination were accounted for 17.2 and 12.8% of the most common detected interactions, respectively. Seventy-eight percent of DDIs induced no harm to patient. Clinical pharmacist provided different types of recommendations to manage detected interactions, which ranged from therapy outcome monitoring to stop DDIs. A great proportion of pharmacist's interventions (92%) were accepted by prescribers. Compared to patients with stage 3 and 4 CKD, patients with stage 5 had a significantly higher number of DDIs (stage 3 vs 5: p = 0.0019, stage 4 vs 5: p = 0.0456). The number of comorbidities (p = 0.0003) and (p <0.0001) medications were found to be significantly greater in group A. CONCLUSION Clinical pharmacist performed important interventions in timely identifying, managing DDIs, and prevention of associated patient harms. HOW TO CITE THIS ARTICLE Aghili M, Kasturirangan MN. Management of Drug-Drug Interactions among Critically Ill Patients with Chronic Kidney Disease: Impact of Clinical Pharmacist's Interventions. Indian J Crit Care Med 2021;25(11):1226-1231.
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Affiliation(s)
- Mina Aghili
- Department of Pharmacy Practice, Visveswarapura Institute of Pharmaceutical Sciences, Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka, India; Department of Pharmacy Practice, Kempegowda Institute of Medical Sciences Hospital and Research Centre, Bengaluru, Karnataka, India
| | - Meera Neelathahalli Kasturirangan
- Department of Pharmacy Practice, Visveswarapura Institute of Pharmaceutical Sciences, Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka, India; Department of Pharmacy Practice, Kempegowda Institute of Medical Sciences Hospital and Research Centre, Bengaluru, Karnataka, India
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Okoro RN. Clinical pharmacist as a member of the multidisciplinary kidney care team in low‐ and middle‐income countries: An opportunity to reduce the incidence of drug‐related problems. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Roland Nnaemeka Okoro
- Department of Clinical Pharmacy and Pharmacy Administration University of Maiduguri Maiduguri Nigeria
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Arredondo E, Udeani G, Horseman M, Hintze TD, Surani S. Role of Clinical Pharmacists in Intensive Care Units. Cureus 2021; 13:e17929. [PMID: 34660121 PMCID: PMC8513498 DOI: 10.7759/cureus.17929] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 01/22/2023] Open
Abstract
The cost of health care has been rising in the United States and globally and will continue to increase. Intensive care unit (ICU) care carries a significant portion of the cost for the hospitals. The Institute of Medicine and subsequent studies have suggested that medication errors account for significant morbidity, mortality, and cost, frequently encountered in the ICU. Over the past three decades, clinical pharmacists have emerged from dispensing medication to getting involved in direct patient care and have become an integral part of the multidisciplinary critical care team. Clinical pharmacists play a significant role in reducing medication errors and costs, medication reconciliation, antibiotic stewardship, and patient and health care provider education. This review will discuss the health care and ICU cost, the evolving role of clinical pharmacists in managing critically ill patients, and their contributions in the ICU to mitigate the risks, improve patient outcomes, and decrease health care costs.
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Affiliation(s)
- Enrique Arredondo
- Pharmacy, Irma Lerma Rangel College of Pharmacy, Texas A&M Health Science Center, Kingsville, USA
| | - George Udeani
- Pharmacy, Irma Lerma Rangel College of Pharmacy, Texas A&M Health Science Center, Kingsville, USA
| | - Michael Horseman
- Pharmacy, Irma Lerma Rangel College of Pharmacy, Texas A&M Health Science Center, Kingsville, USA
| | - Trager D Hintze
- Pharmacy, Irma Lerma Rangel College of Pharmacy, Texas A&M Health Science Center, Kingsville, USA
| | - Salim Surani
- Anesthesiology, Mayo Clinic, Rochester, USA
- Medicine, Irma Lerma Rangel College of Pharmacy, Texas A&M Health Science Center, Kingsville, USA
- Medicine, University of North Texas, Dallas, USA
- Internal Medicine, Pulmonary Associates, Corpus Christi, USA
- Clinical Medicine, University of Houston, Houston, USA
- Medicine, College of Medicine, Texas A&M Health Science Center, Bryan, USA
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Mohan A, Manikandan S, Ravikumar TS, Batmanabane G. Decreasing medication errors in four intensive care units of a tertiary care teaching hospital in India using a sensitization programme. NATIONAL MEDICAL JOURNAL OF INDIA 2020; 32:207-212. [PMID: 32769240 DOI: 10.4103/0970-258x.291294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Medication errors have an adverse impact on the healthcare system by increasing patient morbidity and mortality. They are preventable, and educational or technology-based interventions are needed to reduce their prevalence and improve medication safety. We aimed to study the impact of a sensitization programme and a blame-free reporting tool for doctors and nurses on the prevalence and reporting of medication errors in the intensive care units (ICUs) of a tertiary care teaching hospital. Methods This prospective interventional study was conducted in the ICUs of cardiology, medicine, paediatrics and neonatology. Baseline medication errors were detected by prescription order review and direct observation of administration of medication for 30 days. A sensitization programme was conducted for doctors and nurses in these ICUs, the results were discussed, and a blame-free medication error reporting tool was introduced. Medication charts were modified to remove the transcription process in the cardiology and paediatrics ICUs. The follow-up study was conducted for 30 days in each ICU to monitor the impact of the sensitization programme. Results The prevalence of medication errors was found to be 334.1/1000 patient observation days. Prescription errors were the most common types of errors at 129.1/1000 patient observation days. The interventions significantly reduced the error rate in all four ICUs. The overall number of prescriptions with errors was reduced from 9.1% (177/1944) to 3.5% (48/1373) and no medication error was reported using the tool. Conclusion The sensitization programme on medication errors for doctors and nurses may be effective in improving medication safety. The impact was more pronounced in prescription errors. Reporting of medication errors did not improve in this study despite the introduction of a blame-free reporting tool.
