Here are some specific areas where a pharmacist might help ICU improve
Here are some specific areas where a pharmacist might help ICU improve
Develop enteral nutrition protocol
A hospital pharmacist dedicated to the ICU could help with a number of safety and quality improvement initiatives.
These projects might save the hospital money and provide better outcomes for patients.
For example, the University of Colorado Hospital in Aurora, CO, has pharmacists in the ICU who have initiated a number of projects, including reducing use of IV proton pumps inhibitors (PPIs), improving use of factor VII, starting enteral nutrition earlier, reducing patient time on ventilators, and providing goal-directed therapy for sepsis, says Robert MacLaren, PharmD, FCCM, FCCP, an associate professor in the department of clinical pharmacy at the University of Colorado Denver School of Pharmacy in Aurora.
Here are more details about how an ICU pharmacist can help improve efficiency and outcomes:
- IV proton pump inhibitor (PPI) use: "We reduced the amount of IV proton pump inhibitors used, and that saved money," MacLaren says.
When the hospital first made the change from using IV PPIs to an oral agent in the early 2000s, the PPI cost was about $40 per dose, so the savings was substantial initially, he notes.
"Now the cost of PPIs is down to $3 per dose, so it's a little more expensive, but not much more," MacLaren adds. "Before we could save $10,000 per month, but now we might save that much in a year or a half."
- Develop a protocol for using factor VII: The use of factor VII to initiate the process of coagulation sometimes is used in larger doses and with more patients than might be ideal.
"It's an expensive drug that you [usually] don't get reimbursed for unless it's prescribed for hemophiliacs," MacLaren says. "The dose lasts six hours at most, but a lot of physicians were prescribing it to patients who were refractory to other blood products."
Also, several years ago, there were reports that factor VII could lead to adverse events such as deep vein thrombosis, he notes.
"So we met with different hospital physicians, lawyers, and accountants to discussing changing guidelines," MacLaren says.
They developed a new protocol that reduced the dose used and recommended eliminating a few cases in which it was used unnecessarily.
"We eliminated using it for liver failure," MacLaren says. "We still use it every now and then, but not nearly as much as we used to."
And when factor VII is used for transplant patients or patients who have had intracranial hemorrhages, the new protocol recommends a smaller dose, he adds.
"We've reduced charges roughly around $150,000 a year," MacLaren says. "Just that one little intervention of getting a pharmacist involved to reduce the amount of factor VII used has made a big difference."
- Enteral nutrition protocol developed: MacLaren keeps apprised of the latest literature. He quickly noticed new data showing that hospitals could improve patient outcomes and reduce costs by starting enteral nutrition sooner than commonly practiced.
"I think there was a general perception that patients didn't need it, so we had to educate staff to start enteral nutrition earlier," he says.
Also, the way people administered enteral nutrition often made it difficult for patients to tolerate it, so this practice was changed, as well.
The latest national guidelines are to start enteral nutrition within 24-48 hours, and that's what the hospital now has in its enteral nutrition protocol, MacLaren says.
"We implemented an order form that guided people, and we educated nurses and physicians and dietitians about the change," MacLaren says.
As a result of the change, the hospital's enteral nutrition rates at Day 3 of an ICU stay increased from roughly 30%-40% being fed to about 85%-90% being fed, he explains.
"We've done several audits to make sure this rate stays high," MacLaren adds.
- Improve sedation practices: "We showed that we could save money and reduce the time someone is on the ventilator, while making patients more comfortable," MacLaren says.
With pharmacist leadership, the hospital has implemented a standard order form and protocol that directs staff to wake patients daily and to try to get them off the ventilator when they're awake, he says.
Some research shows that if people are woken up they'll get off the ventilator several days earlier than they would otherwise, MacLaren says.
Since ventilator patients are heavily sedated to reduce their anxiety, they sleep continuously, which is why staff will need to stop sedatives until they're able to respond and waken, he explains.
"You stop the sedation until they are able to respond to visual stimuli, and the nurse checks on them," MacLaren says. "When they are awake, the nurse calls the respiratory therapist and physician to check on the patient."
If all appears well, then they can pull the tube out of the patient's throat and let the patient breathe on his or her own for a while.
"This really helps with getting patients off the ventilator, and it helps to keep the patient at the right comfort level of not being too anxious and not being too sedated," MacLaren says.
The hospital made this protocol change about four years ago, and it's resulted in patients being taken off ventilators at least a day earlier than they were previously, he adds.
- Adopting early goal-directed therapy for sepsis: The hospital's emergency department, ICU, and pharmacy have participated in a collaboration with this project, MacLaren says.
As outlined in earlier research, early goal-directed therapy can be administered for six hours before a patient with severe sepsis or septic shock is admitted to the ICU.1
The practice results in significant benefits, including lower, in-hospital mortality, lower lactate concentration, and less severe organ dysfunction among patients receiving early goal-directed therapy vs. those who received standard therapy.1
Reference
- Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-1377.
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