Amy L. Seybert

Grading the Severity of Drug-Drug Interactions in the Intensive Care Unit: A Comparison Between Clinician Assessment and Proprietary Database Severity Rankings

Background: Computerized provider order entry with decision support software offers an opportunity to identify and prevent medication-related errors, including drug-drug interactions (DDIs), through alerting mechanisms. However, the number of alerts generated can overwhelm and lead to “alert fatigue.” A DDI alert system based on severity rankings has been shown to reduce alert fatigue; however, the best method to populate this type of database is unclear. Objective: To compare the severity ranking of proprietary databases to clinician assessment for DDIs occurring in critically ill patients. Methods: This observational, prospective study was conducted over 8 weeks in the cardiac and cardiothoracic intensive care unit. Medication profiles of patients were screened for the presence of DDIs and a severity evaluation was conducted using rankings of proprietary databases and clinician opinion using a DDI severity assessment tool. The primary outcome measure was the number of DDIs considered severe by both evaluation methods. Results: A total of 1150 DDIs were identified after 400 patient medication profiles were evaluated. Of these, 458 were unique drug pairs. Overall, 7.4% (34/458) were considered a severe interaction based upon proprietary database ratings. The assessment by clinicians ranked 6.6% (30/458) of the unique DDIs as severe. Only 3 interactions, atazanavir–simvastatin, atazanavir–tenofovir, and aspirin–warfarin, were considered severe by both evaluation methods. Conclusions: Since proprietary databases and clinician assessment of severe DDIs do not agree, developing a knowledge base for a DDI alert system likely requires proprietary database information in conjunction with clinical opinion.

Drug-drug interactions in cardiac and cardiothoracic intensive care units: an analysis of patients in an academic medical centre in the US.

AbstractBackground: Mortality and morbidity are increased in patients experiencing drug-drug interactions. Unfortunately, there is a paucity of literature describing clinically significant drug-drug interactions occurring in the intensive care unit (ICU). Knowing the clinically significant drug-drug interactions allows the opportunity for prevention through knowledge and computer-assisted programmes. Objective: To identify significant potential drug-drug interactions occurring in the cardiovascular ICU (CCU) and the cardiothoracic ICU (CTICU). Study Design: Prospective, observational study conducted over a total of 8 weeks in February and March 2009. Setting: CCU and CTICU in a major academic medical centre (Presbyterian Hospital, University of Pittsburgh Medical Centre). Patients: All adult patients (≥18 years of age) admitted during 1 month in each ICU. Intervention: Micromedex® and Lexi-Interact™ interaction databases were used to screen each patient’s medication profile daily for the presence of potentially interacting drug pairs that would be considered a potential drug-drug interaction. A severity assessment using these databases was completed after a potential drug-drug interaction was identified. Primary Outcome Measure: The frequency of significant drug-drug interactions, including those that were considered major or contraindicated, according to two commercially available interaction databases. Results: Evaluations of 400 patient medication profiles were conducted, resulting in 225 profiles possessing one or more potential drug-drug interactions. A total of 1150 potential interactions were identified, resulting in 287.5 potential interactions per 100 patient-days. Of the 1150 potential drug-drug interactions, 458 were unique interacting drug pairs; 5–9% of the potential interactions were considered major or contraindicated. Many of the significant and frequent potential interactions involved blood coagulation modifiers, potential interactions that could result in QTc prolongation, and cytochrome P450 inhibition. Micromedex® and Lexi-Interact™ agreed on the severity ratings in 20.5% of the potential interactions. Conclusions: Significant potential drug-drug interactions occur in the CCU and CTICU, highlighting the need for active surveillance to potentially prevent patient harm. Clinicians should also consider using two references for identifying interactions, due to the lack of congruence between sources.

Elective course in acute care using online learning and patient simulation.