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Affiliation(s)
- Anbarasan Mohan
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - S Manikandan
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - T S Ravikumar
- Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
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Li L, Li X, Xia Y, Chu Y, Zhong H, Li J, Liang P, Bu Y, Zhao R, Liao Y, Yang P, Lu X, Jiang S. Recommendation of Antimicrobial Dosing Optimization During Continuous Renal Replacement Therapy. Front Pharmacol 2020; 11:786. [PMID: 32547394 PMCID: PMC7273837 DOI: 10.3389/fphar.2020.00786] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 05/12/2020] [Indexed: 12/13/2022] Open
Abstract
Continuous Renal Replacement Therapy (CRRT) is more and more widely used in patients for various indications recent years. It is still intricate for clinicians to decide a suitable empiric antimicrobial dosing for patients receiving CRRT. Inappropriate doses of antimicrobial agents may lead to treatment failure or drug resistance of pathogens. CRRT factors, patient individual conditions and drug pharmacokinetics/pharmacodynamics are the main elements effecting the antimicrobial dosing adjustment. With the development of CRRT techniques, some antimicrobial dosing recommendations in earlier studies were no longer appropriate for clinical use now. Here, we reviewed the literatures involving in new progresses of antimicrobial dosages, and complied the updated empirical dosing strategies based on CRRT modalities and effluent flow rates. The following antimicrobial agents were included for review: flucloxacillin, piperacillin/tazobactam, ceftriaxone, ceftazidime/avibactam, cefepime, ceftolozane/tazobactam, sulbactam, meropenem, imipenem, panipenem, biapenem, ertapenem, doripenem, amikacin, ciprofloxacin, levofloxacin, moxifloxacin, clindamycin, azithromycin, tigecycline, polymyxin B, colistin, vancomycin, teicoplanin, linezolid, daptomycin, sulfamethoxazole/trimethoprim, fluconazole, voriconazole, posaconzole, caspofungin, micafungin, amphotericin B, acyclovir, ganciclovir, oseltamivir, and peramivir.
