Critical care pharmacist perspectives on optimal practice models and prioritization of professional activities: A cross-sectional survey.

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: Critical care pharmacists (CCPs) are essential members of the multidisciplinary critical care team. Professional activities of the CCP are outlined in a 2020 position paper on critical care pharmacy services. This study looks to characterize CCP perspectives for priorities in optimizing pharmacy practice models and professional activities. METHODS: This was a cross-sectional survey conducted from July 24 to September 20, 2023. A 41-question survey instrument was developed to assess 7 domains: demographics, CCP resource utilization, patient care, quality improvement, research and scholarship, training and education, and professional development. This voluntary survey was sent to members of the American College of Clinical Pharmacy's Critical Care Practice and Research Network. The survey was open for a total of 6 weeks. RESULTS: There was a response rate of 20.7% (332 of 1,605 invitees), with 66.6% of respondents (n = 221) completing at least 90% of the survey questions. Most respondents were clinical specialists (58.2%) and/or practiced at an academic medical center (58.5%). Direct patient care, quality improvement and medication safety, and teaching and precepting were identified as the CCP activities of highest importance to CCPs. The CCP-to-patient ratios considered ideal were 1:11-15 (selected by 49.8% of respondents) and 1:16-20 (33.9% of respondents). The ideal percentage of time dedicated to direct patient care activities, as identified by survey respondents, was 50% (interquartile range, 40-50). CONCLUSION: These findings highlight the professional activities viewed as having the highest priority by CCPs. Future research is needed to define optimal CCP practice models for the delivery of patient care in real-world settings.

Exploring social media influences on vaccine decision-making in parents: a netnography.

Background: Immunization is one of the most significant health initiatives of recent times. Despite this, vaccine hesitancy is increasing and was listed as one of the top 10 threats to global health by the World Health Organization in 2019. A major factor associated with vaccine hesitancy is thought to be the viral spread of misinformation by a small but active anti-vaccination movement. Objectives: The purpose of this study was to explore the influences of social media on vaccine decision-making in parents. Design: This study is part of a larger body of research that explored vaccine decision-making in parents. Other methods included were an online survey and semi-structured interviews. This study investigated the influence of cyberculture on parents in an online environment. Method: This study employed netnography, a form of qualitative inquiry with its roots in ethnography as methodology and a purpose-designed Facebook page as the means of exploring a purpose-designed online community with a particular focus on the culture, belief systems and influences present. Both manual and computer-assisted thematic analyses were used to analyse the data obtained. Results: Three key themes were identified in this study. These included vaccine safety concerns, the emotional debate and COVID-19-specific issues. The results indicated the presence of strong anti-vaccination sentiment combined with an 'infodemic' of conspiracy theories, misinformation and vitriol with the potential to negatively impact parents seeking immunization information. Conclusion: Given the popularity and accessibility of social media and the ready access to misinformation present online, it is evident that parental vaccine decision-making may be impacted adversely. Therefore, it is important that healthcare professionals are aware of this and provide adequate and timely education prior to parents seeking information on social media.

Exploring the influence of social media on vaccine decision-making in parents: a netnography This research explored the impact of Facebook interactions on the vaccine decision-making of parents.

A common data model for the standardization of intensive care unit medication features.

Objective: Common data models provide a standard means of describing data for artificial intelligence (AI) applications, but this process has never been undertaken for medications used in the intensive care unit (ICU). We sought to develop a common data model (CDM) for ICU medications to standardize the medication features needed to support future ICU AI efforts. Materials and Methods: A 9-member, multi-professional team of ICU clinicians and AI experts conducted a 5-round modified Delphi process employing conference calls, web-based communication, and electronic surveys to define the most important medication features for AI efforts. Candidate ICU medication features were generated through group discussion and then independently scored by each team member based on relevance to ICU clinical decision-making and feasibility for collection and coding. A key consideration was to ensure the final ontology both distinguished unique medications and met Findable, Accessible, Interoperable, and Reusable (FAIR) guiding principles. Results: Using a list of 889 ICU medications, the team initially generated 106 different medication features, and 71 were ranked as being core features for the CDM. Through this process, 106 medication features were assigned to 2 key feature domains: drug product-related (n = 43) and clinical practice-related (n = 63). Each feature included a standardized definition and suggested response values housed in the electronic data library. This CDM for ICU medications is available online. Conclusion: The CDM for ICU medications represents an important first step for the research community focused on exploring how AI can improve patient outcomes and will require ongoing engagement and refinement.

