Evaluating the carbon footprint of sedation practices in intensive care.

BACKGROUND: Healthcare's carbon footprint contributes to 4.4% of global net emissions and intensive care units (ICUs) are very resource intensive. Existing studies on environmental sustainability in ICUs focused on carbon footprint generated from energy and electricity consumption, use of medical consumables and equipment, but few studies quantified carbon footprint generated from pharmaceuticals used in ICUs. AIM: To evaluate carbon footprint arising from sedation practices in the ICUs. STUDY DESIGN: A pilot, prospective observational study was conducted in two ICUs from 1 August to 22 September 2022 in Singapore General Hospital. Adult patients who were consecutively sedated, intubated and expected to be mechanically ventilated for at least 24 h were included. Total amount of analgesia and sedatives used and wasted in eligible patients were collected. Carbon emission from ICU sedation practices were then quantified using available life cycle assessment data. RESULTS: A total of 31 patients were recruited. Top analgesia and sedative used in both ICUs were fentanyl and propofol, respectively. Carbon footprint from sedative usage and wastage across 7 weeks in both ICUs were 2.206 kg CO2-e and 0.286 g CO2-e, respectively. In total, this equates to driving 15.8 km by car. Proportion of drug wasted ranged from 5.1% to 25.0%, with the top reason for wastage being the drug was no longer clinically indicated. Recommendations to reduce carbon footprint include choosing sedatives with lower carbon emissions where possible and having effective communication among doctors and nurses regarding management plans to minimize unnecessary wastage. CONCLUSION: Our study quantified carbon footprint arising from sedation practices, mainly drug usage and wastage in two ICUs in Singpore General Hospital. RELEVANCE TO CLINICAL PRACTICE: Adopting a holistic approach to environmental sustainability in the ICU, sedation practices also contribute to generating greenhouse gases, albeit small, and can be targeted to reduce unnecessary carbon footprint.

A cost avoidance study of critical care pharmacists' interventions in a tertiary institution in Singapore.

PURPOSE: The economic impact of critical care pharmacists in the intensive care unit (ICU) setting has not been evaluated in Singapore despite ICUs being high-cost areas. This study was conducted to determine the costs avoided as a result of pharmacists' interventions within multidisciplinary ICU teams in a tertiary hospital in Singapore. METHODS: A single-center, retrospective observational study of accepted pharmacists' interventions was conducted over 6 months in 2020. We adopted a previously published systematic approach to estimate the costs avoided by the healthcare system through pharmacists' interventions. Interventions were independently reviewed by a critical care pharmacist, an intensivist, and an investigator. Cost avoidance was calculated in terms of the additional ICU length of stay that would have resulted had a pharmacist not intervened as well as the direct cost savings achieved. RESULTS: There were 632 medication-related problems (MRPs) associated with the 527 accepted interventions, as some interventions involved multiple MRPs. The most common interventions included correcting inappropriate drug regimens (n = 363; 57%), recommending drug monitoring (n = 65; 10%) and addressing omission of drugs (n = 50; 8%). Over 6 months, gross cost avoidance and net cost avoidance achieved were $186,852 and $140,004, respectively, resulting in a ratio of potential monetary cost avoidance to pharmacist salary of 3.99:1. The top 3 interventions that resulted in the greatest cost avoidance were those that corrected inappropriate drug regimens ($146,870; 79%), avoided adverse drug events (ADEs) ($10,048; 5%), and led to discontinuation of medications without any indication ($7,239; 4%). CONCLUSION: Pharmacists can reduce healthcare expenditure substantially through cost avoidance by performing various interventions in ICUs, particularly in the areas of correcting inappropriate drug regimens, avoiding ADEs, and discontinuing unnecessary medications.

Therapeutic drug monitoring of meropenem and piperacillin-tazobactam in the Singapore critically ill population - A prospective, multi-center, observational study (BLAST 1).

PURPOSE: To determine percentage of patients with sub-therapeutic beta-lactam exposure in our intensive care units (ICU) and to correlate target attainment with clinical outcomes. MATERIALS AND METHODS: Multi-centre, prospective, observational study was conducted in ICUs from three hospitals in Singapore from July 2016 to May 2018. Adult patients (≥21 years) receiving meropenem or piperacillin-tazobactam were included. Four blood samples were obtained during a dosing interval to measure and determine attainment of therapeutic targets: unbound beta-lactam concentration above (i) minimum inhibitory concentration (MIC) at 40% (meropenem) or 50% (piperacillin) of dosing interval (40-50%fT > MIC) and (ii) 5 × MIC at 100% of dosing interval (100%fT > 5 × MIC). Correlation to clinical outcomes was evaluated using Cox regression. RESULTS: Beta-lactam levels were highly variable among 61 patients, with trough meropenem and piperacillin levels at 21.5 ± 16.8 mg/L and 101.6 ± 81.1 mg/L respectively. Among 85 sets of blood samples, current dosing practices were able to achieve 94% success for 40-50%fT > MIC and 44% for 100%fT > 5 × MIC. Failure to achieve 40-50%fT > MIC within 48 h was significantly associated with all-cause mortality (HR: 9.0, 95% CI: 1.8-45.0), after adjustment for APACHE II score. Achievement of 100%fT > 5 × MIC within 48 h was significantly associated with shorter length of hospital stay. CONCLUSION: Current dosing practices may be suboptimal for ICU patients. Beta-lactam TDM may be useful.

