Pharmacist monitoring of QTc interval-prolonging medications in critically ill medical patients: a pilot study

Use of portable single-lead electrocardiogram device as an alternative for QTc monitoring in critically ill patients

PURPOSE

Acquired QT prolongation is frequent and leads to a higher mortality rate in critically ill patients. KardiaMobile 1L® (KM1L) is a portable, user-friendly single lead, mobile alternative to conventional 12-lead electrocardiogram (12-L ECG) that could be more readily available, potentially facilitating more frequent QTc assessments in intensive care units (ICU); however, there is currently no evidence to validate this potential use.

METHODS

We conducted a prospective diagnostic test study comparing QT interval measurement using KM1L with conventional 12-L ECG ordered for any reason in patients admitted to an ICU. We compared the mean difference using a paired t-test, agreement using Bland-Altman analysis, and Lin's concordance coefficient, numerical precision (proportion of QT measurements with <10 ms difference between KM1L and conventional 12-L ECG), and clinical precision (concordance for adequate discrimination of prolonged QTc).

RESULTS

We included 114 patients (61.4% men, 60% cardiovascular etiology of hospitalization) with 131 12-L ECG traces. We found no statistical difference between corrected QT measurements (427 ms vs. 428 ms, p = .308). Lin's concordance coefficient was 0.848 (95% CI 0.801-0.894, p = .001). Clinical precision was excellent in males and substantial in females (Kappa 0.837 and 0.781, respectively). Numerical precision was lower in patients with vasoactive drugs (-13.99 ms), QT-prolonging drugs (13.84 ms), antiarrhythmic drugs (-12.87 ms), and a heart rate (HR) difference of ≥5 beats per minute (bpm) between devices (-11.26 ms).

CONCLUSION

Our study validates the clinical viability of KM1L, a single-lead mobile ECG device, for identifying prolonged QT intervals in ICU patients. Caution is warranted in patients with certain medical conditions that may affect numerical precision.

Pharmacist Reported Protocols for QTc Monitoring of Psychiatric Medications

Background Psychiatric medications, such as antipsychotics and antidepressants, are associated with QTc interval prolongation. There is currently no consensus best practice on how to mitigate this risk. This study aimed to collect and analyze information about methods used for QTc monitoring in patients taking psychiatric medications to better understand current practice. Methods An anonymous electronic survey was distributed on September 22, 2022, using a national psychiatric pharmacist organization email list. The survey closed on December 15, 2022. Descriptive statistics were used to analyze the multiple-choice questions. Qualitative analysis applying grounded theory for thematic analysis was performed for free response questions. Results A total of 48 initiated the survey. Of the respondents, 11.4% (5/44) reported that their institution had a formal protocol for monitoring QTc intervals in patients receiving psychiatric medications, while 32.4% (12/37) reported that their institution had an informal process. Out of those with a protocol or process, approximately half reported that it was drug-specific. Among the respondents, 88.6% (31/35) reported that there was a psychiatric clinical pharmacy specialist at their institution and 34.3% (12/35) reported that pharmacists could order an electrocardiogram (ECG). Major themes that emerged from the qualitative analysis included pharmacist-driven QTc monitoring, referring the patient to another provider for monitoring, and encountering significant barriers to monitoring. Conclusion A variety of methods are currently being employed to monitor QTc prolongation risk in patients taking psychiatric medications. Pharmacist authorization to order ECGs may be an opportunity to advance practice and improve care for this population. Further research is needed to more clearly understand best practices for QTc prolongation risk mitigation in patients receiving psychiatric medications.

Quantifying Critical Care Pharmacist Interventions in COVID-19

Purpose/Background: Pharmacists have been shown to play an important role in the medication management of critically ill patients. Pharmacist interventions in the care of critically ill patients with coronavirus disease 2019 (COVID-19) have not been quantitatively described. Methodology: A single center, retrospective, observational study was conducted at Vanderbilt University Medical Center in Nashville, Tennessee. All adult patients admitted to the COVID-19 intensive care unit (ICU) or Medical ICU with a COVID-19 diagnosis between March 1, 2020, and June 30, 2021, were included. All interventions made by pharmacists were documented electronically, collected, categorized, and analyzed. The primary outcome of this study was the median number of interventions by pharmacists per patient. The secondary outcome was the number of different types of interventions performed. Results: A total of 768 patients were included in the analysis. The median age was 63 years old; 63% of patients were male and 71% were Caucasian. Median hospital length of stay (LOS) was 12 days (interquartile range (IQR) 7-21) and ICU LOS was 5 days (IQR 1-11). The median Sequential Organ Failure Assessment score was 4 (IQR 2-7) and Charlson Comorbidity Index was 3 (IQR 2-5). Mortality at 60 days occurred in 352 patients (46%). Pharmacists performed a total of 7027 interventions for 655 patients with a median number of pharmacist interventions per patient of 6 (IQR 3-14). The most common pharmacist interventions were medication discontinuation (24%), completion of components of the ICU liberation bundle (19%), medication dose adjustment (18%), therapeutic drug monitoring (15%), and medication initiation (10%). Conclusions: Pharmacists made multiple interventions related to medication use and management in critically ill patients with COVID-19. This study adds important information of the evolving role clinical pharmacists play in the care of critical illness, specifically during the COVID-19 pandemic.

Critical Care Pharmacists: A Focus on Horizons

Critical care pharmacy has evolved rapidly over the last 50 years to keep pace with the rapid technological and knowledge advances that have characterized critical care medicine. The modern-day critical care pharmacist is a highly trained individual well suited for the interprofessional team-based care that critical illness necessitates. Critical care pharmacists improve patient-centered outcomes and reduce health care costs through three domains: direct patient care, indirect patient care, and professional service. Optimizing workload of critical care pharmacists, similar to the professions of medicine and nursing, is a key next step for using evidence-based medicine to improve patient-centered outcomes.

