Development and implementation of an in-hospital pharmacist emergency response simulation training curriculum.

BACKGROUND: Medical simulation is an effective educational tool used to increase confidence, improve knowledge, and refine skills when responding to high-acuity situations. Despite established roles of the pharmacist on the hospital code team, most institutions lack formalized pharmacist training for code team responses. OBJECTIVE: This pre-post analysis aimed to evaluate the impact of a didactic and simulation-based code response training for pharmacists on self-perceived improvement and preparedness when responding to in-hospital medical emergencies. METHODS: An emergency response curriculum (ERC) was developed for pharmacists and pharmacy residents at our institution. The curriculum, led by 4 lead clinical pharmacy specialists, included a 60-minute didactic code competency lecture followed by 2 medical emergency simulations and a debrief after each scenario. After completion of the simulation portion of the ERC, participants were given a survey to complete that assessed their confidence using a 5-point Likert scale (1 = very unconfident to 5 = very confident) in completing the course objectives before and after the ERC. RESULTS: Seventy-two pharmacists completed the ERC and 60 completed the postcourse survey. Of those who completed the postcourse survey, 70% were pharmacy residents. Using a 5-point Likert scale (1 = very unconfident to 5 = very confident), median participant confidence rose from 3 (interquartile range [IQR] 2-4) before the session to 4 (IQR 3-5) after the session (P < 0.001). Of the participants, 95% believed the ERC training should be required annually or multiple times a year and 100% of respondents felt the ERC training was beneficial. CONCLUSION: Development of a pharmacist ERC including didactic and simulation-based learning improved the confidence and preparedness of pharmacists when participating as members of the hospital code team. Future studies should continue to evaluate pharmacist training and curriculum development in code team responses.

Safety of peripherally administered 3% hypertonic saline.

BACKGROUND: Administration of 3% sodium chloride through a peripheral venous catheter is associated with risk of infusion-related adverse events (IRAE) due to its high osmolarity. Given this concern and the paucity of data regarding these events, many hospitals have policies that require central line administration of 3% sodium chloride. OBJECTIVE: The objective of this analysis was to evaluate the incidence of IRAE associated with peripheral administration of 3% sodium chloride. METHODS: This analysis included patients who received 3% sodium chloride via a peripheral venous catheter between May 2017 and August 2019. The major endpoint of this analysis was the overall incidence of IRAE, defined as the documentation of infiltration or phlebitis. A multivariable logistic regression was performed to identify potential risk factors (e.g., age, infusion rate, infusion duration, peripheral venous catheter location, and needle gauge) for development of IRAE. RESULTS: A total of 706 administrations in 422 patients were included. Seventy-four (10.5%) administrations were associated with a documented event. Based on the Infusion Nurses grading scale for infiltration or phlebitis, 48% of the events in this analysis were grade 1 in severity. Duration of infusion of 3% sodium chloride was found to be associated with an increased odds of an IRAE (OR per 1 h 1.02, 95% CI 1.01-1.02) in the multivariable analysis. Age, infusion rate, peripheral venous catheter location, and needle gauge were not independently associated with an increased risk of an IRAE. CONCLUSION: These data suggest that IRAE occurred more frequently when 3% sodium chloride was administered over a longer duration and the majority of events were mild with no permanent tissue injury. It may be reasonable to consider peripheral administration of 3% sodium chloride in the acute care setting for a short duration, although additional studies are needed to continue to evaluate its safety.

Evaluation of Dexmedetomidine Withdrawal and Management After Prolonged Infusion.

PURPOSE: Dexmedetomidine is often used for longer than its labeled indication of 24 hours, raising concerns for potential withdrawal. Data are limited regarding this syndrome in adult patients. This study aimed to further characterize dexmedetomidine withdrawal in critically ill adult patients after prolonged use. METHODS: This was an institutional review board-approved, single-center, retrospective chart review conducted at a tertiary academic medical center. Adult intensive care unit (ICU) patients on dexmedetomidine for ≥72 hours in 2019 were screened for inclusion. Exclusion criteria were interruption of dexmedetomidine for >6 hours, indications for dexmedetomidine other than sedation, or patients with neurological or burn injury. The major end point was the incidence of dexmedetomidine withdrawal, defined as meeting ≥2 of the following criteria within 24 hours of discontinuation: newly positive Confusion Assessment Method for ICU, Richmond Agitation Sedation Scale score of ≥+2, hypertension, and tachycardia. Minor end points were incidence of individual withdrawal signs as previously described, additional sedatives or antipsychotics required, dose and duration of dexmedetomidine infusion, length of ventilation, ICU and hospital length of stay, and new onset of the following: fever, vomiting, loose stools/diarrhea, diaphoresis, or seizure. FINDINGS: Of the 152 patients included, dexmedetomidine withdrawal occurred in 54 patients (35.5%). Rebound hypertension was the most common withdrawal sign (47 patients [87.0%]). In the withdrawal group, significantly more patients required additional ß-blockers (29 [53.7%] vs 10 [10.2%]; P < 0.01), were reinitiated on dexmedetomidine (16 [29.6%] vs 10 [10.2%]; P < 0.01), and required a start or increased dose of clonidine (6 [11.1%] vs 3 [3.1%]; P = 0.04). There was no significant difference in the cumulative dose or duration of dexmedetomidine between the groups. Length of ventilation was longer in the withdrawal group (171 hours [83.7-280.8 hours] vs 159 hours [149.0-335.7 hours]; P < 0.01), but there was no difference in ICU or hospital length of stay. IMPLICATIONS: Prolonged use of dexmedetomidine was associated with withdrawal syndrome in 35.5% of patients in our study. Larger trials are needed to confirm the risk factors for dexmedetomidine withdrawal and identify measures to prevent withdrawal.