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Affiliation(s)
- Lu Li
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xin Li
- Department of Pharmacy, Second Hospital of Jilin University, Changchun, China
| | - Yanzhe Xia
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanqi Chu
- Department of Pharmacy, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Haili Zhong
- Department of Pharmacy, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jia Li
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Pei Liang
- Department of Pharmacy, Nanjing Drum Tower Hospital, Nanjing, China
| | - Yishan Bu
- Department of Pharmacy, Tianjin First Central Hospital, Tianjin, China
| | - Rui Zhao
- School of Medicine, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Yun Liao
- Department of Pharmacy, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ping Yang
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xiaoyang Lu
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Saiping Jiang
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
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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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Wei M, Wang X, Zhang D, Zhang X. Relationship between the number of hospital pharmacists and hospital pharmaceutical expenditure: a macro-level panel data model of fixed effects with individual and time. BMC Health Serv Res 2020; 20:91. [PMID: 32024515 PMCID: PMC7003417 DOI: 10.1186/s12913-020-4907-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 01/14/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The rapid increase in pharmaceutical expenditure (PE) has been a main problem of global healthcare reform for decades. Previous studies demonstrated that pharmacists play an indispensable role in controlling PE, but macro-research evidence is scarce. Exploring the role of pharmacists from a macro-perspective is essential for pharmacy source allocation with an advantage of extensive applicability over regions. This study aimed to explore the relationship between the number of hospital pharmacists and hospital PE and to provide a macro-perspective evidence to curb the increasing PE and decline unnecessary medications. METHODS Data were extracted from China Health Statistics Yearbook from 2011 to 2018. A panel dataset with 31 provinces from 2010 to 2017 was constructed. Amongst them, 'Number of hospital pharmacists per 1 million of population' (HLPT) was selected as an independent variable, 'Per visit of hospital outpatient pharmaceutical expenditure' (OTPE) and 'Per capita of hospital inpatient pharmaceutical expenditure' (ITPE) were selected as dependent variables, and 'Number of hospital physicians per 1 million of population' (HLPN) and 'Drug price index' (DPI) were applied as control variables. Fixed-effect panel data analysis was performed to evaluate the relationship between the number of hospital pharmacists and hospital PE. RESULTS HLPT had a significant and negative relationships with OTPE (β1 = - 0.0893, p = 0.0132) and ITPE (β1 = - 4.924, p < 0.001). Considering the control variables, the significant and negative relationships with HLPT and OTPE remained unchanged (β1 = - 0.141, p < 0.001; β1 = - 4.771, p < 0.001, respectively), indicating that an increase in hospital pharmacist per 1 million of population led to a decrease of ¥474 million ($67.4 million) OTPE and ¥902 million ($128 million) ITPE in 2017. Overall, in 2017, an increase of 1 hospital pharmacist led to a decrease of approximately ¥1 million ($142 thousands) hospital PE nationwide. CONCLUSION This study confirmed the negative relationship between hospital pharmacists and hospital PE, indicating that hospital pharmacists might play a significant role in controlling PE. Pharmacists were encouraged to participate in more drug-therapy-related activities, such as medication reconciliation.
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Affiliation(s)
- Ming Wei
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xuemei Wang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Dandan Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
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Al Raiisi F, Stewart D, Fernandez-Llimos F, Salgado TM, Mohamed MF, Cunningham S. Clinical pharmacy practice in the care of Chronic Kidney Disease patients: a systematic review. Int J Clin Pharm 2019; 41:630-666. [PMID: 30963447 PMCID: PMC6554252 DOI: 10.1007/s11096-019-00816-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 03/27/2019] [Indexed: 11/24/2022]
Abstract
Background Clinical pharmacy services have potential to contribute significantly to the multidisciplinary team providing safe, effective and economic care for patients. Given recent practice developments (e.g. polypharmacy reviews and pharmacist prescribing) there is a need to provide a current synthesis of the evidence base for characteristics and outcomes of clinical pharmacy practice in chronic kidney disease patients. Aim of the review To critically appraise, synthesise and present the available evidence of the characteristics (structures and processes) and outcomes of clinical pharmacy practice as part of the multidisciplinary care of patients with chronic kidney disease. Method PubMed, International Pharmaceutical Abstracts (IPA), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline and Scopus were searched for peer reviewed papers using improved search strategy. Included studies were quality assessed using Downs and Black tool for controlled studies and the mixed methods appraisal tool for all controlled and non-controlled studies. Data were extracted and synthesised using a narrative approach. Screening, quality assessment and data extraction were performed by two independent researchers. Ethics approval was not required. Results Forty-seven studies were identified from a variety of countries, with 31 based in a hospital setting. Controlled study designs were employed in 20, with only ten of these using randomisation. Resources available for service provision were poorly reported in all papers. Positive impact on clinical outcomes included significant improvement in parathyroid hormone, blood pressure, haemoglobin and creatinine clearance. Pharmacists identified 5302 drug related problems in 2933 patients and made 3160 recommendations with acceptance rates up to 95%. Impact on humanistic outcomes was shown through improvement in health related quality of life and patient satisfaction. Economic benefits arose from significant cost savings through pharmaceutical care provision. Conclusion While there is some evidence of positive impact on clinical, humanistic and economic outcomes, this evidence is generally of low quality and insufficient volume. While the existing evidence is in favour of pharmacists' involvement in the multidisciplinary team providing care to patients with chronic kidney disease, more high-quality research is warranted.
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Affiliation(s)
- Fatma Al Raiisi
- School of Pharmacy & Life Sciences, Robert Gordon University, Aberdeen, Scotland, UK
| | - Derek Stewart
- School of Pharmacy & Life Sciences, Robert Gordon University, Aberdeen, Scotland, UK
| | - Fernando Fernandez-Llimos
- Research Institute for Medicines and Pharmaceutical Sciences (iMed.UL), Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal
| | - Teresa M Salgado
- Department of Pharmacotherapy & Outcomes Science, Center for Pharmacy Practice Innovation, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
| | | | - Scott Cunningham
- School of Pharmacy & Life Sciences, Robert Gordon University, Aberdeen, Scotland, UK.
