Embedding clinical pharmacists in critical care rehab carousel clinics

Introduction: Clinical pharmacists specialising in critical care have become integrated into the critical care workforce providing valuable contributions to patient care.1 These findings are supported through the inclusion of clinical pharmacy services within national professional and commissioned standards for critical care.2,3 On admission to critical care, clinical focus changes from management of any chronic conditions to that of immediate preservation of life. This is inherently associated with acute changes in prescribed medicines.Medicines reconciliation on admission to and discharge from critical care is included specifically within the commissioning standards3 and aims to address any discrepancies generated by this change in focus. Unprecedented pressures experienced during the COVID-19 pandemic have resulted in stretched staff to patient ratios and mobilisation of less experienced staff. This has negatively impacted the end-to-end reconciliation process causing patients to be discharged home with unresolved medicines discrepancies. In line with recent NICE4 and Intensive Care Society guidance,5 rehabilitation of patients, post-critical care is important in completing unresolved actions and optimising care. Consequently, in September 2020 a carousel rehab clinic was introduced. All professional groups were invited to contribute. Objectives: To embed a pharmacist within the rehabilitation clinic to focus on any unresolved medicines reconciliation issues. Methods: Five senior critical care pharmacists (band 8a or above) participated in service provision to the clinic, which ran on two days a week. For consistency and structure, a local SOP and electronic note template was produced. All interventions recommended were discussed with the patient at the time and for GPs to review and action as appropriate in the context of their responsibility for ongoing care. Data collection for this service evaluation was retrospective and performed by one of the critical care pharmacists who had participated in the clinic. Historic clinic dates for September - November 2020 (inclusive) were reviewed on the electronic scheduling system to identify patients who attended clinic;these were then filtered for pharmacist entries to ascertain: • Number of patients reviewed • Number of medication-related interventions made • Intervention type and medication(s) involved Results: Over the 3-month period 51 patients were reviewed with a total of 59 medicine interventions made. The average number of interventions per patient was 1.2, with a range of 0 - 7. Eight intervention categories were identified (see Figure 1);the top three of which recommended stopping a medication (27%), reviewing a medication's need (19%) or restarting a medication (17%). The drugs most frequently intervened on were lansoprazole (12%) and bisoprolol (7%). Examples of significant clinical interventions made include: • Stopping acutely initiated bisoprolol (resolution of acute AF secondary to acute sepsis/dehydration on ICU) • Stopping of acutely started olanzapine for ICU-related agitation/delirium • Dose optimisation of bisporolol (post recent NSTEMI) • Re-initiation of atorvastatin (for secondary prevention of IHD) Conclusion: Medication interventions made by pharmacists in the post ICU rehabilitation clinic setting are clinically significant and add value to patient care both in terms of morbidity and mortality. Our results demonstrate a reduction in polypharmacy burden in line with wider healthcare initiatives.

Correction to: Heparin resistance in COVID­19 patients in the intensive care unit.

In the original publication of this article, one of the co-author name "D. de Monteverde-Robb" was inadvertently mentioned as "R. de Monteverde-Robb". The correct author name is "D. de Monteverde-Robb". This error has been corrected with this erratum.

Heparin resistance in COVID-19 patients in the intensive care unit.

Patients with COVID-19 have a coagulopathy and high thrombotic risk. In a cohort of 69 intensive care unit (ICU) patients we investigated for evidence of heparin resistance in those that have received therapeutic anticoagulation. 15 of the patients have received therapeutic anticoagulation with either unfractionated heparin (UFH) or low molecular weight heparin (LMWH), of which full information was available on 14 patients. Heparin resistance to UFH was documented in 8/10 (80%) patients and sub-optimal peak anti-Xa following therapeutic LMWH in 5/5 (100%) patients where this was measured (some patients received both anticoagulants sequentially). Spiking plasma from 12 COVID-19 ICU patient samples demonstrated decreased in-vitro recovery of anti-Xa compared to normal pooled plasma. In conclusion, we have found evidence of heparin resistance in critically unwell COVID-19 patients. Further studies investigating this are required to determine the optimal thromboprophylaxis in COVID-19 and management of thrombotic episodes.