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Barreto EF, Chitre PN, Pine KH, Shepel KK, Rule AD, Alshaer MH, Abdul Aziz MH, Roberts JA, Scheetz MH, Ausman SE, Moreland-Head LN, Rivera CG, Jannetto PJ, Mara KC, Boehmer KR. Why is the Implementation of Beta-Lactam Therapeutic Drug Monitoring for the Critically Ill Falling Short? A Multicenter Mixed-Methods Study. Ther Drug Monit 2023; 45:508-518. [PMID: 37076424 PMCID: PMC10348918 DOI: 10.1097/ftd.0000000000001059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/02/2022] [Indexed: 04/21/2023]
Abstract
BACKGROUND Beta-lactam therapeutic drug monitoring (BL TDM; drug level testing) can facilitate improved outcomes in critically ill patients. However, only 10%-20% of hospitals have implemented BL TDM. This study aimed to characterize provider perceptions and key considerations for successfully implementing BL TDM. METHODS This was a sequential mixed-methods study from 2020 to 2021 of diverse stakeholders at 3 academic medical centers with varying degrees of BL TDM implementation (not implemented, partially implemented, and fully implemented). Stakeholders were surveyed, and a proportion of participants completed semistructured interviews. Themes were identified, and findings were contextualized with implementation science frameworks. RESULTS Most of the 138 survey respondents perceived that BL TDM was relevant to their practice and improved medication effectiveness and safety. Integrated with interview data from 30 individuals, 2 implementation themes were identified: individual internalization and organizational features. Individuals needed to internalize, make sense of, and agree to BL TDM implementation, which was positively influenced by repeated exposure to evidence and expertise. The process of internalization appeared more complex with BL TDM than with other antibiotics (ie, vancomycin). Organizational considerations relevant to BL TDM implementation (eg, infrastructure, personnel) were similar to those identified in other TDM settings. CONCLUSIONS Broad enthusiasm for BL TDM among participants was found. Prior literature suggested that assay availability was the primary barrier to implementation; however, the data revealed many more individual and organizational attributes, which impacted the BL TDM implementation. Internalization should particularly be focused on to improve the adoption of this evidence-based practice.
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Affiliation(s)
| | - Pooja N. Chitre
- School for the Future of Innovation in Society, Arizona State University, Tempe, AZ
| | - Kathleen H. Pine
- College of Health Solutions, Arizona State University, Phoenix, AZ
| | | | - Andrew D. Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
- Division of Epidemiology, Mayo Clinic, Rochester, MN
| | - Mohammad H. Alshaer
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL
| | - Mohd Hafiz Abdul Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane and Women’s Hospital, Australia
| | - Jason A. Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane and Women’s Hospital, Australia
| | - Marc H. Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL
- Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL
| | - Sara E. Ausman
- Department of Pharmacy, Mayo Clinic Health System, Eau Claire, WI
| | | | | | - Paul J. Jannetto
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN
| | - Kristin C. Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Kasey R. Boehmer
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
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May HP, Krauter AK, Finnie DM, McCoy RG, Kashani KB, Griffin JM, Barreto EF. Acute Kidney Injury Survivor Care Following Hospital Discharge: A Mixed-Methods Study of Nephrologists and Primary Care Providers. Kidney Med 2023; 5:100586. [PMID: 36970221 PMCID: PMC10034506 DOI: 10.1016/j.xkme.2022.100586] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Rationale & Objective Widespread delivery of high-quality care for acute kidney injury (AKI) survivors after hospital discharge requires a multidisciplinary team. We aimed to compare management approaches between nephrologists and primary care providers (PCPs) and explored strategies to optimize collaboration. Study Design Explanatory sequential mixed-methods study using a case-based survey followed by semi-structured interviews. Setting & Participants Nephrologists and PCPs providing AKI survivor care at 3 Mayo Clinic sites and the Mayo Clinic Health System were included. Outcomes Survey questions and interviews elucidated participants' recommendations for post-AKI care. Analytical Approach Descriptive statistics were used to summarize survey responses. Qualitative data analysis used deductive and inductive strategies. A connecting and merging approach was used for mixed-methods data integration. Results 148 of 774 (19%) providers submitted survey responses (24/72 nephrologists and 105/705 PCPs). Nephrologists and PCPs recommended laboratory monitoring and follow-up with a PCP shortly after hospital discharge. Both indicated that the need for nephrology referral, and its timing should be dictated by clinical and non-clinical patient-specific factors. There were opportunities for improvement in medication and comorbid condition management in both groups. Incorporation of multidisciplinary specialists (eg, pharmacists) was recommended to expand knowledge, optimize patient-centered care, and alleviate provider workload. Limitations Survey findings may have been affected by non-response bias and the unique challenges facing clinicians and health systems during the COVID-19 pandemic. Participants were from a single health system, and their views or experiences may differ from those in other health systems or serving different populations. Conclusions A multidisciplinary team-based model of post-AKI care may facilitate implementation of a patient-centered care plan, improve adherence to best practices, and reduce clinician and patient burden. Individualizing care for AKI survivors based on clinical and non-clinical patient-specific factors is needed to optimize outcomes for patients and health systems.