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Hammond DA, Gurnani PK, Flannery AH, Smetana KS, Westrick JC, Lat I, Rech MA. Scoping Review of Interventions Associated with Cost Avoidance Able to Be Performed in the Intensive Care Unit and Emergency Department. Pharmacotherapy 2019; 39:215-231. [PMID: 30664269 DOI: 10.1002/phar.2224] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A framework for evaluating pharmacists' impact on cost avoidance in the intensive care unit (ICU) and emergency department (ED) has not been established. This scoping review was registered (CRD42018091217) and conducted to identify, aggregate, and qualitatively describe the highest quality evidence for cost avoidance generated by clinical pharmacists on interventions performed in an ICU or ED. Searches were conducted in PubMed, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from inception until April 2018. The level of evidence (LOE) for each specific category of intervention was evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation evidence-to-decision framework. The risks of bias for articles were evaluated using Newcastle Ottawa and Cochrane Collaboration tools. The values from all interventions were inflated to 2018 U.S. dollars using the consumer price index for medical care. Of the 464 articles initially identified, 371 were excluded and 93 were included. After reviewing references from the articles included, an additional 71 articles were also reviewed. The 38 cost intervention categories were supported by varying LOEs: IA (0 categories), IB (1 category), IIA (4 categories), IIB (0 categories), III (27 categories), and IV (6 categories), and articles mostly displayed low to moderate risks of bias. Pharmacists generate cost avoidance through a variety of interventions in critically and emergently ill patients. The quality of evidence supporting specific cost avoidance values is generally low. Quantification of and factors associated with the cost avoidance generated from pharmacists caring for these patients are of paramount importance.
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Affiliation(s)
- Drayton A Hammond
- Medical Intensive Care Unit, Rush University Medical Center, Chicago, Illinois
| | - Payal K Gurnani
- Cardiovascular Intensive Care Unit, Rush University Medical Center, Chicago, Illinois
| | - Alexander H Flannery
- Medical Intensive Care Unit, University of Kentucky HealthCare, Lexington, Kentucky
| | - Keaton S Smetana
- Neurosciences Intensive Care Unit, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Ishaq Lat
- Department of Pharmacy, Shirley Ryan AbilityLab, Chicago, Illinois
| | - Megan A Rech
- Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
- Department of Emergency Medicine, Loyola University Medical Center, Maywood, Illinois
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15
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Al-Dorzi HM, Eissa AT, Khan RM, Harbi SAA, Aldabbagh T, Arabi YM. Dosing errors of empirical antibiotics in critically ill patients with severe sepsis or septic shock: A prospective observational study. Int J Health Sci (Qassim) 2019; 13:48-55. [PMID: 31341455 PMCID: PMC6619455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Effective antibiotic therapy is crucial in sepsis management. Studies have emphasized on antibiotic administration timing more than dosing. We evaluated the frequency and risk factors of antibiotic dosing errors in sepsis. MATERIALS AND METHODS This prospective observational study compared the doses of intravenous empirical antibiotics in the 1st day of sepsis diagnosis with those recommended by Micromedex, considering sepsis source and glomerular filtration rate estimated by the modification of diet in renal disease equation. The doses were classified as under-dosed, over-dosed, or appropriate. We excluded antibiotics which did not need a dose adjustment. The under-dosing rate was retrospectively evaluated according to the creatinine clearance estimated by the Cockcroft-Gault equation. RESULTS Between October 1, 2013, and April 30, 2014, 189 patients were evaluated (age 61.6 ± 18.6 years, acute physiology and chronic health evaluation II score 22.8 ± 7.0, 58.7% septic shock) with 415 antibiotic prescriptions (2.2 ± 0.9 prescriptions per patient). Antibiotic dosing was appropriate in 50.8% of patients; under-dosing in 30.7% and overdosing in 25.9%. Under-dosing prevalence was 39.4% when kidney function was assessed by the Cockcroft-Gault equation. Vancomycin was associated with the highest under-dosing rate (39.4%), followed by piperacillin/tazobactam (12.1%). The cohort mortality was 35.4%. Age, shock, chronic kidney disease, and cirrhosis independently predicted mortality on multivariable logistic regression analysis. Antibiotic dosing error was not associated with mortality: Over-versus appropriate dosing (odds ratio [OR], 1.41; 95% confidence interval [CI], 0.57-3.47), under-versus appropriate dosing (OR, 0.57; 95% CI, 0.24-1.35). CONCLUSIONS Antibiotic dosing errors were common in patients with sepsis. Vancomycin had the highest under-dosing rate. Antibiotic dosing errors were not associated with increased mortality.