Defining the "ideal state": A primer on critical care pharmacy practice models.

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: Critical care pharmacists (CCPs) have been clearly established as value-added members of the interprofessional team, and their contributions positively impact patient outcomes in the intensive care unit (ICU). Despite this, not every critically ill patient in the US receives care from a CCP and the model through which CCPs practice is variable, which has important implications. The purpose of this primer is to review current CCP models and discuss elements of the optimal CCP practice model. SUMMARY: Current CCP practice models are defined, including the drug processing and dispensing model, clinical pharmacy specialist model, integrated pharmacy generalist model, and hybrid model, as well as unit-based vs service-based models. The optimal CCP practice model considers the Triple Domain of CCP workload, which includes direct patient care, indirect patient care, and professional service. Elements of the ideal CCP practice model including 24/7/365 CCP services, unit- vs service-based models, prescriptive authority, operational support, and CCP-to-patient ratio are discussed. Other vital elements include protected offline time, use of appropriate workload metrics, development of career ladders, opportunities for professional development, and providing wellness resources. The ideal CCP practice model must also be considered through the lens of the patient and medical team, the CCP, the institution, and professional organizations. Strategies for optimizing current CCP practice models are provided, and application of optimal CCP practice model elements is explored through 5 case studies. CONCLUSION: The optimal CCP practice model includes multiple elements and incorporates the viewpoints of patients, providers, CCPs, institutions, and professional organizations; this model will increase access of all ICU patients to CCPs, enhance the scope of CCP cognitive services, and ensure the economic sustainability of CCP practice while establishing CCP involvement in activities outside of patient care and in professional service.

Unsupervised machine learning analysis to identify patterns of ICU medication use for fluid overload prediction.

INTRODUCTION: Intravenous (IV) medications are a fundamental cause of fluid overload (FO) in the intensive care unit (ICU); however, the association between IV medication use (including volume), administration timing, and FO occurrence remains unclear. METHODS: This retrospective cohort study included consecutive adults admitted to an ICU ≥72 hours with available fluid balance data. FO was defined as a positive fluid balance ≥7% of admission body weight within 72 hours of ICU admission. After reviewing medication administration record (MAR) data in three-hour periods, IV medication exposure was categorized into clusters using principal component analysis (PCA) and Restricted Boltzmann Machine (RBM). Medication regimens of patients with and without FO were compared within clusters to assess for temporal clusters associated with FO using the Wilcoxon rank sum test. Exploratory analyses of the medication cluster most associated with FO for medications frequently appearing and used in the first 24 hours was conducted. RESULTS: FO occurred in 127/927 (13.7%) of the patients enrolled. Patients received a median (IQR) of 31 (13-65) discrete IV medication administrations over the 72-hour period. Across all 47,803 IV medication administrations, ten unique IV medication clusters were identified with 121-130 medications in each cluster. Among the ten clusters, cluster 7 had the greatest association with FO; the mean number of cluster 7 medications received was significantly greater in patients in the FO cohort compared to patients who did not experience FO (25.6 vs.10.9. p<0.0001). 51 of the 127 medications in cluster 7 (40.2%) appeared in > 5 separate 3-hour periods during the 72-hour study window. The most common cluster 7 medications included continuous infusions, antibiotics, and sedatives/analgesics. Addition of cluster 7 medications to a prediction model with APACHE II score and receipt of diuretics improved the ability for the model to predict fluid overload (AUROC 5.65, p =0.0004). CONCLUSIONS: Using ML approaches, a unique IV medication cluster was strongly associated with FO. Incorporation of this cluster improved the ability to predict development of fluid overload in ICU patients compared with traditional prediction models. This method may be further developed into real-time clinical applications to improve early detection of adverse outcomes.

