ABSTRACT
Introduction: The 'ICU Liberation Bundle' is recommended by Society of Critical Care Medicine guidelines as standard supportive care. Significant deviations were made to providing bundled care during the COVID-19 pandemic. Implications on patient outcomes are unknown. Research Question or Hypothesis: What influence did COVID-19 have on bundle adherence and clinical outcomes? Study Design: A single-center retrospective cohort study of adult medical ICU patients requiring mechanical ventilation (MV) >= 48 hours and ICU stay >= 7 days. Patients with comfort measures within 48 hours, long-term care residents, and hospital transfers were excluded. Patients were separated into three cohorts based on ICU admission time and COVID-19 status: (Pre-pandemic [pre-group] April 2019-March 2020;Pandemic COVID-19 negative [COV-neg] and Pandemic COVID-19 positive [COV-pos]: April 2020-March 2021). Method(s): Assessment of daily bundle eligibility and adherence was performed over the first 7 days after intubation. Primary outcomes were average daily adherence and days of complete adherence. Secondary outcomes included days alive and free of MV and delirium, readmission, and mortality. Categorical data were compared using Fisher's exact test and continuous data using Kruskal-Wallis/Mann Whitney U tests. Result(s): A total of 410 patients were eligible. A random sample of 170 patients found 137 meeting inclusion of which 31 were excluded. An additional random sample was performed including 67 patients in the final analysis (pre-group n=21;COV-neg n=21;COV-pos n=25). Baseline demographics were similar. Median daily adherence and days of complete adherence were statistically different across cohorts (pregroup 68.6% [65-72.8] vs COV-neg 51.4% [45-60.7] vs COV-pos 32.6% [22.6-47.6];p <0.001) and (pre-group 1 [0-1] vs COV-neg 0 [0-0] vs COV-pos 0 [0-0];p <0.001), respectively. Days alive and free of MV was significantly higher pre-pandemic (pre-group 23 [21-24] vs COV-neg 20[15-22] vs COV-pos 18 [7-21];p=0.0149). No other outcomes were different. Conclusion(s): ICU bundle adherence was significantly reduced during the COVID-19 pandemic with possible implications on patient outcomes..
ABSTRACT
Service or Program: Clinical pharmacists as part of an interdisciplinary team implemented a new clinical service model to care for critically ill patients with COVID-19. Pharmacists created an admission order set in the electronic medical record, a critical drug shortage guidance document with alternatives to intravenous analgesic and sedative medications, and a clinical practice guideline for COVID-19 pharmacotherapy to guide providers in the medication-ordering process. Initiatives were made to preserve personal protective equipment and ensure safe medication administration including the creation of bundled care times and promotion of infusions over intermittent dosing whenever possible. An enhanced venous thromboembolism prophylaxis guideline was created which contained more aggressive, weight-based enoxaparin dosing and a period of anti-Xa monitoring. Finally, critical care pharmacists reviewed the charts of all critically ill COVID-19 patients on a daily basis utilizing a task list containing key interventions to ensure optimal pharmacotherapy. Recommendations were communicated directly with ICU providers and documented in progress notes. Justification/Documentation: Over the course of seven weeks, clinical pharmacists reviewed the charts of 138 unique patients, made 1487 interventions, and wrote a total of 944 progress notes documenting both patient-specific recommendations and all routine elements reviewed. The majority of patients (94%) received at least one pharmacist intervention. The most common interventions were pharmacokinetic monitoring (49% of patients), home medication management (46%), analgesia/sedation management with and without neuromuscular blockade (43%), venous thromboembolism prophylaxis or treatment dose recommendations (41%), antimicrobial stewardship measures (36%), and optimization of glycemic control (35%). Adaptability: Residency-trained clinical pharmacists are capable of designing and implementing new processes as part of an interdisciplinary team to help optimize medical care. Significance: Pharmacists can be key leaders in the implementation of new clinical service models that ensure safe and effective pharmacotherapy while addressing specific challenges associated with providing optimal care during an infectious disease pandemic.