Multidisciplinary Intensive Care Unit Team Research Articles

Clinical and economic impact of comprehensive medication management implementation by clinical pharmacists in an intensive care unit: a cost–benefit analysis

Abstract Objectives Critically ill patients are at risk of drug-related problems (DRPs) and healthcare-related cost. Clinical pharmacists are specifically trained in pharmacotherapy evaluation; they can identify and prevent DRPs. We aim to evaluate clinical and economic impact of clinical pharmacist by cost–benefit analysis in intensive care unit. Methods This was a prospective, interventional study from healthcare provider perspective which conducted over 6 months in a neurosurgery intensive care unit (ICU) of a university hospital on 162 patients. A clinical pharmacist was dedicated to implement comprehensive medication management. All pharmacotherapy problems were categorized and economic impact of clinical pharmacist’s interventions including cost–benefit ratio and net benefit in the ICU was assessed. Key findings A total of 1524 interventions were done. The top five pharmacotherapy-related problems were defined as, drug selection (33.3%), dose adjustment (17.32%), fluid and electrolyte management (12.99%), drug discontinuation (12.07%) and therapeutic drug monitoring (6.75%). The minimum and maximum benefit–cost ratio was 8.4:1 to 12.7:1 and net benefit was $169,205 to $266,633, respectively over the 6-month period. Conclusions The participation of a clinical pharmacist in a multidisciplinary ICU team by implementation of comprehensive medication management may reduce healthcare expenditures and improve drug safety.

A multisite study of multidisciplinary ICU team member beliefs toward early mobility

BackgroundEarly mobility is underutilized in critical care. ObjectiveDescribe multidisciplinary intensive care unit (ICU) providers beliefs about the conduct of early mobility during critical illness. MethodsA 7-item elicitation survey was administered to a multidisciplinary sample of ICU team members. We conducted independent thematic analysis of n = 95 surveys. ResultsAnalysis resulted in three themes: immediate risk vs. long-term reward conflict, nurse is the initiator and coordinator of early mobilization, and situational factors. Staffing was the primary facilitator and barrier to early mobility. Enablers included protection from complications of hospitalization, reduced hospital length of stay, and improved patient morale. Barriers strongly revolved around team member risk aversion (e.g., falls, hemodynamic instability, line dislodgment). Nurses were equally identified as positive and negative referents for early mobility. ConclusionsStrong positive and negative attitudinal beliefs were elicited. Early mobility is a protective behavior that requires sufficient numbers of trained staff and equipment.

Consecutive outbreaks of Burkholderia cepacia complex caused by intrinsically contaminated chlorhexidine mouthwashes

We report 2 consecutive outbreaks of the Burkholderia cepacia complex (Bcc) in an intensive care unit (ICU) and describe its characteristics and consequences. Over a 72-day period, a multidisciplinary ICU team detected 2 distinct periods of high and unusual incidence of Bcc isolates that were recovered from cultures of endotracheal aspirate. Cultures of tap water, ultrasound gel and mouthwash (opened and unopened bottles) were performed. Bcc was identified with the BD-Phoenix and MALDI-TOF MS systems, with molecular typing using the enterobacterial repetitive intergenic consensus-polymerase chain reaction technique. In both outbreak 1 (6 patients) and outbreak 2 (5 patients), the point sources of Bcc were chlorhexidine mouthwashes of 2 different brands, both of them intrinsically contaminated. All patients had a clinical diagnosis of ventilator-associated pneumonia (VAP), and 6 died. MALDI-TOF MS identified 2 species of Bcc (B. cenocepacia and B. cepacia). Enterobacterial repetitive intergenic consensus-polymerase chain reaction typing confirmed 100% genetic similarity between patient and mouthwash isolates from each period. The first outbreak was controlled in 20 days and the second in 6 days. The surveillance program for multidrug-resistant organisms, especially in high-risk patients, with the active participation of a multidisciplinary team, was crucial for success in controlling these outbreaks.

From Communication Skills to Skillful Communication: A Longitudinal Integrated Curriculum for Critical Care Medicine Fellows.

