Implementation, Evolution and Impact of ICU Telepharmacy Services Across a Health care System.

Purpose: A review of the implementation and development of telepharmacy services that ensure access to a critical care-trained pharmacist across a healthcare system. Summary: Teleintensive care unit (tele-ICU) services use audio, video, and electronic databases to assist bedside caregivers. Telepharmacy, as defined by the American Society of Health-System Pharmacists, is a method in which a pharmacist uses telecommunication technology to oversee aspects of pharmacy operations or provide patient care services. Telepharmacists can ensure accurate and timely order verification, recommend interventions to improve patient care, provide drug information to clinicians, assist in standardization of care, and promote medication safety. This tele-ICU pharmacy team is one of the only entirely clinical-based tele-ICU pharmacy models among the tele-ICU programs across the United States. The use of technology for customized alert generation and intervention proposal with medication orders and chart notation are unique. In a 34-month period from September 2015 to July 2018, more than 110 000 alerts were generated and 13 000 interventions were performed by telepharmacists. Conclusions: Tele-ICU pharmacists employ limited resources to provide critical care pharmacy expertise to multiple sites within a healthcare system during nontraditional hours with documented clinical and financial benefits. Further study is needed to determine the impact of tele-ICU pharmacists on ICU and hospital length of stay, morbidity, and mortality.

Evaluation of a New Vancomycin Dosing Protocol in Morbidly Obese Patients.

BACKGROUND: Optimal dosing of vancomycin in morbidly obese patients (>100 kg and at least 140% of their ideal body weight) has not been determined. Conventional dosing strategies have led to the observation of supratherapeutic trough concentrations (>20 mcg/mL). OBJECTIVE: To evaluate the effectiveness of a new vancomycin dosing protocol in morbidly obese patients in achieving therapeutic trough concentrations between 10 and 20 mcg/mL and to determine patient-specific factors influencing the trough concentration attained. METHODOLOGY: A single-center, retrospective chart review included morbidly obese adult patients with a pharmacy-to-dose vancomycin consult and at least 1 trough concentration obtained at steady state. Patients were excluded if they had a creatinine clearance (CrCl) less than 35 mL/min or unstable renal function, were not dosed according to the revised protocol, or received vancomycin prior to initiation of the protocol. RESULTS: Of the 48 patients included, 17 (35.4%) achieved a therapeutic vancomycin trough concentration. Subtherapeutic concentrations (<10 mcg/mL) were observed in 27 patients (56.3%) and supratherapeutic concentrations were observed in 4 (8.3%) patients. Age less than 45 years and CrCl greater than 100 mL/min were associated with subtherapeutic trough concentrations. CONCLUSION: This study demonstrates that the revised vancomycin dosing protocol led to the attainment of therapeutic trough concentrations in 35.4% of patients. The majority had subtherapeutic concentrations, which increases the risk of treatment failures and resistance. Further study is needed to determine the optimal dosing strategy in this patient population.

Characterization of dayshift tele-ICU pharmacist activities.

BACKGROUND: Critical care services have expanded over the last decade to include tele-ICU. In 2015, Atrium Health's pharmacy services began covering tele-ICU patients from 3-11 PM. In 2017, dayshift tele-ICU pharmacy services were added on Monday, Wednesday and Friday from 8 AM to 12 PM. Cutting-edge technology and software integration allow alerts to be generated in areas of abnormal glucose, electrolyte and lactate levels. This analysis was conducted to describe the interventions recommended during dayshift hours. METHODS: Data collected from 1 August 2017 to 30 June 2018, the first 11 months of dayshift pharmacist coverage, include number of charts reviewed per shift, interventions and specific types logged, if the intervention was tied to an alert and if it was accepted or rejected. Interventions can originate from alerts or from proactive assessment by the pharmacist. Descriptive statistics were reported. RESULTS: On average, 41 charts were reviewed per shift. Over an 11-month period, 1024 interventions were made for 634 patient chart reviews. Some 89% of all interventions were accepted or accepted with modifications. Of the total interventions, 37 (3.6%) were adverse drug events avoided and 658 (64.4%) were interventions unrelated to alert data. Medication management accounted for 44.3% of all interventions. DISCUSSION: Proactive assessment rather than alert review resulted in the majority of interventions, demonstrating that reviewing every ICU patient is vital for improving patient care. Determining optimal avenues for intervention delivery and integration with the bedside multidisciplinary teams remains one of the biggest challenges. Dayshift innovations included weekly virtual rounds and providing drug information for the bedside teams.

Antifungal use in immunocompetent, critically ill patients with pneumonia does not improve clinical outcomes.

PURPOSE: To determine if treating bronchoalveolar lavage (BAL) culture-positive patients with antifungal therapy impacted mortality compared to not treating due to presumed colonization. METHODS: We conducted a retrospective study of immunocompetent, critically ill adult patients from 2010 to 2014. Patients with a BAL culture-positive for Candida or unspeciated yeast and a clinical suspicion of pneumonia were included. The treatment group received an antifungal agent for at least 5 days, and the control group received either no antifungal therapy or an antifungal agent for less than 48 h. Recruitment occurred in a 2:1 ratio of untreated versus treated patients. RESULTS: Seventy-five patients were included. In-hospital mortality was similar between treated and untreated groups (24% vs. 26%, P = 0.85). Length of stay and duration of mechanical ventilation also did not differ between the two groups. CONCLUSION: We did not observe a difference in mortality or clinical outcomes in patients treated with antifungal agents. Presumptive antifungal therapy for BAL-positive Candida or yeast in immunocompetent patients did not result in improved clinical outcomes.