Implementation of a Pharmacist Monitoring Process for Patients on QTc Prolonging Antibiotics: A Pilot Study

Purpose: The purpose of this pilot study was to implement a pharmacist monitoring process for 4 antimicrobials; azithromycin, ciprofloxacin, levofloxacin, and fluconazole. This pilot study was a patient safety initiative to screen patients and engage providers about therapies at risk for QT prolongation. Methodology: A concurrent chart review was performed at a single center from January 6, to February 22, 2020, of adult patients ≥ 18 years of age initiated on azithromycin, ciprofloxacin, levofloxacin, and fluconazole. Patient risk factors assessed: age, female sex, loop diuretic use, potassium ≤ 3.5 mEq/L, QTc ≥ 450 ms, acute myocardial infarction (MI) or heart failure, 1 or more QTc prolonging agents, and sepsis. The primary endpoint was successful implementation of the QTc monitoring process by pharmacists. Secondary endpoints were the interventions made by pharmacists. Results: From January 6, to February 22, 2020, there were a total of 412 orders for one of the target antimicrobials that resulted in 157 documented pharmacist reviews (38.1%). Of the 157 evaluations, 100 of these represented patients in our high risk group (84 moderate, 16 high risk). Successful implementation was observed through documentation of assessment on all patients with moderate or high risk scores in the 100 person cohort. Conclusion: The pilot study demonstrated a successful implementation of a QTc monitoring process by pharmacists since all patients had documented reviews. Further steps include investigating how to improve efficiency, as well as ways for continued success in monitoring.

Role of Clinical Pharmacists in Intensive Care Units

The cost of health care has been rising in the United States and globally and will continue to increase. Intensive care unit (ICU) care carries a significant portion of the cost for the hospitals. The Institute of Medicine and subsequent studies have suggested that medication errors account for significant morbidity, mortality, and cost, frequently encountered in the ICU. Over the past three decades, clinical pharmacists have emerged from dispensing medication to getting involved in direct patient care and have become an integral part of the multidisciplinary critical care team. Clinical pharmacists play a significant role in reducing medication errors and costs, medication reconciliation, antibiotic stewardship, and patient and health care provider education. This review will discuss the health care and ICU cost, the evolving role of clinical pharmacists in managing critically ill patients, and their contributions in the ICU to mitigate the risks, improve patient outcomes, and decrease health care costs.

Position Paper on Critical Care Pharmacy Services: 2020 Update

OBJECTIVES

To provide a multiorganizational statement to update recommendations for critical care pharmacy practice and make recommendations for future practice. A position paper outlining critical care pharmacist activities was last published in 2000. Since that time, significant changes in healthcare and critical care have occurred.

DESIGN

The Society of Critical Care Medicine, American College of Clinical Pharmacy Critical Care Practice and Research Network, and the American Society of Health-Systems Pharmacists convened a joint task force of 15 pharmacists representing a broad cross-section of critical care pharmacy practice and pharmacy administration, inclusive of geography, critical care practice setting, and roles. The Task Force chairs reviewed and organized primary literature, outlined topic domains, and prepared the methodology for group review and consensus. A modified Delphi method was used until consensus (> 66% agreement) was reached for each practice recommendation. Previous position statement recommendations were reviewed and voted to either retain, revise, or retire. Recommendations were categorized by level of ICU service to be applicable by setting and grouped into five domains: patient care, quality improvement, research and scholarship, training and education, and professional development.

MAIN RESULTS

There are 82 recommendation statements: 44 original recommendations and 38 new recommendation statements. Thirty-four recommendations represent the domain of patient care, primarily relating to critical care pharmacist duties and pharmacy services. In the quality improvement domain, 21 recommendations address the role of the critical care pharmacist in patient and medication safety, clinical quality programs, and analytics. Nine recommendations were made in the domain of research and scholarship. Ten recommendations were made in the domain of training and education and eight recommendations regarding professional development.

CONCLUSIONS

Critical care pharmacists are essential members of the multiprofessional critical care team. The statements recommended by this taskforce delineate the activities of a critical care pharmacist and the scope of pharmacy services within the ICU. Effort should be made from all stakeholders to implement the recommendations provided, with continuous effort toward improving the delivery of care for critically ill patients.

Predictive Validity of a QTc Interval Prolongation Risk Score in the Intensive Care Unit

BACKGROUND

Torsade de pointes is a form of polymorphic ventricular tachycardia associated with heart rate-corrected QT (QT_c ) interval prolongation. With approximately 24-61% of critically ill patients experiencing QT_c interval prolongation, a predictive tool to identify high-risk patients could assist in the monitoring and management in the intensive care unit (ICU). The Tisdale et al. Risk Score (TRS) is a predictive tool that was developed and validated in a cardiac critical care unit.

OBJECTIVES

The objective of this study was to evaluate the predictive validity (sensitivity and specificity) and likelihood ratios of the TRS in a medical ICU.

METHODS

This was a longitudinal, retrospective, cohort study of consecutive patients who met the inclusion criteria from October 2017 to June 2018 with a sample size of 264 patients. The sample size was derived based on the number of TRS covariates and an exploratory variable. Baseline characteristics and risk factors were documented from electronic health records. The first occurrence of QT_c interval prolongation, defined as a QT_c interval > 500 ms or an increase ≥ 60 ms above baseline, was the primary endpoint.