Communication with patients and families in critical care medicine (CCM) can be complex and challenging. A longitudinal curricular model integrating multiple techniques within classroom and clinical milieus may facilitate skillful communication across diverse settings. In 2014-2015, the authors developed and implemented a curriculum for CCM fellows at the Cumming School of Medicine, University of Calgary, to promote the longitudinal development of skillful communication. A departmental needs assessment informed curriculum development. Five 4-hour classroom sessions were developed: basic communication principles, family meetings about goals and transitions of care, discussing patient safety incidents, addressing conflict, and offering organ donation. Teaching methods-including instructor-led presentations incorporating a consistent framework for approaching challenging conversations, simulation and clinical practice, and feedback from peers, trained facilitators, family members, and clinicians-supported integration of skills into the clinical setting and longitudinal development of skillful communication. Seven fellows participated during the first year of the curriculum. CCM fellows engaged enthusiastically in the program, commented that the framework provided was helpful, and highly valued the opportunity to practice challenging communication scenarios, learn from observing their peers, and receive immediate feedback. More detailed accounts of fellows', patients', and family members' experiences will be obtained to guide curricular development. The curriculum will be expanded to involve other members of the multidisciplinary intensive care unit team, and faculty education initiatives will be offered to enhance the quality of the feedback provided. The impact of the curriculum on initial skill development, retention, and progression will be assessed.

Effectiveness of pharmacist dosing adjustment for critically ill patients receiving continuous renal replacement therapy: a comparative study.

BackgroundThe impact of continuous renal replacement therapy (CRRT) on drug removal is complicated; pharmacist dosing adjustment for these patients may be advantageous. This study aims to describe the development and implementation of pharmacist dosing adjustment for critically ill patients receiving CRRT and to examine the effectiveness of pharmacist interventions.MethodsA comparative study was conducted in an intensive care unit (ICU) of a university-affiliated hospital. Patients receiving CRRT in the intervention group received specialized pharmacy dosing service from pharmacists, whereas patients in the no-intervention group received routine medical care without pharmacist involvement. The two phases were compared to evaluate the outcome of pharmacist dosing adjustment.ResultsThe pharmacist carried out 233 dosing adjustment recommendations for patients receiving CRRT, and 212 (90.98%) of the recommendations were well accepted by the physicians. Changes in CRRT-related variables (n=144, 61.81%) were the most common risk factors for dosing errors, whereas antibiotics (n=168, 72.10%) were the medications most commonly associated with dosing errors. Pharmacist dosing adjustment resulted in a US$2,345.98 ICU cost savings per critically ill patient receiving CRRT. Suspected adverse drug events in the intervention group were significantly lower than those in the preintervention group (35 in 27 patients versus [vs] 18 in eleven patients, P<0.001). However, there was no significant difference between length of ICU stay and mortality after pharmacist dosing adjustment, which was 8.93 days vs 7.68 days (P=0.26) and 30.10% vs 27.36% (P=0.39), respectively.ConclusionPharmacist dosing adjustment for patients receiving CRRT was well accepted by physicians, and was related with lower adverse drug event rates and ICU cost savings. These results may support the development of strategies to include a pharmacist in the multidisciplinary ICU team.

