Pharmacist Optimization of Bowel Preparations in the Critically Ill: The Poopy Study

INTRODUCTION: Critically ill patients undergo stressful states while in the intensive care unit (ICU) and thus have alterations in bowel habits, including constipation in 20- 83% and diarrhea in 3.3-78%. Patients frequently receive opioid analgesics to assist with sedation and pain control. Appropriate bowel management is essential to prevent further complications during the ICU stay. The purpose of this study is to examine the various bowel preparations (BP) used in ICU patients, time to first bowel movement after initiation or escalation of a BP, and reason for BP discontinuation. METHOD(S): This multi-center, multi-ICU, retrospective observational review evaluated tele-critical care pharmacist interventions documenting initiation or change in BP from January 2, 2021 to June 30, 2021. Interventions were excluded if the BP was renewed, duplicate therapy and/or change in formulation. Descriptive statistics were used to describe the data. RESULT(S): One hundred ninety-six unique patients had at least one BP intervention. Baseline characteristics include 55% male, average age of 64 years, a BMI of 32.9, and 66% COVID-19 positive. One hundred seventy-four unique patients had a BP initiated or added on to current therapy, while 62 unique patients had current therapy escalated. The median days to first bowel movement after initiation or addition of a BP was 5.4 days (range 0-19). Ninety-eight percent of patients received an opioid, either continuous infusion or oral, and 90% received enteral nutrition. Docusate and senna were the primary BPs added when a regimen was initiated. Then, polyethylene glycol was added as the next BP. Lactulose and bisacodyl suppositories were added as 4th line treatment if the patient had not experienced a bowel movement. Methylnaltrexone was used in 1 patient. Fifty-two unique patients had one or more medications from their current bowel regimen discontinued due increased stool output, diarrhea, multiple bowel movements within last 24 hours, or the patient refusing the medication. CONCLUSION(S): Initiation of BPs in critically ill patients, especially if receiving an opiate, may be delayed. Bowel regimen initiation should be considered when the patient is placed on opiate therapy. If the patient continues to have a delayed response to therapy, prompt escalation of therapy may be warranted.

Tele-Critical Care Pharmacist Interventions before and after an Emergency Prescribing Protocol

INTRODUCTION: Prior to the COVID-19 pandemic, telecritical care (TCC) pharmacists evaluated patients at multiple ICUs across this healthcare system using clinical decision support (CDSS) alerts for abnormal laboratory values. To increase provider capacity for higher acuity activities, a critical care pharmacist emergency protocol (CCPEP) was enacted, allowing TCC pharmacists to manage therapy in multiple domains. The purpose of this review was to characterize TCC pharmacist interventions prior to and after CCPEP implementation. METHOD(S): This multi-center, multi-ICU, retrospective observational quality improvement project evaluated TCC pharmacist interventions documented from September 1, 2019, through November 30, 2019 (pre-CCPEP) compared with September 1, 2020, through November 30, 2020 (post- CCPEP). Descriptive statistics were reported. RESULT(S): In the pre-CCPEP period, 1448 interventions were performed in 655 unique patients (mean 2.2 interventions/patient) across 10 ICUs as compared to 2115 interventions in 861 unique patients (mean 2.5 interventions/ patient) across 8 ICUs post-CCPEP, a 46.1% increase in the total number of interventions. Glycemic control interventions decreased from 38.7% to 26.4% of interventions, while medication management interventions increased from 28.3% to 41.3% from the pre- to post-CCPEP period, respectively. In medication management, sedation and analgesia interventions increased from 57 (13.9%) in the pre- CCPEP period to 251 (28.8%) in the post-CCPEP period, cardiovascular medication recommendations decreased from 60 (14.6%) to 50 (5.7%), and gastrointestinal agent recommendations increased from 8 (2%) to 68 (7.8%). Electrolyte management, venous thromboembolism prophylaxis, and stress ulcer prophylaxis intervention rates remained similar. CONCLUSION(S): Implementation of a CCPEP facilitated more interventions by TCC pharmacists than CDSS review alone, especially in general medication management. Increased sedation and analgesia interventions in the post-CCPEP period suggest enhanced complexity of recommendations. More patients were intervened on in the post-CCPEP period with more interventions per patient, which may be due to increased census and acuity in addition to the CCPEP. Future directions include pursuing clinical pharmacist practitioner status in the TCC space.

