Evaluation of the impact of a tele-ICU pharmacist on the management of sedation in critically ill mechanically ventilated patients.

BACKGROUND: An organized and uniform approach to managing sedation in critically ill patients has been associated with improved outcomes, but the most effective means of optimizing sedative medication use in clinical practice has not been fully determined. Pharmacist interventions directed at improving sedation guideline compliance have been shown to reduce the duration of mechanical ventilation. OBJECTIVE: To determine the impact that pharmacy staffing configurations that include a tele-ICU pharmacist have on compliance with an intensive care unit (ICU) sedation guideline in critically ill mechanically ventilated patients requiring continuous-infusion sedative medications. METHODS: Compliance with an established ICU sedation guideline, the performance of daily sedative interruptions, and the number of sedative medication-related interventions were evaluated before and after expansion of the ICU pharmacist staffing model to include comprehensive off-hours pharmacist coverage supported with established tele-ICU resources. In both groups, sedation was managed by the primary ICU team. In the intervention group, a pharmacist working in the tele-ICU center performed electronic record audits and made sedative medication recommendations to the primary team. RESULTS: The addition of third shift tele-ICU pharmacist support was associated with a significant increase in the percentage of patients who received a daily sedative interruption (45% vs 54%; p < 0.0001). This occurred in the context of significant increases in the total number of ICU pharmacist interventions (36 vs 49.4 per 100 patient days, p < 0.0001), the number of therapeutic interventions (20.4 vs 26.1 per 100 patient days, p < 0.001), and the number of sedative-related interventions (0.9 vs 4.4 per 100 patient days, p < 0.0001). CONCLUSIONS: Tele-ICU resources can be utilized to increase compliance with an established ICU sedation guideline and extend the benefits that daytime ICU clinical pharmacy services provide. Increased ICU pharmacist availability may have additional benefits not measured in this study.

Pilot comparison of three cardiopulmonary resuscitation medication dosing strategies in overweight children.

OBJECTIVES: Dose calculations using three variations of patient weight estimates (actual body weight [ABW], ideal body weight [IBW], and the Broselow Pediatric Emergency Tape [BPET, a length-based weight estimation tool]) were compared to administered doses of cardiopulmonary resuscitation medications in overweight and obese children to assess for differences in dose. METHODS: This retrospective cohort analysis included 54 consecutive pediatric patients who underwent emergency resuscitation at UMass Memorial Medical Center between January 2000 and October 2008. Patients were identified using ICD-9 codes related to cardiopulmonary resuscitation. Patients were included if they were overweight or obese, less than 12 years of age, less than 146 centimeters in length, and received emergency resuscitation medication(s). Doses of administered medications were recorded and compared to potential doses calculated based on ABW, IBW and the dose recommended by the BPET. Dose differences greater than 10% were considered clinically significant and dose differences greater than 20% were considered to be potential medication errors. RESULTS: Out of 54 possible patients, four overweight patients were included; none were obese. Ten total medication doses were assessed (minimum two per patient). In all patients, at least one comparator dose varied by greater than 20% from the administered dose. Four out of 10 doses calculated according to ABW, eight out of 10 doses calculated with IBW, and eight out of 10 doses recommended by the BPET all differed by greater than 20% from the administered dose. CONCLUSIONS: Dosing variations were observed when the dose received was compared to dosing using three variants of patient weight estimates. The largest dosing differences were observed upon comparison of the administered dose versus the dose recommended by the BPET.

Pharmacist-conducted medication reconciliation in an emergency department.

PURPOSE: The effect of pharmacist conducted medication reconciliation on compliance with a hospital's medication reconciliation policy was studied. METHODS: In this eight-week pilot study, one pharmacist worked in the emergency department (ED) to facilitate the safe and accurate transfer of medication histories for admitted patients. During the first four weeks, retrospective chart review was performed for 100 patients in March 2006 to determine the compliance rate to the hospital's medication reconciliation policy (medication reconciliation completed for every patient using the hospital-approved form). Over the next four weeks, the same pharmacist prospectively obtained medication histories from consecutive patients in April 2006; these patients comprised the study group. The pharmacist completed the medication reconciliation form and identified and corrected all discrepancies. Unpaired t tests and Fisher's exact test were used to determine significant differences between groups. RESULTS: The hospital-approved medication form was used for 78% of patients in the control group (78 of 100) and 100% of patients in the study group (60 of 60). The mean +/- S.D. number of errors per form was significantly higher in the control group than in the study group, and the percentage of forms containing at least one error was significantly higher in the control group (p = 0.001 for both comparisons). Allergy documentation was recorded for 62 patients in the study group versus all 60 in the study group (p = 0.001). CONCLUSION: Pharmacist-conducted medication reconciliation in the ED increased compliance to the institution's medication reconciliation policy for admitted patients. Pharmacist-acquired medication histories had significantly fewer errors in documentation and had more documentation of patient allergies.