Hello, and welcome to today's webcast. What can your critical care pharmacist do for you? My name is Paul Jung. I'm a professor of pharmacy practice at St. Louis College of Pharmacy in St. Louis. I'm also a clinical specialist in the MICU at Barnes-Jewish Hospital, also here in St. Louis, Missouri. I'll be moderating today's webcast. A recording of this webcast will be available within five to seven business days after today's meeting. To access, log into your MySCCM.org and navigate to the My Learning tab to access the recording. A couple of housekeeping items before we get started. There will be a Q&A at the end of the webcast. To submit questions throughout the presentation, type in the question box located on the control panel. You'll also have the opportunity to participate in several interactive polls. When you see a poll, simply click on the bubble next to your choice. Please note the disclaimer stating that the content is to follow for educational purposes. And now I'd like to introduce our three speakers for today. Dr. Brittany Bissell is a clinical pharmacist in the pulmonary medical intensive care units at University of Kentucky in Lexington, Kentucky. Dr. Joanna Stolling is the medical intensive care unit clinical pharmacy specialist at Vanderbilt University Medical Center in Nashville, Tennessee. And finally, Dr. Kerry Griffiths is associate professor at Wingate University School of Pharmacy and telecritical care pharmacist with Atrian Health in Wingate, North Carolina. And now I'll turn things over to our first presenter, Dr. Brittany Bissell. Hey, everyone. Thanks for joining me today. My name, as Paul said, is Brittany Bissell. I'll be talking today on some of the work that I was able to accomplish in my time at the University of Kentucky. Compared to Dr. Stolling and Dr. Griffiths, who are focusing on really great topics surrounding what I think is really broad ICU care impact, I'm a little bit different in that I'm focusing on a really narrow specific area that I still think is really important on clinical outcomes. So it's no secret now, probably one of the things that have been most well established over the last five to 10 years in relationship to fluid use is that we in the United States, and I know specifically at our institution, likely overuse intravenous fluids in a few different ways. If you look at per person usage in the United States compared to our colleagues in Australia and New Zealand, you see that on average, we have about three liters of sodium chloride used per person per year in the United States compared to 250 mLs or 250 CCs in those countries. And so while that's not a perfect number and it doesn't show exact use, it kind of speaks to the amount of volume that is utilized in the United States. And that really was true for us at the University of Kentucky as well. I'm not sure if anyone on this webcast today has tried to quantify fluid use. It's one of the most challenging areas, in my opinion, to really narrow down and specify within your institution. But at our hospital, we ran reports to look at the amount of fluids that we were using. And we saw that we had over 12,000 liter bags of sodium chloride that were being used per month. Now, again, that's not a perfect number. It doesn't promise that all of those mLs are given or all of that volume is directly given to the patients. But again, that's a huge number and I think just speaks to the amount of IV fluids. And that's just one fluid, right, that is coming in and out of the doors every month and potentially impacting patient care. Now looking at how we counteract this volume resuscitation, I think we really focus on the lute diuretic therapies. There are other therapies that I'm not going to talk about today, ultrafiltration, particularly for those with renal function that's not amenable to lute diuretic therapy and some other diuretics. But by far, our strongest and most effective diuretic therapy with any intensive care population are definitely our lutes. And I think, in my opinion, we tend to make lutes a little bit more complicated than what they really are. And that might be just because we have a lack of understanding of them really in the critically ill population. We know that lute diuretics, of course, are sodium potassium chloride co-transporters. And these, intriguingly, these transporters are really found all over the body, even within our pulmonary system, with studies of inhaled furosemide being done in the ARDS population. We know that their mechanism of action prevents the renal reabsorption of about a quarter of sodium and chloride. And there's three key drugs within this class, including furosemide, torsemide, and bumetanide. Now, issues that arise with lute diuretic therapy are those issues surrounding lute excretion. So if we have decreased renal function, we may see a decrease in our lute excretion, therefore decreasing ability to actually obtain the goal of diuresis that we're looking to achieve. And intriguingly, and especially important for us in the ICU, inflammation can down-regulate these receptors, also attenuating the ability of the lute diuretics to work effectively. We also know that a lot of patients may develop resistance or come in with lute diuretic resistance to some degree, via decreased responsiveness or just tubular hypertrophy. Looking at our three key agents, when we were developing our protocol in the pharmacist-driven diuresis within our intensive care unit to really overcome some of this large fluid balance and fluid overload, comparing these three agents, there's not a lot of reason to really choose between one or the other. I think furosemide is definitely the most well-studied, but as far as mechanism, action, and efficacy, I don't think there's any overwhelming evidence that you must use one versus the other. It really comes down to more operational issues, IV availability, lack of shortage at the time, what we have on site, and so forth. Other key differences, furosemide is secreted via the organic ion-anion transport, whereas bumetanide is transported via the organic-based transport. Furosemide gets called out a little bit more often just because of the sympathetic clearance, but in studies of the critically ill, really lack of studies in the critically ill population don't really demonstrate a reason that you would necessarily choose for this over other agents. Now, specifically in the ICU population, there's really one