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Affiliation(s)
- Hasan M. Al-Dorzi
- Department of Intensive Care, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia,Address for correspondence: Hasan M. Al-Dorzi, Department of Intensive Care, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, ICU 1425 PO Box 22490, Riyadh 11426, Kingdom of Saudi Arabia. Tel.: +966 (11) 801-1111. Ext.: 18855/18877. E-mail:
| | - Abdullah T. Eissa
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia,Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Raymond M. Khan
- Department of Intensive Care, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Shmeylan A. Al Harbi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia,Department of Pharmaceutical Care, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Tarek Aldabbagh
- Department of Intensive Care, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Yaseen M. Arabi
- Department of Intensive Care, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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16
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Khanal A, Peterson GM, Jose MD, Castelino RL. Comparison of equations for dosing of medications in renal impairment. Nephrology (Carlton) 2018; 22:470-477. [PMID: 27278107 DOI: 10.1111/nep.12834] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 04/29/2016] [Accepted: 06/05/2016] [Indexed: 11/30/2022]
Abstract
AIM The aim of this study is to determine the concordance among the Cockcroft-Gault, the Modification of Diet in Renal Disease and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations in hypothetical dosing of renally cleared medications. METHODS A total of 2163 patients prescribed at least one of the 31 renally cleared drugs under review were included in the study. Kidney function was estimated using the three equations. We compared actual prescribed dosages of the same drug with recommended dosages based on the kidney function as calculated by each of the equations and applying dosing recommendations in the Australian Medicines Handbook. RESULTS There was a significant difference in the kidney function values estimated from the three equations (P < 0.001). Despite the good overall agreement in renal drug dosing, we found selected but potentially important discrepancies among the doses rendered from the equations. The CKD-EPI equation non-normalized for body surface area had a greater rate of concordance with the Cockcroft-Gault equation than the Modification of Diet in Renal Disease equation for renal drug dosing. CONCLUSIONS There is need for a long-term multi-centre study in a diverse population to define the clinical effects of the discrepancies among the equations for drug dosing. Given the greater concordance of the non-normalized CKD-EPI equation with the Cockcroft-Gault equation for dosing, the recommendation by Kidney Health Australia and the United States National Kidney Disease Education Program that 'dosing based on either eCrCl or an eGFR with body surface area normalization removed are acceptable' seems suitable and practicable for the purpose of dosing of non-critical drugs in the primary care setting.
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Affiliation(s)
- Aarati Khanal
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | | | - Matthew D Jose
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
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17
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Mei JP, Ali-Moghaddam A, Mueller BA. Survey of pharmacists’ antibiotic dosing recommendations for sustained low-efficiency dialysis. Int J Clin Pharm 2016; 38:127-34. [PMID: 26499505 DOI: 10.1007/s11096-015-0214-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 10/15/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND The use of hybrid renal replacement therapies like sustained low efficiency dialysis (SLED) is increasing in ICUs worldwide. However, pharmacokinetic studies designed to inform therapeutic antibiotic dosing in critically ill patients receiving SLED are limited. SLED operational characteristics vary across institutions. Pharmacists in institutions that utilize SLED are challenged to recommend therapeutic doses for antibiotics. OBJECTIVE To characterize pharmacist-recommended antibiotic regimens for SLED. METHODS An electronic survey was sent to pharmacist members of the American College of Clinical Pharmacy in the Nephrology or Critical Care Practice and Research Network. Dosing recommendations for a hypothetical critically ill septic patient were collected for cefepime, ceftaroline, daptomycin, levofloxacin, meropenem, and piperacillin/tazobactam. Main outcome measure Antibiotic regimens for the six antibiotics, their frequency, pharmacist’s experience with renal replacement therapies (RRT), post-graduate training, years of clinical experience, number of staffed beds in their hospital, and RRT employed in their ICUs. RESULTS The survey was completed by 69 clinical pharmacists who had 8.5 ± 7.5 (mean ± SD) years of experience. All pharmacists had experience dosing medications for patients receiving RRT. The most frequently recommended regimen for each antibiotic was: cefepime 1000 mg every 24 h, ceftaroline 200 mg every 12 h, daptomycin 6 mg/kg every 24 h, levofloxacin 500 mg every 24 h, meropenem 1000 mg every 12 h, and piperacillin/tazobactam 2250 mg every 8 h. Up to nine distinct regimens were recommended for each antibiotic, and the total daily dose between these regimens ranged by as much as a 12-fold. Neither pharmacist’s experience with SLED, post-graduate training, nor years of clinical experience were significantly associated with particular dosing recommendations for the antibiotics. CONCLUSION Pharmacists working in institutions that utilize SLED make antibiotic dosing recommendations that vary 4–12-fold depending on the drug. Published research does not provide adequate guidance to optimally dose antibiotics in patients receiving SLED. More SLED pharmacokinetic trials, real-time serum concentration monitoring and advanced pharmacokinetic modeling techniques are necessary to ensure therapeutic dosing in patients receiving SLED.