Tele-critical care medication management interventions via an emergency pharmacy protocol

INTRODUCTION: As a result of the COVID-19 pandemic, this healthcare system enacted a critical care pharmacist emergency prescribing protocol allowing pharmacists to manage therapy in multiple domains. Interventions performed by tele-critical care (TCC) pharmacists across 8 ICUs were categorized into venous thromboembolism prophylaxis, glucose management, electrolyte management, stress ulcer prophylaxis, and general medication management. The purpose of this study was to further characterize TCC pharmacist medication management interventions. METHODS: This multi-center, multi-ICU, retrospective observational review evaluated TCC pharmacist interventions categorized as medication management for adult, ICU-status patients documented from January 4th, 2021, to June 30th, 2021. Descriptive statistics were reported. RESULTS: A total of 2331 medication management interventions were documented for 700 unique patients (mean 3.3 interventions per patient). The average age was 63.4 years and 54.7% of patients were male. An average of 388.5 interventions were performed per month. The most common activities included discontinuing medications (39.2%), adding medications (15.6%), order clarification (11.8 %), dose adjustment (7.7%), changing route/ formulation (5.7%), and laboratory management (5.7%). Sedation medications were the most commonly involved (25.2%) followed by bowel regimens (14.2%), vasopressors (8.2%), and antibiotics (5.8%). Updating sedation score goals (45.5%) and discontinuing orders (45.3%) accounted for the majority of sedation interventions. Other interventions included neuromuscular blockade management, drug shortage management, adding corneal abrasion and ventilator-associated pneumonia prophylaxis, and home medication management. Four of the 8 facilities covered accounted for 83.6% of interventions performed, with one facility accounting for 25.2% of interventions. CONCLUSION: An emergency prescribing protocol allowed TCC pharmacists to proactively optimize pharmacotherapy across multiple categories of medication management interventions. This data will be used to support clinical pharmacist practitioner status in the TCC setting.

Tele-critical care (TCC) pharmacy first shift compared to second shift tcc pharmacist interventions

INTRODUCTION: Tele-critical care (TCC) use expanded dramatically during COVID19 pandemic. As a result of anticipated surges in ICU capacity and increased patient acuity secondary to the pandemic, this healthcare system enacted a critical care pharmacist emergency protocol (CCPEP) allowing critical care pharmacists to manage therapy in multiple domains, ultimately increasing provider bandwidth for additional patient review and higher acuity activities. The purpose of this study was to characterize TCC pharmacist interventions made using the CCPEP comparing first shift versus second shift. METHODS: This multi-center, multi-ICU, retrospective observational review evaluated TCC pharmacist interventions documented from September 1, 2020 through November 30, 2020 for first shift vs. second shift. Prospective chart review occurred for each ICU status patient on first shift, while patient review on second shift was in response to alerts or new admissions. Descriptive statistics were reported. RESULTS: A total of 2152 (1266 on 1st shift and 886 on 2nd shift) documented pharmacist interventions were made during the 3-month period using the critical care pharmacist emergency protocol for 861 unique patients (52.1% on 1st shift). An average of 2.8 interventions per patient were made on 1st shift and 2.1 interventions per patient on 2nd shift. In addition to interventions made for glucose, electrolyte management, stress ulcer prophylaxis and venous thromboembolism prophylaxis, the most common interventions (873/2150, 40%) were categorized as medication management. First shift had 588 interventions versus 2nd shift with 285 interventions. Examples of these interventions overall include sedation, analgesia, and paralytic management (35%);dose adjustments (13%);vasopressor management (4%);fluid management (3%) and clustering care for patients (3%). Adverse drug events avoided totaled 103, with 84% of interventions occurring on 2nd shift. CONCLUSION: Proactive review of patients led to more medication management interventions through use of the CCPEP. The use of the CCPEP expanded pharmacist practice during the COVID-19 pandemic to practice at the top of their license. Future directions include using this data as justification for clinical pharmacist practitioner status and additional critical care pharmacist positions.

