Abstract Critical care (CC) pharmacists have been contributing to patient outcomes, team effectiveness, education, research and quality improvement for approximately 50 years. Current CC specialists are evolving the practice, science and scholarship into new and exciting areas as described in the series of articles collected for a special series in this journal. To summarize past accomplishments and contemplate how next level achievements may develop, brainstorming by experienced CC specialists, researchers, educators, and scholars was done to establish a foundation for this paper and three of that group summarized it into an overview of the challenges of the past and opportunities that are shaping the future. A small group of CC pharmacists identified need and opportunity to improve patient care in a limited number of settings but subsequent CC pharmacists have expanded into numerous specialties and subspecialties. Comprehensive medication management of CC patients and survivors of their critical illness is now a standard, but delivery may be influenced by new technology and equipment. Improved quality of care and outcome measures are being developed and measured. The imperative to move practice forward and adopt new practices while maintaining a core set of guideline‐based practices may be facilitated by technology such as wearable devices, personalized medicine, machine learning or artificial intelligence. However, these new tools may create new obstacles. Similar changes in education and expansion into administrative roles afford new opportunities and challenges. CC pharmacists have created a solid foundation, but continued growth in number and expansion of roles requires the next generation to continue to push ahead and continue to demonstrate value in key areas.
ABSTRACT Purpose To characterize trajectories of nephrotoxic potential (NxP) drug use among older adults with Type 2 Diabetes (T2D) treated with SGLT2is and identify associated patient characteristics. Methods Using 2012–2019 Medicare data, we selected patients with T2D who filled at least one prescription for SGLT2is. Index date was the date of the first SGLT2i prescription filled. We quantified the number of drugs with NxP used every month during the first 12 months following the index date. The monthly counts of drugs with NxP were incorporated into the group‐based trajectory model to identify groups with similar drug use patterns. Finally, we performed a multinomial logistic regression model to examine the association between patient characteristics and group membership. Results The study cohort comprised 8811 Medicare beneficiaries with T2D who initiated SGLT2i during the study period with the mean age 67.5 ± 10.6 years. We identified 3 trajectories NxP drug use: no ( n = 2142, 24%), low ( n = 4752, 54%) and high ( n = 1917, 22%) use of drugs with NxP, with patients falling into these categories based on the number of drugs with NxP they used over the time: no drugs, one drug, or two or more drugs. Age, gender, low‐income subsidy eligibility and clinical characteristics were associated with group membership. Conclusions We successfully identified three trajectory groups, with a substantial proportion of patients showing low use of drugs with NxP. Both social and clinical factors were associated with the use of NxP drugs.
Introduction: Medical care requires coordinated teamwork and communication between different disciplines,especially in a complex environment like the ICU; yet, healthcare students are rarelyafforded the opportunity to learn effective interprofessional (IP) communication andteamwork strategies during their education. Hypothesis: We hypothesize that the use of high fidelity simulation (HFS) to teach critical careconcepts will improve students’ IP communication and team skills, and enforce the importanceof IP collaboration. Methods: This was a pilot, prospective, observational study that included medical, pharmacy, nursing,physician assistant, and social work students in the last year of their professionalprograms. Four HFS sessions on critical care concepts were provided during the 4-weeks ofthe ICU interdisciplinary rotation to 8 students. Each HFS was videotaped and viewed by 2independent clinicians who evaluated IP communication and team skills using theCommunication and Teamwork Skills (CATS) Assessment. Students completed an anonymous Likertscale-based survey (1= strongly disagree; 5=strongly agree) after the 4 HFS sessions,evaluating perceived benefit of HFS for IP education. ANOVA with Bonferonni for comparisonbetween groups, and intra-class correlation coefficient (ICC) was used for analysis. Results: CATS scores significantly improved from the HFS session 1 to 2, (p = 0.01), 2 to 3(p=0.035), and overall from session 1 to 4 (p-=0.001), and the inter-rater reliabilitybetween evaluators as high (0.85, 95% CI 0.71, 0.99). Students perceived the HFS improvedtheir ability to communicate with other professionals (Median=4); improved confidence inpatient care in an IP team (median=4); stimulated student interest in IP work (median=4.5);and was an efficient use of student time (median=4.5). Conclusions: High fidelity simulation appears to be an effective tool to increase student IPcommunication and team skills for critically ill patients. It is also accepted positivelyby students and increases confidence in working in an IP environment. This pilot studysuggests HFS should be considered as part of the IP curriculum for schools of the healthsciences.