Implementation of Patient Blood Management in Orthotopic Heart Transplants: A Single Centre Retrospective Observational Review.

BACKGROUND: Blood transfusion in the perioperative cardiothoracic setting has accepted risks including deep sternal wound infection, increased intensive care unit length of stay, lung injury, and cost. It has an immunomodulatory effect which may cause allo-immunisation. This may influence long-term survival through immune-mediated factors. Targeting coagulation defects to reduce unnecessary or inappropriate transfusions may reduce these complications. METHODS: In 2012, an institution-wide patient blood management evidence-based algorithmic bleeding management protocol was implemented at The Prince Charles Hospital, Brisbane, Australia. The benefit of this has been previously reported in our lung transplant and cardiac surgery (excluding transplants) cohorts. This study aimed to investigate the effect of this on our orthotopic heart transplant recipients. RESULTS: After the implementation of the protocol, despite no difference in preoperative haemoglobin levels and higher risk patients (EuroSCORE 20 vs 26; p=0.013), the use of packed red blood cells (13.0 U vs 4.4 U; p=0.046) was significantly lower postoperatively and fresh frozen plasma was significantly lower both intra- and postoperatively (7.4 U vs 0.6 U; p<0.001, and 3.3 U vs 0.6 U; p=0.011 respectively). Concurrently, the use of prothrombin complex concentrate (33% vs 78%; p<0.001) and desmopressin (5% vs 22%; p=0.0028) was significantly higher in the post-protocol group, while there was less use of recombinant factor VIIa (15% vs 4%; p=0.058). Intraoperative units of cryoprecipitate also rose from 0.9 to 2.0 (p=0.006). CONCLUSIONS: We have demonstrated that a targeted patient blood management protocol with point-of-care testing for heart transplant recipients is correlated with fewer blood products used postoperatively, with some increase in haemostatic products and no evidence of increased adverse events.

Exploration of Norepinephrine Dose-Capping Practices: Report From an International, Interprofessional Survey of Critical Care Clinicians.

Purpose: The Joint Commission standards for titrated infusions require specification of maximum rates of infusion. This practice has led to the development of protocolized maximum doses that can be overridden by provider order ("soft maximums") and to dose caps that cannot be superseded ("hard maximums"). The purpose of this study was to determine the prevalence of and attitudes towards dose capping of norepinephrine. Methods: A 20-item cross-sectional survey assessing norepinephrine dose capping practices, perceptions of norepinephrine protocols, and respondent and practice site demographics was distributed electronically to the mailing list of an international medical podcast. Responses were stratified according to use of weight-based dosing (WBD) or non-WBD of norepinephrine. The primary objective was to characterize norepinephrine dosing practices including protocolized maximum doses and/or dose capping. Categorical and continuous variables were compared using the Chi-square test and Mann-Whitney U test, respectively, with P < .05 indicating statistical significance. Results: The survey was completed by 586 physicians, nurses, pharmacists, and advanced practice providers. WBD was used by 51% and non-WBD by 47%. A standardized titration protocol was reported by 65% and dose capping was reported by 19%. The protocolized maximum dose ranged from 20-400 mcg/min for respondents using non-WBD (median [interquartile range] 30 [30-50]) and ranged from .2-10 mcg/kg/min for respondents using WBD (1 [.5-3]). The dose cap was 50 (40-123) mcg/min with non-WBD and 2 (1-3) mcg/kg/min with WBD. Conclusions: An international, multi-professional survey of critical care and emergency medicine clinicians revealed wide variability in norepinephrine dosing practices including maximum doses allowed.

Long-Term Retention of Advanced Cardiovascular Life Support Knowledge and Confidence in Doctor of Pharmacy Students.

