Critical care pharmacy workforce: a 2020 re-evaluation of the UK deployment and characteristics.

INTRODUCTION: Critical care pharmacists improve the quality and efficiency of medication therapy whilst reducing treatment costs where they are available. UK critical care pharmacist deployment was described in 2015, highlighting a deficit in numbers, experience level, and critical care access to pharmacy services over the 7-day week. Since then, national workforce standards have been emphasised, quality indicators published, and service commissioning documents produced, reinforced by care quality assessments. Whether these initiatives have resulted in further development of the UK critical care pharmacy workforce is unknown. This evaluation provides a 2020 status update. METHODS: The 2015 electronic data entry tool was updated and circulated for completion by UK critical care pharmacists. The tool captured workforce data disposition as it was just prior to the COVID-19 pandemic, at critical care unit level. MAIN FINDINGS: Data were received for 334 critical care units from 203 organisations (96% of UK critical care units). Overall, 98.2% of UK critical care units had specific clinical pharmacist time dedicated to the unit. The median weekday pharmacist input to each level 3 equivalent bed was 0.066 (0.043-0.088) whole time equivalents, a significant increase from the median position in 2015 (+ 0.021, p < 0.0001). Despite this progress, pharmacist availability remains below national minimum standards (0.1/level 3 equivalent bed). Most units (71.9%) had access to prescribing pharmacists. Geographical variation in pharmacist staffing levels were evident, and weekend services remain extremely limited. CONCLUSIONS: Availability of clinical pharmacists in UK adult critical care units is improving. However, national standards are not routinely met despite widely publicised quality indicators, commissioning specifications, and assessments. Additional measures are needed to address persistent deficits and realise gains in organisational and patient-level outcomes. These measures must include promotion of cross-professional collaborative working, adjusted funding models, and a nationally recognised training pathway for critical care pharmacists.

An international survey on aminoglycoside practices in critically ill patients: the AMINO III study.

BACKGROUND: While aminoglycosides (AG) have been used for decades, debate remains on their optimal dosing strategy. We investigated the international practices of AG usage specifically regarding dosing and therapeutic drug monitoring (TDM) in critically ill patients. We conducted a prospective, multicentre, observational, cohort study in 59 intensive-care units (ICUs) in 5 countries enrolling all ICU patients receiving AG therapy for septic shock. RESULTS: We enrolled 931 septic ICU patients [mean ± standard deviation, age 63 ± 15 years, female 364 (39%), median (IQR) SAPS II 51 (38-65)] receiving AG as part of empirical (761, 84%) or directed (147, 16%) therapy. The AG used was amikacin in 614 (66%), gentamicin in 303 (33%), and tobramycin in 14 (1%) patients. The median (IQR) duration of therapy was 2 (1-3) days, the number of doses was 2 (1-2), the median dose was 25 ± 6, 6 ± 2, and 6 ± 2 mg/kg for amikacin, gentamicin, and tobramycin respectively, and the median dosing interval was 26 (23.5-43.5) h. TDM of Cmax and Cmin was performed in 437 (47%) and 501 (57%) patients, respectively, after the first dose with 295 (68%) patients achieving a Cmax/MIC > 8 and 353 (71%) having concentrations above Cmin recommended thresholds. The ICU mortality rate was 27% with multivariable analysis showing no correlation between AG dosing or pharmacokinetic/pharmacodynamic target attainment and clinical outcomes. CONCLUSION: Short courses of high AG doses are mainly used in ICU patients with septic shock, although wide variability in AG usage is reported. We could show no correlation between PK/PD target attainment and clinical outcome. Efforts to optimize the first AG dose remain necessary. Trial registration Clinical Trials, NCT02850029, registered on 29th July 2016, retrospectively registered, https://www.clinicaltrials.gov.

Fever in a patient with osteomyelitis: the diagnosis could be serotonin syndrome.

Awareness of rare differential diagnoses of common clinical presentations helps promote early detection and prompt management of serious conditions. A 54-year-old man, with an infected non-union following a high tibial osteotomy, presented with an acutely discharging abscess to his proximal tibia. He was generally unwell with a Staphylococcus aureus bacteraemia. The tibia was debrided, CERAMENT G used as dead space management and a spanning external fixator applied. Postoperatively, pregabalin and tapentadol were commenced in addition to amitriptyline and sertraline, which the patient was taking regularly. Overnight, the patient developed hyperthermia, inducible clonus, hyperreflexia, agitation, confusion and rigors. Prompt recognition of the possibility of serotonin syndrome resulted in early cessation of serotonergic medications and a positive outcome. From this case an important message is that fever in a patient taking serotonergic medications should prompt a screening neurological examination. Clinicians should also be wary when patients are commenced on multimodal analgesia, including tapentadol.

