Translating Clinical Decision-Making Skills From a Critical Care Pharmacy Elective to the Required Curriculum.

OBJECTIVE: To examine the impact of a critical care pharmacy elective (CCPE) on student performance in other courses in the Doctor of Pharmacy curriculum that emphasize clinical reasoning and decision making. METHODS: This is a retrospective, cohort study including all students from the 2019-2021 graduating classes enrolled in required courses, Pharmacotherapy and Integrated Patient Cases (IPCs). Students were divided for comparison based on completion of the CCPE. The primary outcome was outstanding performance, defined by a final course grade ≥90%, in Pharmacotherapy and IPC. Baseline characteristics and outcomes were analyzed using descriptive statistics and the χ2 test or two-sided t test for categorical and continuous variables, respectively. Binary logistic regression models were constructed to identify variables associated with the primary outcome. RESULTS: Of 377 students included, 129 (34%) completed the CCPE. Baseline characteristics were similar between both groups, except more females completed the CCPE. Students that completed the CCPE were not more likely to demonstrate outstanding performance in Pharmacotherapy III (20% vs 30%) or Pharmacotherapy IV (27% vs 24%), but were more likely in IPC (34% vs 23%). In the adjusted analysis, CCPE students were almost twice as likely to exhibit outstanding performance in IPC. CONCLUSION: Students that completed the CCPE were more likely to demonstrate outstanding performance in IPC, but not in either of the Pharmacotherapy courses. Students may benefit from practicing clinical reasoning earlier in the curriculum to build-up to effective and efficient clinical decision-making. Implications of course structure on student performance should be further explored.

Optimal Dosing of Enoxaparin in Critically Ill Patients with Venous Thromboembolism.

Background: Evidence suggests that goal anti-Xa levels are achieved in only 33% of critically ill patients receiving standard prophylactic enoxaparin dosing. There has been limited focus on the potential suboptimal anticoagulation effect on medical intensive care unit (MICU) patients receiving therapeutic enoxaparin dosing for venous thromboembolism (VTE). Methods: MICU patients receiving enoxaparin 1 mg/kg twice daily or 1.5 mg/kg daily for VTE treatment in a 350-bed community teaching hospital between 2013 and 2019 with at least one peak anti-Xa level measured were included. The primary outcome was the proportion who achieved therapeutic anti-Xa levels with standard dosing. Secondary outcomes included types of dose-adjustments required and the proportion requiring subsequent dose-adjustments. Descriptive statistics were presented for all outcomes. Results: Fifty-three patients were evaluated, including those receiving either twice-daily or once-daily standard therapeutic dosing. Optimal anti-Xa levels at first measurement were recorded after the initiation of enoxaparin in 26.4% (n=14) patients. Dose adjustments were required in 70.7% (n=29) of patients receiving twice-daily dosing and in 83.3% (n=10) receiving once-daily dosing (P=0.97) to appropriately increase or decrease the enoxaparin dose. By the third anti-Xa level measurement, 3 patients remained outside of the therapeutic range. Conclusions: Standard therapeutic enoxaparin dosing did not result in optimal anti-Xa levels for a majority of MICU patients regardless of dosing regimen used or patient specific factors. Future studies should identify patient factors associated with the requirement for higher or lower enoxaparin dosing.

Outcomes of Intravenous Push versus Intermittent Infusion Administration of Cefepime in Critically Ill Patients.