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Affiliation(s)
- Heather P. May
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | | | - Dawn M. Finnie
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Rozalina G. McCoy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kianoush B. Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joan M. Griffin
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota
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3
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Smith RE, Shifrin MM. Critical Care Considerations in Adult Patients With Influenza-Induced ARDS. Crit Care Nurse 2021; 40:15-24. [PMID: 33000130 DOI: 10.4037/ccn2020746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
TOPIC Acute respiratory distress syndrome is a complex respiratory disease that can be induced by influenza virus infection. Critical care providers are uniquely positioned to manage this pathological progression in adult patients through evidence-based practice. CLINICAL RELEVANCE Influenza and subsequent acute respiratory distress syndrome are associated with extremely high morbidity and mortality in adult patients in the United States. Although evidence-based medical management strategies can alter the clinical trajectory of acute respiratory distress syndrome and improve outcomes, critical care providers do not always implement these measures. PURPOSE To provide critical care providers with an overview of the pathological progression of influenza-induced acute respiratory distress syndrome and the current evidence-based strategies for management. CONTENT COVERED This article reviews the epidemiology and pathophysiology associated with influenza-induced acute respiratory distress syndrome, the criteria for diagnosis, and the evidence-based medical management.
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Affiliation(s)
- Rachel E Smith
- Rachel E. Smith is an acute care nurse practitioner in the medical intensive care unit at Saint Thomas West Hospital, Nashville, Tennessee
| | - Megan M Shifrin
- Megan M. Shifrin is an assistant professor and the coordinator of the Adult-Gerontology Acute Care Nurse Practitioner Intensivist Focus at Vanderbilt University School of Nursing, Nashville, Tennessee
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4
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Barreto EF, Rule AD, Alshaer MH, Roberts JA, Abdul Aziz MH, Scheetz MH, Mara KC, Jannetto PJ, Gajic O, O'Horo JC, Boehmer KR. Provider perspectives on beta-lactam therapeutic drug monitoring programs in the critically ill: a protocol for a multicenter mixed-methods study. Implement Sci Commun 2021; 2:34. [PMID: 33762025 PMCID: PMC7992791 DOI: 10.1186/s43058-021-00134-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/09/2021] [Indexed: 12/14/2022] Open
Abstract
Background Beta-lactams (i.e., penicillins, cephalosporins, carbapenems, monobactams) are the most widely used class of antibiotics in critically ill patients. There is substantial interpatient variability in beta-lactam pharmacokinetics which renders their effectiveness and safety largely unpredictable. One strategy to ensure achievement of therapeutic concentrations is drug level testing (“therapeutic drug monitoring”; TDM). While studies have suggested promise with beta-lactam TDM, it is not yet widely available or implemented. This protocol presents a mixed-methods study designed to examine healthcare practitioners’ perspectives on the use and implementation of beta-lactam TDM in the critically ill. Methods An explanatory sequential mixed-methods design will be used [QUANT → qual]. First, quantitative data will be collected through a web-based questionnaire directed at clinicians at three academic medical centers at different phases of beta-lactam TDM implementation (not yet implemented, partially implemented, fully implemented). The sampling frame will include providers from a variety of disciplines that interact with drug level testing and interpretation in the critical care environment including pharmacists, intensivists, infectious diseases experts, medical/surgical trainees, and advanced practice providers. Second, approximately 30 individuals will be purposively sampled from survey respondents to conduct in-depth qualitative interviews to explain and expand upon the results from the quantitative strand. Normalization Process Theory and the Consolidated Framework for Implementation Science will be used to guide data analysis. Discussion These data will be used to answer two specific questions: “What are ICU practitioners’ perspectives on implementing beta-lactam TDM?” and “What factors contribute to the success of beta-lactam TDM program implementation?” Results of this study will be used to design future implementation strategies for beta-lactam TDM programs in the critically ill. Trial registration NCT04755777. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00134-9.