OBJECTIVE: This study aimed to evaluate the impact of American Heart Association (AHA) advanced cardiovascular life support (ACLS) education and training on long-term retention of ACLS knowledge and confidence in Doctor of Pharmacy (PharmD) students. METHODS: This multicenter study included PharmD students who received ACLS training through different means: 1-hour didactic lecture (didactic), 1-hour didactic lecture with 2-hour skills practice (didactic + skills), and comprehensive AHA ACLS certification through an elective course (elective-certification). Students completed a survey before training, immediately after training, and at least 6-12 months after training to assess demographics and ACLS confidence and knowledge. The primary outcome was a passing score, defined as ≥ 84% on the long-term knowledge assessment. Secondary outcomes included overall knowledge score and perceived confidence, assessed using the Dreyfus model. RESULTS: The long-term assessment was completed by 160 students in the didactic group, 66 in the didactic + skills group, and 62 in the elective-certification group. Six (4%), 8 (12%), and 14 (23%) received a passing score on the long-term knowledge assessment in the didactic, didactic + skills, and elective-certification groups, respectively. The median (IQR) scores on the long-term knowledge assessment were 50% (40-60), 60% (50-70), and 65% (40-80) in the 3 groups. On the long-term assessment, confidence was higher in the elective-certification group, demonstrated by more self-ratings of competent, proficient, and expert, and fewer self-ratings of novice and advanced beginner. CONCLUSION: Long-term retention of ACLS knowledge was low in all groups, but was higher in students who received AHA ACLS certification through an ACLS elective course.

Translating Clinical Decision-Making Skills From a Critical Care Pharmacy Elective to the Required Curriculum.

OBJECTIVE: To examine the impact of a critical care pharmacy elective (CCPE) on student performance in other courses in the Doctor of Pharmacy curriculum that emphasize clinical reasoning and decision making. METHODS: This is a retrospective, cohort study including all students from the 2019-2021 graduating classes enrolled in required courses, Pharmacotherapy and Integrated Patient Cases (IPCs). Students were divided for comparison based on completion of the CCPE. The primary outcome was outstanding performance, defined by a final course grade ≥90%, in Pharmacotherapy and IPC. Baseline characteristics and outcomes were analyzed using descriptive statistics and the χ2 test or two-sided t test for categorical and continuous variables, respectively. Binary logistic regression models were constructed to identify variables associated with the primary outcome. RESULTS: Of 377 students included, 129 (34%) completed the CCPE. Baseline characteristics were similar between both groups, except more females completed the CCPE. Students that completed the CCPE were not more likely to demonstrate outstanding performance in Pharmacotherapy III (20% vs 30%) or Pharmacotherapy IV (27% vs 24%), but were more likely in IPC (34% vs 23%). In the adjusted analysis, CCPE students were almost twice as likely to exhibit outstanding performance in IPC. CONCLUSION: Students that completed the CCPE were more likely to demonstrate outstanding performance in IPC, but not in either of the Pharmacotherapy courses. Students may benefit from practicing clinical reasoning earlier in the curriculum to build-up to effective and efficient clinical decision-making. Implications of course structure on student performance should be further explored.

Machine learning vs. traditional regression analysis for fluid overload prediction in the ICU.

Fluid overload, while common in the ICU and associated with serious sequelae, is hard to predict and may be influenced by ICU medication use. Machine learning (ML) approaches may offer advantages over traditional regression techniques to predict it. We compared the ability of traditional regression techniques and different ML-based modeling approaches to identify clinically meaningful fluid overload predictors. This was a retrospective, observational cohort study of adult patients admitted to an ICU ≥ 72 h between 10/1/2015 and 10/31/2020 with available fluid balance data. Models to predict fluid overload (a positive fluid balance ≥ 10% of the admission body weight) in the 48-72 h after ICU admission were created. Potential patient and medication fluid overload predictor variables (n = 28) were collected at either baseline or 24 h after ICU admission. The optimal traditional logistic regression model was created using backward selection. Supervised, classification-based ML models were trained and optimized, including a meta-modeling approach. Area under the receiver operating characteristic (AUROC), positive predictive value (PPV), and negative predictive value (NPV) were compared between the traditional and ML fluid prediction models. A total of 49 of the 391 (12.5%) patients developed fluid overload. Among the ML models, the XGBoost model had the highest performance (AUROC 0.78, PPV 0.27, NPV 0.94) for fluid overload prediction. The XGBoost model performed similarly to the final traditional logistic regression model (AUROC 0.70; PPV 0.20, NPV 0.94). Feature importance analysis revealed severity of illness scores and medication-related data were the most important predictors of fluid overload. In the context of our study, ML and traditional models appear to perform similarly to predict fluid overload in the ICU. Baseline severity of illness and ICU medication regimen complexity are important predictors of fluid overload.