Objective. To enhance students’ knowledge of and critical-thinking skills in the management of acutely ill patients using online independent learning partnered with high-fidelity patient simulation sessions. Design. Students enrolled in the Acute Care Simulation watched 10 weekly Web-based video presentations on various critical care and advanced cardiovascular pharmacotherapy topics. After completing each online module, all students participated in groups in patient-care simulation exercises in which they prepared a pharmacotherapeutic plan for the patient, recommended this plan to the patients physician, and completed a debriefing session with the facilitator. Assessment. Students completed a pretest and posttest before and after each simulation exercise, as well as midterm and final evaluations and a satisfaction survey. Pharmacy students significantly improved their scores on 9 of the 10 tests (p ≤ 0.05). Students’ performance on the final evaluation improved compared with performance on the midterm evaluation. Overall, students were satisfied with the unique dual approach to learning and enjoyed the realistic patient-care environment that the simulation laboratory provided. Conclusion. Participation in an elective course that combined self-directed Web-based learning and hands-on patient simulation exercises increased pharmacy students’ knowledge and critical-thinking skills in acute care.

Drug-drug interactions contributing to QT prolongation in cardiac intensive care units

PURPOSE To determine the most common drug-drug interaction (DDI) pairs contributing to QTc prolongation in cardiac intensive care units (ICUs). MATERIALS AND METHODS This retrospective evaluation included patients who were admitted to the cardiac ICUs between January 2009 and July 2009 aged ≥ 18 years with electrocardiographic evidence of a QTc ≥ 500 ms. Patients receiving at least two concomitant drugs known to prolong the QT interval were considered to experience a pharmacodynamic DDI. Drugs causing CYP450 inhibition of the metabolism of QT prolonging medications were considered to cause pharmacokinetic DDIs. The causality between drug and QTc prolongation was evaluated with an objective scale. RESULTS One hundred eighty-seven patients experienced QT prolongation out of a total of 501 patients (37%) admitted during the study period. Forty-three percent and 47% of patients experienced 133 and 179 temporally-related pharmacodynamic and pharmacokinetic interactions, respectively. The most common medications related to these DDIs were ondansetron, amiodarone, metronidazole, and haloperidol. CONCLUSION DDIs may be a significant cause of QT prolongation in cardiac ICUs. These data can be used to educate clinicians on safe medication use. Computerized clinical decision support could be applied to aid in the detection of these events.

Comparing intravenous amiodarone or lidocaine, or both, outcomes for inpatients with pulseless ventricular arrhythmias.

Objective:To compare survival rates of patients with in-hospital cardiac arrest due to pulseless ventricular tachycardia/ventricular fibrillation treated with lidocaine, amiodarone, or amiodarone plus lidocaine. Design:Multicenter retrospective medical record review. Setting:Three academic medical centers in the United States. Patients:Hospitalized adult patients who received amiodarone, lidocaine, or a combination for pulseless ventricular tachycardia/ventricular fibrillation between August 1, 2000, and July 31, 2002. Measurements and Main Results:Data were collected according to the Utstein style. In-hospital proportion of patients living at 24 hrs and discharge were analyzed using chi-square analysis. Of the 605 patient medical records reviewed, 194 met criteria for inclusion (n = 79 for lidocaine, n = 74 for amiodarone, n = 41 for combination). Available data showed no difference in proportion of patients alive 24 hrs post–cardiac arrest (p = .39). Cox regression analysis indicated a decreased likelihood of survival in patients with pulseless ventricular tachycardia/ventricular fibrillation as an initial rhythm as compared with those who presented with bradycardia followed by pulseless ventricular tachycardia/ventricular fibrillation and in those patients who received amiodarone as compared with lidocaine. However, only 14 patients (25%) in the amiodarone group received the recommended initial 300-mg intravenous bolus, and amiodarone was administered an average of 8 mins later in the code compared with lidocaine (p < .001). Conclusions:These results generate the hypothesis that inpatients with cardiac arrest may have different benefits from lidocaine and amiodarone than previously demonstrated. Inadequate dosing and later administration of amiodarone in the code were two confounding factors in this study. Prospective studies evaluating these agents are warranted. LEARNING OBJECTIVESOn completion of this article, the reader should be able to: Describe the recommended treatment of pulseless ventricular arrhythmias as outlined in the 2000 revision of the American Heart Association (AHA) Advanced Cardiac Life Support (ACLS) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (“guidelines”). Compare the benefits of drugs used for the treatment of ventricular arrhythmias. Use this information in a clinical setting. Dr. Rea is on the speakers bureau of Sancfi Aventis. Dr. Seybert was/is the recipient of direct grant/research funds from Abbott and KOS and is/was on the speakers bureau of The Medicine Company, Millenium, Merck, and Wyeth. All of the remaining authors have disclosed that they have no financial relationships with or interests in any commercial companies pertaining to this educational activity. Lippincott CME Institute, Inc., has identified and resolved all faculty conflicts of interest regarding this educational activity. Visit the Critical Care Medicine Web site (www.ccmjournal.org) for information on obtaining continuing medical education credit.