Intravenous levothyroxine stewardship program at a tertiary academic medical center.

PURPOSE: Based on the pharmacokinetic profile of levothyroxine, a 3-day hold guideline for adult patients ordered for intravenous (IV) levothyroxine was implemented at a tertiary academic medical center. The purpose of this study was to evaluate the impact of the implementation of an IV levothyroxine hold guideline. METHODS: This single-center, retrospective analysis identified patients ordered for IV levothyroxine during a 13-week period before and after implementation of the guideline. The primary outcome was guideline adherence, defined as full implementation of the 3-day hold. Secondary outcomes included the number of IV levothyroxine administrations avoided in the post-guideline group, extrapolated yearly cost avoidance (EYCA) after guideline implementation, reasons for guideline non-adherence, and number of safety reports involving IV levothyroxine. RESULTS: A total of 166 and 134 patients met inclusion criteria for the pre- and post-guideline groups, respectively. Guideline adherence was observed in 94 (70.1%) patients, resulting in 276 vials saved in the 13-week post-guideline period, which translated to an EYCA of $139,877. Forty orders (29.9%) were non-adherent to the guideline, with the most common reason stated as nil per os (NPO). No difference in safety outcomes was seen between the pre- and post-guideline groups, as evidenced by 1 safety report in each group. CONCLUSION: We observed a high rate of adherence to an IV levothyroxine hold guideline. This was associated with a substantial cost savings over the study period with no increase in reported safety events. To our knowledge, this is the first published report of an inpatient IV levothyroxine 3-day hold guideline.

Serum glucose and phosphorus concentrations during continuous renal replacement therapy using commercial replacement solutions with or without phosphorus.

INTRODUCTION: Continuous venovenous hemofiltration (CVVH) is a common practice in the intensive care unit often associated with electrolyte derangements. Recently, our institution added a phosphate dialysis solution, Phoxillum®, to our formulary as an option for CVVH fluid in addition to the bicarbonate-based Prismasol® products available. We sought to evaluate the impact of Phoxillum in patients who required CVVH when compared to Prismasol with regard to phosphate and glucose management. METHODS: This was a single-center, retrospective, observational cohort analysis approved by Partners Health Care System Institutional Review Board that included patients who received a minimum of 24 hours of either Prismasol 4/2.5 or Phoxillum for CVVH from February 2017 to November 2017. Phosphate and glucose levels were monitored daily while on CVVH. Prevalence of hypoglycemia (glucose <70 mg/dL), hyperglycemia (glucose >180 mg/dL), hypophosphatemia (phosphate <2.5 mg/dL), and hyperphosphatemia (phosphate >4.3 mg/dL) were collected in terms of days of occurrence while on CVVH. Oral and intravenous phosphate repletion requirements were collected for all patients. FINDINGS: Hypophosphatemia occurred more frequently while patients were receiving Prismasol as compared to Phoxillum (130 [24.9%] vs. 13 [6.2%], rate ratio [RR] 0.20 [95% confidence interval-CI = 0.10-0.42, P < 0.0001]), and consequently there was a numerically lower need for intravenous phosphorous repletion in the Phoxillum group (RR = 0.58, 95% CI [0.26, 1.30], P = 0.19]. There was a numerically higher incidence of hyperphosphatemia while patients were on Phoxillum therapy as compared to Prismasol (78 [37%] vs. 145 [27.7%], RR 1.25 [95% CI = 0.84, 1.86, P = 0.27]). There was no difference between the Phoxillum and Prismasol groups in terms of hypoglycemia or hyperglycemia. There was no notable difference in the cost found between the two therapies. DISCUSSION: The findings suggest that the use of Phoxillum for CVVH may be associated with decreased incidence of hypophosphatemia and a potentially decreased need for phosphate repletion in patients who require CVVH.

Valproic Acid for the Management of Agitation and Delirium in the Intensive Care Setting: A Retrospective Analysis.

PURPOSE: Valproic acid has been proposed as an alternative agent for treatment of agitation and delirium in the intensive care unit (ICU). Clinical data to support the use of valproic acid for this indication are limited. The objective of this analysis was to assess the efficacy and safety associated with the use of valproic acid for the management of agitation and delirium in the ICU. METHODS: This retrospective descriptive analysis included patients who were prescribed valproic acid for a minimum of 3 days for the treatment of agitation and/or delirium in the cardiac, surgical, or medical ICU from May 31, 2015 to December 31, 2017. The prevalence of agitation and delirium was assessed during valproic acid therapy for up to 7 days. Additional data analyzed included opioid, sedative, and antipsychotic requirements and safety outcomes. FINDINGS: A total of 47 patients met the inclusion criteria. There was an observed downward trend in the prevalence of agitation (47.8% vs 16.7%) and delirium (84.8% vs. 63.3%) throughout valproic acid therapy. In addition, the proportion of patients who required dexmedetomidine, benzodiazepines, antipsychotics, and opioids decreased while patients were taking valproic acid. No adverse effects attributed to valproic acid occurred in this patient population. IMPLICATIONS: Valproic acid may be an alternative option to assist in the management of agitation and delirium in the ICU. Additional prospective data are needed to validate the use of this agent for the treatment of agitation and delirium in critically ill patients.