Optimal Dosing of Enoxaparin in Critically Ill Patients with Venous Thromboembolism.

Background: Evidence suggests that goal anti-Xa levels are achieved in only 33% of critically ill patients receiving standard prophylactic enoxaparin dosing. There has been limited focus on the potential suboptimal anticoagulation effect on medical intensive care unit (MICU) patients receiving therapeutic enoxaparin dosing for venous thromboembolism (VTE). Methods: MICU patients receiving enoxaparin 1 mg/kg twice daily or 1.5 mg/kg daily for VTE treatment in a 350-bed community teaching hospital between 2013 and 2019 with at least one peak anti-Xa level measured were included. The primary outcome was the proportion who achieved therapeutic anti-Xa levels with standard dosing. Secondary outcomes included types of dose-adjustments required and the proportion requiring subsequent dose-adjustments. Descriptive statistics were presented for all outcomes. Results: Fifty-three patients were evaluated, including those receiving either twice-daily or once-daily standard therapeutic dosing. Optimal anti-Xa levels at first measurement were recorded after the initiation of enoxaparin in 26.4% (n=14) patients. Dose adjustments were required in 70.7% (n=29) of patients receiving twice-daily dosing and in 83.3% (n=10) receiving once-daily dosing (P=0.97) to appropriately increase or decrease the enoxaparin dose. By the third anti-Xa level measurement, 3 patients remained outside of the therapeutic range. Conclusions: Standard therapeutic enoxaparin dosing did not result in optimal anti-Xa levels for a majority of MICU patients regardless of dosing regimen used or patient specific factors. Future studies should identify patient factors associated with the requirement for higher or lower enoxaparin dosing.

Optimizing Pharmacist Team-Integration for ICU Patient Management: Rationale, Study Design, and Methods for a Multicentered Exploration of Pharmacist-to-Patient Ratio.

BACKGROUND: The workload of healthcare professionals including physicians and nurses in the ICU has an established relationship to patient outcomes, including mortality, length of stay, and other quality indicators; however, the relationship of critical care pharmacist workload to outcomes has not been rigorously evaluated and determined. The objective of our study is to characterize the relationship of critical care pharmacist workload in the ICU as it relates to patient-centered outcomes of critically ill patients. METHODS: Optimizing Pharmacist Team-Integration for ICU patient Management is a multicenter, observational cohort study with a target enrollment of 20,000 critically ill patients. Participating critical care pharmacists will enroll patients managed in the ICU. Data collection will consist of two observational phases: prospective and retrospective. During the prospective phase, critical care pharmacists will record daily workload data (e.g., census, number of rounding teams). During the retrospective phase, patient demographics, severity of illness, medication regimen complexity, and outcomes will be recorded. The primary outcome is mortality. Multiple methods will be used to explore the primary outcome including multilevel multiple logistic regression with stepwise variable selection to exclude nonsignificant covariates from the final model, supervised and unsupervised machine learning techniques, and Bayesian analysis. RESULTS: Our protocol describes the processes and methods for an observational study in the ICU. CONCLUSIONS: This study seeks to determine the relationship between pharmacist workload, as measured by pharmacist-to-patient ratio and the pharmacist clinical burden index, and patient-centered outcomes, including mortality and length of stay.

Netnography: A novel methodology for nursing research.