Categorization of full-time tele-critical care pharmacist interventions based on shift

INTRODUCTION: Due to an anticipated patient surge related to the COVID-19 pandemic, a critical care pharmacist emergency prescribing protocol (EPP) was enacted allowing pharmacists to manage therapy in multiple domains. As a result of the EPP and an identified need for more proactive medication management, fulltime tele-critical care (TCC) pharmacists transitioned from working second shift to first shift hours, facilitating collaboration with multiple bedside providers in intensive care units (ICU) at 8 facilities. The purpose of this study was to categorize pharmacists' interventions completed on first versus second shift. METHODS: This multi-center, multi-ICU, retrospective observational review evaluated fulltime TCC pharmacist interventions documented from September 1, 2020 to November 30, 2020 (second shift) compared with February 8, 2021 to May 7, 2021 (first shift). While clinical decision support alerts triggered the majority of chart reviews on second shift, prospective chart reviews of select ICU patients were performed on first shift. Descriptive statistics were reported. RESULTS: On second shift, 710 interventions were performed in 395 patients;while on first shift, 1024 interventions were performed in 357 patients. Glycemic control interventions accounted for 43% of second shift interventions compared to 19.5% on first shift. Medication management interventions comprised 30% of second shift activities in contrast with 52.2% on first shift. As the TCC pharmacists cover multiple facilities across the system, a change in facility focus occurred as well. During second shift, one facility totaled 35% of all interventions. With the change to dayshift, two other facilities became the primary focus at 34% and 21.7%, respectively. CONCLUSIONS: By changing from a reactive or alert-driven model to prospective chart review utilizing EPP, a change in intervention type occurred. Medication management, which included sedation management, was a greater focus on first shift owing to greater collaboration with bedside providers. This information will be shared with critical care and pharmacy leadership to continue advancing care and for eventual justification of clinical pharmacist practitioner status in the inpatient space.

Necrotizing fasciitis and candidemia after tocilizumab initiation: A case report

INTRODUCTION: Tocilizumab (TCZ) is an interleukin-6 receptor antagonist approved for the treatment of moderate to severe active rheumatoid arthritis (RA) in patients with inadequate response to one or more disease-modifying anti-rheumatic drugs. It carries a boxed warning for serious infections. Here we describe a case in which a patient experienced both community and hospital-acquired infections (HAI) with multiple pathogens after TCZ receipt. METHODS: A septuagenarian female with an extensive medical history presented to the emergency department with cellulitis and leg swelling 3 days after receiving the first outpatient dose of 380 mg IV TCZ for RA after failing therapy with golimumab, abatacept, and tofacitinib. At the time of the first infusion, an eraser-sized wound was noted on her leg. The patient reported that it had been scratched a week prior. She rapidly developed septic shock with necrotizing fasciitis that necessitated an emergent above-the-knee amputation. The wound culture and initial blood cultures grew Serratia marcescens. A central line was placed for vasopressor administration and she was treated in the ICU for septic shock and acute kidney injury. On hospital days 3 and 4, the patient remained febrile and blood cultures grew Candida albicans, which was deemed a central line-associated blood stream infection. The patient died on hospital day 6 from complications related to her infections. RESULTS: These observed events in our patient highlight important findings regarding therapy with TCZ. There exist previous case reports linking TCZ with development of similar skin and soft tissue infections. Many of these reports raise the concern that TCZ treatment may mask or delay symptoms and laboratory markers of severe life-threatening infections, leading to delays in presentation and treatment. With the use of TCZ in some hospitalized patients with COVID-19 infection, additional reports have described development of candidemia following TCZ administration. This patient rapidly experienced two serious infections shortly after initiation of TCZ therapy, highlighting the need for close patient monitoring and vigorous infection control measures in this population. Further study is warranted to better describe the potential relationship between TCZ and risk for HAI.