MAIN RESULTS

The sensitivity and specificity of the TRS for low-risk patients against the moderate-risk and high-risk patients were 97% (95% CI 91-99%) and 16% (95% CI 11-23%), respectively. These results corresponded to a positive likelihood ratio of 1.15 (95% CI 1.07-1.24) and a negative likelihood ratio of 0.20 (95% CI 0.06-0.65).

CONCLUSIONS

In conclusion, the TRS showed a high sensitivity, making it useful in identifying patients at risk of developing QT_c interval prolongation. Furthermore, patients categorized as low risk by the tool can be considered as having minimal risk of developing QT_c interval prolongation. Given the tool's low specificity, it does not reliably identify all patients at low risk of QT_c interval prolongation.

QTc Prolongation in the Critically Ill: Tread with Caution!

How to cite this article: Elangovan A. QTc Prolongation in the Critically Ill: Tread with Caution! Indian J Crit Care Med 2020;24(4):220-221.

Standards for Neurologic Critical Care Units: A Statement for Healthcare Professionals from The Neurocritical Care Society

Neurocritical care is a distinct subspecialty focusing on the optimal management of acutely ill patients with life-threatening neurologic and neurosurgical disease or with life-threatening neurologic manifestations of systemic disease. Care by expert healthcare providers to optimize neurologic recovery is necessary. Given the lack of an organizational framework and criteria for the development and maintenance of neurological critical care units (NCCUs), this document is put forth by the Neurocritical Care Society (NCS). Recommended organizational structure, personnel and processes necessary to develop a successful neurocritical care program are outlined. Methods: Under the direction of NCS Executive Leadership, a multidisciplinary writing group of NCS members was formed. After an iterative process, a framework was proposed and approved by members of the writing group. A draft was then written, which was reviewed by the NCS Quality Committee and NCS Guidelines Committee, members at large, and posted for public comment. Feedback was formally collated, reviewed and incorporated into the final document which was subsequently approved by the NCS Board of Directors.

Identification of Patients At-Risk of QT Interval Prolongation during Medication Reviews: A Missed Opportunity?

The prolongation of the QT interval is a relatively rare but serious adverse drug reaction. It can lead to torsade de pointes, which is potentially life-threatening. The study’s objectives were: determine the use of QT interval-prolonging drugs in an elderly community-dwelling population at risk of medication misadventure and identify recommendations regarding the risk of QT interval prolongation made by pharmacists when performing medication reviews. In a retrospective evaluation, 500 medication review reports from Australian pharmacists were analysed. In patients taking at least one QT interval-prolonging drug, the individual risk of drug-induced QT interval prolongation was assessed. Recommendations of pharmacists to avoid the occurrence of this drug-related problem were examined. There was a high prevalence of use of potentially QT interval-prolonging drugs (71% patients), with 11% of patients taking at least one drug with a known risk. Pharmacists provided specific recommendations in only eight out of 35 patients (23%) with a high-risk score and taking drugs with known risk of QT interval prolongation. Pharmacists’ recommendations, when present, were focused on drugs with known risk of QT interval prolongation, rather than patients’ additional risk factors. There is a need to improve knowledge and awareness of this topic among pharmacists performing medication reviews.

QTc interval prolongation in critically ill patients: Prevalence, risk factors and associated medications

PURPOSE

To investigate the prevalence and risk factors of acquired long QT syndrome (LQTS) on admission to a general Intensive Care Unit (ICU), and to assess the risk of LQTS associated with prescribed medications.

METHODS

Prospective observational, cross-sectional study approved by the Institutional Review Board. Between May 2014 and July 2016, 412 patients >18 years-old consecutively admitted to the ICU of a university hospital were included. LQTS was defined as a QT interval on the admission electrocardiogram corrected using Bazett's formula (QTc) >460 ms for men and >470 ms for women. All medications administered within 24 hours before admission were recorded. Logistic regression was used.

RESULTS

LQTS prevalence was 27.9%. In LQTS patients, 70.4% had ≥ 1 LQTS-inducing drug prescribed in the 24 hours prior to ICU admission versus 70.4% in non-LQTS patients (p = 0.99). Bradycardia and Charlson morbidity index score are independent risk factors for LQTS. Haloperidol (OR 4.416), amiodarone (OR 2.509) and furosemide (OR 1.895) were associated with LQTS, as well as another drug not yet described, namely clopidogrel (OR 2.241).

CONCLUSIONS

The LQTS is highly prevalent in critically ill patients, ICU patients are often admitted with LQTS-inducing medications, and patients with slow heart rate or with high Charlson comorbidity index should be evaluated for LQTS.

Introduction to surgical and perioperative clinical pharmacy for third-year pharmacy students: A pilot study of an elective course

INTRODUCTION

The objective of this study was to implement and assess an elective course that exposes pharmacy students to clinical pharmacy in the surgical and perioperative setting.

METHODS

A blended-design elective that included synchronous and asynchronous learning was developed and offered to third-year pharmacy students. Students' knowledge and perception regarding clinical topics in perioperative pharmacy was assessed using pre- and post-course assessments, online quizzes, a journal club, and course assignments. Knowledge of pharmacy operations was assessed using course assignments and reflective journal entries.

RESULTS

Pre- and post-course assessment improvement was seen in the categories of perioperative optimization of pharmacotherapy (29.1-70.1%, p=0.006), common surgical complications (45.8-91.7%, p = 0.001), and anesthetic agents (25-71.9%, p <0.001). Overall, the course was successful in increasing clinical pharmacy knowledge and was well received by students. Course evaluations were completed by 100% of students, and all rated the course as "excellent." Students demonstrated mastery of course content, though the course may not have provided optimal exposure to operating room/post-anesthesia care unit operations.

