Identification and categorisation of drug-related problems on admission to an adult intensive care unit

Clinical pharmacist interventions in nutrition-and drug-related problems in critically ill patients with renal dysfunction: a non-randomized controlled study

Background

Critically ill intensive care unit (ICU) patients often face life-threatening drug-related problems (DRPs) and malnutrition. Clinical pharmacists (CPs) play a crucial role in mitigating these issues and improving outcomes.

Aim

This study was designed to detect, prevent, reduce or resolve nutrition-related problems (NRPs) and DRPs in intensive care patients with renal dysfunction through clinical pharmacy services.

Method

This 9-month, prospective, non-randomized, controlled study was conducted in the ICU. During the intervention period (IP), CP recommendations addressing NRPs and DRPs were provided to the healthcare team. NRPs were evaluated using an expert-developed enteral nutrition consensus protocol, while DRPs were classified according to the Pharmaceutical Care Network Europe (PCNE) Classification for Drug-Related Problems Version 9.1.

Results

The study included 60 patients with a median age of 73 years (IQR: 60.5-80). A total of 504 DRPs (8.4 per patient) were identified across all patients. DRPs were decreased by 50% during the IP compared to the observation period (OP) (p < 0.001). The most common causes of DRPs were 'too low a drug dose' (22.2%), 'drug-drug interactions' (17%), and 'too high a drug dose' (16.4%). Of the recommendations made to the prescribing physician, 140 (97.9%) were accepted. In the IP, targeted calorie and protein supplementation was fully achieved in more patients (p < 0.05). The most common recommendations included 'changes in the rate of nutrition' (66.7%), 'vitamin supplementation' (16.7%), and 'changes in enteral nutrition products' (7.7%).

Conclusion

This study highlights the high incidence of DRPs and malnutrition risk in ICU patients with renal dysfunction, emphasizing the vital role of clinical pharmacists. Their collaboration with healthcare professionals significantly reduced both DRPs and NRPs.

Clinical pharmacist interventions in an intensive care unit reduces ICU mortality at a tertiary hospital in Dubai, United Arab Emirates

Background

Drug-related problems (DRPs) are prevalent in critical care settings and can be life-threatening. Involving clinical pharmacists (CP) within the critical care team is recommended to optimize therapy and improve patient survival.

Objective

To classify DRPs identified by a CP in the Intensive Care Unit (ICU) and to assess the impact of CP interventions accepted by physicians on the length of ICU stay and in-hospital survival.

Methods

This study was conducted prospectively at the Medical ICU of Rashid Hospital, a tertiary hospital in Dubai, over a 16-month period from September 2021 to December 2022. The study included patients admitted to ICU during the study period. CP interventions were documented, and DRPs were classified using the modified Pharmaceutical Care Network Europe V.9.1.

Results

During the study period, 1004 interventions were recommended for 200 patients. The majority of these interventions, 92% (n = 922), received physician acceptance, and 82% (n = 820) were fully implemented by the physician. In total, 1033 drug-related problems (DRPs) were identified, with a median of 3 DRPs per patient. The most common DRPs was drug selection (61%), followed by dose selection (22%). There were 337 DRPs related to antimicrobial agents. Interestingly, we noted that when we adjusted for patients' demographic data and the Glasgow Coma Scale severity score, patients who received >4 implemented interventions exhibited lower cumulative hazard of death within 90 days of their ICU stay in comparison to their counterparts (adjusted Hazard Ratio: 0.10, 95% CI of 0.02-0.41; P = 0.027).

Conclusion

The study emphasizes the critical role of CP in the ICU, addressing DRPs, and enhancing overall patient care. Furthermore, it highlights the potential impact of pharmacist interventions in improving patient survival outcomes. This underscores the importance of implementing CP services in ICUs across the UAE.

Evaluation of medication risk at the transition of care: a cross-sectional study of patients from the ICU to the non-ICU setting

OBJECTIVES

To describe the incidence and types of medication errors occurring during the transfer of patients from the intensive care unit (ICU) to the non-ICU setting and explore the key factors affecting medication safety in transfer care.

DESIGN

Multicentre, retrospective, epidemiological study.

PARTICIPANTS

Patients transferred from the ICU to a non-ICU setting between 1 July 2019 and 30 June 2020.

MAIN OUTCOME MEASURES

Incidence and types of medication errors.

RESULTS

Of the 1546 patients transferred during the study period, 899 (58.15%) had at least one medication error. Most errors (83.00%) were National Coordinating Council (NCC) for Medication Error Reporting and Prevention (MERP) category C. A small number of errors (17.00%) were category D. Among patients with medication errors, there was an average of 1.68 (SD, 0.90; range, 1-5) errors per patient. The most common types of errors were route of administration 570 (37.85%), dosage 271 (17.99%) and frequency 139 (9.23%). Eighty-three per cent of medication errors reached patients but did not cause harm. Daytime ICU transfer (07:00-14:59) and an admission diagnosis of severe kidney disease were found to be factors associated with the occurrence of medication errors as compared with the reference category (OR, 1.40; 95% CI 1.01 to 1.95; OR, 6.78; 95% CI 1.46 to 31.60, respectively).Orders for bronchorespiratory (OR, 5.92; 95% CI 4.2 to 8.32), cardiovascular (OR, 1.91; 95% CI 1.34 to 2.73), hepatic (OR, 1.95; 95% CI 1.30 to 2.91), endocrine (OR, 1.99; 95% CI 1.37 to 2.91), haematologic (OR, 2.58; 95% CI 1.84 to 3.64), anti-inflammatory/pain (OR, 2.80; 95% CI 1.90 to 4.12) and vitamin (OR, 1.73; 95% CI 1.26 to 2.37) medications at transition of care were associated with an increased odds of medication error.

