Pharmacist-Driven Methicillin-Resistant S. aureus Polymerase Chain Reaction Testing for Pneumonia.

BACKGROUND: Nasal colonization with methicillin-resistant Staphylococcus aureus (MRSA) can be detected using nasal swab polymerase chain reaction (PCR) assay and is associated with clinical MRSA infection. The MRSA nasal PCR has a rapid turnaround time and a negative predictive value for MRSA pneumonia of >98%; however, data are limited in critically ill patients. OBJECTIVE: The purpose of this study is to determine the impact of a pharmacist-driven algorithm, utilizing MRSA PCR nasal screening on duration of anti-MRSA therapy in patients admitted to the intensive care unit (ICU) with suspected pneumonia. METHODS: A single-center pre/post study was conducted in 4 ICUs at a large tertiary care community hospital. Adult patients admitted to the ICU initiated on vancomycin or linezolid for pneumonia managed using a pharmacist-driven MRSA PCR algorithm were included in the algorithm cohort. A historical cohort with standard management was matched 1:1 by age, type of pneumonia, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. The primary outcome was duration of anti-MRSA therapy. Secondary outcomes included MRSA rates, number of vancomycin levels, new onset of acute kidney injury (AKI), ICU length of stay (LOS), hospital LOS, and mortality. RESULTS: Of the 245 patients screened, 50 patients met inclusion criteria for the algorithm cohort and were matched to 50 patients in the historical cohort. The duration of anti-MRSA therapy was significantly lower compared with the historical cohort (47 vs 95 hours; P < 0.001). Secondary outcomes were similar between groups for MRSA rates, new onset of AKI, LOS, and mortality. There were less vancomycin levels ordered in the algorithm cohort (2 vs 3, P = 0.026). CONCLUSIONS: A pharmacist-driven MRSA PCR algorithm significantly reduced anti-MRSA duration of therapy in critically ill patients with pneumonia. Future studies should validate these results in critically ill populations and in settings where MRSA pneumonia is more prevalent.

Treatment of Severe Hypertriglyceridemia With Insulin Infusions in Severe COVID-19: A Case Series.

PURPOSE: Rapid onset of severe hypertriglyceridemia was quickly recognized in critical COVID-19 patients. Associated causes have been due to secondary hemophagocytic lymphohystiocytosis (HLH) syndrome, medication-induced, or acute liver failure. Statins, omega-3 polyunsaturated acids, niacin, and fibrates are common oral lipid lowering therapy options in patients at risk for hypertriglyceridemia. The severity of hypertriglyceridemia in COVID-19 patients with triglyceride values reaching greater than 1,000 mg/dL put them at a heightened risk of pancreatitis and therefore an essential need to acutely lower their levels. We present a case series of 5 patients who achieved rapid triglyceride lowering through continuous insulin infusion therapy. METHODS: A retrospective chart review of 48 critical COVID-19 patients who were admitted from March 22 to April 15, 2020 was conducted. Inclusion criteria consisted of mechanical ventilation and continuous insulin infusion to treat severe hypertriglyceridemia resulting with 5 eligible patients in this case report. RESULTS AND CONCLUSION: In addition to standard oral lipid lowering therapies, continuous insulin infusion successfully treated severe hypertriglyceridemia in critically ill COVID-19 patients. None of the patients experienced pancreatitis or hypoglycemia necessitating cessation of insulin. Further studies are needed to show the optimum dose and duration of insulin infusion as monotherapy and in combination with oral therapies.

Sleep-Promotion Bundle Development, Implementation, and Evaluation in Critically Ill Adults: Roles for Pharmacists.

OBJECTIVE: To review evidence for intensive care unit (ICU) sleep improvement bundle use, identify preferred sleep bundle components and implementation strategies, and highlight the role for pharmacists in developing and evaluating bundle efforts. DATA SOURCES: Multiple databases were searched from January 1, 1990, to September 1, 2021, using the MeSH terms sleep, intensive care or critical care, protocol or bundle to identify comparative studies evaluating ICU sleep bundle implementation. STUDY SELECTION AND DATA EXTRACTION: Study screening, data extraction, and risk-of-bias evaluation were conducted in tandem. The ICU quality improvement literature and Institute for Healthcare Improvement bundle improvement guidance were also reviewed to identify recommended strategies for successful sleep bundle use. DATA SYNTHESIS: Nine studies (3 randomized, 1 quasi-experimental, 5 before-and-after) were identified. Bundle elements varied and were primarily focused on nonpharmacological interventions designed to be performed during either the day or night; only 2 studies included a medication-based strategy. Five studies were associated with reduced delirium; 2 studies were associated with improved total sleep time and 2 with improved patient-perceived sleep. Pharmacists were involved directly in 4 studies. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Sleep improvement bundles are recommended for use in all critically ill adults; specific bundle elements and ICU team member roles should be individualized at the institution/ICU level. Pharmacists can help lead bundle development efforts and routinely deliver key elements. CONCLUSIONS: Pharmacists can play an important role in the development and implementation of ICU sleep bundles. Further research regarding the relative benefit of individual bundle elements on relevant patient outcomes is needed.