The equivalence of intravenous push (IVP) and piggyback (IVPB) administration has not been evaluated in the critically ill population for most medications, but it is especially relevant for antibiotics, such as cefepime, that exhibit time-dependent bactericidal activity. A single center, retrospective, observational pre/post-protocol change study included critically ill adults who received cefepime as empiric therapy between August 2015 and 2021. The primary outcome was treatment failure, which was defined as a composite of escalation of antibiotic regimen or all-cause mortality. Secondary outcomes included adverse drug events, days of cefepime therapy, total days of antibiotic therapy, and ICU and hospital length of stay. Outcomes were compared using Chi-squared, Mann Whitney U, and binary logistic regression as appropriate. A total of 285 patients were included: 87 IVPB and 198 IVP. Treatment failure occurred in 18% (n = 16) of the IVPB group and 27% (n = 54) of the IVP group (p = 0.109). There were no significant differences in secondary outcomes. Longer duration of antibiotics (odds ratio [OR] 1.057, 95% confidence interval [CI] 1.013-1.103), SOFA score (OR 1.269, 95% CI 1.154-1.397) and IVP administration of cefepime (OR 2.370, 95% CI 1.143-4.914) were independently associated with treatment failure. Critically ill patients who received IVP cefepime were more likely to experience treatment failure in an adjusted analysis. The current practice of IVP cefepime should be reevaluated, as it may not provide similar clinical outcomes in the critically ill population.

Hidden Fluids in Plain Sight: Identifying Intravenous Medication Classes as Contributors to Intensive Care Unit Fluid Intake.

Introduction: Fluid stewardship targets optimal fluid management to improve patient outcomes. Intravenous (IV) medications, flushes, and blood products, collectively referred to as hidden fluids, contribute to fluid intake in the intensive care unit (ICU). The impact of specific IV medications on fluid intake is unknown. Objective: Characterize IV medication classes based on contribution to ICU fluid intake by frequency of administration and total volume infused to identify targets for fluid stewardship. Methods: This multi-center, retrospective nested cohort study included patients admitted to a medical or surgical ICU between January 2017 and December 2018. The primary outcome was to identify the volume contribution of specific IV medication classes administered over the first 3 ICU days. Secondary outcomes were the administration frequency of these medications and their proportion of total daily volume intake over the first 3 ICU days. Results: The study included 210 patients. The largest mean administration volumes over the course of the first 3 ICU days were attributed to antibacterials (968 ± 846 mL), vitamins/minerals/electrolytes (416 ± 935 mL), pain/agitation/delirium agents (310 ± 512 mL), and vasoactive agents (282 ± 744 mL). The highest frequencies over the course of the first 3 ICU days were attributed to antibacterials (n = 180; 86%), pain/agitation/delirium agents (n = 143; 68%), vitamins/minerals/electrolytes (n = 123; 59%), and vasoactive agents (n = 96; 46%). IV medications contributed 2601 ± 2573 mL of fluid volume per patient over the first 3 ICU days, accounting for 42% ± 29% of overall volume. Conclusion: IV medications contribute over 40% of total fluid intake within the first 3 days of ICU admission, with antibacterials as top contributors by administration volume and frequency. Future research implementing fluid stewardship to ICU fluid sources, such as concentrating IV medications, switching IV medications to oral formulations, de-escalation of antibacterials, and reduction of maintenance fluids, should be performed to minimize hidden fluids from IV medications.

Impact of the COVID-19 pandemic on faculty at research-intensive United States schools/colleges of pharmacy.

INTRODUCTION: To describe the impact of the SARS-CoV-2 pandemic on teaching, research, practice, and work-life integration for pharmacy faculty at research-intensive institutions. METHODS: An online survey related to transition to remote work, impact on faculty responsibilities, demographics, and other elements was sent to nine research-intensive United States public schools/colleges of pharmacy. Respondents were asked to describe challenges in moving to remote instruction as a result of the pandemic. The 75-item survey asked respondents to rate the degree to which factors were challenging and levels of concern with the abrupt transition. Responses were analyzed using descriptive statistics and comparison of means using paired samples t-tests between spring and fall semesters, for the types of students taught, and for faculty discipline. RESULTS: Surveys were completed by 279 faculty (36% response rate), with 62% self-identifying as pharmacy practice faculty. The highest reported challenges were family/home responsibilities (41%), assisting children with schoolwork (28%), and availability of childcare (22%). Concerns most identified by respondents were increased workload, potential for academic dishonesty, and inability to effectively conduct hands-on activities. Practice faculty encountered barriers using telehealth and delivering virtual experiential education, while both practice and research faculty reported concerns with research progress. CONCLUSIONS: The pandemic has led to substantial challenges and increased workload in many areas. As the pandemic persists, administration should consider reported barriers and concerns to inform expectations. Evaluation of novel instructional design, assessment methods, and best practices in the virtual learning environment is highly encouraged to ensure student competencies are met.