Advancing interprofessional education through the use of high fidelity human patient simulators

Background Modern medical care increasingly requires coordinated teamwork and communication between healthcare professionals of different disciplines. Unfortunately, healthcare professional students are rarely afforded the opportunity to learn effective methods of interprofessional (IP) communication and teamwork strategies during their education. The question of how to best incorporate IP interactions in the curricula of the schools of health professions remains unanswered. Objective We aim to solve the lack of IP education in the pharmacy curricula through the use of high fidelity simulation (HFS) to allow teams of medical, pharmacy, nursing, physician assistant, and social work students to work together in a controlled environment to solve cases of complex medical and social issues. Methods Once weekly for a 4-week time period, students worked together to complete complex simulation scenarios in small IP teams consisting of pharmacy, medical, nursing, social work, and physician assistant students. Student perception of the use of HFS was evaluated by a survey given at the conclusion of the HFS sessions. Team communication was evaluated through the use of Communication and Teamwork Skills (CATS) Assessment by 2 independent evaluators external to the project. Results The CATS scores improved from the HFS sessions 1 to 2 (p = 0.01), 2 to 3 (p = 0.035), and overall from 1 to 4 (p = 0.001). The inter-rater reliability between evaluators was high (0.85, 95% CI 0.71, 0.99). Students perceived the HFS improved: their ability to communicate with other professionals (median =4); confidence in patient care in an IP team (median=4). It also stimulated student interest in IP work (median=4.5), and was an efficient use of student time (median=4.5) Conclusions The use of HFS improved student teamwork and communication and was an accepted teaching modality. This method of exposing students of the health sciences to IP care should be incorporated throughout the curricula.

Drug–drug interactions in the medical intensive care unit: an assessment of frequency, severity and the medications involved

Mortality and morbidity are increased in patients experiencing drug–drug interactions (DDIs). Critically ill patients are at an increased risk of adverse events from DDIs due to the large number of medications that they take and their changes in organ function. Currently, there is a lack of literature describing DDIs in the intensive care unit (ICU). The purpose of this study is to evaluate frequency, severity and drug combinations involved in DDIs occurring in a medical ICU (MICU).

Patient simulation in pharmacy education.