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Affiliation(s)
- Erin F Barreto
- Department of Pharmacy, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA. .,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
| | - Andrew D Rule
- Division of Epidemiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.,Division of Nephrology and Hypertension, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Mohammad H Alshaer
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, 1600 SW Archer Rd, Gainesville, FL, 32610, USA.,Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, 1600 SW Archer Rd, Gainesville, FL, 32610, USA
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, 4029, USA
| | - Mohd Hafiz Abdul Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, 4029, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st St, Downers Grove, IL, 60515, USA.,Pharmacometrics Center of Excellence, Midwestern University, 555 31st St, Downers Grove, IL, 60515, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Paul J Jannetto
- Department of Laboratory Medicine & Pathology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - John C O'Horo
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.,Division of Infectious Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Kasey R Boehmer
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
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Yao L, Luo Y, Wang Y, Zhang Z, Tian J, Yang L, Cai P, Gu Y, Li Y. Comparative efficacy of various preventive methods for exposure keratopathy among critically ill patients: A network meta-analysis of randomized controlled trials. Int J Nurs Stud 2021; 118:103926. [PMID: 33813085 DOI: 10.1016/j.ijnurstu.2021.103926] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 02/22/2021] [Accepted: 03/03/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is a wide variety of preventive methods currently available for the treatment of exposure keratopathy. Because of a lack of evidence from head-to-head randomized controlled trials (RCTs), the relative effects of these preventive methods in exposure keratopathy patients remain unclear. The purpose of our study is to carry out a network meta-analysis comparing the efficacy of different methods for the prevention of exposure keratopathy and rank these nursing methods for practical consideration. METHODS A literature search was performed of the MEDLINE (PubMed), EMBASE, Web of Science, China National Knowledge Infrastructure Library (CNKI), China Science and Technology Journal Database (Weipu), WanFang Database and China Biology Medicine disc. Two authors independently extracted data from each included RCTs according to a predesigned Excel spreadsheet and assessed the methodological quality of included RCTs using the Cochrane risk of bias tool. Data was analyzed using the R (V.3.6.2) and the Stata (V.15.0). RESULTS 21 RCTs involving 2022 patients and evaluating 11 preventive methods were included. Rankings based on posterior probabilities revealed that artificial tear ointment might be the best way to prevent exposure keratopathy (35%), polyethylene covers might be the second-best (31%), swimming goggles might be the third-best (21%), foam dressing might be the fourth-best (18%). CONCLUSIONS This network meta-analysis indicated that artificial tear ointment, polyethylene covers, swimming goggles and foam dressing might be selected for the prevention of exposure keratopathy in intensive care unit patients, which is important in future research. Although evidence is scant, more attention should be paid to head-to-head comparisons of the most commonly used prevention methods in this field.