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18
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Lazaryan M, Abu-Kishk I, Rosenfeld-Yehoshua N, Berkovitch S, Toledano M, Reshef I, Kanari T, Ziv-Baran T, Berkovitch M. Pharmacist Remote Review of Medication Prescriptions for Appropriateness in Pediatric Intensive Care Unit. Front Pharmacol 2016; 7:243. [PMID: 27555821 PMCID: PMC4977293 DOI: 10.3389/fphar.2016.00243] [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: 05/31/2016] [Accepted: 07/25/2016] [Indexed: 11/13/2022] Open
Abstract
Background: One aspect of ordering and prescribing medication is the requirement for a trained professional to review medication orders or prescriptions for appropriateness. In practice, this review process is usually performed by a clinical pharmacist. However, in many medical centers there is a shortage of staff and a pharmacist is not always available. Objective: To determine whether remote review of medication orders by a pharmacist is a plausible method in a pediatric intensive care unit (PICU). Methods: A pharmacist from the pharmacy department reviewed medication orders of patients admitted to our PICU over a 7-month period for appropriateness. A special form for medical orders was filled in and sent to the physician in the PICU, who replied informing whether the recommendation had been accepted. The time spent by the pharmacist for this activity was recorded. Results: The review time for one medical record was 8.9 (95% CI, 6.9–10.9) min. Every additional drug prescribed increased the total review time by 0.8 (95% CI, 0.45–1.11) min. The pharmacist filled in 186 forms on 117 admissions for 109 children. The median review time was 15 (12.8–18.8) and 12 (9–15) min, respectively, for patients with psychiatric-neurologic disorders compared to those without (p = 0.032). Usually, a daily workload of 240 min was needed for the pharmacist accompanying the round in contrast to 108 min per day needed to review all the medical records in 95% of the cases. The physician accepted 51.2%, rejected 11.9%, and made no comment on 36.9% of the recommendations. Conclusion: Hospitals facing budget shortages can carry out focused remote reviews of prescriptions by the pharmacist.
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Affiliation(s)
- Moran Lazaryan
- Pharmacy Department, Assaf Harofeh Medical Center, Zerifin, affiliated to Sackler School of Medicine, Tel-Aviv University Tel-Aviv, Israel
| | - Ibrahim Abu-Kishk
- Pediatric Intensive Care Unit, Assaf Harofeh Medical Center, Zerifin, affiliated to Sackler School of Medicine, Tel-Aviv University Tel-Aviv, Israel
| | - Noa Rosenfeld-Yehoshua
- Pediatric Intensive Care Unit, Assaf Harofeh Medical Center, Zerifin, affiliated to Sackler School of Medicine, Tel-Aviv University Tel-Aviv, Israel
| | - Sofia Berkovitch
- Pharmacy Department, Assaf Harofeh Medical Center, Zerifin, affiliated to Sackler School of Medicine, Tel-Aviv University Tel-Aviv, Israel
| | - Michal Toledano
- Pharmacy Department, Assaf Harofeh Medical Center, Zerifin, affiliated to Sackler School of Medicine, Tel-Aviv University Tel-Aviv, Israel
| | - Iris Reshef
- Pediatric Intensive Care Unit, Assaf Harofeh Medical Center, Zerifin, affiliated to Sackler School of Medicine, Tel-Aviv University Tel-Aviv, Israel
| | - Tal Kanari
- Pediatric Intensive Care Unit, Assaf Harofeh Medical Center, Zerifin, affiliated to Sackler School of Medicine, Tel-Aviv University Tel-Aviv, Israel
| | - Tomer Ziv-Baran
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler School of Medicine, Tel-Aviv University Tel-Aviv, Israel
| | - Matitiahu Berkovitch
- Clinical Pharmacology Unit, Assaf Harofeh Medical Center, Zerifin, affiliated to Sackler School of Medicine, Tel-Aviv University Tel-Aviv, Israel
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Yogaratnam D, Ditch K, Medeiros K, Miller MA, Smith BS. The Impact of Liver and Renal Dysfunction on the Pharmacokinetics and Pharmacodynamics of Sedative and Analgesic Drugs in Critically Ill Adult Patients. Crit Care Nurs Clin North Am 2016; 28:183-94. [PMID: 27215356 DOI: 10.1016/j.cnc.2016.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The use of sedative and analgesic drug therapy is often necessary for the care of critically ill patients. Renal and hepatic dysfunction, which occurs frequently in this patient population, can significantly alter drugs' pharmacokinetic and pharmacodynamics properties. By anticipating how these medications may be affected by liver or kidney dysfunction, health care practitioners may be able to provide tailored dosing regimens that ensure optimal comfort while minimizing the risk of adverse events.
