Critical care pharmacists improve the quality and efficiency of medication therapy whilst reducing treatment costs where they are available. UK critical care pharmacist deployment was described in ...2015, highlighting a deficit in numbers, experience level, and critical care access to pharmacy services over the 7-day week. Since then, national workforce standards have been emphasised, quality indicators published, and service commissioning documents produced, reinforced by care quality assessments. Whether these initiatives have resulted in further development of the UK critical care pharmacy workforce is unknown. This evaluation provides a 2020 status update.
The 2015 electronic data entry tool was updated and circulated for completion by UK critical care pharmacists. The tool captured workforce data disposition as it was just prior to the COVID-19 pandemic, at critical care unit level.
Data were received for 334 critical care units from 203 organisations (96% of UK critical care units). Overall, 98.2% of UK critical care units had specific clinical pharmacist time dedicated to the unit. The median weekday pharmacist input to each level 3 equivalent bed was 0.066 (0.043-0.088) whole time equivalents, a significant increase from the median position in 2015 (+ 0.021, p < 0.0001). Despite this progress, pharmacist availability remains below national minimum standards (0.1/level 3 equivalent bed). Most units (71.9%) had access to prescribing pharmacists. Geographical variation in pharmacist staffing levels were evident, and weekend services remain extremely limited.
Availability of clinical pharmacists in UK adult critical care units is improving. However, national standards are not routinely met despite widely publicised quality indicators, commissioning specifications, and assessments. Additional measures are needed to address persistent deficits and realise gains in organisational and patient-level outcomes. These measures must include promotion of cross-professional collaborative working, adjusted funding models, and a nationally recognised training pathway for critical care pharmacists.
In the UK, 10% of admissions to intensive care units receive continuous renal replacement therapy with regional citrate anticoagulation replacing systemic heparin anticoagulation over the last ...decade. Regional citrate anticoagulation is now used in > 50% of intensive care units, despite little evidence of safety or effectiveness.
The aim of the Renal Replacement Anticoagulant Management study was to evaluate the clinical and health economic impacts of intensive care units moving from systemic heparin anticoagulation to regional citrate anticoagulation for continuous renal replacement therapy.
This was an observational comparative effectiveness study.
The setting was NHS adult general intensive care units in England and Wales.
Participants were adults receiving continuous renal replacement therapy in an intensive care unit participating in the Intensive Care National Audit & Research Centre Case Mix Programme national clinical audit between 1 April 2009 and 31 March 2017.
Exposure - continuous renal replacement therapy in an intensive care unit after completion of transition to regional citrate anticoagulation. Comparator - continuous renal replacement therapy in an intensive care unit before starting transition to regional citrate anticoagulation or had not transitioned.
Primary effectiveness - all-cause mortality at 90 days. Primary economic - incremental net monetary benefit at 1 year. Secondary outcomes - mortality at hospital discharge, 30 days and 1 year; days of renal, cardiovascular and advanced respiratory support in intensive care unit; length of stay in intensive care unit and hospital; bleeding and thromboembolic events; prevalence of end-stage renal disease at 1 year; and estimated lifetime incremental net monetary benefit.
Individual patient data from the Intensive Care National Audit & Research Centre Case Mix Programme were linked with the UK Renal Registry, Hospital Episode Statistics (for England), Patient Episodes Data for Wales and Civil Registrations (Deaths) data sets, and combined with identified periods of systemic heparin anticoagulation and regional citrate anticoagulation (survey of intensive care units). Staff time and consumables were obtained from micro-costing. Continuous renal replacement therapy system failures were estimated from the Post-Intensive Care Risk-adjusted Alerting and Monitoring data set. EuroQol-3 Dimensions, three-level version, health-related quality of life was obtained from the Intensive Care Outcomes Network study.
Out of the 188 (94.9%) units that responded to the survey, 182 (96.8%) use continuous renal replacement therapy. After linkage, data were available from 69,001 patients across 181 intensive care units (60,416 during periods of systemic heparin anticoagulation use and 8585 during regional citrate anticoagulation use). The change to regional citrate anticoagulation was not associated with a step change in 90-day mortality (odds ratio 0.98, 95% confidence interval 0.89 to 1.08). Secondary outcomes showed step increases in days of renal support (difference in means 0.53 days, 95% confidence interval 0.28 to 0.79 days), advanced cardiovascular support (difference in means 0.23 days, 95% confidence interval 0.09 to 0.38 days) and advanced respiratory support (difference in means, 0.53 days, 95% CI 0.03 to 1.03 days) with a trend toward fewer bleeding episodes (odds ratio 0.90, 95% confidence interval 0.76 to 1.06) with transition to regional citrate anticoagulation. The micro-costing study indicated that regional citrate anticoagulation was more expensive and was associated with an estimated incremental net monetary loss (step change) of -£2376 (95% confidence interval -£3841 to -£911). The estimated likelihood of cost-effectiveness at 1 year was less than 0.1%.