613

Introduction: Morning rounds in the Intensive Care Unit (ICU) are an important platform for formulating a daily plan of care. The availability of an electronic medical record (EMR) is anticipated to improve health care quality, advance patient safety and reduce waste. It is increasingly recognized that providers with access to an EMR spend a significant amount of time in passive activities (e.g. data gathering, presentation) rather than active patient engagement. A novel user interface was developed by a multidisciplinary ICU team to better manage information available within the EMR with the objective of reducing the amount of time spent on low level tasks such as data gathering. The purpose of this paper is to assess the perceptions of providers to the introduction of this enhancement of the existing EMR. Hypothesis: A novel user interface, designed around the information needs of ICU providers will improve satisfaction with the EMR. Methods: Between March 26, 2012 and June 3, 2012 the novel user interface was introduced in a stepped wedge cluster randomized trial conducted in four ICUs at a tertiary medical center. ICU providers (Attending physicians, clinical fellows, residents, interns, nurses and respiratory therapists) were asked to complete a modified version of a previously validated, questionnaire designed to capture various aspects of provider perception with either the standard EMR or EMR enhanced with the novel user interface. Surveys were presented to providers around the time of ICU morning rounds. A Likert scale was used to assess user perceptions (1 strongly disagree to 5 strongly agree). Mean and standard deviation (mean± SD) were used to compare each question between pre and post surveys. Results: A total of 36 providers, (response rate 86%) and 25 providers (response rate 86%) competed the pre and post implementation surveys respectively. There was a significant difference in 7 out of the 10 survey questions, (EMR v novel user interface) as follows; information was available in a timely fashion (mean± SD, p value) (3.3 ± 1.02 vs. 3.9 ± 0.81, P <0.001); information was up to date (3.7 ± 0.85 vs. 4.1 ± 0.79, P<0.001); information was accurate (4.0 ± 0.75 vs. 3.8 ± 0.86, P 0.01); information was presented in a useful format (2.7 ± 1.08 vs. 4.0 ± 0.93, P<0.001); presented information was clear (3.2 ± 0.98 vs. 4.1 ± 0.62, P <0.001), data gathering was difficult (2.1 ± 0.83 vs. 3.39 ± 1.12, P<0.001) and data was mentally demanding (2.1 ± 0.86 vs. 3.17 ± 1.14, P<0.001). Conclusions: A locally designed and implemented novel user interface improved ICU providers’ satisfaction with the EMR.

Do physicians’ beliefs influence treatment options at the end of life?

Do physicians’ beliefs influence treatment options at the end of life?

How diaries can improve the experience of intensive care patients

Post-discharge intensive care unit (ICU) patients are often left with psychological problems and, while follow-up clinics and patient support groups are the best way to manage these problems, they are difficult to set up in the current economic climate. Staff in the ICU at Royal Gwent Hospital have started using patient diaries to reduce the risk of long-term psychological effects. Diary entries are made by nurses, other multidisciplinary ICU team members, and family members and friends to provide patients with complete narratives and visual records of their time in the unit.

The role of the dietitian in the intensive care unit

The role of the intensive care unit registered dietitian has evolved over the past few years to become a vital component of the intensivist-led multidisciplinary intensive care unit team. The purpose of this review is to define the level of clinical practice and skill set of the intensive care unit dietitian, which defines them as a clinician, educator and researcher worthy to practice alongside their colleagues on the intensive care unit team. An intensive care unit registered dietitian must be a dedicated professional with advanced training in critical care nutrition, the ability to read critically and evaluate new literature, a willingness to think 'outside the box', the fortitude to be an active participant in the intensive care unit team, the aptitude to educate colleagues and students from all disciplines, and the desire to participate in clinical research. Intensive care unit registered dietitians have published research concerning the nutritional assessment of the critically ill patient, the route of nutritional support, nutritional access, fluid and electrolyte issues, speciality enteral products, and optimal blood glucose control. They continue to attain skills and knowledge to extend their scope of practice and improve the quality of care in the intensive care unit. Recent guidelines adapted to the nutritional care of critically ill patients have been published for guidance. The scope of practice of intensive care dietitians defines them as clinicians, educators and researchers. Their skill set is a unique and vital component of the intensivist-led multidisciplinary intensive care unit team.

Translating family satisfaction data into quality improvement.

Improvement of clinical care requires measurement of key dimensions of health care quality and action based on these measurements. Families, data analysts, clinicians, and administrators all have important roles to play. To outline an approach to the measurement and utilization of family satisfaction data so that these data can be translated into health care quality improvement initiatives. Using a synthesis of existing knowledge about translation of satisfaction data into improvement strategies, this approach starts with selecting and implementing a satisfaction survey that reflects the key processes, providers, and places for the delivery of critical care. The survey results can be expressed in a way that prioritizes the opportunities for improvement. A comparison of results across sites, or use of a performance-importance grid, can assist in this prioritization process. High-priority items can then be addressed by the multidisciplinary intensive care unit team using a systematic, evidence-based approach to improvement that includes implementation strategies that have been proven to effectively change clinician behavior.