Prolonged Refractory ICU Delirium Successfully Treated With Valproic Acid: Case Report and Literature Review.

Intensive care unit (ICU) delirium is characterized by acute onset of cerebral dysfunction with a change or fluctuation in baseline mental status. Delirium management includes non-pharmacologic and pharmacologic treatment. However at times, alternative pharmacologic treatment is warranted. Valproic acid (VPA) is a potential pharmacologic agent that can be utilized to treat ICU delirium, though there is a paucity of evidence for its use, especially in patients with a history of substance abuse. We review the literature on VPA use in ICU delirium, and describe a challenging case of a 27-year-old female with a history of substance abuse experiencing hyperactive ICU delirium for greater than a month, refractory to multiple treatment modalities, and successfully treated with VPA therapy.

Impact of a Pharmacist-Led Intensive Care Unit Sleep Improvement Protocol on Sleep Duration and Quality.

BACKGROUND: Sleep improvement protocols are recommended for use in the intensive care unit (ICU) despite questions regarding which interventions to include, whether sleep quality or duration will improve, and the role of pharmacists in their development and implementation. OBJECTIVE: To characterize the impact of a pharmacist-led, ICU sleep improvement protocol on sleep duration and quality as evaluated by a commercially available activity tracker and patient perception. METHODS: Critical care pharmacists from a 40-bed, mixed ICU at a large community hospital led the development and implementation of an interprofessional sleep improvement protocol. It included daily pharmacist medication review to reduce use of medications known to disrupt sleep or increase delirium and guideline-based recommendations on both environmental and nonpharmacological sleep-focused interventions. Sleep duration and quality were compared before (December 2018 to December 2019) and after (January to June 2019) protocol implementation in non-mechanically ventilated adults using both objective (total nocturnal sleep time [TST] measured by an activity tracker (Fitbit Charge 2) and subjective (patient-perceived sleep quality using the Richards-Campbell Sleep Questionnaire [RCSQ]) measures. RESULTS: Groups before (n = 48) and after (n = 29) sleep protocol implementation were well matched. After protocol implementation, patients had a longer TST (389 ± 123 vs 310 ± 147 minutes; P = 0.02) and better RCSQ-perceived sleep quality (63 ± 18 vs 42 ± 24 mm; P = 0.0003) compared with before implementation. CONCLUSION AND RELEVANCE: A sleep protocol that incorporated novel elements led to objective and subjective improvements in ICU sleep duration and quality. Application of this study may result in increased utilization of sleep protocols and pharmacist involvement.

Framework and Outcomes of a Critical Care Pharmacy Visiting Clinical Professor Program.

OBJECTIVES: Experiences with utilizing a visiting clinical professor program to mentor institutions and collaborate on best practices in critical care pharmacy are described to provide a framework for these services and a synopsis of key outcomes. DESIGN: The Society of Critical Care Medicine Clinical Pharmacy and Pharmacology Section implemented a visiting clinical professor program to address the need for collaboration, idea-sharing, mentorship, and diffusion of innovation to clinicians in critical care practice. SETTING: Critical care pharmacy departments at 12 medical centers. SUBJECTS: Twelve visiting clinical professors and host institutions from 2007-2018. INTERVENTION: After an application is submitted to the section steering committee, an experienced clinician is paired with an institution, and a site visit is planned in collaboration with the visiting clinical professor program coordinators. The expert clinician visits the institution to share their insights and best practices based on visit goals and objectives. Reflective debriefing with both the host institution and the visiting clinical professor occurs after the visit. MEASUREMENTS AND MAIN RESULTS: The program has demonstrated numerous benefits including shared best practices related to critical care clinical services, expansion and refinement of care delivery models, development and optimization of research programs, and advancement of new training programs including specialty pharmacy residencies. Both the site and visiting professor find these partnerships beneficial, which has resulted in sustained success of the program over an 11-year period. Key resultant deliverables after visits have included new pharmacist positions, advancement of pharmacy services, and expanded access to academic opportunities. CONCLUSIONS: A professional organization led visiting clinical professor program is viable, sustainable, and yields clear benefit for critical care pharmacy programs across the country. Application of this framework to other areas of pharmacy practice may be an avenue to share best practices and advance pharmacy services.