Lack of patient-level treatment data means that the results represent average effects of changing to regional citrate anticoagulation in intensive care units. Administrative data are subject to variation in data quality over time, which may contribute to observed trends.
The introduction of regional citrate anticoagulation has not improved outcomes for patients and is likely to have substantially increased costs. This study demonstrates the feasibility of evaluating effects of changes in practice using routinely collected data.
(1) Prioritise other changes in clinical practice for evaluation and (2) methodological research to understand potential implications of trends in data quality.
This trial is registered as ClinicalTrials.gov NCT03545750.
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in
; Vol. 26, No. 13. See the NIHR Journals Library website for further project information.
The use of medication to support patients and optimise outcomes is a fundamental strand of care. Pharmacists provide a key role managing medication within the complexity of various routes of ...administration, severe and rapidly shifting pharmacokinetic and dynamic parameters, and extremes of physiology in critical illness. Pharmacists intercept and resolve medication errors, optimise medication therapy and undertake broader professional activities within the job role that contribute to the smooth running of ICU. These activities are associated with improved quality, reduced mortality and reduced costs.
Vitamin C for Patients Hospitalized With COVID-19 McKenzie, Cathrine; Moore, Lorraine; Borthwick, Mark
JAMA : the journal of the American Medical Association,
2024-Mar-12, Letnik:
331, Številka:
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Journal Article
Mechanical ventilation for acute respiratory failure is one of the most common indications for admission to intensive care units (ICUs). Airway mucus clearance is impaired in these patients ...medication, impaired mucociliary motility, increased mucus production etc. and mucoactive agents have the potential to improve outcomes. However, studies to date have provided inconclusive results. Despite this uncertainty, mucoactives are used in adult ICUs, although the extent of use and perceptions about place in therapy are not known.
We aim to describe the use of mucoactive agents in mechanically ventilated patients in UK adult critical care units. Specifically, our objectives are to describe clinicians perceptions about the use of mucoactive agents, understand the indications and anticipated benefits, and describe the prevalence and type of mucoactive agents in use.
We conducted three surveys. Firstly, a practitioner-level survey aimed at nurses, physiotherapists and doctors to elucidate individual practitioners perceptions about the use of mucoactive agents. Secondly, a critical care unit-level survey aimed at pharmacists to understand how these perceptions translate into practice. Thirdly, a point prevalence survey to describe the extent of prescribing and range of products in use. The practitioner-level survey was disseminated through the UK Intensive Care Society for completion by a multi-professional membership. The unit-level and point prevalence surveys were disseminated cthrough the UK Clinical Pharmacy Association for completion by pharmacists.
The individual practitioners survey ranked 'thick secretions' as the main reason for commencing mucoactive agents determined using clinical assessment. The highest ranked perceived benefit for patient centred outcomes was the duration of ventilation. Of these respondents, 79% stated that further research was important and 87% expressed support for a clinical trial. The unit-level survey found that mucoactive agents were used in 83% of units. The most highly ranked indication was again 'thick secretions' and the most highly ranked expected patient centred clinical benefit being improved gas exchange and reduced ventilation time. Only five critical care units provided guidelines to direct the use of mucoactive agents (4%). In the point prevalence survey, 411/993 (41%) of mechanically ventilated patients received at least one mucoactive agent. The most commonly administered mucoactives were inhaled sodium chloride 0.9% (235/993, 24%), systemic carbocisteine (161/993, 16%) and inhaled hypertonic sodium cloride (127/993, 13%).
Mucoactive agents are used extensively in mechanically ventilated adult patients in UK ICUs to manage 'thick secretions', with a key aim to reduce the duration of ventilation. There is widespread support for clinical trials to determine the optimal use of mucoactive agent therapy in this patient population.
Proton pump inhibitors are often used in critically ill patients to prevent gastrointestinal bleeding despite limited evidence for benefit. Patients with acute kidney injury requiring renal ...replacement therapy (RRT) are at high risk of gastrointestinal bleeding as (pre-)uremia induces coagulopathy through effects on platelets and coagulation cascades. No high-quality randomized clinical trials have previously assessed the benefits and harms of prophylactic proton pump inhibitor use in this high-risk population of adult critically ill patients.