Patients with kidney disease represent a medically complex group of patients with high medication burdens that could benefit from clinical pharmacy services as part of the interdisciplinary care team to optimize medication use. The "Advancing American Kidney Health" executive order includes new value-based reimbursement models to be tested by the Center for Medicare and Medicaid Innovation beginning January 2021 and January 2022. Advancing American Kidney Health executive order poses opportunities for the inclusion of comprehensive medication management. Following an iterative process integrating input from a diverse expert panel, published standards, clinical practice guidelines, peer review, and stakeholder feedback, our group developed practice standards for pharmacists caring for patients with kidney disease in health care settings. The standards focus on activities that are part of direct patient care and also include activities related to public health and advocacy, population health, leadership and management, and teaching, education and dissemination of knowledge. These standards are intended to be used by a variety of professionals, from pharmacists starting new practices to practice managers looking to add a pharmacist to the clinical team, to create standardization in services provided.
Therapeutic opioid use continues to grow, with greater than a fivefold increase in usage of fentanyl-based products over a 10-year period. Opioids are known for their side-effect profile, including bradycardia and respiratory depression; questions remain, however, regarding lesser known side effects such as opioid-induced hyperalgesia (OIH).A systematic review of published literature addressing remifentanil OIH in the surgical setting was completed. A search was conducted of PubMed, Embase and Ovid from 1946 until June 2013. Inclusion criteria consisted of age ≥ 18 years, humans, full-text articles and English language. A total of 35 unique articles were included. Sixteen articles reported outcomes that supported remifentanil OIH and 6 that refuted and 22 were focused on prevention.There is conflicting evidence regarding the existence of remifentanil OIH. Outcomes evaluating measures of hyperalgesia frequently conclude that remifentanil OIH exists, while those evaluating opioid consumption do not. Therefore, remifentanil does induce a degree of hyperalgesia, but we do not believe that it reaches a level of clinical significance that requires prevention. If a significant concern for the development of remifentanil OIH is suspected, we suggest using the least possible effective dose of remifentanil as the primary prevention strategy.
Purpose: Benzodiazepines are the drug of choice for alcohol withdrawal syndrome (AWS); however, phenobarbital is an alternative agent used with or without concomitant benzodiazepine therapy. In this systematic review, we evaluate patient outcomes with phenobarbital for AWS. Methods: Medline, Cochrane Library, and Scopus were searched from 1950 through February 2017 for controlled trials and observational studies using ["phenobarbital" or "barbiturate"] and ["alcohol withdrawal" or "delirium tremens."] Risk of bias was assessed using tools recommended by National Heart, Lung, and Blood Institute. Results: From 294 nonduplicative articles, 4 controlled trials and 5 observational studies (n = 720) for AWS of any severity were included. Studies were of good quality (n = 2), fair (n = 4), and poor (n = 3). In 6 studies describing phenobarbital without concomitant benzodiazepine therapy, phenobarbital decreased AWS symptoms (P < .00001) and displayed similar rates of treatment failure versus comparator therapies (38% vs 29%). A study with 2 cohorts showed similar rates of intensive care unit (ICU) admission (phenobarbital: 16% and 9% vs benzodiazepine: 14%) and hospital length of stay (phenobarbital: 5.85 and 5.30 days vs benzodiazepine: 6.64 days). In 4 studies describing phenobarbital with concomitant benzodiazepine therapy, phenobarbital groups had similar ICU admission rates (8% vs 25%), decreased mechanical ventilation (21.9% vs 47.3%), decreased benzodiazepine requirements by 50% to 90%, and similar ICU and hospital lengths of stay and AWS symptom resolution versus comparator groups. Adverse effects with phenobarbital, including dizziness and drowsiness, rarely occurred. Conclusion: Phenobarbital, with or without concomitant benzodiazepines, may provide similar or improved outcomes when compared with alternative therapies, including benzodiazepines alone.