DISCUSSION AND CONCLUSIONS

Students agreed that the course was valuable and helped them develop new skills otherwise not developed by the curriculum; this conclusion was supported by objective assessment data. A team-teaching model allowed for minimal resources to operate the course. Moving forward, an early lecture addressing perioperative operations may supplement an area the course was lacking. Additionally, a longer duration of operating room shadowing may provide requested opportunities for observation of direct patient care.

Critical Care Pharmacists and Medication Management in an ICU Recovery Center

BACKGROUND

Many patients experience complications following critical illness; these are now widely referred to as post-intensive care syndrome (PICS). An interprofessional intensive care unit (ICU) recovery center (ICU-RC), also known as a PICS clinic, is one potential approach to promoting patient and family recovery following critical illness.

OBJECTIVES

To describe the role of an ICU-RC critical care pharmacist in identifying and treating medication-related problems among ICU survivors.

METHODS

A prospective, observational cohort study was conducted of all outpatient appointments of a tertiary care hospital's ICU-RC between July 2012 and December 2015. The pharmacist completed a full medication review, including medication reconciliation, interview, counseling, and resultant interventions, during the ICU-RC appointment.

RESULTS

Data from all completed ICU-RC visits were analyzed (n = 62). A full medication review was performed in 56 (90%) of these patients by the pharmacist. The median number of pharmacy interventions per patient was 4 (interquartile range = 2, 5). All 56 patients had at least 1 pharmacy intervention; 22 (39%) patients had medication(s) stopped at the clinic appointment, and 18 (32%) patients had new medication(s) started. The pharmacist identified 9 (16%) patients who had an adverse drug event (ADE); 18 (32%) patients had ADE preventive measures instituted. An influenza vaccination was administered to 13 (23%) patients despite an inpatient protocol to ensure influenza vaccination prior to discharge. A pneumococcal vaccination was administered to 2 (4%) patients.

CONCLUSIONS

Use of a critical care pharmacist resulted in the identification and treatment of multiple medication-related problems in an ICU-RC as well as implementation of preventive measures.

Impact of Pharmacist Intervention on Electrocardiogram Monitoring of Pediatric Patients on Multiple QTc Interval-Prolonging Medications

OBJECTIVES

To determine whether dedicated pharmacy services improve the rate of electrocardiogram (ECG) monitoring in patients at risk for medication-induced QTc interval prolongation. In addition, determine how pediatric institutions currently monitor patients at risk for medication-induced QTc interval prolongation.

METHODS

A pharmacist-driven monitoring protocol to detect medication-induced QTc interval prolongation was developed using published literature. If patients were prescribed 3 or more medications known to prolong the QTc interval, they were recommended to have a baseline ECG to assess the QTc interval. If 3 or more QTc interval-prolonging medications were administered for 5 or more days, a follow-up ECG was recommended. Patients prescribed medications known to prolong the QTc interval were identified. Prior to pharmacist intervention, electronic medical records were reviewed to determine if baseline and follow-up ECGs were obtained in patients meeting criteria for monitoring. A dedicated pharmacist then prospectively reviewed charts and recommended monitoring. The rate of monitoring during the intervention and baseline period was compared. To determine current practice at pediatric institutions, a survey was distributed to pharmacists.

RESULTS

Pharmacist intervention improved the rate of ECG monitoring in patients at risk for medication-induced QTc interval prolongation from 47.8% to 100% (p = 0.0009). Of the 55 survey participants, 6 stated their institution had QTc interval monitoring procedures in place, 35 did not have any, and 3 had procedures in process.

CONCLUSIONS

Targeted pharmacist intervention improved the rate of ECG monitoring in patients at risk for medication-induced prolonged QTc interval. Our research and survey data reveal that institutions could benefit from targeted pharmacist intervention to monitor patients for medication-induced QTc interval prolongation.

Impact of pharmaceutical care on pain and agitation in a medical intensive care unit in Thailand

Background Currently, a lack of pharmaceutical care exists concerning pain and agitation in medical intensive care units (MICU) in Thailand. Pharmaceutical care focusing on analgesics/sedatives would improve clinical outcomes. Objective To investigate the impact of pharmaceutical care of pain and agitation on ICU length of stay (LOS), hospital LOS, ventilator days and mortality. Setting The MICU of a university hospital. Method A before/after study was conducted on mechanically ventilated patients receiving analgesics/sedatives. Medical chart reviews and data collection were conducted in the retrospective group (no pharmacists involved). In the prospective group, pharmacists involved with the critical care team helped select analgesics/sedatives for individual patients. Main outcome measure ICU LOS Results In total, 90 and 66 patients were enrolled in retrospective and prospective groups, respectively. The median duration of ICU LOS was reduced from 10.00 (2.00-72.00) in the retrospective group to 6.50 days (2.00-30.00) in the prospective group (p = 0.002). The median hospital stay was reduced from 30.50 days (2.00-119.00) in the retrospective group to 17.50 days (2.00-110.00) in the prospective group (p < 0.001). Also, the median ventilator days was reduced from 14.00 days (2.00-90.00) to 8.50 days (1.00-45.00), p = 0.008. Mortality was 53.03% in the prospective group and 46.67% in the retrospective group (p = 0.432). Conclusion Pharmacist participation in a critical care team resulted in a significant reduction in the duration of ICU LOS, hospital LOS and ventilator days, but not mortality.

QTc prolongation during erythromycin used as prokinetic agent in ICU patients

Background

High-dose erythromycin used as antibiotic prolongs QTc interval. Low-dose erythromycin is frequently used as a prokinetic agent, especially in patients in the intensive care unit (ICU). It is unknown whether low-dose erythromycin affects cardiac repolarisation and puts patients at risk for torsades de pointes.

