Improvement in Diagnosis and Management of Nosocomial Pneumonias in a Cardiovascular Surgery Intensive Care Unit: A Multidisciplinary Approach.

BACKGROUND: While criteria for the diagnosis of nosocomial pneumonias exist, objective definitions are a challenge and there is no gold standard for diagnosis. We analyzed the impact of the implementation of a logical, consensus-based diagnostic and treatment protocol for managing nosocomial pneumonias in the cardiovascular surgery intensive care unit (CVS-ICU). METHODS: We conducted a quasi-experimental, interrupted time series analysis to evaluate the impact of a diagnostic and treatment protocol for nosocomial pneumonias in the CVS-ICU. Impacts were measured relative to patient outcomes, diagnostic processes, and antimicrobial stewardship improvement. Descriptive statistics were used to analyze results. RESULTS: Overall, 35 pre-protocol and 39 post-protocol patients were included. Primary clinical variables suggesting pneumonia in pre- and post-protocol patients were new lung consolidation (50% vs. 71%), new leukocytosis (59% vs. 64%), and positive culture (32% vs. 55%). Appropriate diagnostic testing improved (23% vs. 54%, p = 0.008) after protocol implementation. The proportion of patients meeting the criteria for nosocomial pneumonia (77% vs. 87%) was not statistically significant, though more patients in the post-protocol group met probable diagnostic criteria (51% vs. 77%). Duration of therapy was not significantly different (6 days [IQR = 5.0, 10.0] vs. 7 days [IQR = 6.0, 9.0]). CONCLUSIONS: The implementation of a diagnostic and treatment protocol for management of nosocomial pneumonias in the CVS-ICU resulted in improved diagnostic accuracy, advanced antimicrobial and diagnostic stewardship efforts, and laboratory cost savings without an adverse impact on patient-centered outcomes.

Incorporation of pharmacist pre-surgical calls to improve medication history completion rates.

BACKGROUND: The accuracy and timeliness of documenting a medication history is an important aspect to ensure appropriate medication reconciliation during transitions of care. Surgical patients often have their medication history recorded just moments before surgery which may be rushed, incomplete or missed entirely. Between January and May 2020, 76.7% of surgical patients admitted to our institution had a medication history completed by a pharmacist prior to surgery. OBJECTIVE: The objective of this work is to improve the pharmacist medication history completion rates for pre-surgical patients before surgery by integrating pharmacist-led medication histories into the pre-operative pathway. METHODS: Through interdisciplinary collaboration, the pre-operative pathway for surgical patients was evaluated for opportunities to complete medication histories days prior to their scheduled procedure. Plan-Do-Study-Act (PDSA) cycles were utilized to make incremental improvements in practice. INTERVENTIONS: Through an iterative process, the pathway for cardiovascular surgery (CVS) patients was modified to include a scheduled pharmacist phone appointment in the days leading up to their surgical procedure. Utilizing these phone appointments, pharmacists complete patient medication history reviews and share a feedback loop to cardiovascular and peri-operative health care providers. RESULTS: The iterative PDSA cycles revealed challenges to completing pre-surgical medication history calls without advance notice. Patient responsiveness to pre-surgical medication history calls improved with the incorporation of scheduled phone appointments. Between January 18 and May 31, 2021, pharmacists completed 359 of 376 scheduled CVS appointments (95.5%), improving the medication history completion rates for cardiovascular surgery patients from 84.8 to 93.0% (p = 0.000025). The completion rate for all surgical patients also improved from 76.7 to 85.1% (p < 0.00001). CONCLUSIONS: Incorporating scheduled pharmacist medication history appointments as a part of the pre-operative pathway was shown to expand the capacity for pharmacists to complete medication histories for patients prior to surgery. By reducing pharmacist workload on the morning of surgery, fewer patients were admitted to surgery without having their medication history reviewed by pharmacy. Future investigation should be considered to evaluate the impact on patient outcomes.

Impact of sex on antidepressant discontinuation in groups of similar cytochrome P450 phenotypes.

Introduction: Although there are studies assessing reasons for antidepressant discontinuation, little is known about the impact of sex differences or cytochrome P450 phenotypes. Our objective is to assess discontinuation rates between males and females and whether CYP450 phenotype influences discontinuation. Methods: This is a retrospective review of patients previously enrolled in the Right Drug, Right Dose, Right Time: Using Genomic Data to Individualize Treatment database with major depressive disorder. Patients were evaluated for antidepressants trialed between January 1, 2009, and September 30, 2019. Survival analyses with competing risks were used to analyze discontinuation reasons. A Kaplan-Meier estimation method was used to assess the time to discontinuation and discontinuation rates. Analyses were also completed to assess discontinuation between men and women by phenotypic groups. All tests were two-sided, and p-values ≤ .05 were considered statistically significant. Results: There were 620 antidepressant discontinuation events discovered from 1015 antidepressant trials included. Overall, the median time to discontinuation for males was 2.6 years and 1.9 years for females (hazard ratio [HR] 0.97 [95% confidence interval (CI): 0.80, 1.19], p = .77). The risk of discontinuation was not different between males and females in any of the phenotype groups, which was consistent in the multivariable analyses. Concomitant use of medications that inhibited or induced antidepressant metabolism increased the overall risk of discontinuation (HR 1.45, 95% CI [1.06, 1.99], p = .020) in a time-dependent analysis. Discussion: We did not detect a significant difference in risk of antidepressant discontinuation rates between males and females even when accounting for cytochrome P450 phenotype. Future studies should account for whether medications that inhibit or induce antidepressant metabolism may be a crucial factor in antidepressant discontinuation.