AIM: The aim of this paper is to critically reflect on our team's experience of using netnography to explore vaccine-hesitant parents and pregnant women, a group who have traditionally been difficult to recruit to research studies and a methodology that is underutilized in nursing research. DESIGN: This paper takes the form of a discussion paper that will utilize data obtained from a qualitative netnographic study. Relevant literature was searched including 2015-2023. METHOD: This paper utilized data obtained from a qualitative study that used netnography as methodology and an online minable data source. Netnography is a relatively new methodology that uses the online environment to explore digital cultures and study networked society. It pays particular attention to cultural insights and conditions that impact the human experience. This methodology is particularly relevant to nursing research which is often humanistic and always conducted to ensure optimal patient outcomes. RESULTS: Using netnography for the first time has resulted in four main insights. These include the adaptability of the process; the creativity involved in designing the site; the ready acceptance of the site by participants and the co-creation knowledge that resulted. CONCLUSIONS: Netnography is a creative methodology that was successful in accessing and engaging the vaccine-hesitant community, a group who are often marginalized. Netnography has the advantage of using a platform that is familiar and safe for many people and provides access to an extensive minable data source.

Evaluation of medication regimen complexity as a predictor for mortality.

While medication regimen complexity, as measured by a novel medication regimen complexity-intensive care unit (MRC-ICU) score, correlates with baseline severity of illness and mortality, whether the MRC-ICU improves hospital mortality prediction is not known. After characterizing the association between MRC-ICU, severity of illness and hospital mortality we sought to evaluate the incremental benefit of adding MRC-ICU to illness severity-based hospital mortality prediction models. This was a single-center, observational cohort study of adult intensive care units (ICUs). A random sample of 991 adults admitted ≥ 24 h to the ICU from 10/2015 to 10/2020 were included. The logistic regression models for the primary outcome of mortality were assessed via area under the receiver operating characteristic (AUROC). Medication regimen complexity was evaluated daily using the MRC-ICU. This previously validated index is a weighted summation of medications prescribed in the first 24 h of ICU stay [e.g., a patient prescribed insulin (1 point) and vancomycin (3 points) has a MRC-ICU = 4 points]. Baseline demographic features (e.g., age, sex, ICU type) were collected and severity of illness (based on worst values within the first 24 h of ICU admission) was characterized using both the Acute Physiology and Chronic Health Evaluation (APACHE II) and the Sequential Organ Failure Assessment (SOFA) score. Univariate analysis of 991 patients revealed every one-point increase in the average 24-h MRC-ICU score was associated with a 5% increase in hospital mortality [Odds Ratio (OR) 1.05, 95% confidence interval 1.02-1.08, p = 0.002]. The model including MRC-ICU, APACHE II and SOFA had a AUROC for mortality of 0.81 whereas the model including only APACHE-II and SOFA had a AUROC for mortality of 0.76. Medication regimen complexity is associated with increased hospital mortality. A prediction model including medication regimen complexity only modestly improves hospital mortality prediction.

Caring for two in the ICU: Pharmacologic management of pregnancy-related complications.

Maternal mortality continues to be an issue globally despite advances in technology and pharmacotherapy. Pregnancy can lead to complications that necessitate immediate action to prevent severe morbidity and mortality. Patients may need escalation to the ICU setting for close monitoring and administration of advanced therapies not available elsewhere. Obstetric emergencies are rare but high-stakes events that require clinicians to have prompt identification and management. The purpose of this review is to describe complications of pregnancy and provide a focused resource of pharmacotherapy considerations that clinicians may encounter. For each disease state, the epidemiology, pathophysiology, and management are summarized. Brief descriptions of non-pharmacological (e.g., cesarean or vaginal delivery of the baby) interventions are provided. Mainstays of pharmacotherapy highlighted include oxytocin for obstetric hemorrhage, methotrexate for ectopic pregnancy, magnesium and antihypertensive agents for preeclampsia and eclampsia, eculizumab for atypical hemolytic uremic syndrome, corticosteroids, and immunosuppressive agents for thrombotic thrombocytopenic purpura, diuretics, metoprolol, and anticoagulation for peripartum cardiomyopathy, and pulmonary vasodilators for amniotic fluid embolism.