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Affiliation(s)
- Li Yao
- Department of Nursing, The Affiliated Hospital of Guizhou Medical University, No. 28 GuiyiRoad, Yunyan District, Guiyang 550000, China
| | - Yuhong Luo
- School of Nursing, Lanzhou University, Lanzhou 730000, China
| | - Yinhua Wang
- Department of Nursing, The Affiliated Hospital of Guizhou Medical University, No. 28 GuiyiRoad, Yunyan District, Guiyang 550000, China
| | - Zhigang Zhang
- Intensive Care Units, The First University of Lanzhou University, Lanzhou 730000, China
| | - Jinhui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China
| | - Liping Yang
- Intensive Care Units, The First University of Lanzhou University, Lanzhou 730000, China
| | - Peng Cai
- Department of Nursing, The Affiliated Hospital of Guizhou Medical University, No. 28 GuiyiRoad, Yunyan District, Guiyang 550000, China
| | - Ying Gu
- Department of Nursing, The Affiliated Hospital of Guizhou Medical University, No. 28 GuiyiRoad, Yunyan District, Guiyang 550000, China
| | - Yaling Li
- Department of Nursing, The Affiliated Hospital of Guizhou Medical University, No. 28 GuiyiRoad, Yunyan District, Guiyang 550000, China.
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Nursing Considerations When Using Neuromuscular Blocking Agents to Assist With Intubation: A Review of Literature. Crit Care Nurs Q 2019; 42:30-40. [PMID: 30507661 DOI: 10.1097/cnq.0000000000000234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The use of neuromuscular blocking agents (NMBAs) in acute care settings during intubation is vitally important. The NMBAs increase first pass success rates significantly while protecting patients from gastric aspiration, tracheal injury, and death. During emergent intubations, succinylcholine and rocuronium are commonly used, but each comes with specific risks and individualized interventions. First pass success can be increased by ensuring correct dosing for overweight patients and employing the use of video laryngoscope. For planned, nonemergent intubations with sustained paralysis, the chosen NMBA can be individualized to fit the patient's needs. This includes dosages based on upregulation or downregulation of acetylcholine as well as speed of administration to prevent histamine release. Nurses must provide specific care when managing the treatment in high-risk patient populations (coronary artery disease, hyperkalemia, renal failure, liver failure, and traumatic brain injuries) who may receive certain types of NMBAs. Finally, because of the wide range of adverse effects with these drugs, close assessments are essential to prevent complications.
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Grissinger M. Paralyzed by Mistakes - Reassess the Safety of Neuromuscular Blockers in Your Facility. P & T : A PEER-REVIEWED JOURNAL FOR FORMULARY MANAGEMENT 2019; 44:91-107. [PMID: 30828226 PMCID: PMC6385733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Neuromuscular blockers have been inadvertently administered to patients who were not receiving proper ventilatory assistance, causing death or permanent injuries.
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Aredes JDS, Giacomin KC, Firmo JOA. A PRÁXIS MÉDICA NO PRONTO ATENDIMENTO DIANTE DO PACIENTE COM SEQUELAS CRÔNICAS: CULPA, TEMOR E COMPAIXÃO. TRABALHO, EDUCAÇÃO E SAÚDE 2018. [DOI: 10.1590/1981-7746-sol00151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Resumo Qual é a relação entre as urgências e o cuidado crônico? Esta questão, aparentemente paradoxal, foi abordada em uma etnografia realizada no maior hospital de pronto socorro de uma metrópole brasileira, a qual investigou o cuidado médico desde a admissão até a ratificação da condição clínico-funcional do paciente sequelado grave. Entre dezembro de 2012 e agosto de 2013 foram realizadas observação participante e entrevistas com 43 médicos: 25 homens e 18 mulheres, de 28 a 69 anos. A análise, guiada pelo modelo dos signos, significados e ações, levou à constatação de que o cuidado varia segundo o contexto: na ‘porta de entrada’ e no ‘centro de terapia intensiva’ luta-se intensamente pela manutenção da vida; no setor ‘crônicos’, cuida-se de pessoas que sobrevivem, mas com alto grau de dependência. Para o médico, ‘vida’ significa a recuperação da funcionalidade prévia, enquanto a sobrevida com dependência seria uma ‘morte em vida’. O médico se esquiva de lidar com um ser humano altamente limitado, pois sente-se de algum modo culpado pelo quadro, embora se compadeça diante do paciente que demanda cuidados crônicos. A insuficiência de uma rede de cuidados continuados e a falta de formação paliativista do médico geram sofrimentos a quem cuida e a quem é cuidado.