Fluid Stewardship of Maintenance Intravenous Fluids.

Despite the frequent use of maintenance intravenous fluids (mIVF) in critically ill patients, limited guidance is available. Notably, fluid overload secondary to mIVF mismanagement is associated with significant adverse patient outcomes. The Four Rights (right drug, right dose, right duration, right patient) construct of fluid stewardship has been proposed for the safe evaluation and use of fluids. The purpose of this evidence-based review is to offer practical insights for the clinician regarding mIVF selection, dosing, and duration in line with the Four Rights of Fluid Stewardship.

Scholastic synergy: A team prototype for pharmacy faculty engagement in education, research, and service.

INTRODUCTION: Many clinical faculty members are challenged by competing factors of scholarly productivity, education, service obligations, and patient care. A team-based approach has the potential to synergistically increase productivity and mitigate factors associated with burnout. METHODS: The purpose of this report is to discuss a prototype for a small, team-based, practice-oriented collaborative approach to advancing critical care pharmacy practice through research and education. Productivity was evaluated in the areas of scholarship and teaching. RESULTS: This team was formed in 2017 and includes five critical care faculty across four campuses from a single academic institution. This collaborative has published peer-reviewed articles, secured grant funding, and developed novel teaching modalities. CONCLUSIONS: Challenges encountered include timeline adherence, development of uniform data collection processes, clarifying roles and expectations for different projects, and authorship. This team may act as a prototype for clinical faculty teams to enhance engagement and scholarship productivity in a practice-based setting.

Low Prevalence of Thrombosis Prophylaxis Dose Adjustments Highlights Implications for Patient Safety.

Background: Pharmacologic thromboprophylaxis (PTP) is the mainstay prevention strategy for venous thromboembolism (VTE). PTP agents traditionally dosed, like unfractionated heparin (UFH) and enoxaparin (ENOX), are associated with failure and bleeding in obese and underweight patients, respectively. Objectives: This study aimed to describe the prevalence of unadjusted ENOX and UFH dosing for PTP based on anthropometric measures. Patients/Methods:This was a post-hoc, multicenter, cross-sectional analysis of critically ill adults receiving PTP with ENOX or UFH. The primary outcome was the prevalence of unadjusted PTP based on body mass index (BMI) and total body weight (TBW). Definitions for dose adjustments were developed based on existing literature. A secondary outcome was to identify factors associated with unadjusted dosing per BMI and TBW using multivariable generalized linear mixed-effect models. Results: The nested cohort included 172 patients (ENOX=46, UFH=126). Unadjusted PTP was observed in 118 patients (68.6%) based on BMI and 74 (43%) per TBW. When comparing UFH to ENOX, more patients who received UFH had doses unadjusted by BMI (78.6% vs. 41.3%, p<0.05) but not TBW (43.7% vs. 41.3%). Factors independently associated with unadjusted PTP per BMI were receipt of UFH (OR 6.93, 95% CI 1.06-8.77) or a BMI underweight or overweight/obese (OR 10.45, 95% CI 4.38-24.92). Having a TBW <50kg or >100kg (OR 4.85, 95% CI 2.15-10.96) were independently associated with unadjusted PTP based on TBW. Conclusions: Unadjusted dosing of PTP occurs frequently in critically ill adults receiving ENOX or UFH. This was seen in body size extremes by both BMI and TBW.

Association of hidden fluid administration with development of fluid overload reveals opportunities for targeted fluid minimization.