Critical care pharmacy workforce: UK deployment and characteristics in 2015.

OBJECTIVE: Clinical pharmacists reduce medication errors and optimize the use of medication in critically ill patients, although actual staffing level and deployment of UK pharmacists is unknown. The primary aim was to investigate the UK deployment of the clinical pharmacy workforce in critical care and compare this with published standards. METHODS: An electronic data entry tool was created and distributed for UK critical care pharmacy services to record their critical care workforce deployment data. KEY FINDINGS: Data were received for 279 critical care units in 171 organizations. Clinical pharmacist input was identified for 98.6% of critical care units. The median weekday pharmacist input to critical care was 0.045 whole time equivalents per Level 3 (ICU) bed with significant interregional variation. Weekend services were sparse. Pharmacists spent 24.5% of time on the multidisciplinary team ward round, 58.5% of time on independent patient review and 17% of time on other critical care professional support activities. There is significant variation in staffing levels when services are stratified by highest level of competence of critical care pharmacist within an organization (P = 0.03), with significant differences in time spent on the multi-disciplinary ward round (P = 0.010) and on other critical care activities (P = 0.009), but not on independent patient review. CONCLUSIONS: Investment in pharmacy services is required to improve access to clinical pharmacy expertise at weekends, on MDT ward rounds and for other critical care activities.

Infusion medication concentrations in UK's critical care areas: Are the Intensive Care Society's recommendations being used?

Following two studies done in 2007 and 2009, a follow-up of the adherence to the suggested guidelines on drug standardisation has been performed with a suggestion for future standards that can be achieved, to complement the recently published Carter report. The Intensive Care Society (ICS) introduced recommendations for infusion concentrations of 16 medications commonly used in critical care areas. The importance being improvement in patient safety and rationalised use of available critical care resources. Five years after publication of these recommendations, a further audit has been undertaken to assess the level of acceptance and application. This revealed that 89.5% of the 133 surveyed units (representing 42.49% critical care units across the UK) have adopted the recommendations. There are further medication concentrations which could also be standardised.

Postnatal Hyperoxia Exposure Durably Impairs Right Ventricular Function and Mitochondrial Biogenesis.

Prematurity complicates 12% of births, and young adults with a history of prematurity are at risk to develop right ventricular (RV) hypertrophy and impairment. The long-term risk for pulmonary vascular disease, as well as mechanisms of RV dysfunction and ventricular-vascular uncoupling after prematurity, remain poorly defined. Using an established model of prematurity-related lung disease, pups from timed-pregnant Sprague Dawley rats were randomized to normoxia or hyperoxia (fraction of inspired oxygen, 0.85) exposure for the first 14 days of life. After aging to 1 year in standard conditions, rats underwent hemodynamic assessment followed by tissue harvest for biochemical and histological evaluation. Aged hyperoxia-exposed rats developed significantly greater RV hypertrophy, associated with a 40% increase in RV systolic pressures. Although cardiac index was similar, hyperoxia-exposed rats demonstrated a reduced RV ejection fraction and significant RV-pulmonary vascular uncoupling. Hyperoxia-exposed RV cardiomyocytes demonstrated evidence of mitochondrial dysregulation and mitochondrial DNA damage, suggesting potential mitochondrial dysfunction as a cause of RV dysfunction. Aged rats exposed to postnatal hyperoxia recapitulate many features of young adults born prematurely, including increased RV hypertrophy and decreased RV ejection fraction. Our data suggest that postnatal hyperoxia exposure results in mitochondrial dysregulation that persists into adulthood with eventual RV dysfunction. Further evaluation of long-term mitochondrial function is warranted in both animal models of premature lung disease and in human adults who were born preterm.

Advanced Level Practice Education: UK Critical Care Pharmacists' Opinions in 2015.

National UK standards for critical care highlight the need for clinical pharmacists to practice at an advanced level and above. The aim of this research paper was to describe the views of UK critical care pharmacists on the current provision of Advanced Level Practice (ALP) education and accreditation. It sought to identify whether there is a need for a national or regional training programme. A questionnaire was delivered electronically targeting UK critical care pharmacists. Whilst the response rate was low at 40% (166/411); the views expressed were representative of UK practitioners with the majority of responders meeting the national specifications for clinical pharmacist staffing in critical care areas. The responses highlighted work-based learning as the main resource for developing ALP and a lack of suitable training packages. The vast majority of pharmacists identified that a national or regional training programme was required for ALP. The results also identified the main barriers to undertaking ALP accreditation were lack of time, uncertainty regarding the process and its professional benefits and a lack of education and training opportunities. In conclusion, the responses clearly indicated that, for the necessary progression of critical care pharmacists to ALP, a national or regional training programme is required.

