Medication Histories in Critically Ill Patients Completed by Pharmacy Personnel

Development and prioritisation of policy recommendations for medication safety improvement for intensive care units: a European Association of Hospital Pharmacists Special Interest Group Delphi Study

OBJECTIVES

Medication errors (MEs) are a leading cause of morbidity and mortality in the healthcare system. Patients admitted to intensive care units (ICUs) are potentially more susceptible to MEs due to severity of illness, the complexity of treatments they receive and the challenging nature of the ICU setting. The European Association of Hospital Pharmacists established a Special Interest Group (SIG) to undertake a programme of work to develop and prioritise recommendations to support medication safety improvement in ICUs across Europe.

METHODS

Initial policy recommendations for medication safety within the ICU environment were developed following reviews of the literature and engagement with relevant stakeholders. A Delphi panel of 21 members of the SIG, that comprised healthcare professionals (HCPs) with expertise in ICU and/or medication safety, was convened in 2022. We conducted two rounds using a modified Delphi technique whereby participants anonymously ranked on a 9-point Likert Scale the policy recommendations according to their priority for implementation.

RESULTS

In total, 32 policy recommendations were developed. In Delphi Round 1, 19 HCPs participated; consensus was achieved on most recommendations and partial consensus on six. In Delphi Round 2, 18 HCPs participated. After two Delphi rounds, consensus was achieved on all 32 recommendations. All recommendations were considered 'high priority' except one that was considered 'medium priority'.

CONCLUSIONS

Through this study it was possible to develop and prioritise evidence-based policy recommendations to enhance medication safety, which may contribute to reducing MEs in ICUs across Europe. All recommendations were considered 'high priority' for implementation except one, indicating the perceived value of these recommendations in improving medication safety through preventing MEs in ICUs.

Benefits of pharmacist intervention in the critical care patients with infectious diseases: A propensity score matching retrospective cohort study

BACKGROUND

The importance of optimising antimicrobial therapy is highlighted in the hospital intensive care unit (ICU) patients. But roles of ICU pharmacists are still in its infancy in China.

OBJECTIVES

This study's objective was to evaluate the values of clinical pharmacist interventions in the antimicrobial stewardship (AMS) on ICU patients with infections.

AIM

The aim of this study was to evaluate the value of clinical pharmacist interventions in the antimicrobial stewardship (AMS) in critically ill patients with infections.

METHODS

From 2017 to 2019, a propensity score matching retrospective cohort research was conducted on critically ill patients with infectious illnesses. The trial was split into groups that received pharmacist assistance and those who did not. Baseline demographics, pharmacist actions, and clinical results were compared between the two groups. Factors influencing mortality were demonstrated using univariate analysis and bivariate logistic regression. The State Administration of Foreign Exchange in China monitored the exchange rate between the RMB and the US dollar and also gathered the charges of the agents as an economic indicator.

RESULTS

Out of the 1523 patients who were evaluated, 102 critically ill patients with infectious diseases were included in each group after matching. The top five prescription regimens adjusted were settled by sickness progression, microbiological results, de-escalation, drug withdrawal, and therapeutic drug monitoring suggestions. The pharmacist exposure group's antibiotic use density (AUD) decreased significantly (p = 0.018) compared to the control group, going from 241.91 to 176.64 defined daily doses/100 bed days. Following pharmacist interventions, the AUD proportion for carbapenems dropped from 23.7 to 14.43%, while for tetracyclines, it dropped from 11.5 to 6.26%. In the group exposed to the pharmacist, the median cost of antibiotics decreased significantly from $836.3 to $362.15 per patient stay (p < 0.001), and the median cost of all medications dropped from $2868.18 to $1941.5 per patient stay (p = 0.06). RMB was converted into US dollars according to the current exchange rate. According to univariate analyses, pharmacist interventions did not differ between the groups that survived and died (p = 0.288).

CONCLUSIONS

This study showed that antimicrobial stewardship had a significant financial return on investment without raising the mortality rate.

Medication Regimen Complexity Index Score at Admission as a Predictor of Inpatient Outcomes: A Machine Learning Approach

BACKGROUND

In the intensive care unit, traditional scoring systems use illness severity and/or organ failure to determine prognosis, and this usually rests on the patient's condition at admission. In spite of the importance of medication reconciliation, the usefulness of home medication histories as predictors of clinical outcomes remains unexplored.

METHODS

A retrospective cohort study was conducted using the medical records of 322 intensive care unit (ICU) patients. The predictors of interest included the medication regimen complexity index (MRCI) at admission, the Acute Physiology and Chronic Health Evaluation (APACHE) II, the Sequential Organ Failure Assessment (SOFA) score, or a combination thereof. Outcomes included mortality, length of stay, and the need for mechanical ventilation. Machine learning algorithms were used for outcome classification after correcting for class imbalances in the general population and across the racial continuum.

RESULTS

The home medication model could predict all clinical outcomes accurately 70% of the time. Among Whites, it improved to 80%, whereas among non-Whites it remained at 70%. The addition of SOFA and APACHE II yielded the best models among non-Whites and Whites, respectively. SHapley Additive exPlanations (SHAP) values showed that low MRCI scores were associated with reduced mortality and LOS, yet an increased need for mechanical ventilation.

CONCLUSION

Home medication histories represent a viable addition to traditional predictors of health outcomes.

Accuracy and safety of medication histories obtained at the time of intensive care unit admission of delirious or mechanically ventilated patients

PURPOSE

Obtaining an accurate medication history from patients on hospital admission is a priority in pharmacy practice. Timely and accurate histories are imperative as they may help determine the etiology of illness and prevent medication errors. We conducted a quality improvement project to assess the accuracy of alternate-source medication histories obtained for critically ill patients who were delirious or mechanically ventilated at the time of intensive care unit admission.

METHODS

Included patients were 18 years of age or older, admitted to the medical intensive care unit from August 2017 through January 2018, and had a medication history obtained from a family member or outpatient pharmacy due to active delirium or mechanical ventilation. Patients were directly interviewed after resolution of delirium or extubation. Discrepancies between the initial and follow-up histories were documented and categorized using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for Categorizing Medication Errors.

RESULTS

Forty patients were included. One hundred four discrepancies were documented, with a median of 2 discrepancies per patient. The most common types of discrepancies were addition (51.9%), followed by omission (24.0%). NCC MERP index category A (51%) was the most common error classification identified.

CONCLUSION

Discrepancies between initial and follow-up medication histories occurred at a frequent rate in delirious or mechanically ventilated patients; however, these discrepancies tended to be of low risk severity.