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Affiliation(s)
- Dinesh Yogaratnam
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences University, 19 Foster Street, Worcester, MA 01608, USA.
| | - Kristen Ditch
- Department of Pharmacy, Neuro-Trauma Burn Intensive Care Unit, UMass Memorial Medical Center, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Kristin Medeiros
- Department of Pharmacy, UMass Memorial Medical Center, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Melissa A Miller
- Emergency Medicine, New York-Presbyterian Hospital, 525 East 68th Street, New York, NY 10065, USA
| | - Brian S Smith
- Specialty Pharmacy Services, UMass Memorial Shields Pharmacy, 55 Lake Avenue North, Worcester, MA 01655, USA
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20
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DeWitt KM, Weiss SJ, Rankin S, Ernst A, Sarangarm P. Impact of an emergency medicine pharmacist on antibiotic dosing adjustment. Am J Emerg Med 2016; 34:980-4. [PMID: 26947363 DOI: 10.1016/j.ajem.2016.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 02/01/2016] [Accepted: 02/10/2016] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE Overall medication-related errors in the emergency department (ED) are 13.5 times more likely to occur in the absence of an emergency medicine pharmacist (EMP). Although the effectiveness of pharmacist-driven renal dosing adjustment has been studied in the intensive care unit, data are lacking in the ED setting. The aim of our study was to evaluate the appropriateness of antibiotic dosing when an EMP is physically present in the ED compared to when absent. METHODS This was a retrospective cohort study of patients treated in a level I trauma center with 75 adult and 12 pediatric beds and an annual census of 90000 patients. The study period was from March 1 to September 30, 2014. An EMP was physically present in the ED from 11:00 to 01:30 and absent from 01:31 to 10:59. Male and female patients 18years and older were considered for inclusion if cefazolin, cefepime, ciprofloxacin, piperacillin-tazobactam, or vancomycin was ordered. The primary outcome was the composite rate of correct antibiotic dose and frequency. Statistics included a multivariable logistic regression using age, sex, presence of EMP, and creatinine clearance as independent predictors of correct antibiotic use. RESULTS A total 210 cases were randomly chosen for evaluation, half during times when EMPs were present and half when they were absent. There were 130 males (62%) with an overall mean age of 54±18years. Overall, 178 (85%) of 210 of the antibiotic orders were appropriate, with 95% appropriate when an EMP was present compared to 74% when an EMP was absent (odds ratio, 6.9; 95% confidence interval, 2.5-18.8). In a logistic regression model, antibiotic appropriateness was independently associated with the presence of the EMP and creatinine clearance. CONCLUSION Antibiotics that require renal and/or weight dosing adjustment are 6.5 times more likely to be appropriate in the ED when an EMP is present. Prevalence of antibiotic dosing error is related to both the presence of EMPs and the degree of renal impairment.