Methods

In this prospective study, we included ICU patients treated with erythromycin as prokinetic in a dose of 200 mg twice a day. An ECG was performed before, 15 min and 24 hours after the start of erythromycin. Cardiac repolarisation was assessed by rate-corrected analysis of the QT interval (QTc) on the ECG by two independent investigators. Starting or stopping other possibly QTc prolonging drugs during the study period was an exclusion criterion. Wilcoxon signed-rank test and Friedman's test were used for statistical analysis to assess prolongation of QTc. Primary outcome was defined by the prolongation of QTc after 15 min and 24 hours.

Results

51 patients were eligible for this study. In these patients, QTc increased significantly from 430 ms at baseline to 439 ms (p=0.03) after 15 min and 444 ms (p=0.01) after 24 hours. After 15 min and 24 hours, the upper limit of 95% CI for prolongation of QTc was well above 10 ms. No QTc-related arrhythmias were seen.

Conclusions

During treatment with erythromycin in a dose of 200 mg twice a day. QTc prolonged mildly but significantly. Sequential ECG registration should be performed when low-dose erythromycin is prescribed, especially in the presence of other risk factor for QTc prolongation.

Adverse Drug Reactions in the Intensive Care Unit

Adverse drug reactions (ADRs) are undesirable effects of medications used in normal doses [1]. ADRs can occur during treatment in an intensive care unit (ICU) or result in ICU admissions. A meta-analysis of 4139 studies suggests the incidence of ADRs among hospitalized patients is 17% [2]. Because of underreporting and misdiagnosis, the incidence of ADRs may be much higher and has been reported to be as high as 36% [3]. Critically ill patients are at especially high risk because of medical complexity, numerous high-alert medications, complex and often challenging drug dosing and medication regimens, and opportunity for error related to the distractions of the ICU environment [4]. Table 1 summarizes the ADRs included in this chapter.

Impact of clinical pharmacist in an Indian Intensive Care Unit

BACKGROUND AND OBJECTIVES

A critically ill patient is treated and reviewed by physicians from different specialties; hence, polypharmacy is a very common. This study was conducted to assess the impact and effectiveness of having a clinical pharmacist in an Indian Intensive Care Unit (ICU). It also evaluates the clinical pharmacist interventions with a focus on optimizing the quality of pharmacotherapy and patient safety.

MATERIALS AND METHODS

The prospective, observational study was carried out in medical and surgical/trauma ICU over a period of 1 year. All detected drug-related problems and interventions were categorized based on the Pharmaceutical Care Network Europe system.

RESULTS

During the study period, average monthly census of 1032 patients got treated in the ICUs. A total of 986 pharmaceutical interventions due to drug-related problems were documented, whereof medication errors accounted for 42.6% (n = 420), drug of choice problem 15.4% (n = 152), drug-drug interactions were 15.1% (n = 149), Y-site drug incompatibility was 13.7% (n = 135), drug dosing problems were 4.8% (n = 47), drug duplications reported were 4.6% (n = 45), and adverse drug reactions documented were 3.8% (n = 38). Drug dosing adjustment done by the clinical pharmacist included 140 (11.9%) renal dose, 62 (5.2%) hepatic dose, 17 (1.4%) pediatric dose, and 104 (8.8%) insulin dosing modifications. A total of 577 drug and poison information queries were answered by the clinical pharmacist.

CONCLUSION

Clinical pharmacist as a part of multidisciplinary team in our study was associated with a substantially lower rate of adverse drug event caused by medication errors, drug interactions, and drug incompatibilities.

Outcomes of expanded use of clinical pharmacist practitioners in addition to team-based care in a community health system intensive care unit

PURPOSE

Clinical and cost benefits achieved through expanded use of state-licensed clinical pharmacist practitioners (CPPs) with prescribing authority on a critical care team are reported.

METHODS

A retrospective pre-post analysis was conducted to evaluate patient care outcomes and cost savings during one-year periods before and after the number of CPPs on a North Carolina community health system's neurotrauma intensive care unit (NTICU) team was increased from one to three. Outcomes assessed included the number and types of medication management encounters, estimated cost savings, and the rate of preventable adverse drug events (ADEs) with expanded use of CPPs.

RESULTS

During the two-year study period, CPPs conducted 13,386 documented medication encounters involving 2,198 patients; associated cost savings totaled an estimated $2,118,426. During the 12 months after CPP involvement on the NTICU team was increased, there was a 182% increase in encounters for therapeutic optimization (p = 0.01), with an associated 29% increase in cost savings and an improved return on investment. The CPP service expansion was also associated with a reduction in preventable ADEs, including a 75% reduction in prescribing-related ADEs (risk ratio [RR], 0.25; 95% confidence interval [CI], 0.05-1.2; p = 0.09) and a 37% reduction in higher-severity ADEs (RR, 0.63; 95% CI, 0.25-1.57; p = 0.36).

CONCLUSION

With expanded CPP involvement on the NTICU team, there was a substantial increase in therapeutic optimization interventions and a clinically notable reduction in preventable ADEs, as well as an estimated 30% increase in associated cost savings.