CONCLUSIONS

More than half of ICU patients experienced medication errors during the transition of care. The vast majority of medication errors reached the patient but did not cause harm.

Clinical pharmacist assessment of drug-related problems among intensive care unit patients in a Turkish university hospital

BACKGROUND

Critically ill patients treated in the intensive care units (ICUs) often suffer from side effects and drug-related problems (DRPs) that can be life-threatening. A way to prevent DRPs and improve drug safety and efficacy is to include clinical pharmacists in the clinical team. This study aims to evaluate the classification of drug-related problems and the implementation of clinical pharmacy services by a clinical pharmacist in the ICU of a university hospital in Turkey.

METHODS

This study was carried out prospectively between December 2020 and July 2021 in Gazi University Medical Faculty Hospital Internal Diseases ICU. All patients hospitalized in the intensive care unit for more than 24 h were included in the study. During the study, the clinical pharmacist's interventions and other clinical services for patients were recorded. DRPs were classed according to the Pharmaceutical Care Network Europe V.8.02.

RESULTS

A total of 151 patients were included during the study period corresponding to 2264 patient-days. Patients with DRPs had a longer hospital stay and a higher mortality rate (p < 0.05). 108 patients had at least one DRP and the total number of DRPs was 206. There was an average of 1.36 DRPs per patient, 71.5% of patients experienced DRP and 89.22 DRPs per 1000 patient-days. A total of 35 ADEs were observed in 32 patients. ADE incidence was per 1000 patient-days 15.45. ADEs were caused by nephrotoxicity (48.57%), electrolyte disorders (17.14%), drug-induced thrombocytopenia (17.14%), liver enzyme increase (8.57%) and other causes (8.57%). Drug selection (40.29%) and dose selection (54.36%) constituted most of the causes of DRPs. Dose change was the highest percentage of planned interventions with a rate of 56.79%. Intervention was accepted at a rate of 90.8% and it was fully implemented.

CONCLUSION

In this study, the importance of the clinical pharmacist in the determination and analysis of DRPs was emphasized. Clinical pharmacy services like the one described should be implemented widely to increase patient safety.

Impact of medication therapy management on pharmacotherapy safety in an intensive care unit

Background Drug-related problems are mostly preventable or predictable circumstances that may impact on health outcomes. Clinical pharmacy activities such as medication therapy management can identify and solve these problems, with potential to improve medication safety and effectiveness. Objective To evaluate ability of medication therapy management service to detect drug-related problems and prevent adverse drug events. This study also aimed to assess the risk factors for drugrelated problem occurrence. Setting Medical intensive care unit of a public tertiary hospital in Brazil. Methods Patients were evaluated by a clinical pharmacist, who provided medication therapy management service. Detected drug-related problems were categorized according to the Pharmaceutical Care Network Europe methodology and analyzed in multinomial regression to identify risk factors. Main outcome measure Potential risk factors for drug-related problem occurrence. Results The proposed medication therapy management service allowed detection of 170 drug-related problems that had potential to reach patients causing harm and other 50 unavoidable adverse events. Drug-related problems identified were more often associated with antibacterial use, caused by improper combinations or inadequate drug dosage. These problems required interventions that were accepted by the multidisciplinary team, resulting in more than 85% adherence and total problem solving. Main risk factors identified were previous diagnosis of kidney injury (OR = 8.38), use of midazolam (OR = 7.96), furosemide (OR = 5.87) and vancomycin (OR = 4.82). Conclusion Medication therapy management proved to be an effective method not only for drug-related problem detection, but also for adverse drug event prevention, contributing to improve patient safety.

In vitro aerodynamic characteristics of aerosol delivered from different inhalation methods in mechanical ventilation

Aerodynamic characteristics of aerosol delivery during invasive mechanical ventilation (IMV) are mostly determined by inserting cascade impactor in the circuit. Impactor might have some effect on airflow within IMV. Hence, the aim of the present study was to develop and evaluate new in vitro aerodynamic characterization methodology without affecting airflow in IMV. Breathing simulator was set in standard adult IMV circuit with inspiratory and expiratory pressures of 20 and 5 cm H₂O, 1:3 inspiratory-expiratory ratio, 15 breaths min^-1, and tidal volume of 500 ml. Two ml of salbutamol solution containing 10,000 μg was nebulized using three different vibrating mesh nebulizers (VMNs) and Sidestream jet nebulizer (JET). Sixteen-metered doses, containing 100 μg salbutamol each, were delivered using three different spacers. Each device was placed in inspiration limb of Y-piece of ventilator tubing. Aerodynamic characteristics of aerosol delivered were measured using cooled Andersen cascade impactor, with mixing inlet connected to it. VMNs used had significantly more total mass in the impactor (p < .001) and fine particle dose (p < .001) compared to JET. Spacers used had higher total mass in the impactor percent (p < .001) and fine particle fraction compared to nebulizers. The in vitro IMV methodology setting suggested here showed encouraging results in comparison of different aerosol delivery systems in intubated patient.