BACKGROUND: Fluid overload is associated with poor outcomes, but mitigating its occurrence poses significant challenges. OBJECTIVE: This study sought to assess the impact of hidden fluid volume on fluid overload. METHODS: This study was a multi-center, retrospective evaluation of adults admitted to a medical or surgical intensive care unit for at least 72 h. Patients were divided into tertiles (low, moderate, and high) based on the hidden fluid volume received. Hidden fluids were defined as intravenous medications, line flushes, blood products, and enteral nutrition. The primary outcome was the incidence of fluid overload at intensive care unit (day 3). Secondary outcomes included mechanical-ventilation free days and association of hidden fluid volume with fluid overload, length of stay, and mortality. RESULTS: A total of 219 (73 per tertile) were included, with hidden fluid volume comprising ⩽2500, 2501-4400, and >4400 mL in the low, moderate, and high tertiles, respectively. Incidence of fluid overload was significantly different across groups (low: 3%, moderate: 14%, high: 25%; p < 0.001). No difference existed in mechanical-ventilation free days or in-hospital mortality across tertiles. In binary logistic regression, hidden fluid volume received at 3 days was independently associated with fluid overload (odds ratio = 1.40, 95% confidence interval = 1.15-1.70). CONCLUSION: The volume of hidden fluid volume administered by intensive care unit day 3 independently predicted development of fluid overload.

Teaching research skills to student pharmacists: A multi-campus, multi-semester applied critical care research elective.

BACKGROUND AND PURPOSE: Research electives are commonly offered in doctor of pharmacy programs but are typically limited to one faculty member mentoring individual students at a single site for a semester long self-study experience. The purpose of this paper is to describe pharmacy student experiences and perceptions of the research process after completing a multi-campus, multi-investigator critical care research elective. EDUCATIONAL ACTIVITY AND SETTING: The Research in Critical Care Pharmacotherapy elective was launched in spring 2019 and implemented a novel approach to the pharmacy research elective that promoted collaborative research across four campuses that may be continued for up to four semesters of credit. FINDINGS: Six second- and third-year doctor of pharmacy students enrolled in the course during the first offering. Three students were located on the main campus with one student on each of the extended campuses. Students completed a median of five unique research activities with at least one student participating in 15 of the 19 activities evaluated. Students were asked to complete a pre- and post-course survey assessing perceived research abilities using the Dreyfus model. There was a significant decrease in the number of novice responses in the post-course survey (pre- 10 vs. post- 2, p = 0.043). SUMMARY: A multi-campus, multi-investigator critical care research elective provided broad research experiences and increased student confidence related to numerous research skills.

Multicenter, Observational Cohort Study Evaluating Third-Generation Cephalosporin Therapy for Bloodstream Infections Secondary to Enterobacter, Serratia, and Citrobacter Species.

OBJECTIVES: There is debate on whether the use of third-generation cephalosporins (3GC) increases the risk of clinical failure in bloodstream infections (BSIs) caused by chromosomally-mediated AmpC-producing Enterobacterales (CAE). This study evaluates the impact of definitive 3GC therapy versus other antibiotics on clinical outcomes in BSIs due to Enterobacter, Serratia, or Citrobacter species. METHODS: This multicenter, retrospective cohort study evaluated adult hospitalized patients with BSIs secondary to Enterobacter, Serratia, or Citrobacter species from 1 January 2006 to 1 September 2014. Definitive 3GC therapy was compared to definitive therapy with other non-3GC antibiotics. Multivariable Cox proportional hazards regression evaluated the impact of definitive 3GC on overall treatment failure (OTF) as a composite of in-hospital mortality, 30-day hospital readmission, or 90-day reinfection. RESULTS: A total of 381 patients from 18 institutions in the southeastern United States were enrolled. Common sources of BSIs were the urinary tract and central venous catheters (78 (20.5%) patients each). Definitive 3GC therapy was utilized in 65 (17.1%) patients. OTF occurred in 22/65 patients (33.9%) in the definitive 3GC group vs. 94/316 (29.8%) in the non-3GC group (p = 0.51). Individual components of OTF were comparable between groups. Risk of OTF was comparable with definitive 3GC therapy vs. definitive non-3GC therapy (aHR 0.93, 95% CI 0.51-1.72) in multivariable Cox proportional hazards regression analysis. CONCLUSIONS: These outcomes suggest definitive 3GC therapy does not significantly alter the risk of poor clinical outcomes in the treatment of BSIs secondary to Enterobacter, Serratia, or Citrobacter species compared to other antimicrobial agents.