Effect of critical care pharmacist's intervention on medication errors: A systematic review and meta-analysis of observational studies

Pharmacists are integral members of the multidisciplinary team for critically ill patients. Multiple nonrandomized controlled studies have evaluated the outcomes of pharmacist interventions in the intensive care unit (ICU). This systematic review focuses on controlled clinical trials evaluating the effect of pharmacist intervention on medication errors (MEs) in ICU settings. Two independent reviewers searched Medline, Embase, and Cochrane databases. The inclusion criteria were nonrandomized controlled studies that evaluated the effect of pharmacist services vs no intervention on ME rates in ICU settings. Four studies were included in the meta-analysis. Results suggest that pharmacist intervention has no significant contribution to reducing general MEs, although pharmacist intervention may significantly reduce preventable adverse drug events and prescribing errors. This meta-analysis highlights the need for high-quality studies to examine the effect of the critical care pharmacist.

Pharmacist contributions as members of the multidisciplinary ICU team

Critical care pharmacy services in the ICU have expanded from traditional dispensing responsibilities to being recognized as an essential component of multidisciplinary care for critically ill patients. Augmented by technology and resource utilization, this shift in roles has allowed pharmacists to provide valuable services in the form of assisting physicians and clinicians with pharmacotherapy decision-making, reducing medication errors, and improving medication safety systems to optimize patient outcomes. Documented improvements in the management of infections, anticoagulation therapy, sedation, and analgesia for patients receiving mechanical ventilation and in emergency response help to justify the need for clinical pharmacy services for critically ill patients. Contributions to quality improvement initiatives, scholarly and research activities, and the education and training of interdisciplinary personnel are also valued services offered by clinical pharmacists. Partnering with physician and nursing champions can garner support from hospital administrators for the addition of clinical pharmacy critical care services. The addition of a pharmacist to an interprofessional critical care team should be encouraged as health-care systems focus on improving the quality and efficiency of care delivered to improve patient outcomes.

Agreement between ICU clinicians and electrophysiology cardiologists on the decision to initiate a QTc-interval prolonging medication in critically ill patients with potential risk factors for torsade de pointes: a comparative, case-based evaluation

STUDY OBJECTIVES

To measure concordance between different intensive care unit (ICU) clinicians and a consensus group of electrophysiology (EP) cardiologists for use of a common rate-corrected QT interval (QTc)-prolonging medication in cases containing different potential risk factor(s) for torsade de pointes (TdP).

DESIGN

Prospective case-based evaluation.

SETTING

Academic medical center with 320 beds.

SUBJECTS

Medical house staff (MDs) and ICU nurses (RNs) from one center and select critical care pharmacists (PHs).

INTERVENTION

Completion of a survey containing 10 hypothetical ICU cases in which patients had agitated delirium for which a psychiatrist recommended intravenous haloperidol 5 mg every 6 hours. Each case contained different potential risk factor(s) for TdP in specific combinations. A group of five EP cardiologists agreed that haloperidol use was safe in five cases and not safe in five cases.

MEASUREMENTS AND MAIN RESULTS

For each case, participants were asked to document whether they would administer haloperidol, to provide a rationale for their decision, and to state their level of confidence in that decision. Most clinicians (92 of 115 [80%]) invited to participate completed the cases. Among the five cases where EP cardiologists agreed that haloperidol was not safe, 29% of respondents felt that haloperidol was safe. Conversely, in the five cases where EP cardiologists felt haloperidol was safe, 21% of respondents believed that it was not safe. Overall respondent-EP cardiologist agreement for haloperidol use across the 10 cases was moderate (κ = 0.51). MDs and PHs were in agreement with the EP cardiologists more than RNs (p=0.03). Interprofessional variability existed for the TdP risk factors each best identified. Clinician confidence correlated with EP cardiologist concordance for MDs (p=0.002) and PHs (p=0.0002), but not for RNs (p=0.69).

CONCLUSION

When evaluating use of a QTc interval-prolonging medication, ICU clinicians often fail to identify the TdP risk factors that EP cardiologists feel should prevent its use. Clinician-EP cardiologist concordance varies by the specific risk factor(s) for TdP and the ICU professional conducting the assessment.

Acquired long QT syndrome: frequency, onset, and risk factors in intensive care patients

BACKGROUND

Acquired long QT syndrome is a reversible condition that can lead to torsades de pointes and sudden cardiac death.

OBJECTIVE

To determine the frequency, onset, frequency of medications, and risk factors for the syndrome in intensive care patients.

METHODS

In a retrospective chart review of 88 subjects, hourly corrected QT intervals calculated by using the Bazett formula were collected. Acquired long QT syndrome was defined as a corrected QT of 500 milliseconds or longer or an increase in corrected QT of 60 milliseconds or greater from baseline level. Risk factors and medications administered were collected from patients' medical records.

RESULTS

The syndrome occurred in 46 patients (52%); mean time of onset was 7.4 hours (SD, 9.4) from time of admission. Among the 88 patients, 52 (59%) received a known QTc-prolonging medication. Among the 46 with the syndrome, 23 (50%) received a known QT-prolonging medication. No other risk factor studied was significantly predictive of the syndrome.

CONCLUSIONS

Acquired long QT syndrome occurs in patients not treated with a known QT-prolonging medication, indicating the importance of frequent QT monitoring of all intensive care patients.

Drug-drug interactions contributing to QT prolongation in cardiac intensive care units

PURPOSE

To determine the most common drug-drug interaction (DDI) pairs contributing to QTc prolongation in cardiac intensive care units (ICUs).

MATERIALS AND METHODS

This retrospective evaluation included patients who were admitted to the cardiac ICUs between January 2009 and July 2009 aged ≥ 18 years with electrocardiographic evidence of a QTc ≥ 500 ms. Patients receiving at least two concomitant drugs known to prolong the QT interval were considered to experience a pharmacodynamic DDI. Drugs causing CYP450 inhibition of the metabolism of QT prolonging medications were considered to cause pharmacokinetic DDIs. The causality between drug and QTc prolongation was evaluated with an objective scale.