The ADMIN-ICU survey: a survey on antimicrobial dosing and monitoring in ICUs.

OBJECTIVES: There is little evidence and few guidelines to inform the most appropriate dosing and monitoring for antimicrobials in the ICU. We aimed to survey current practices around the world. METHODS: An online structured questionnaire was developed and sent by e-mail to obtain information on local antimicrobial prescribing practices for glycopeptides, piperacillin/tazobactam, carbapenems, aminoglycosides and colistin. RESULTS: A total of 402 professionals from 328 hospitals in 53 countries responded, of whom 78% were specialists in intensive care medicine (41% intensive care, 30% anaesthesiology, 14% internal medicine) and 12% were pharmacists. Vancomycin was used as a continuous infusion in 31% of units at a median (IQR) daily dose of 25 (25-30) mg/kg. Piperacillin/tazobactam was used as an extended infusion by 22% and as a continuous infusion by 7%. An extended infusion of carbapenem (meropenem or imipenem) was used by 27% and a continuous infusion by 5%. Colistin was used at a daily dose of 7.5 (3.9-9) million IU (MIU)/day, predominantly as a short infusion. The most commonly used aminoglycosides were gentamicin (55%) followed by amikacin (40%), with administration as a single daily dose reported in 94% of the cases. Gentamicin was used at a daily dose of 5 (5-6) mg/day and amikacin at a daily dose of 15 (15-20) mg/day. Therapeutic drug monitoring of vancomycin, piperacillin/tazobactam and meropenem was used by 74%, 1% and 2% of the respondents, respectively. Peak aminoglycoside concentrations were sampled daily by 28% and trough concentrations in all patients by 61% of the respondents. CONCLUSIONS: We found wide variability in reported practices for antibiotic dosing and monitoring. Research is required to develop evidence-based guidelines to standardize practices.

Pharmacokinetic considerations and dosing strategies of antibiotics in the critically ill patient.

The treatment of sepsis remains a significant challenge and is the cause of high mortality and morbidity. The pathophysiological alterations that are associated with sepsis can complicate drug dosing. Critical care patients often have capillary leak, increased cardiac output and altered protein levels which can have profound effects on the volume of distribution (Vd) and clearance (Cl) of antibacterial agents, both of which may affect the pharmacokinetics (PK) / pharmacodynamics (PD) of the drug. Along with antibacterial factors such as the hydrophilicity and its kill characteristics and the susceptibility and site of action of the microorganism, different dosing and administration strategies may be needed for the different drug classes. In conclusion, developing dosing and administration regimes of antibacterials that adhere to PK/PD principles increase antibacterial exposure. Tailoring therapy to the individual patient combined with TDM may contribute to improved clinical efficacy and contain the spread of resistance.

The landscape of services for drug users in Yogyakarta, Indonesia.

INTRODUCTION AND AIMS: Drug use has increased rapidly in Indonesia since the late 1990s. The formal drug treatment sector has grown within the bounds of available government funding; however, there is also a substantial informal sector which provides a range of services for current and former users. While information regarding the former is available from the provincial and national governments, there are few sources that detail the latter. The aim of the current study, therefore, is to document the drug treatment services in one Indonesian city, Yogyakarta. DESIGN AND METHODS: This qualitative study utilised nine key informant interviews with drug treatment workers from nine government and non-government treatment services. Transcripts were analysed thematically. RESULTS: There exists a patchwork of enthusiastic yet under-resourced non-government services that complement the government rehabilitation and withdrawal programs in Yogyakarta. The focus of most such services is on abstinence (including several faith-based residential rehabilitation programs); however, some harm reduction programs have emerged in recent years. Under-utilisation is a feature of many non-government services, and all respondents acknowledged a significant gap in service coordination. DISCUSSION AND CONCLUSIONS: Yogyakarta has a drug treatment sector in which most major treatment types are represented, and there appears to be potential for growth within many organisations. Nevertheless, the number and reach of the services are limited by a lack of resources and collaboration, and there are substantial cultural barriers to improving inter-organisational coordination. This study suggests that Yogyakarta and greater Indonesia may benefit from greater service coordination facilitated by local government.