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Affiliation(s)
- Kyle M DeWitt
- Departments of Pharmacy, University of New, Mexico, Albuquerque, NM
| | - Steven J Weiss
- Department of Emergency Medicine, University of New, Mexico, Albuquerque, NM
| | - Shannon Rankin
- Departments of Pharmacy, University of New, Mexico, Albuquerque, NM
| | - Amy Ernst
- Department of Emergency Medicine, University of New, Mexico, Albuquerque, NM
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21
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Sime FB, Roberts JA. Antibiotic Dosing In Critically Ill Patients Receiving Renal Replacement Therapy. Expert Rev Clin Pharmacol 2016; 9:497-499. [PMID: 26677734 DOI: 10.1586/17512433.2016.1133290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Fekade Bruck Sime
- a Burns, Trauma & Critical Care Research Centre , The University of Queensland , Brisbane , Queensland , Australia.,b Department of Molecular and Clinical Pharmacology , University of Liverpool , Liverpool , UK
| | - Jason A Roberts
- a Burns, Trauma & Critical Care Research Centre , The University of Queensland , Brisbane , Queensland , Australia.,b Department of Molecular and Clinical Pharmacology , University of Liverpool , Liverpool , UK.,c Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Queensland , Australia.,d Pharmacy Department , Royal Brisbane and Women's Hospital , Brisbane , Queensland , Australia.,e School of Pharmacy , The University of Queensland , Brisbane , Queensland , Australia
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22
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Tiru B, DiNino EK, Orenstein A, Mailloux PT, Pesaturo A, Gupta A, McGee WT. The Economic and Humanistic Burden of Severe Sepsis. PHARMACOECONOMICS 2015; 33:925-937. [PMID: 25935211 DOI: 10.1007/s40273-015-0282-y] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Sepsis and severe sepsis in particular remain a major health problem worldwide. Their cost to society extends well beyond lives lost, as the impact of survivorship is increasingly felt. A review of the medical literature was completed in MEDLINE using the search phrases "severe sepsis" and "septic shock" and the MeSH terms "epidemiology", "statistics", "mortality", "economics", and "quality of life". Results were limited to human trials that were published in English from 2002 to 2014. Articles were classified by dominant themes to address epidemiology and outcomes, including quality of life of both patient and family caregivers, as well as societal costs. The severity of sepsis is determined by the number of organ failures and the presence of shock. In most developed countries, severe sepsis and septic shock account for disproportionate mortality and resource utilization. Although mortality rates have decreased, overall mortality continues to increase and is projected to accelerate as people live longer with more chronic illness. Among those who do survive, impaired quality of life, increased dependence, and rehospitalization increase healthcare consumption and, along with increased mortality, all contribute to the humanistic burden of severe sepsis. A large part of the economic burden of severe sepsis occurs after discharge. Initial inpatient costs represent only 30 % of the total cost and are related to severity and length of stay, whereas lost productivity and other indirect medical costs following hospitalization account for the majority of the economic burden of sepsis. Timeliness of treatment as well as avoidance of intensive care unit (ICU)-acquired illness/morbidity lead to important differences in both cost and outcome of treatment for severe sepsis and represent areas where improvement in care is possible. The degree of sophistication of a health system from a national perspective results in significant differences in resource use and outcomes for patients with serious infections. Comprehensive understanding of the cost and humanistic burden of severe sepsis provides an initial practical framework for health policy development and resource use.
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Affiliation(s)
- Bogdan Tiru
- Medicine, Tufts University School of Medicine, Boston, MA, USA,
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23
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Jiang SP, Chen J, Zhang XG, Lu XY, Zhao QW. Implementation of pharmacists' interventions and assessment of medication errors in an intensive care unit of a Chinese tertiary hospital. Ther Clin Risk Manag 2014; 10:861-6. [PMID: 25328401 PMCID: PMC4199561 DOI: 10.2147/tcrm.s69585] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Pharmacist interventions and medication errors potentially differ between the People’s Republic of China and other countries. This study aimed to report interventions administered by clinical pharmacists and analyze medication errors in an intensive care unit (ICU) in a tertiary hospital in People’s Republic of China. Method A prospective, noncomparative, 6-month observational study was conducted in a general ICU of a tertiary hospital in the People’s Republic of China. Clinical pharmacists performed interventions to prevent or resolve medication errors during daily rounds and documented all of these interventions and medication errors. Such interventions and medication errors were categorized and then analyzed. Results During the 6-month observation period, a total of 489 pharmacist interventions were reported. Approximately 407 (83.2%) pharmacist interventions were accepted by ICU physicians. The incidence rate of medication errors was 124.7 per 1,000 patient-days. Improper drug frequency or dosing (n=152, 37.3%), drug omission (n=83, 20.4%), and potential or actual occurrence of adverse drug reaction (n=54, 13.3%) were the three most commonly committed medication errors. Approximately 339 (83.4%) medication errors did not pose any risks to the patients. Antimicrobials (n=171, 35.0%) were the most frequent type of medication associated with errors. Conclusion Medication errors during prescription frequently occurred in an ICU of a tertiary hospital in the People’s Republic of China. Pharmacist interventions were also efficient in preventing medication errors.
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Affiliation(s)
- Sai-Ping Jiang
- Department of Pharmacy, Zhejiang University, Hangzhou, People's Republic of China
| | - Jian Chen
- Intensive Care Unit, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Xing-Guo Zhang
- Department of Pharmacy, Zhejiang University, Hangzhou, People's Republic of China
| | - Xiao-Yang Lu
- Department of Pharmacy, Zhejiang University, Hangzhou, People's Republic of China
| | - Qing-Wei Zhao
- Department of Pharmacy, Zhejiang University, Hangzhou, People's Republic of China
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