pharmacokinetic, pharmacodynamics study that has been performed looking at loop diuretics. Studies have shown, depending on the specific disease state, there's a lot of doses that have been utilized, but in the ICU, in that pharmacokinetic evaluation, decreased creatinine clearance essentially decreases responsiveness or predicts the responsiveness to decrease in the ICU population. Other than that, we're really left with nothing. We have studies, we can see doses based on studies, but a lot of these studies, a lot of these key hallmark studies really didn't have pharmacist involvement. A lot of these major ICU trials implementing loop diuretics didn't have pharmacists included, and that tends to really align with some of the data that we see coming out from everyday practice, and I'll talk about that here in a moment. When looking at the roles of an ICU pharmacist, I would argue that there are a lot of different niche areas where an ICU pharmacist could really drive protocolized care, but of course, this specific presentation, we're going to focus on that deresuscitation piece. Now, to me, it's a perfect area for an ICU pharmacist because I think it's one of the areas that kind of gets forgotten. Once patients are stabilized, they've received all of this volume, the active issue, not as pressing, it isn't usually to diurese your patients, right? If you have three patients crash in a unit, one's getting intubated, another is in florid septic shock that you're actively trying to resuscitate, the patient down the hall that needs diuresis, that may be not be the first thing on the forefront of everyone's mind when they're in the intensive care unit, and it's not an overall, like I had mentioned before, it's not an overly complicated area. I think it's just one that we tend to overcomplicate, and so when you think about it like that, it's a nice area, in my opinion, for the pharmacist to become involved. It's really low-hanging fruit that is often forgotten, and if you look at the hallmark roles of a clinical ICU pharmacist, protocolized diuresis can really fall into any of these categories, in my opinion, whether you're just looking at the fundamental roles of an ICU pharmacist, looking at adverse events, managing or preventing these, so specifically, you know, if you're not able to extubate a patient because of the amount of volume that's on board, to me, that is an adverse event that is, or an adverse outcome that is occurring because of a medication, i.e. fluids, so here, again, how do we counteract that? How do we avoid that? How do we mitigate that? Diuresis is a potential, you know, modifiable factor. Desirable roles of a clinical pharmacist, again, critical care-specific pharmacotherapy, looking at how we diuresis patients in the ICU population, the coordination, development of drug therapy protocols, so again, a de-resuscitation or a diuretic protocol really fits into this desirable role, and again, optimal, if you look at the optimal status of, or the optimal roles of an ICU pharmacist in this clinical spectrum, collaboration with other critical care practitioners to evaluate, again, the impact of guidelines or the protocols that are used in the ICU, so no matter kind of where you are in this pathway or what your role is in your practice, I think this type of protocol is an area that any pharmacist could really be involved in with all of the things considered. Now, looking at the role of a pharmacist and where pharmacists were involved, so we performed a study a couple years ago just looking at the everyday practice patterns of ICU pharmacists, how often are ICU pharmacists involved in diuresis, how is de-resuscitation initiated, who's thinking about it, when are they thinking about it, and so forth, and you'll see here on the top left graph that the current practice in relation to how much is pharmacy involved, where are the protocols, are there guidelines, what does it look like, how is the pharmacist integrated within this practice, you'll see the vast majority of pharmacists said there was no current practice, there wasn't even necessarily pharmacist education on diuresis or de-resuscitation intensive care unit, and so, you know, again, greater than 50% of people were saying, we have nothing to do with this, nothing to do with this whatsoever in our intensive care unit, and this was reflected to when they were specifically, pharmacists were specifically asked about their involvement, so when they're initiating diuresis, you know, clinically in their everyday practice patterns, not just, you know, from a systemic broad level, how often is the pharmacist in the day-to-day being involved with this, and you'll see here, bottom left graph, for half of the time, the pharmacist said they were not typically involved with diuresis, with 12 and a half percent of pharmacists saying they were never involved with administering diuresis, they weren't helping with dosing, they weren't helping with initiation, they weren't recommending discontinuation, they were never involved with diuresis or de-resuscitation in their unit, which I think, again, is just really surprising, right, this is a low-hanging fruit, an easy area, and really for a pharmacist to be involved, but I think it just speaks to how we were currently practicing at the time, really across the board in relationship to de-resuscitation. A couple other statistics that we gathered from this survey, that I, there was many more, but ones that I think are important to call out, particularly when it comes to the need for this protocol, is the indication for de-resuscitation that pharmacists identified at their institution, and almost the overwhelmingly majority of pharmacists said that signs of edema were one of the key areas for de-resuscitation, positive volume status, and difficult ventilator wean. Those three areas, to me, are, you know, kind of raise my, bring attention, or bring to my attention, because these are really signs that we've probably waited too long. If you're already seeing issues with a difficult ventilator wean because of volume overload, we've probably waited too long to initiate diuresis, and so, again, just an area where maybe we can get involved sooner and be more effective and more efficient in this practice with pharmacist involvement. Some other key statistics that were pulled out of this survey, over half of pharmacists said that the assessment of diuretic effectiveness happened greater than eight hours