Society of Critical Care Medicine and the Infectious Diseases Society of America Guidelines for Evaluating New Fever in Adult Patients in the ICU.

RATIONALE: Fever is frequently an early indicator of infection and often requires rigorous diagnostic evaluation. OBJECTIVES: This is an update of the 2008 Infectious Diseases Society of America and Society (IDSA) and Society of Critical Care Medicine (SCCM) guideline for the evaluation of new-onset fever in adult ICU patients without severe immunocompromise, now using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. PANEL DESIGN: The SCCM and IDSA convened a taskforce to update the 2008 version of the guideline for the evaluation of new fever in critically ill adult patients, which included expert clinicians as well as methodologists from the Guidelines in Intensive Care, Development and Evaluation Group. The guidelines committee consisted of 12 experts in critical care, infectious diseases, clinical microbiology, organ transplantation, public health, clinical research, and health policy and administration. All task force members followed all conflict-of-interest procedures as documented in the American College of Critical Care Medicine/SCCM Standard Operating Procedures Manual and the IDSA. There was no industry input or funding to produce this guideline. METHODS: We conducted a systematic review for each population, intervention, comparison, and outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the GRADE approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak or as best-practice statements. RESULTS: The panel issued 12 recommendations and 9 best practice statements. The panel recommended using central temperature monitoring methods, including thermistors for pulmonary artery catheters, bladder catheters, or esophageal balloon thermistors when these devices are in place or accurate temperature measurements are critical for diagnosis and management. For patients without these devices in place, oral or rectal temperatures over other temperature measurement methods that are less reliable such as axillary or tympanic membrane temperatures, noninvasive temporal artery thermometers, or chemical dot thermometers were recommended. Imaging studies including ultrasonography were recommended in addition to microbiological evaluation using rapid diagnostic testing strategies. Biomarkers were recommended to assist in guiding the discontinuation of antimicrobial therapy. All recommendations issued were weak based on the quality of data. CONCLUSIONS: The guidelines panel was able to formulate several recommendations for the evaluation of new fever in a critically ill adult patient, acknowledging that most recommendations were based on weak evidence. This highlights the need for the rapid advancement of research in all aspects of this issue-including better noninvasive methods to measure core body temperature, the use of diagnostic imaging, advances in microbiology including molecular testing, and the use of biomarkers.

Leadership and effective succession planning in health-system pharmacy departments.

Leadership succession planning is crucial to the continuity of the comprehensive vision of the hospital pharmacy department. Leadership development is arguably the main component of training and preparing pharmacists to assume managerial positions. Succession planning begins with a review of the organizational chart in the context of the institution's strategic plan. Then career ladders are developed and key positions that require succession plans are identified. Employee profiles and talent inventory should be performed for all employees to identify education, talent, and experience, as well as areas that need improvement. Employees should set objective goals that align with the department's strategic plan, and management should work collaboratively with employees on how to achieve their goals within a certain timeframe. The succession planning process is dynamic and evolving, and periodic assessments should be conducted to determine how improvements can be made. Succession planning can serve as a marker for the success of hospital pharmacy departments.

Practice Management Training in the PGY1 Residency Year: Best Practices From Two Nationwide Surveys.

PURPOSE: The development of future pharmacy leaders is vital to the advancement of our profession. Postgraduate year 1 (PGY1) residency training requires residents to exercise leadership and practice management skills. Two national surveys were conducted to describe the current state of practice management experiences and elucidate best practice recommendations. METHODS: The surveys, online multiple choice and free response, queried American Society of Health-System Pharmacists (ASHP)-accredited residency program practice management preceptors (survey 1) and PGY1 residents (survey 2) and were distributed via the ASHP residency program directors' listserv. Responses were reviewed and analyzed by members of the University HealthSystem Consortium Pharmacy Council Strategic Initiatives and Programming Committee. RESULTS: Survey 1, completed by 240 institutions, identified that a combination of concentrated and longitudinal practice management experiences were used most frequently (47%), followed by concentrated alone (33%). Universally noted activities included meeting attendance (98%), projects (94%), and committee involvement (92%). Sixty-seven percent of the programs changed the experience in the previous 3 years, with 43% planning changes in the coming year. Survey 2 was completed by 58 PGY1 residents from 42 programs. Most (80%) residents stated they had enough time with their preceptors, and 55% rated their enjoyment of the rotation as 4 or 5 on a 1 to 5 scale (5 = most enjoyed). CONCLUSION: Our findings suggest that there is not a best practice for the structure or content of the PGY1 practice management experience. These results highlight key recommendations, including the need for practice management-specific preceptor development, incorporation of longitudinal experiences, and more practice management and leadership activities.