RESULTS

One hundred eighty-seven patients experienced QT prolongation out of a total of 501 patients (37%) admitted during the study period. Forty-three percent and 47% of patients experienced 133 and 179 temporally-related pharmacodynamic and pharmacokinetic interactions, respectively. The most common medications related to these DDIs were ondansetron, amiodarone, metronidazole, and haloperidol.

CONCLUSION

DDIs may be a significant cause of QT prolongation in cardiac ICUs. These data can be used to educate clinicians on safe medication use. Computerized clinical decision support could be applied to aid in the detection of these events.

Pharmacist proactive medication recommendations using electronic documentation in a UK general critical care unit

BACKGROUND

Specific data on the actual clinical practice of United Kingdom pharmacists in Critical Care are limited. Within the general critical care units of Sheffield Teaching Hospitals, clinical pharmacists have the facility to electronically document, communicate and follow-up proactive recommendations using a Pharmacy Review Form via the Clinical Information System, MetaVision(®).

OBJECTIVE

The objective of the service evaluation was to describe the acceptance rate by medical staff of pharmacist proactive medication recommendations; including data on the types of recommendations and reasons thereof, for general intensive care patients of a UK teaching hospital trust.

SETTING

Sheffield Teaching Hospitals National Health Service Foundation Trust with 20 intensive care beds located on two hospital sites admitting Level 3 and 2 mixed general medical, surgical, trauma, burns and haematology/ oncology patients.

METHOD

Retrospective analysis of pharmacist proactive recommendations recorded electronically from January 2009 to July 2011 in general intensive care unit patients. Main outcome 5,623 electronic medication recommendations were documented, providing an average of 2.2 proactive recommendations per patient admitted to intensive care from January 2009 to July 2011. 5,101 (90.7%) of the recommendations were accepted and acted upon by medical staff.

RESULTS

The most common recommendations were Add Drug 1,862 (28.2%); Dose Review 1,707 (25.8%); Discontinue Drug 1,185 (17.9%); Alternative Drug 903 (13.7%); Alternative Route 770 (11.7%). The most common reasons for the proactive medication recommendations were related to changes in gastrointestinal absorption 951 (15.6%); compliance with medication guidelines 857 (14.1%); sedation/delirium/agitation management 764 (12.6%); dose adjustment for renal dysfunction or continuous renal replacement therapies 756 (12.4%); and medication reconciliation 612 (10.1%). The majority of medication recommendations involved drugs in Gastrointestinal, Central Nervous System, Cardiovascular, Infection, Nutrition and Blood classes (British National Formulary).

CONCLUSION

There was a high acceptance rate for proactive medication-related recommendations made by critical care pharmacists via the electronic review form. The majority of pharmacist recommendations were related to adding or refining currently prescribed medication. Ten percent of recommendations related to medication reconciliation of patients' pre-admission medication.

Prevalence of potential drug-drug interactions in bone marrow transplant patients

OBJECTIVE

To assess the prevalence of potential drug-drug interactions (DDIs) in bone marrow transplantation (BMT) patients at the time of pre-infusion (day -1), to describe the potential DDIs and assess their frequency and severity.

SETTING

The study was developed in a tertiary care hospital in São Paulo, Brazil.

METHOD

Cross-sectional study based on examining the medical prescriptions from the pre-infusion day (day -1) of 70 BMT patients. Potential DDIs were analyzed using Drug-Reax(®) and categorized according to levels of severity, evidence, and onset (rapid and delayed). Only interactions of major or moderate severity were included in the potential DDI analysis.

MAIN OUTCOME MEASURE

Prevalence of potential DDIs in patients during the preinfusion phase of BMT.

RESULTS

Data were analysed for 70 BMT patients. The median age was 36.5 years; 52.9% (37) of the patients were male, and 65.7% (46) were undergoing autologous BMT. The patients received a median of 8 drugs each. Up to 128 potential DDIs were detected, 60.0% (42) of patients had at least 1 potential DDI and 21.4% (15) were exposed to at least 1 major potential DDI. The most commonly involved drugs were cyclosporine (9, 28.1%), phenytoin (8, 25%) and fluconazole (5, 15.6%). Most potential DDIs had moderate severity (110, 85.9%), a pharmacokinetic mechanism (67, 52.3%), and were classified as delayed onset (106, 82.8%). For major interactions, fluconazole + sulfamethoxazole/trimethoprim, diazepam + fentanyl, fluconazole + levofloxacin and fentanyl + fluconazole were the most frequent.

CONCLUSIONS

The prevalence of potential DDIs during the conditioning period of BMT was high as a consequence of the therapeutic complexity of the procedure. Most potential DDIs identified in the study may result in clinically relevant consequences as they could lead to nephrotoxicity, cardiotoxicity, and other undesirable adverse effects. Careful monitoring of clinical and laboratory parameters is essential to ensure a successful BMT and to avoid adverse drug events related to DDI.

Current Perceptions and Practices Surrounding the Recognition and Treatment of Delirium in the Intensive Care Unit: A Survey of 250 Critical Care Pharmacists from Eight States

Background:

Pharmacists are key members of the intensive care unit (ICU) team; however, few data exist regarding their clinical role, perceptions, and current practices in recognizing and managing delirium.

Objective:

To describe current practices and perceptions of ICU pharmacists regarding delirium recognition and treatment relative to current recommendations.

Methods:

A self-administered survey was distributed to 457 pharmacists in 8 states who are members of the Society of Critical Care Medicine or the American College of Clinical Pharmacy and who spend 25% or more of their time providing clinical ICU pharmacy services.