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Kousha O, Kousha Z, Paddle J. Incidence, risk factors and impact of protocolised care on exposure keratopathy in critically ill adults: a two-phase prospective cohort study. Crit Care 2018; 22:5. [PMID: 29338772 PMCID: PMC5771067 DOI: 10.1186/s13054-017-1925-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 12/15/2017] [Indexed: 11/10/2022] Open
Abstract
Background Exposure keratopathy (EK) has a high incidence in critically ill patients. We aimed to determine the rate of EK in patients admitted to our intensive care unit (ICU), identify risk factors for developing EK and ascertain the effectiveness of a protocol to prevent EK. Methods We undertook a two-phase prospective cohort single-centre study in a general adult ICU. The first phase of the study was observational. In the second phase of the study an eye care protocol was introduced. Daily ophthalmic assessment was carried out using a portable slit lamp. We also recorded Acute Physiology and Chronic Health Evaluation II score, daily Sequential Organ Failure Assessment score, mechanical ventilation, Richmond Agitation-Sedation Scale, and level of eye care. Student’s t test and χ2 statistics were used for simple analysis of continuous data and categorical data, respectively. Binary logistic regression was used to analyse the relationship between EK (yes/no), as the dependent variable, and multiple independent variables, calculating unadjusted and adjusted odds ratios. Results We studied 371 patients. In the first phase, the overall rate of EK was 21% but the rate in mechanically ventilated patients was 56%; χ2 (1, N = 257) = 80.8, p < 0.001. Adjusted odds ratios (AOR) for development of EK were 28.6 (8.19–43.37), 13.0 (3.16–54.38) and 1.2 (1.03–1.33) with incomplete eye closure, mechanical ventilation, and higher SOFA score, respectively. Following the introduction of the protocol in the second phase, the overall rate of EK reduced to 2.6% (three cases); χ2 (1, N = 371) = 18.6, p < 0.001. Compliance with the protocol was 97%. Conclusions EK is common in critically ill patients, and is associated with mechanical ventilation and incomplete eye closure. A simple protocol substantially reduces the incidence of EK and is easily achieved in clinical practice.
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Affiliation(s)
- Obaid Kousha
- Critical Care Unit, Royal Cornwall Hospital, Royal Cornwall Hospitals NHS Trust, Treliske, Truro, TR1 3LJ, UK.
| | - Zubaid Kousha
- UCL Medical School, University College London, Gower Street, London, WC1E 6BT, UK
| | - Jonathan Paddle
- Critical Care Unit, Royal Cornwall Hospital, Royal Cornwall Hospitals NHS Trust, Treliske, Truro, TR1 3LJ, UK
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10
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Exposure keratopathy: Incidence, risk factors and impact of protocolised care on exposure keratopathy in critically ill adults. J Crit Care 2017; 44:413-418. [PMID: 29353117 DOI: 10.1016/j.jcrc.2017.11.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 11/08/2017] [Accepted: 11/27/2017] [Indexed: 02/08/2023]
Abstract
PURPOSE We aimed to determine the rate of exposure keratopathy (EK) in critically ill patients, identify risk factors for developing EK and ascertain the effectiveness of a protocol to prevent EK. MATERIALS AND METHODS We undertook a two-phase prospective cohort study in a general adult ICU with first-phase being observational and an eye care protocol was introduced in the second-phase. Daily ophthalmic assessment was carried out along with recording of various risk factors. RESULTS We studied 371 patients. In the first phase, the overall rate of EK was 21% but the rate in mechanically ventilated patients was 56%; χ2 (1, N=257)=80.8, p<0.001. Adjusted odds ratios (AOR) for development of EK was 28.6 (8.19-43.37), 13.0 (3.16-54.38) and 1.2 (1.03-1.33) with incomplete eye closure, mechanical ventilation, and higher sequential organ failure assessment score respectively. Following the introduction of the protocol, the overall rate of EK reduced to 2.6% (3 cases); χ2 (1, N=371)=18.6, p<0.001. CONCLUSIONS EK is common in critically ill patients and a simple protocol substantially reduces the incidence of EK and is easily achieved in clinical practice.