Impact of a clinical pharmacy admission medication reconciliation program on medication errors in "high-risk" patients.

BACKGROUND: Medication errors are common upon hospital admission. Clinical pharmacist involvement in medication reconciliation is effective in identifying and rectifying medication errors. However, data is lacking on the economic impact, time requirements, and severity of errors resolved by clinical pharmacists. OBJECTIVE: To determine the incidence of unintended admission medication discrepancies resolved by clinical pharmacists. Secondary objectives were to determine the type of discrepancies, potential severity, proximal cause, and economic impact of this clinical pharmacy program. METHODS: This was a single-center, prospective, observational study conducted at a major teaching medical institution. Following institutional review board approval, data collection was conducted over a 4-week period (August 22, 2011, to September 16, 2011). Descriptive statistical methods were performed for all data analyses. RESULTS: A total of 517 patients involving 5006 medications were included in this study. More than 25% (n = 132) of patients had at least 1 error associated with a medication ordered on hospital admission. Pharmacists resolved a total of 467 admission medication errors (3.5 ± 2.3 errors/patient). The most common type of medication error resolved was medication omission (79.6%). In regard to severity, 46% of medication errors were considered significant or serious. Overall, the mean total time was 44.4 ± 21.8 minutes per medication reconciliation. This clinical pharmacy program was estimated to carry a net present value of $5.7 million over 5 years. CONCLUSION: Clinical pharmacist involvement within a multidisciplinary health care team during the admission medication reconciliation process demonstrated a significant improvement in patient safety and an economic benefit.

Prioritizing pharmacogenomics implementation initiates: a survey of healthcare professionals.

Aim: Characterize current perceptions, practices, preferences and barriers to integrating pharmacogenomics into patient care at an institution with an established pharmacogenomics clinic. Materials & methods: A 16-item anonymous survey was sent to healthcare professionals practicing at Tampa General Hospital and the University of South Florida Health. Results: Survey participants consisted of nine advanced practice providers, 41 pharmacists and 64 physicians. Majority of survey participants did not feel confident in their ability to interpret and apply pharmacogenomic results. In the past 12 months, 27% of physicians reported ordering a pharmacogenomic test. The greatest reported barrier to integrating pharmacogenomics was the absence of established guidelines or protocols. Conclusion: Most clinicians believed pharmacogenomics would be useful in their clinical practice but do not feel prepared to interpret pharmacogenomic results.

Lay abstract Pharmacogenomics is a field of personalized medicine where genetic information may be used to guide treatment decisions. Many advanced practice providers, pharmacists, and physicians are not as familiar with interpreting pharmacogenomic results to make medication changes. This survey was designed and administered to clinicians at Tampa General Hospital and the University of South Florida Health to characterize perceptions, practices, preferences and barriers to integrating pharmacogenomics into patient care. Survey results revealed that most clinicians believed pharmacogenomics would be useful in their clinical practice but do not feel prepared to interpret pharmacogenomic results.

Comparison of Continuous Albumin Infusion, Bolus Albumin, and Crystalloid Fluid Administration in Open-Abdomen Surgical-Trauma Patients.

