Interventions of a clinical pharmacist in a medical intensive care unit - A retrospective analysis

Analysis of clinical pharmacists' interventions in a rehabilitation setting

Background

To elucidate the role of clinical pharmacists in rehabilitation programmes by examining the type, severity, medications involved, and the level of acceptance of pharmacists' interventions.

Methods

A cross-sectional study was conducted at the Qatar Rehabilitation Institute (QRI) in Doha, Qatar. Clinical pharmacists' interventions and their underlying rationales were categorised by the type of intervention using a validated classification system. The severity of these interventions was assessed using the National Patient Safety Agency (NPSA) Risk Matrix. Linear regression and chi-square analyses were employed to examine the relationships between patient-related and medication-related characteristics and the pharmacist interventions.

Results

A total of 3,807 clinical pharmacists' interventions involving 815 patients were collected and analysed. The majority of patients (n = 501, 61.5%) had three or more interventions. Findings indicated that most interventions were addressing pharmacological strategy (n = 1670, 43.9%) and drug quantity (n = 1166, 30.7%). The most frequently reported intervention subtypes included dose optimisation (n = 749, 19.7%), additional drug therapy (n = 673, 17.7%), and medication discontinuation (n = 476, 12.5%). Cardiovascular agents were involved in 37.1% of the interventions, followed by endocrine medications (17.1%) and centrally acting agents (11.7%). A significant proportion of interventions were deemed to have moderate severity (79.8%). Statistical analysis revealed a positive linear correlation between age and the number of interventions per patient (p < 0.001); with no significant difference in the severity of interventions between adult and elderly patients (p = 0.09).

Conclusion

This study highlights the diverse roles of clinical pharmacists in the rehabilitation field. The unique complexity of rehabilitation patients creates a challenging environment for clinical pharmacists, requiring adherence to fundamental practice principles while customising approaches to address individual patient needs. Further research is needed to assess the impact of these interventions on clinically significant outcomes.

Experience of Vancomycin Therapeutic Drug Monitoring in Two Multidisciplinary Hospitals in Latvia

Background and Objectives: Management of infectious diseases is a huge burden to every healthcare system worldwide. Antimicrobial resistance, including antibacterial resistance, is an increasing problem worldwide; therefore, more new antibiotics are necessary to be discovered. Meanwhile, “old” antibacterial agents are still administered to fight infectious diseases caused by resistant bacteria. One of these antibacterial agents is vancomycin, which is effective in treating serious systemic infections caused by gram-positive bacteria. Thus, it is necessary to perform vancomycin concentration measurements in plasma due to its narrow therapeutic index. Various approaches are implemented for more precise therapy, including therapeutic drug monitoring (TDM) of vancomycin and with a supervision of a clinical pharmacist. The purpose of the study was to investigate if the TDM practice is improved with a local vancomycin TDM protocol applied in a hospital. The results of TDM in two multidisciplinary hospitals, one with a local TDM protocol implemented and applied and the other with no local TDM protocol implemented and applied, were compared. Materials and Methods: A retrospective study was performed in two multidisciplinary hospitals in Latvia. The data were collected for a time period of 4 years (2016−2020) in a hospital without a local TDM protocol and for a time period of 2 years (2018−2020) in a hospital with a local TDM protocol, starting with a period of time when the vancomycin TDM protocol was developed. The data about the patients included in the study were analyzed based on gender, age, body weight, and renal function. Vancomycin therapy was analyzed based on dosing schemes (vancomycin dose and dosing interval), data about loading and maintenance doses, vancomycin concentration, and details about vancomycin concentration (sampling time and concentration level). Results: Differences between the hospitals were found in terms of the initiation of vancomycin administration and concentration sampling. In the hospital with a TDM protocol compared with the hospital without a TDM protocol, more accurate initiation was found, alongside adaption of therapy (97.22% vs. 18.95%, p < 0.001), better performance of administration of a loading dose (22.73% vs. 1.29%, p < 0.01), and reaching of target concentration (55.56% vs. 35.29%, p < 0.01). Concentration sampling in the correct timeframe before the vancomycin dose and vancomycin administration did not show statistically better results in either of the hospitals (4.60% vs. 6.29%, p = 0.786). Conclusions: Better results of adequate adjustments of vancomycin therapy were achieved in the hospital with a TDM protocol. In the long term, sustainable results and regular medical professionals’ training is necessary.

Clinically Relevant Interactions with Anti-Infectives on Intensive Care Units-A Multicenter Delphi Study

Patients in intensive care units (ICUs) are at high risk of drug–drug interactions (DDIs) due to polypharmacy. Little is known about type and frequency of DDIs within German ICUs. Clinical pharmacists’ interventions (PI) recorded in a national database (ADKA-DokuPIK) were filtered for ICU patients. Binary DDIs involving ≥1 anti-infective agent with >1 database entry were selected. A modified two-step Delphi process with a group of senior hospital pharmacists was employed to evaluate selected DDIs for clinical relevance by using a five-point scale and to develop guidance for clinical practice. In total, 16,173 PI were recorded, including 1836 (11%) DDIs in the ICU setting. Of the latter, 41% (756/1836) included ≥1 anti-infective agent, 32% (590/1836) were binary DDIs, and 25% (455/1836) were listed at least twice. This translates into 88 different DDIs, 74% (65/88) of which were rated as being clinically relevant by our expert panel. The majority of DDIs (76% [67/88]) included macrolides, antifungals, or fluoroquinolones. This percentage was even higher in DDIs being rated as clinically relevant by the experts (85% [55/65]). It is noted that an inter-professional discussion and approach is needed in the individual patient management of DDIs. The guidance developed might be a tool for decision support.