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11
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Torbic H, Bauer SR, Personett HA, Dzierba AL, Stollings JL, Ryder LP, Daniels CE, Caples SM, Frazee EN. Perceived safety and efficacy of neuromuscular blockers for acute respiratory distress syndrome among medical intensive care unit practitioners: A multicenter survey. J Crit Care 2016; 38:278-283. [PMID: 28012426 DOI: 10.1016/j.jcrc.2016.11.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/12/2016] [Accepted: 11/30/2016] [Indexed: 12/12/2022]
Abstract
PURPOSE Neuromuscular blocking agents (NMBAs) are frequently used in patients with acute respiratory distress syndrome (ARDS). The purpose of this survey is to describe providers' knowledge and perceived efficacy and safety of NMBAs in patients with ARDS. MATERIALS AND METHODS We performed a prospective, multicenter survey of medical intensive care unit intensivists, fellows, nurse practitioners (NPs), physician's assistants (PAs), and pharmacists at 5 tertiary care centers between July 2012 and May 2013. RESULTS A total of 335 surveys were sent to providers, with a 47% response rate. Ninety-eight percent of providers correctly identified that NMBAs lack anxiolytic and analgesic properties. The effect of end-organ damage on NMBA clearance was less commonly identified by NPs/PAs for both hepatic (P=.0077) and renal (P=.0272) dysfunction compared with physicians. More NP/PAs identified the association of consciousness with the use of NMBAs than physicians (P=.047). Forty-two percent of prescribers reported always or frequently using continuous-infusion NMBAs in patients with severe ARDS, with 89% initiating NMBAs because of ventilator dyssynchrony. Prescribers perceived continuous NMBAs to be more effective than inhaled prostaglandins (74% vs 56%) in severe ARDS but less safe (45% vs 84%). Train of 4 was identified by 54% of prescribers as their primary method for titration. CONCLUSION Providers are knowledgeable about NMBAs, but educational opportunities exist. Perceptions about the efficacy and safety of NMBAs varied among prescribers, and inconsistencies existed in the prioritization of management strategies for ARDS.
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Affiliation(s)
- Heather Torbic
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Ave, Hb-105, Cleveland, OH 44195.
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Ave, Hb-105, Cleveland, OH 44195
| | | | - Amy L Dzierba
- Department of Pharmacy, New York Presbyterian Hospital, 612 W 168th St, New York, NY 10032
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232
| | - Lindsay P Ryder
- Department of Pharmacy, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, OH 43210
| | - Craig E Daniels
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55901
| | - Sean M Caples
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55901
| | - Erin N Frazee
- Department of Pharmacy, Mayo Clinic, 200 1st St SW, Rochester, MN 55901
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12
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Cohen MR, Smetzer JL. Aggrastat-Argatroban Mix-ups Don't Expect Radiofrequency Identification Stock Systems to be Perfect Paralyzed by Mistakes: Reassess the Safety of Neuromuscular Blockers in Your Facility. Hosp Pharm 2016; 51:877-883. [DOI: 10.1310/hpj5111-877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site ( www.ismp.org ), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.
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Affiliation(s)
- Michael R. Cohen
- Institute for Safe Medication Practices, Horsham, Pennsylvania, 200 Lakeside Drive, Suite 200, Horsham, PA 19044
| | - Judy L. Smetzer
- Institute for Safe Medication Practices, Horsham, Pennsylvania, 200 Lakeside Drive, Suite 200, Horsham, PA 19044
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