Background: The open abdomen (OA), an intentional lack of fascial closure following abdominal cavity opening, is utilized for various indications among surgical-trauma patients. Among intravenous fluid options, administration of albumin as a continuous infusion may improve outcomes in OA. The purpose of this study is to compare the time to abdomen closure among patients with OA according to type of fluid administration. Methods: We conducted a retrospective cohort study of adults with OA from 2012 through 2018 and stratified by intravenous fluid administration into one of three groups: continuous albumin infusion, intermittent bolus albumin, or crystalloid. The primary outcome was median time to abdomen closure. Secondary outcomes included hemodynamic parameters, length of stay (LOS), and mortality. Time to final abdomen closure was analyzed by Cox proportional hazards regression. Results: Eighty-four patients were included with 28 in each cohort. Compared to crystalloids (44.2 [interquartile range, IQR, 36.3-62.9] hours), median time to abdomen closure was significantly longer in bolus albumin (79.0 [IQR, 44.5-130.8] hours; P = .002) and continuous albumin groups (63.6 [IQR, 42.9-139.6] hours; P = .001) in Cox regression analysis. The incidence of hospital mortality was highest in the bolus albumin cohort (continuous albumin: 21.4% vs bolus albumin: 50.0% vs crystalloid: 25.0%; P = .044). All other secondary outcomes were similar between groups. Conclusions: Among patients with OA, administration of intravenous crystalloid was associated with the shortest time to abdomen closure compared to bolus or continuous albumin. Further evaluation of continuous albumin infusion in patients with OA is needed.

Retrospective evaluation of commonly used equations to predict energy expenditure in mechanically ventilated, critically ill patients.

STUDY OBJECTIVE: To determine which of four commonly used equations to estimate energy expenditure is precise and unbiased compared with energy expenditure as measured by indirect calorimetry. DESIGN: Retrospective, observational study. SETTING: Adult medical intensive care unit in a research hospital of the National Institutes of Health Clinical Center. PATIENTS: Seventy-six adult, mechanically ventilated, critically ill patients. INTERVENTION: Indirect calorimetry reports generated by the National Institutes of Health Critical Care Medicine Department's Metabolic Cart Consult Service were reviewed. Bias and precision of resting energy expenditure (REE) estimated by equations were computed using mean prediction error (ME) and root mean squared prediction error (MSE). Equations were considered precise if the 95% confidence interval for MSE was within 15% of the measured energy expenditure (MEE) determined by indirect calorimetry. Equations were considered unbiased if the 95% confidence interval for ME included zero. Paired t tests were used to compare estimated REE values for each predictive equation with MEE values determined by indirect calorimetry. Data were stratified into regions of bias using classification and regression tree analysis, as well as visual inspection of estimated REE-versus-MEE curves for each equation. MEASUREMENTS AND MAIN RESULTS: The Harris-Benedict equation multiplied by an activity factor of 1.2 was unbiased and precise. The Ireton-Jones equation was precise but biased. The American College of Chest Physicians' consensus recommendation was biased and imprecise. The Harris-Benedict equation without an activity factor also demonstrated bias and imprecision. CONCLUSIONS: The Harris-Benedict equation multiplied by an activity factor of 1.2 is suitable for predicting REE and may be used in the absence of indirect calorimetry.

Procalcitonin and enteral nutrition tolerance in critically ill patients.

BACKGROUND: Serum procalcitonin concentrations have been reported to be elevated in patients with bacterial infection. Early enteral nutrition (EN) has been shown to decrease infections in trauma patients. The purpose of this study was to characterize procalcitonin and other serum proteins during EN of trauma patients based on EN tolerance and presence of infection. METHODS: Twenty traumatized patients received a high-protein enteral formulation within 5 days of injury. Serum for procalcitonin, C-reactive protein, and prealbumin was analyzed on days 1 and 7 of EN. The procalcitonin/prealbumin and C-reactive protein/prealbumin ratios were calculated the same days. Patients who were infected during the study were compared with those not infected, and enteral-tolerant patients were compared with enteral-intolerant patients using these measurements. RESULTS: In the 20 trauma patients, procalcitonin (10.35 +/- 27.87 versus 1.03 +/- 1.24 ng/mL, p < .001) and procalcitonin/prealbumin ratio (1.70 +/- 4.20 versus 0.18 +/- 0.28, p < .01) decreased significantly over the 7-day period of EN. In the 12 patients who had infection, procalcitonin (16.33 +/- 35.31 versus 1.37 +/- 1.41 ng/mL, p < .004) and procal- citonin/prealbumin ratio (2.74 +/- 5.31 versus 0.26 +/- 0.33, p < .01) decreased significantly over the 7-day period of enteral nutrition. There were no significant changes in the measurements for 8 patients without infection. In the 15 patients who were enteral-tolerant, procalcitonin (12.56 +/- 32.84 versus 1.07 +/- 1.23 ng/mL, p < .004) and procalcitonin/prealbumin ratio (2.03 +/- 4.93 versus 0.20 +/- 0.29, p < .01) decreased significantly. CONCLUSION: Procalcitonin serum concentrations decrease significantly during EN in enteral-tolerant, critically ill patients with infection.

