Impact of continuous infusions of opioids on discharge opioid prescriptions.

INTRODUCTION: The 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep guidelines from the Society of Critical Care Medicine recommend opioids as a first-line treatment option for non-neuropathic pain among critically ill adults and prioritize pain management optimization before the administration of sedatives. Although analagosedation is recommended, the downstream effects, such as intensive care unit (ICU)-acquired opioid dependence, are not well described. The purpose of this study is to determine the impact of continuous infusions of opioids for mechanically ventilated patients prescribed opioids on discharge. METHODS: This was a single-center, retrospective chart review of mechanically ventilated patients admitted to the medical ICU at a tertiary medical center from July 1, 2018 to June 30, 2019. The primary objective of this study was to compare the incidence of opioid prescriptions at discharge between those who received opioid infusions versus intermittent administrations. Secondary objectives included risk factors for receiving opioid prescriptions at discharge and readmission within 90 days with an active opioid prescription and/or a diagnosis of opioid use disorder. RESULTS: A total of 100 patients were included. There was no statistically significant difference in the incidence of opioid prescriptions at discharge between the groups (p = 0.933). Only one patient was readmitted within 90 days with documented opioid use disorder and 11 patients with prescription opioids on their home medication list. A best-fit logistic regression model including the type of opioid administration (p = 0.275), length of stay (p = 0.018), and opioid dose (p = 0.137) showed that length of stay was the only significant predictor of discharge opioid prescribing. CONCLUSION: The incidence of opioid prescriptions at discharge for critically ill, mechanically ventilated patients did not differ based on opioid administration strategy. ICU length of stay appears to be a predictive factor of opioid discharge prescriptions.

Outcomes of Continuous Renal Replacement Therapy in a Community Health System.

OBJECTIVE: Continuous renal replacement therapy (CRRT) is commonly used in critically ill, hemodynamically unstable patients with acute kidney injury (AKI). This procedure is resource intensive with reported high in-hospital mortality. We evaluated mortality with CRRT in our healthcare system and markers associated with decreased survival. METHODS: A retrospective cohort study collected data on patients 18 years or older, without prior history of end stage kidney disease (ESKD), who received CRRT in the intensive care units at one of three hospitals in our health system in Columbus, OH from July 1, 2016 to July 1, 2019. Data included demographics, presenting diagnosis, comorbidities, laboratory markers, and patient disposition. In-hospital mortality rates and sequential organ failure assessment (SOFA) scores were calculated. We then compared information between two groups (patients who died during hospitalization and survivors) using univariate comparisons and multivariate logistic regression models. RESULTS: In-hospital mortality was 56.8% (95%CI: 53.4-60.1) among patients who received CRRT. Mean SOFA scores did not differ between survival and mortality groups. The odds for in-patient mortality were increased for patients age ≥60 (OR = 1.74, 95%CI: 1.23-2.44), first bilirubin >2 mg/dL (OR = 1.73, 95%CI: 1.12-2.69), first creatinine < 2 mg/dL (OR = 1.57, 95%CI: 1.04-2.37), first lactate > 2 mmol/L (OR = 2.08, 95%CI: 1.43-3.04). The odds for in-patient mortality were decreased for patients with cardiogenic shock (OR = .32, 95%CI: .17-.58) and hemorrhagic shock (OR = .29, 95%CI: .13-.63). CONCLUSIONS: We report in-hospital mortality rates of 56.8% with CRRT. Unlike prior studies, higher mean SOFA scores were not predictive of higher in-hospital mortality in patients utilizing CRRT.

Lean into Clinical Pharmacy: An Experience in Implementing Key Performance Indicators and Gemba Walks into Clinical Pharmacy Services.

Purpose: The Lean methodology was applied to clinical metrics by a critical care pharmacy team. The experiences associated with the development and implementation of clinical metrics and their impact on daily workflow are described. Summary: The Lean methodology has been introduced into the healthcare system as a means of process improvement, which can eliminate waste through appropriate medication utilization. At OhioHealth Riverside Methodist Hospital, the department of pharmacy was tasked with the development of clinical metrics after a health system wide Gemba walk was initiated. The pharmacy department's critical care team developed a strategy identifying and evaluating clinical metrics pertaining to their everyday workflow. Each clinical metric was evaluated in accordance with a pre-defined goal. Metrics requiring heavy documentation and those in which the pharmacist does not have autonomous authority to manage were often challenging to implement and were less successful. Throughout this process, the lessons learned focused on generating ideas that were easily documented, evidence-based, and department specific. The critical care team discovered that the outcome of the most successful metrics highlighted clinical pharmacist value and data generated could be used to support funding for additional resources. Conclusion: The critical care pharmacy team developed a streamlined process to implement clinical metrics as means of identifying areas for improvement using the Lean methodology.