Pharmacy education continues to evolve, thus demanding innovative active learning to enhance pharmacotherapeutic knowledge and clinical skills. Simulation-based pharmacy education enhances students’ fundamental knowledge, improves learner confidence, enhances clinical performance, stimulates critical thinking, and decreases medication administration errors. Given educators’ increasing and innovative use of simulation throughout pharmacy and interprofessional curricula, a supplement issue that reviews the status of simulation in pharmacy education and relevant issues surrounding it seemed merited. As technology continues to advance, methods of knowledge delivery will need to adjust rapidly. The Pharmacy Simulation supplement will explore the role of simulation education in the development of clinical skills, enhancement of critical-thinking skills, and performance of critical assessment in pharmacy students; review opportunities to improve patient safety; and discuss simulations use in introductory pharmacy practice experiences (IPPEs). With the integration of simulation methods into pharmacy education, the Accreditation Council on Pharmacy Education (ACPE) has approved the use of simulation in IPPEs for up to 20% or 60 hours of the total 300 hour experiential education requirement.1 Use of high-fidelity human patient simulation is an example of an acceptable method of simulating patient care activities. A critical element in the use of simulation as a component of IPPEs is that the educational encounter connects the pharmacy or patient care activity to a high-fidelity human patient simulator. Both medical and nursing educators also recognize the completion of simulated patient care exercises as acceptable experience within their professional curriculums and have provided guidance in the effective use of simulation in education.2-4 Several pharmacy programs use high-fidelity human patient simulation at various points in their curricula while others have integrated it successfully throughout the curriculum. High-fidelity human patient simulation in this supplement refers to the use of simulators with programmable physiologic responses to disease states, interventions, and medications. These simulators can speak, breathe, have realistic heart, lung, and bowel sounds, display hemodynamic parameters in real time, seize, sweat, display cyanosis, and other physiologic responses at various levels depending on the model used. The initial costs of implementing this type of learning include a simulator (

Assessment of human patient simulation-based learning.

16,000 to

Simulation-based learning versus problem-based learning in an acute care pharmacotherapy course.

90,000), a functional space for the equipment, and simulation specialist support to begin programming. Patient simulation and debriefing can help to identify individual learner needs and address them immediately. For example, if a student is on an acute care/critical care experience and has not witnessed a cardiac arrest (or only has seen one from the hallway while 20+ healthcare workers and trainees take care of the patient), educators can simulate a cardiac arrest using a patient simulator and allow the student to learn about the underlying disease, see the rhythm on the heart monitor, decide on drug therapy and dose, mix the necessary medications, and observe their effects on the patient. Because of this ability to control and monitor every aspect of the event (patients symptoms, vital signs, etc) while creating a realistic experience for the student, the simulation laboratory can be a more robust learning environment than the patients bedside. Some examples of situations where faculty members may want to provide a standardized experience with simulation include: cardiac arrest, respiratory arrest, surgeries, allergic reactions, cardiac pulmonary resuscitation, basic first aid, myocardial infarction, stroke procedures, renal failure, bleeding, trauma, etc. While simulation should not replace students spending time with real patients; it provides opportunities to prepare students, complements classroom learning, fulfills curricular goals, standardizes experiences, and enhances assessment opportunities In this supplement, Dr. Crea summarizes the development of practice skills through the use of simulation. The opportunity to apply foundational knowledge learned in the classroom and to enhance patient care skills that simulation affords makes it a valuable addition to traditional teaching approaches. By building a solid foundation of instruction delivery, pharmacy educators can streamline the learning and assessment of patient care concepts while potentially achieving higher-order learning. Dr. Vyas and colleagues look at these higher-order thought processes, problem-solving skills, and critical thinking, as well as how simulation can complement what is taught in the curriculum. As Dr. Bray and colleagues demonstrate, simulation offers unique learning environments with adaptable and practical assessment opportunities. Assessment in the simulated environment can be immediate, reliable, consistent, formative, summative, and valuable. Simulation offers comprehensive assessment capabilities that can complement current teaching methods or fill knowledge gaps. Dr. Kane and colleagues explore the impact of simulation education on direct patient care and outline refinements to this educational tool that ultimately could improve patient safety. Finally, Dr. Travlos and colleagues discuss the ACPEs guidance on the use of simulation in IPPEs. This supplement hopefully will encourage discussion within pharmacy education on how simulation can be used within the curriculum to improve student learning and ultimately improve patient care.