Results:

A total of 250 (55%) pharmacists responded. A delirium screening tool was routinely used by few (7%) pharmacists. Lack of time (34%) and the belief that screening is a nursing role (24%) were key barriers to pharmacist screenings. Most (85%) said that delirium should be pharmacologically managed; 66% responded that 2 or more medications should be used. The treatments of first choice included Haloperidol (76%), an atypical antipsychotic (14%), or a benzodiazepine (10%). Frequently used treatments were Haloperidol (87%), quetiapine (59%), and lorazepam (47%). Haloperidol was perceived by many (42%) to have 1 or more randomized trials supporting its use for delirium and Food and Drug Administration approval for this indication (34%). Haloperidol was most often administered on a scheduled basis (62%), intravenously (92%), and al a daily dose of 5–10 mg (58%). While the QTc interval was frequently measured at least once per shift using an electrocardiogram strip (64%), it was not routinely measured in 20% of ICUs, and 60% continued haloperidol when the QTc exceeded 500 msec.

Conclusions:

Current practices and perceptions surrounding recognition and treatment of delirium in patients in the ICU by the critical care pharmacists surveyed are heterogeneous. Antipsychotics are frequently recommended by pharmacists for delirium treatment, despite a lack of rigorous evidence to support their use. While pharmacists are ideally suited to lead delirium recognition efforts and provide treatment recommendations in this area, these roles need further elucidation. The optimal pedagogical strategy to support these efforts remains unclear, and the potential impact of pharmacists’ efforts on patients’ outcomes is unknown.

Interdisciplinary patient care in the intensive care unit: focus on the pharmacist

The field of critical care medicine began to flourish only within the last 40 years, yet it provides some of the best examples of collaborative pharmacy practice models and evidence for the value of pharmacist involvement in interdisciplinary practice. This collaborative approach is fostered by critical care organizations that have elected pharmacists into leadership positions and recognized pharmacists through various honors. There is substantial literature to support the value of the critical care pharmacist as a member of an interdisciplinary intensive care unit (ICU) team, particularly in terms of patient safety. Furthermore, a number of economic investigations have demonstrated cost savings or cost avoidance with pharmacist involvement. As the published evidence supporting pharmacist involvement in patient care activities in the ICU setting has increased, surveys have demonstrated an increase in the percentage of pharmacists performing clinical activities. In addition, substantial support of pharmacists has been provided by other clinicians, safety officers, and administrative personnel who have been involved with the initiation and expansion of critical care pharmacy services in their own institutions. Although there is still room for improvement in the range of pharmacist involvement, particularly with respect to interdisciplinary activities related to education and scholarship, pharmacists have become essential members of interdisciplinary care teams in ICU settings.

On-ward participation of a hospital pharmacist in a Dutch intensive care unit reduces prescribing errors and related patient harm: an intervention study

Introduction

Patients admitted to an intensive care unit (ICU) are at high risk for prescribing errors and related adverse drug events (ADEs). An effective intervention to decrease this risk, based on studies conducted mainly in North America, is on-ward participation of a clinical pharmacist in an ICU team. As the Dutch Healthcare System is organized differently and the on-ward role of hospital pharmacists in Dutch ICU teams is not well established, we conducted an intervention study to investigate whether participation of a hospital pharmacist can also be an effective approach in reducing prescribing errors and related patient harm (preventable ADEs) in this specific setting.

Methods

A prospective study compared a baseline period with an intervention period. During the intervention period, an ICU hospital pharmacist reviewed medication orders for patients admitted to the ICU, noted issues related to prescribing, formulated recommendations and discussed those during patient review meetings with the attending ICU physicians. Prescribing issues were scored as prescribing errors when consensus was reached between the ICU hospital pharmacist and ICU physicians.

Results

During the 8.5-month study period, medication orders for 1,173 patients were reviewed. The ICU hospital pharmacist made a total of 659 recommendations. During the intervention period, the rate of consensus between the ICU hospital pharmacist and ICU physicians was 74%. The incidence of prescribing errors during the intervention period was significantly lower than during the baseline period: 62.5 per 1,000 monitored patient-days versus 190.5 per 1,000 monitored patient-days, respectively (P < 0.001). Preventable ADEs (patient harm, National Coordinating Council for Medication Error Reporting and Prevention severity categories E and F) were reduced from 4.0 per 1,000 monitored patient-days during the baseline period to 1.0 per 1,000 monitored patient-days during the intervention period (P = 0.25). Per monitored patient-day, the intervention itself cost €3, but might have saved €26 to €40 by preventing ADEs.

Conclusions

On-ward participation of a hospital pharmacist in a Dutch ICU was associated with significant reductions in prescribing errors and related patient harm (preventable ADEs) at acceptable costs per monitored patient-day.

Trial registration number

ISRCTN92487665

Drug-induced arrhythmias

The objective of this review is to characterize the mechanisms, risk factors, and offending pharmacotherapeutic agents that may cause drug-induced arrhythmias in critically ill patients. PubMed, other databases, and citation review were used to identify relevant published literature. The authors independently selected studies based on relevance to the topic. Numerous drugs have the potential to cause drug-induced arrhythmias. Drugs commonly administered to critically ill patients are capable of precipitating arrhythmias and include antiarrhythmics, antianginals, antiemetics, gastrointestinal stimulants, antibacterials, narcotics, antipsychotics, inotropes, digoxin, anesthetic agents, bronchodilators, and drugs that cause electrolyte imbalances and bradyarrhythmias. Drug-induced arrhythmias are insidious but prevalent. Critically ill patients frequently experience drug-induced arrhythmias; however, enhanced appreciation for this adverse event has the potential to improve prevention, treatment, patient safety, and outcomes in this patient population.