A Scoping Review for Debate-Style Journal Clubs in Health Professional Education.

OBJECTIVES: The objectives of this scoping review are to (1) describe the available literature regarding the utility of the debate-style journal club for health professional learners on literature evaluation skills and (2) report the themes found within debate-style journal club research and assessments in the context of professional education. FINDINGS: A total of 27 articles written in the English language were included in this scoping review. Published evaluations of debate-style journal clubs have been predominantly based in the pharmacy profession (48%, n = 13), but are reported in other health professions, such as medicine (22%, n = 6), dentistry (15%, n = 4), nursing (7%, n = 2), occupational therapy (4%, n = 1), and physical therapy (4%, n = 1), as well. The skills assessed in these studies often included critical literature evaluation, application of literature to patient care, critical thinking, knowledge retention, use of supporting literature, and debate-specific skills. Learners typically reported better understanding and application of the literature, and enjoying the experience more than traditional journal clubs, but note the increased assessor and learner time requirement for debating. Pharmacy learner-specific articles more often utilized a traditional, team-based debate format, incorporated grading rubrics for skill assessment and debate performance, and included a grading component for the debate in the course. SUMMARY: Debate-style journal clubs are well-received by learners but require an additional time commitment. Debate platforms, format, rubric use and validation, and outcome assessment vary across published reports.

Pushed to the Fringe - The Impact of Vaccine Hesitancy on Children and Families.

Vaccine hesitancy has been described as any delay or refusal of vaccines despite their availability and is increasing in Australia and other middle to high-income countries. The aim of this study is to gain a deep understanding of the experiences and influences on vaccine hesitant children and their families. A qualitative interview approach was undertaken with vaccine hesitant parents and pregnant women (n = 12). Semi-structured interviews were conducted by telephone. Inductive thematic analysis was undertaken on data obtained using the guidelines of Braun and Clarke. Three main themes were identified in this study, including Pushed to the fringe; A culture of Distrust; and Coerced choices. The study revealed that vaccine hesitant parents felt isolated and pushed to the fringe of society. They also expressed dissatisfaction with the Australian "No Jab - No Pay" and "No Jab - No Play" legislation. This contributed to feelings of marginalization. Participants also cited a breakdown in the therapeutic relationships, which impacted their child's health. Additionally, a lack of sufficient information was received to achieve informed consent. These results suggest that there is a need for enhanced education for some health-care professionals, many of whom have reported being confronted by conversations with vaccine hesitant parents.

Outcomes of Intravenous Push versus Intermittent Infusion Administration of Cefepime in Critically Ill Patients.

The equivalence of intravenous push (IVP) and piggyback (IVPB) administration has not been evaluated in the critically ill population for most medications, but it is especially relevant for antibiotics, such as cefepime, that exhibit time-dependent bactericidal activity. A single center, retrospective, observational pre/post-protocol change study included critically ill adults who received cefepime as empiric therapy between August 2015 and 2021. The primary outcome was treatment failure, which was defined as a composite of escalation of antibiotic regimen or all-cause mortality. Secondary outcomes included adverse drug events, days of cefepime therapy, total days of antibiotic therapy, and ICU and hospital length of stay. Outcomes were compared using Chi-squared, Mann Whitney U, and binary logistic regression as appropriate. A total of 285 patients were included: 87 IVPB and 198 IVP. Treatment failure occurred in 18% (n = 16) of the IVPB group and 27% (n = 54) of the IVP group (p = 0.109). There were no significant differences in secondary outcomes. Longer duration of antibiotics (odds ratio [OR] 1.057, 95% confidence interval [CI] 1.013-1.103), SOFA score (OR 1.269, 95% CI 1.154-1.397) and IVP administration of cefepime (OR 2.370, 95% CI 1.143-4.914) were independently associated with treatment failure. Critically ill patients who received IVP cefepime were more likely to experience treatment failure in an adjusted analysis. The current practice of IVP cefepime should be reevaluated, as it may not provide similar clinical outcomes in the critically ill population.