Patricia Louzon, Pharm.D., BCPS, Heath Jennings, Pharm.D., M.B.A., FASHP, BCPS, Mahmood Ali, M.D., Dina Ibrahim, Pharm.D., BCPS, Seema Patel, Pharm.D., BCPS, Ramy Girgis, Pharm.D., BCPS, Phil Biddlecome, Pharm.D., Marijo Kraisinger, Pharm.D., Julie Vincent, M.B.A., M.S.N., Patricia Celano, M.S.N., R.N., Tom Berlin, D.H.Sc., M.Sc., RRT
Florida Hospital Orlando, Orlando, Florida
A key clinical challenge in intensive care units (ICUs) is the need for intravenous sedation by critically ill patients. However, in many organizations, ICU pharmacists have not taken a formal role in the direct management of pain, agitation, and delirium (PAD). Through application of innovative pharmacist medication management strategies, evidence-based PAD protocols, and progressive leadership of an interdisciplinary team, this comprehensive, two-phase PAD management program sought to improve patient outcomes, reduce hospital expenditures, and advance pharmacist scope of practice within a large community teaching hospital.
Phase 1 was a pilot designed to allow ICU pharmacists to manage sedative therapy for mechanically ventilated patients. A new PAD order set was implemented which included a clinical decision pathway, specific drip weaning parameters, non-benzodiazepine based regimens, and as needed fentanyl/midazolam boluses. The ICU pharmacist performed daily sedation management on a predefined cohort of patients. Phase 2 expanded to the development of an interdisciplinary team designed to encourage early mobilization of mechanically ventilated patients with comprehensive pharmacist management of PAD as part of an integrated Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility (ABCDE) bundle. The program was implemented across the institution, including medical, cardiac, vascular-thoracic, neuroscience, surgical/transplant, and cardiac surgery intensive care units.
Phase 1 was conducted from October 2012 – February 2013. Patients that received pharmacist directed sedation management were exposed to 102 less hours of continuous sedation (p=0.0025), 15 less sedative-analgesic medication drips (p<0.001), 4.6 less benzodiazepine drips (p=0.0029), and the composite of all sedative continuous infusions was reduced by 45.6% (p<0.001). A 5-day reduction in ICU length of stay (LOS) (p=0.011) and an 8.4-day reduction in total hospital LOS was seen. Savings of $1.2 million in direct hospital costs and $183,216 in drug costs were observed. Using this data, 6.6 pharmacist full time equivalents were added to support institution-wide implementation. Phase 2 began in January 2014. The Medical ICU intervention cohort (n=436) was compared to standard of care six months prior to implementation (n=499). Ventilator LOS decreased from a mean of 5.6 to 4 days (p=0.03), Acute Physiology and Chronic Health Evaluation (APACHE) ventilator LOS ratio improved to better than the national average (1.32 to 0.84, p=0.003) and 89% of eligible patients were mobilized daily. APACHE ICU LOS ratio decreased from 0.96 to 0.81 (p=0.02), and APACHE mortality ratio improved from 1.26 to 0.75 (p=0.01). Over the next year, the initiative spread institution-wide, with a sustained decrease in LOS, sedative use, and costs, including $7.2 million in 2014 savings.
The provision of proactive ICU pharmacist services directed at PAD management via a multidisciplinary ABCDE bundle team is an innovative, best practice approach to foster interdisciplinary collaboration, and optimize clinical outcomes such as decreased time on continuous sedation, minimized benzodiazepine and total sedation use, and decreased ventilator days, ICU, and hospital LOS. This unique, sustainable service also has a beneficial financial impact on pharmacy and overall hospital costs, which provides a platform for pharmacy leaders to justify new ICU pharmacist resources for expanded ICU patient care programs.