Among the 3350 patients included in the Stress Ulcer Prophylaxis in the Intensive Care Unit (SUP-ICU) trial-an investigator-initiated international randomized clinical trial on prophylactic proton pump inhibitor versus placebo in acutely admitted adult ICU patients at risk of gastrointestinal bleeding-we will compare the benefits and harms of prophylactic use of proton pump inhibitor in patients in need of RRT versus those not requiring this treatment. We will determine the proportion of patients with clinically important bleeding, the proportion of patients with adverse events including pneumonia, Clostridium difficile enteritis, or acute myocardial ischemia in the ICU, as well as transfusion requirements. Moreover, 90 day and 365 day mortality post-randomization will be investigated. As a secondary analysis, we will examine the association between acute kidney injury and RRT during ICU stay and gastrointestinal bleeding.
With the outlined predefined analysis, we will characterize the balance between the benefits and harms of stress ulcer prophylaxis in acutely admitted adult ICU patients in need of RRT, including the potential interaction of allocation to proton pump inhibitor versus placebo.
ClinicalTrials.gov, NCT02718261 . Registered on 14 March 2016.
The use of anthelmintic and antibiotic medicines is imperative to prevent the suffering of diseased stock in organic farming. However, their use must be minimised to comply with low input ideals and ...prevent the spread of resistance. Reducing such inputs first requires determining their current use, but information is lacking. The objective of this study was to benchmark the current use of anthelmintics and antibiotics in UK organic livestock farming.
Data were gathered by conducting a national survey of organic livestock farmers in the UK and by analysing records of requests for allopathic medicines.
Key findings include (i) anthelmintics used in sheep constitute the greatest input of veterinary medicines in organic systems, (ii) farmers are incorporating alternative/support tools in helminth control to reduce anthelmintic requirements, (iii) the use of antibiotics is targeting individual animals, whereas the use of anthelmintics is targeting groups of animals.
This study provides the first benchmark on the use of anthelmintics and antibiotics in UK organic livestock.
Prophylaxis for gastrointestinal stress ulceration is frequently given to patients in the intensive care unit (ICU), but its risks and benefits are unclear.
In this European, multicenter, ...parallel-group, blinded trial, we randomly assigned adults who had been admitted to the ICU for an acute condition (i.e., an unplanned admission) and who were at risk for gastrointestinal bleeding to receive 40 mg of intravenous pantoprazole (a proton-pump inhibitor) or placebo daily during the ICU stay. The primary outcome was death by 90 days after randomization.
A total of 3298 patients were enrolled; 1645 were randomly assigned to the pantoprazole group and 1653 to the placebo group. Data on the primary outcome were available for 3282 patients (99.5%). At 90 days, 510 patients (31.1%) in the pantoprazole group and 499 (30.4%) in the placebo group had died (relative risk, 1.02; 95% confidence interval CI, 0.91 to 1.13; P=0.76). During the ICU stay, at least one clinically important event (a composite of clinically important gastrointestinal bleeding, pneumonia, Clostridium difficile infection, or myocardial ischemia) had occurred in 21.9% of patients assigned to pantoprazole and 22.6% of those assigned to placebo (relative risk, 0.96; 95% CI, 0.83 to 1.11). In the pantoprazole group, 2.5% of patients had clinically important gastrointestinal bleeding, as compared with 4.2% in the placebo group. The number of patients with infections or serious adverse reactions and the percentage of days alive without life support within 90 days were similar in the two groups.
Among adult patients in the ICU who were at risk for gastrointestinal bleeding, mortality at 90 days and the number of clinically important events were similar in those assigned to pantoprazole and those assigned to placebo. (Funded by Innovation Fund Denmark and others; SUP-ICU ClinicalTrials.gov number, NCT02467621 .).
National UK standards for critical care highlight the need for clinical pharmacists to practice at an advanced level and above. The aim of this research paper was to describe the views of UK critical ...care pharmacists on the current provision of Advanced Level Practice (ALP) education and accreditation. It sought to identify whether there is a need for a national or regional training programme. A questionnaire was delivered electronically targeting UK critical care pharmacists. Whilst the response rate was low at 40% (166/411); the views expressed were representative of UK practitioners with the majority of responders meeting the national specifications for clinical pharmacist staffing in critical care areas. The responses highlighted work-based learning as the main resource for developing ALP and a lack of suitable training packages. The vast majority of pharmacists identified that a national or regional training programme was required for ALP. The results also identified the main barriers to undertaking ALP accreditation were lack of time, uncertainty regarding the process and its professional benefits and a lack of education and training opportunities. In conclusion, the responses clearly indicated that, for the necessary progression of critical care pharmacists to ALP, a national or regional training programme is required.
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