Patient case: impact of smoking cessation on international normalized ratio.

INTRODUCTION: The concurrent use of cigarettes while on warfarin therapy is a common occurrence. Smoking cessation among patients on chronic warfarin therapy is suspected to reduce drug clearance that may require dose adjustments. This type of interaction is particularly important when dealing with narrow therapeutic medications, as is the case with warfarin. Our case describes a series of supratherapeutic international normalized ratios (INRs) due to smoking cessation while on concomitant warfarin therapy. Patient Case: A 51-year-old male presented to the anticoagulation clinic for management of his warfarin therapy for an acute deep vein thrombosis. After 2 months of stable, therapeutic INR levels, the patient abruptly decreased his smoking from 1 pack/day to one-half pack/day and then subsequently stopped smoking completely. The patient's smoking cessation resulted in a major modification of his required weekly warfarin dose to maintain a therapeutic INR (a 39% dose reduction). CONCLUSION: This case exemplifies how certain lifestyle factors, such as smoking, can alter the pharmacokinetics of patients on chronic warfarin therapy. This is the first case to demonstrate a greater than 30% reduction in the weekly warfarin dose following smoking cessation.

Bovine hemoglobin: a nontraditional approach to the management of acute anemia in a Jehovah's Witness patient with autoimmune hemolytic anemia.

INTRODUCTION: Management of severe symptomatic anemia in critically ill Jehovah's Witness patients remains a challenge. The paucity of therapeutic alternatives to human red blood cells has prompted the use of blood substitutes. CASE REPORT: A 19-year-old female Jehovah's Witness patient presented to the emergency department following several episodes of syncope. She was found to have a positive Coombs test and was diagnosed with warm-bodied autoimmune hemolytic anemia. Upon admission, her hemoglobin was 8.4 g/dL, then dropped to a nadir of 2.8 g/dL 4 days later. She received traditional management with corticosteroids, intravenous immune globulin, rituximab, and partial splenic artery embolization. Despite these therapies, hemoglobin levels failed to respond, and she experienced signs of marked ischemia. A decision was made to give 2 units of Hemopure, a bovine hemoglobin-based oxygen carrier, and the hemoglobin levels increased to 8.7 g/dL 10 days later. The patient's overall clinical condition improved leading to subsequent hospital discharge. CONCLUSION: This case exemplifies the ingenuity that health care practitioners must use in critical situations involving the medical management of anemic Jehovah's Witness patients who refuse blood products. Hemopure was used as "bridging treatment" to help save a patient from the devastating effects of ischemia resulting from severe anemia.

Risk evaluation and mitigation strategies: assessment of a medical center's policies and procedures.

PURPOSE: The results of a hospital's initiative to evaluate and improve compliance with federally mandated risk evaluation and mitigation strategies (REMS) are presented. SUMMARY: Food and Drug Administration approved REMS plans are required for more than 145 drugs, but clear guidance on strategies for achieving REMS compliance is lacking. As a first step toward determining the extent of REMS compliance at a large medical center, a systematic assessment was conducted to ascertain existing policies and procedures for the use of drugs subject to REMS requirements applicable in the inpatient setting. About 123 drugs with such "inpatient-applicable" REMS requirements were identified; of those, 10 had been ordered by hospital providers during a specified 18-month time frame and were included in the assessment of policies and procedures. The assessment revealed that the hospital lacked a formal REMS policy and had no REMS-compliant procedures in place for 7 evaluated drugs (ambrisentan, buprenorphine-naloxone, darbepoetin alfa, epoetin alfa, oxycodone controlled-release tablets, prasugrel, and pregabalin). Pursuant to the compliance assessment, new procedures to help ensure the safe use of those 7 drugs were developed, and REMS-focused educational programs, order-entry system enhancements, and drug storage modifications were implemented. CONCLUSION: Quality-improvement initiatives including staff education, incorporation of REMS requirements into existing policy, development of an electronic resource, and creation of a separate storage section for drugs subject to REMS were implemented at a large academic medical center to help ensure compliance with inpatient-applicable REMS requirements.