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Featured Clinical Topic: Role of Critical Care Clinical Pharmacists in Post-Intensive Care Syndrome Clinics

09 Jun 2022 2:04 PM | Anonymous

By: Katelyn Kennedy, PharmD candidate 2022  

Mentor: Kevin Betthauser, PharmD, BCCCP 

In the United States each year there are more than 5 million intensive care unit (ICU) admissions.1In the past 30 years, significant progress has been made to improve the outcomes for patients admitted to the ICU. From 1988 to 2012, mortality rates have decreased by 35%, thus creating an overall survival rate of roughly 80%. While encouraging, these positive trends have brought to light new challenges for healthcare providers and survivors of critical illness. In particular, an increasing population of ICU survivors are experiencing complications following their stay, which may manifest as cognitive impairment, mental health conditions, and physical disabilities (Figure 1). These contribute to high rates of readmission, increased risk of mortality, increased healthcare resource utilization, financial hardship, social impairment, and reduced quality of life.1Due to the increasing prevalence of ICU associated complications, the Society of Critical Care Medicine (SCCM) coined the term “Post-Intensive Care Syndrome” (PICS) to help raise awareness and identify the complications in ICU survivors.2PICS is defined as the “new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization.2Since the formal adoption of PICS, initiatives including SCCM’s THRIVE Collaboration and the Critical and Acute Illness Recovery Organization (CAIRO) have been developed to raise awareness and improve care and overall outcomes of ICU patients, their families, and their caregivers.  

 

Management of PICS remains focused on prevention.1-4 For example, implementation of SCCM’s ABCDEF bundle (Figure 2) has been proven to improve PICS-related complications.3,4 The ICU Liberation study was a multicenter, prospective, national quality improvement collaborative cohort study including over 15,000 adult ICU patients. The implementation of the ABCDEF bundle in this study was associated with clinically significant reductions in factors associated with PICS development including a 65% decrease in next day comas, 40% decrease in next day delirium, and 72% decrease in next day mechanical ventilation.4 Physicians, pharmacists, physical and occupational therapists, dietitians, and other healthcare providers are included to foster a holistic, multidisciplinary approach to the inpatient prevention of PICS. By working collectively, healthcare providers can implement and navigate barriers to the ABCDEF bundle at their specific institution(s).  



Survivors of critical illness who develop PICS may require extensive care coordination. PICS clinics have emerged as a potential strategy to improve outcomes of patients who experience PICS. In a prospective, single-center, randomized pilot trial, the effect of an interdisciplinary ICU recovery center (ICU-RC) on clinical outcomes and measures was observed.5Patients surviving critical illness were randomized into one of two groups: an ICU-RC group (n = 111) and a usual care group (n =121). Patients in the ICU-RC group received structured, interdisciplinary care and resources including an outpatient ICU recovery clinic visit with a physician, nurse practitioner, pharmacist, psychologist, and case manager. Patients in the usual care group did not receive ICU-RC care and had all aspects of care decided by the treating clinicians. No significant difference was observed in the rate of 30-day readmissions in the ICU-RC group compared to the usual care group (14.4% vs. 21.5%, p = 0.16).5 However, 7-day readmission rates (3.6% vs. 11.6%, p = 0.03) and rates of death or readmission within 30 days (18% vs. 29.8%, p = 0.04) were significantly reduced in patients who received care at an ICU-RC. This study concluded that multidisciplinary ICU-RCs could be beneficial to patients following ICU-discharge.5 

Critical care pharmacists have become integral members of PICS clinics across the countrye.1,6-9Pharmacists are uniquely positioned to help manage complex disease states and identify medication-related problems. Through interventions like comprehensive medication reconciliations, pharmacists address problems such as barriers to adherence, administration issues, and adverse effects. Additional opportunities in vaccination screening and administration, healthcare provider and patient education/counseling, and referrals exist for PICS clinic clinical pharmacists as well.1 

Stollings et al. prospectively assessed the role and potential impact of critical care clinical pharmacists in a PICS clinic. In total, data from 62 PICS clinic visits were analyzed in which a critical care pharmacist completed a full medication review in 90% of them. The critical care pharmacist made at least 1 intervention in all patients. Thirty-nine percent of patients had medications discontinued and 20% medications initiated. The most common medications discontinued were acid suppressants, steroids, and antibiotics. The most commonly initiated medications included histamine blockers, anti-constipation medications, and non-opioid analgesics. In addition, the critical care clinical pharmacist identified adverse drug events (ADE), implemented ADE preventive measures, and administered influenza vaccinations at over 15% of all visits.6 This study concluded that critical care pharmacists were instrumental in identifying and treating various medication-related problems and suggests a continued role in this setting.  

In conclusion, PICS is an increasingly recognized and prevalent complication of ICU survivors. Prevention remains the main goal for PICS; however, management of these patients will likely continue to be required. PICS clinics serve as a potential means of PICS management, and clinical pharmacists serve an integral role in this setting. While initial data is encouraging, it is imperative that more studies are conducted to further illustrate the impact of critical care pharmacists in PICS clinics.  

References  

  1. Mohammad RA, Betthauser KD, Korona RB, et. al. Clinical pharmacist services within intensive care unit recovery clinics: an opinion of the critical care practice and research network of the American College of Clinical Pharmacy. JACCP. 2020. 3(7):1369-1379. 
  2. Elliott D, Davidson JE, Harvey MA. Exploring the scope of post-intensive care syndrome therapy and care: engagement of non-critical care providers and survivors in a second stakeholders meeting. Crit Care Med. 2014. 42(12)2518-2526. 
  3. Pun BT, Balas MC, Barnes-Daly MA, et al. Caring for critically ill patients with the ABCDEF bundle: results of the ICU liberation collaborative in over 15,000 adults. Crit Care Med. 2019. 47(1):3-14. 
  4. Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: an overview. J Transl Int Med. June 30, 2017. 5(2): 90-91. 
  5. Bloom SL, Stollings JL, Kirkpatrick O, et al. Randomized clinical trial of an ICU recovery pilotprogram for survivors of critical illness. Crit Care Med. 2019. 47(10):1337-1345. 
  6. Stollings JL, Bloom SL, Wang L, et. al. Critical care pharmacists and medication management in an ICU recovery center. Ann Pharmacother. 2018. 52(8):713-723. 
  7. Coe AB, Bookstaver RE, Fritschle AC, et al. Pharmacists' Perceptions on Their Role, Activities, Facilitators, and Barriers to Practicing in a Post-Intensive Care Recovery Clinic. Hosp Pharm. 2020. 55(2):119-125. 
  8. Bottom-Tanzer SF, Poyant JO, Louzada MT, et al. High occurrence of postintensive care syndrome identified in surgical ICU survivors after implementation of a multidisciplinary clinic. The Journal of Trauma and Acute Care Surgery. 2021. 91(2):406-412. 
  9. MacTavish P, Quasim T, Shaw M, et al. Impact of a pharmacist intervention at an intensive care rehabilitation clinic. BMJ Open Qual. 2019. 27;8(3):e000580. 


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