Patient characterization and predictors of aspirin desensitization response.

BACKGROUND: Hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) may limit the use of aspirin in patients with cardiovascular diseases. Aspirin desensitization, which is a resource-intensive process, can offer such patients access to aspirin through the induction of temporary tolerance to aspirin. However, there is limited information on aspirin desensitization response in patients undergoing aspirin desensitization for cardiac indications in Asia. OBJECTIVE: To characterize patients who have undergone aspirin desensitization, evaluate their responses to the procedure, and identify risk factor(s) associated with failure of aspirin desensitization. METHODS: We conducted a retrospective review of medical records of patients who underwent aspirin desensitization in Singapore General Hospital between 1 June 2014 and 31 October 2017. Chi-square or Fisher exact test were used to analyze categorical data while independent samples t test or Wilcoxon rank-sum test were used for continuous data where appropriate. Multivariate logistic regression was used to identify predictors of aspirin desensitization failure. RESULTS: All 214 patients in our study had cardiovascular indications for aspirin, with angioedema being the most common type of index reaction experienced with NSAIDs (n = 104, 48.6%). One hundred sixty-five patients (77.1%) achieved successful aspirin desensitization. In the selected sample analysis of patients with true NSAID hypersensitivity (n = 163), an index reaction of angioedema to NSAIDs was found to be significantly associated with a higher risk of failing aspirin desensitization (odds ratio, 7.21; 95% confidence interval, 1.94-26.71). CONCLUSION: Majority of the patients who underwent aspirin desensitization in our institution were able to achieve tolerance to aspirin. An index reaction of angioedema to NSAIDs was identified as a risk factor for aspirin desensitization failure. This information can aid in the risk stratification of patients undergoing aspirin desensitization and ensure efficient resource allocation for this procedure.

Patients' and Caregivers' Attitudes Toward Deprescribing in Singapore.

BACKGROUND: Knowledge of decision-making preference of patients and caregivers is needed to facilitate deprescribing. This study aimed to assess the perspectives of caregivers and older adults towards deprescribing in an Asian population. Secondary objectives were to identify and compare characteristics associated with these attitudes and beliefs. METHOD: A cross-sectional survey of two groups of participants was conducted using the Revised Patients' Attitudes Towards Deprescribing questionnaire. Descriptive results were reported for participants' characteristics and questionnaire responses from four factors (belief in medication inappropriateness, medication burden, concerns about stopping, and involvement) and two global questions. Correlation between participant characteristics and their responses was analyzed. RESULTS: A total of 1,057 (615 older adults; 442 caregivers) participants were recruited from 10 institutions in Singapore. In which 511 (83.0%) older adults and 385 (87.1%) caregivers reported that they would be willing to stop one or more of their medications if their doctor said it was possible, especially among older adults recruited from acute-care hospitals (85.3%) compared with older adults in community pharmacies (73.6%). Individuals who take more than five medications and those with higher education were correlated with greater agreement in inappropriateness and involvement, respectively. CONCLUSIONS: Clinicians should consider discussing deprescribing with older adults and caregivers in their regular clinical practice, especially when polypharmacy is present. Further research is needed into how to engage older adults and caregivers in shared decision making based on their attitudes toward deprescribing.

Appropriateness of vancomycin therapeutic drug monitoring and its outcomes among non-dialysis patients in a tertiary hospital in Singapore.

Background Vancomycin therapeutic drug monitoring (TDM) is commonly performed to ensure safe and effective use of the antibiotic. Aim of Study To evaluate appropriateness of vancomycin TDM and its outcomes in Singapore General Hospital. Method A retrospective, cross-sectional study was conducted between 1 January 2014 and 28 February 2014 involving patients who received ≥ 1 dose of intravenous vancomycin with TDM. Patient demographics and relevant vancomycin TDM data were collected from medical records. Results Of 746 vancomycin troughs measured among 234 patients, 459 troughs (61.5%) were taken inappropriately, with a median time of 2.6 h (interquartile range 1.1-4.3) before the next scheduled dose. Inappropriate interpretation of vancomycin troughs resulted in 41 unnecessary dose suspensions, 24 dose changes, and 102 unchanged vancomycin doses. The cost incurred due to inappropriate interpretation and measurement after discontinuation of treatment was US$7286. No differences in rates of vancomycin related nephrotoxicity, ototoxicity, recurrent infection, development of infection secondary to vancomycin resistant microorganism and mortality were observed (p > 0.05). Conclusion This study highlighted a high incidence of inappropriate vancomycin TDM which has led to increased healthcare cost.