Impact of Pharmacists to Improve Patient Care in the Critically Ill: A Large Multicenter Analysis Using Meaningful Metrics With the Medication Regimen Complexity-ICU (MRC-ICU) Score.

OBJECTIVES: Despite the established role of the critical care pharmacist on the ICU multiprofessional team, critical care pharmacist workloads are likely not optimized in the ICU. Medication regimen complexity (as measured by the Medication Regimen Complexity-ICU [MRC-ICU] scoring tool) has been proposed as a potential metric to optimize critical care pharmacist workload but has lacked robust external validation. The purpose of this study was to test the hypothesis that MRC-ICU is related to both patient outcomes and pharmacist interventions in a diverse ICU population. DESIGN: This was a multicenter, observational cohort study. SETTING: Twenty-eight ICUs in the United States. PATIENTS: Adult ICU patients. INTERVENTIONS: Critical care pharmacist interventions (quantity and type) on the medication regimens of critically ill patients over a 4-week period were prospectively captured. MRC-ICU and patient outcomes (i.e., mortality and length of stay [LOS]) were recorded retrospectively. MEASUREMENTS AND MAIN RESULTS: A total of 3,908 patients at 28 centers were included. Following analysis of variance, MRC-ICU was significantly associated with mortality (odds ratio, 1.09; 95% CI, 1.08-1.11; p < 0.01), ICU LOS (ß coefficient, 0.41; 95% CI, 00.37-0.45; p < 0.01), total pharmacist interventions (ß coefficient, 0.07; 95% CI, 0.04-0.09; p < 0.01), and a composite intensity score of pharmacist interventions (ß coefficient, 0.19; 95% CI, 0.11-0.28; p < 0.01). In multivariable regression analysis, increased patient: pharmacist ratio (indicating more patients per clinician) was significantly associated with increased ICU LOS (ß coefficient, 0.02; 0.00-0.04; p = 0.02) and reduced quantity (ß coefficient, -0.03; 95% CI, -0.04 to -0.02; p < 0.01) and intensity of interventions (ß coefficient, -0.05; 95% CI, -0.09 to -0.01). CONCLUSIONS: Increased medication regimen complexity, defined by the MRC-ICU, is associated with increased mortality, LOS, intervention quantity, and intervention intensity. Further, these results suggest that increased pharmacist workload is associated with decreased care provided and worsened patient outcomes, which warrants further exploration into staffing models and patient outcomes.

Timing and appropriateness of initial antibiotic therapy in newly presenting septic patients.

OBJECTIVE: To determine the effectiveness of antibiotic regimens and time to antibiotics in septic patients admitted to an intensive care unit from the emergency department. METHODS: A retrospective case-control study of patients with sepsis syndromes admitted from the emergency department between August 2010 and July 2011 was conducted. Standard demographic information, time frames for written antibiotic orders and administration, and information regarding site of culture, organisms identified, sensitivities, and antibiotic effectiveness were documented. RESULTS: Four hundred medical records were reviewed; 184 patients met the study inclusion criteria and were included in the final analysis. Simplified Acute Physiology Scores II and Sequential Organ Failure Assessment scores were 49 and 6, respectively, and overall in-hospital mortality was 20.7%. Patients with positive blood cultures had higher Simplified Acute Physiology Scores II scores (56.0 vs 46.0, P = .0125). Serum lactate levels were also significantly higher in the in-hospital mortality group (3.2 vs 2.1, P = .0068). Computerized physician order entry dramatically decreased the median times to the last appropriate antibiotic administration (3.183 hours vs 6.992 hours, P < .0001) but did not alter mortality (20.6% vs 20.8%). Appropriateness of empiric antibiotic regimens was similar between patients surviving and those who died during their hospital stay (63.5% vs 68.8%, P = .58). CONCLUSIONS: Median times to the first antibiotic administration and last needed appropriate antibiotic administration were less than 3 and 5 hours, respectively; these times were similar between patients who survived and those who died during their hospital stay. Patients with a serum lactate level higher than 2.5 mmol/L were associated with a 2.5-times increased risk of mortality.

Cholestatic jaundice as a result of combination designer supplement ingestion.

OBJECTIVE: To report a case of cholestatic jaundice as a result of combination herbal and designer supplement use. CASE SUMMARY: A 50-year-old Hispanic male presented to the hospital with a 1-week history of significant painless jaundice; total bilirubin on admission was 29.4 mg/dL. He reported use of both herbal (creatine and whey protein) and designer (Incredible Bulk and Spartan 45) supplements concurrently for approximately 2 months. Upon admission, all supplements were discontinued and multiple laboratory and diagnostic tests were ordered. On day 6 of his hospital admission, a liver biopsy was performed, the results of which indicated drug-induced hepa to toxicity. On day 9 he was discharged with prescriptions for ursodeoxycholic acid and hydroxyzine. Three months post hospital discharge, the patient continued to be supplement-free and bilirubin had decreased substantially. DISCUSSION: Anabolic-androgenic steroids are capable of causing hepatotoxicity, and multiple cases reported in the literature support this. A case report described hepato toxicity secondary to both creatine and whey protein consumption, and several reports have described liver damage secondary to designer supplement use. To our knowledge, this is the first case to describe hepatotoxicity as a result of combination herbal and designer supplement use. The Roussel Uclaf Causality Assess ment Method (RUCAM) score for drug-induced hepatotoxicity indicated a highly probable correlation between the use of combination supplements and cholestatic jaundice. CONCLUSIONS: Health care professionals need to be aware of complications associated with designer supplement use and should be able to identify patients who would benefit from education on herbal and designer supplement use.