Twelve Tips for Synergistic Delivery of Remote Advanced Pharmacy Practice Experience Rotations.

This article was migrated. The article was marked as recommended. In response to the COVID-19 pandemic, many institutions changed their staffing models to incorporate remote work which created a need for pharmacy faculty and preceptors to also shift their rotation experience to a remote format. While initially this may be a daunting task, remote experiences have the potential to equip students with unique skillsets while offering a mutually beneficial effort towards patient care and/or other responsibilities. In addition, these remote experiences can offer students a more customized rotation and a behind the scenes look at the preceptor's career. This article provides 12 tips for developing a remote learning experience.

Fluid Stewardship During Critical Illness: A Call to Action.

Intravenous fluids (IVFs) are the most common drugs administered in the intensive care unit. Despite the ubiquitous use, IVFs are not benign and carry significant risks associated with under- or overadministration. Hypovolemia is associated with decreased organ perfusion, ischemia, and multi-organ failure. Hypervolemia and volume overload are associated with organ dysfunction, delayed liberation from mechanical ventilation, and increased mortality. Despite appropriate provision of IVF, adverse drug effects such as electrolyte abnormalities and acid-base disturbances may occur. The management of volume status in critically ill patients is both dynamic and tenuous, a process that requires frequent monitoring and high clinical acumen. Because patient-specific considerations for fluid therapy evolve across the continuum of critical illness, a standard approach to the assessment of fluid needs and prescription of IVF therapy is necessary. We propose the principle of "fluid stewardship," guided by 4 rights of medication safety: right patient, right drug, right route, and right dose. The successful implementation of fluid stewardship will aid pharmacists in making decisions regarding IVF therapy to optimize hemodynamic management and improve patient outcomes. Additionally, we highlight several areas of focus for future research, guided by the 4 rights construct of fluid stewardship.

Perceived Motivating Factors and Barriers for the Completion of Postgraduate Training Among American Pharmacy Students Prior to Beginning Advanced Pharmacy Practice Experiences.

Objective. To examine perceived motivating factors and barriers (MFB) to postgraduate training (PGT) pursuit among pharmacy students. Methods. Third-year pharmacy students at 13 schools of pharmacy provided demographics and their plan and perceived MFBs for pursuing PGT. Responses were characterized using descriptive statistics. Kruskal-Wallis equality-of-proportions rank tests determined if differences in perceived MFBs existed between students based on plan to pursue PGT. Results. Among 1218 (69.5%) respondents, 37.1% planned to pursue PGT (32.9% did not, 30% were undecided). Students introduced to PGT prior to beginning pharmacy school more frequently planned to pursue PGT. More students who planned to pursue PGT had hospital work experience. The primary PGT rationale was, "I desire to gain more knowledge and experience." Student debt was the most commonly cited barrier. Conclusion. Introducing pharmacy students early to PGT options and establishing work experiences in the hospital setting may increase students' desire to pursue PGT.

Antibiotics in the intensive care unit: focus on agents for resistant pathogens.

Antibiotic resistance is increasing faster than the drug industry can develop and market new antibiotics. Medical personnel commonly must deal with the resistant gram-positive pathogens including MRSA and VRE, in addition to the problem gram-negative bacteria, Pseudomonas, Acinetobacter, and ESBL producing strains of Klebsiella and E. coli. Clinicians should be familiar with treatment strategies for these resistant pathogens. Because of the lack of novel agents to treat resistant infections, clinicians must use antibiotics judiciously and appropriately to limit further development of resistance. Early, appropriate cultures of the blood, urine, sputum and suspected source, ideally obtained before antibiotic initiation, allow for future de-escalation of antibiotics, or the decision to discontinue antibiotics.