Characterisation of ICU sleep by a commercially available activity tracker and its agreement with patient-perceived sleep quality.

BACKGROUND: A low-cost, quantitative method to evaluate sleep in the intensive care unit (ICU) that is both feasible for routine clinical practice and reliable does not yet exist. We characterised nocturnal ICU sleep using a commercially available activity tracker and evaluated agreement between tracker-derived sleep data and patient-perceived sleep quality. PATIENTS AND METHODS: A prospective cohort study was performed in a 40-bed ICU at a community teaching hospital. An activity tracker (Fitbit Charge 2) was applied for up to 7 ICU days in English-speaking adults with an anticipated ICU stay ≥2 days and without mechanical ventilation, sleep apnoea, delirium, continuous sedation, contact isolation or recent anaesthesia. The Richards-Campbell Sleep Questionnaire (RCSQ) was administered each morning by a trained investigator. RESULTS: Available activity tracker-derived data for each ICU study night (20:00-09:00) (total sleep time (TST), number of awakenings (#AW), and time spent light sleep, deep sleep and rapid eye movement (REM) sleep) were downloaded and analysed. Across the 232 evaluated nights (76 patients), TST and RCSQ data were available for 232 (100%), #AW data for 180 (78%) and sleep stage data for 73 (31%). Agreement between TST (349±168 min) and RCSQ Score was moderate and significant (r=0.34; 95% CI 0.18 to 0.48). Agreement between #AW (median (IQR), 4 (2-9)) and RCSQ Score was negative and non-significant (r=-0.01; 95% CI -0.19 to 0.14). Agreement between time (min) spent in light (259 (182 to 328)), deep (43±29), and REM (47 (28-72)) sleep and RCSQ Score was moderate but non-significant (light (r=0.44, 95% CI -0.05 to 0.36); deep sleep (r=0.44, 95% CI -0.11 to 0.15) and REM sleep (r=0.44; 95% CI -0.21 to 0.21)). CONCLUSIONS: A Fitbit Charge 2 when applied to non-intubated adults in an ICU consistently collects TST data but not #AW or sleep stage data at night. The TST moderately correlates with patient-perceived sleep quality; a correlation between either #AW or sleep stages and sleep quality was not found.

Efficacy, safety, and medication errors associated with the use of inhaled epoprostenol for adults with acute respiratory distress syndrome: a pilot study.

BACKGROUND: Acute respiratory distress syndrome (ARDS) is a type of hypoxic respiratory failure that results from ventilation and perfusion mismatching. Inhaled epoprostenol induces relaxation of smooth muscle in pulmonary vasculature, leading to improved oxygenation. OBJECTIVE: To determine if the use of inhaled epoprostenol produced a 10% or greater increase in the ratio of arterial partial pressure of oxygen (PaO2) to fraction of inspired oxygen (FiO2) in ARDS patients and to review adverse events and medication errors. METHODS: An observational chart review was performed based on a report generated from the electronic medical record system. Patients who received at least 1 dose of inhaled epoprostenol from January 1, 2008, to December 31, 2010, at any hospital within the Florida Hospital Health System were considered for inclusion. Demographics, dose, duration of therapy, adverse effects, medication errors, and outcomes data were collected. RESULTS: Sixteen patients were included in the study. Oxygenation improved by 10% or more in 62.5% (10/16) of the patients, with an initial (within the first 4 hours) median increase of 44.5% in PaO2/FiO2. The mean (SD) starting dose was 30 (10) ng/kg/min. Medication errors were observed in 25% (4/16) of patients. Hypotension was the most frequently observed adverse event, with a rate of 18.8% (3/16). CONCLUSIONS: Based on study findings, inhaled epoprostenol may improve oxygenation in patients with ARDS, with findings suggesting a 62.5% response to therapy. The significance of these effects on improving survival remains unknown. The frequency of medication errors observed in this study poses a significant concern regarding the administration of epoprostenol. Further controlled prospective studies are needed to determine the role of inhaled epoprostenol in improving survival in patients with ARDS.