post-dose, so a lot of pharmacists are saying that their institution, a dose of diuresis was given, and probably at about 24 hours, or what would coincide probably with the next morning rounds, was diuresis was finally being evaluated, which, again, is probably not the most efficient approach, right? If you're not adequately dosing your diuresis, which does seem to happen clinically, and you're not rechecking that until the next day, you've, you know, there's a 24-hour gap of where you could have been modifying your therapy, you could have been giving additional doses, you could have been assessing whether the patient is developing resistance, and etc. About just under 30% of pharmacists said the assessment of volume status happened more frequently than daily, so that means 70% were saying that this happened, you know, less often than that, which is also alarming. The appropriate amount of diuresis at 72 hours after shock resolution was an outcome we were looking at, or specifically how many pharmacists felt like the appropriate amount of diuresis was being given within those 72 hours. Again, only 43% of pharmacists felt like the appropriate amount was being given during that time frame. I'm looking at the appropriate administration of diuresis for at least the majority of the ICU stay. Only a quarter of pharmacists felt like the appropriate amount was being given for the majority of stay, so again, really kind of, I feel like I'm, you know, really belaboring the point here, but a lot of opportunity for increasing efficiency, a lot of potential to increase the efficacy of how we're giving diuresis in the ICU. And last but not least, looking at 70% that responded, the majority of patients achieved net negative fluid balance greater than 72 hours after shock resolution. So if the majority of your patients aren't achieving a net negative fluid balance until after 72 hours, we do know that outcomes have shown us that this is really a key, I guess, hallmark in the timeline of ICU volume status that says we really should be net negative at that point. And the majority of pharmacists did not feel like they were currently doing so with their institutions. So looking at a protocol to implement diuresis and to try to overcome some of these barriers and really improve the current clinical approach to diuresis, this is the protocol that we developed at our institution, and specifically kind of how we were able to achieve improved diuresis. So starting top to bottom, just working through the diagram, when every day the pharmacists assess the need for diuresis or assess fluid balance. So for us, fluid balance is something that we look at every day, whether just like you would look at labs, like you're going to look at renal function, creatinine clearance, and so forth. Volume status is in those essential areas. And so if the patient is a potential candidate for diuresis, we would then chat with the team, talk through what a goal fluid balance for the day would look like, and whether or not diuresis would be needed to achieve that. Alongside that, the things that are pretty much standard of care would be to discontinue maintenance fluids, IV to PO interchange at our institution. Maintenance fluids, potentially in the medical population, aren't frequently used. IV to PO interchange is a protocol that pharmacists do have authority to perform on their own anyway. And then concentrating infusions as we're able to in the appropriate patient population. And then administering diuresis, either on the basis of previous exposure and known responsiveness, or renal function on if no known fierce med exposure. Initial protocol at our institution, after the pharmacist does the initial diuresis, was for a two-hour assessment by the nurse involved in bedside care, and then assessing whether we were or were not meeting that goal that we had specified with the clinical team. All of this went into the chart and goes into the chart for us. So the diuretic dose, pure and diuresis, so that we can increase the dose if we're not achieving a goal, and the goals. So every component of this is within the chart and easy for the nurse at bedside to be able to pull up and identify. Of course, if you're identifying a daily fluid balance goal and you're looking at shift fluid balances or two-hour fluid balance, you have to put that in a chart in a way that is more translatable to that moment in time. So usually, we were pre-specifying what the two-hour fluid balance goal would be, or you'll see here on the next slide, we modified that slightly. And then again, if your goal was achieved, continue the dose that was initiated by the pharmacist every six hours. Goal not achieved, double your dose until you've hit a max dose, and reassessing every two hours until you're able to maintain an achievable, or achieving your goal, and then looking every six hours. For safety purposes, and a recommendation that was made to us when just initiating this protocol, we were also doing BMPs every six hours. That's not necessarily a practice that we continued, but just to initially assess safety. Also, erring on the side of caution, I made a number of whole parameters. I won't read all of these to you out on the right side of the screen. Again, just to be protective and make sure that we weren't over-diuresing with early initiation of this protocol. We stopped the protocol about six months in, did an interim assessment of how well the protocol was working in our ICU, and based on feedback from our nursing colleagues, based on some of the patterns that we were seeing in regards to the dosing, we made some modifications that are highlighted here in the more opaque boxes. So the two-hour assessment changed to pharmacist assessment. It seemed that this just worked better for our practice, and that pharmacists tend to hold more comfort in assessing diuretic responsiveness relative to the registered nurse. So, this was another area where pharmacists kind of just stepped up and made it our priority and our focus to assess fluid balance after an early dose of diuresis, and make sure that we were headed on the right trajectory towards achieving our goal. And then we also prolonged our interval for both our dosing and our evaluations to every eight hours. So, what we initially saw was in practice that we felt like we were needing every six hours to achieve goal, but once we started having a pharmacist involved in the initial dose, and we started to see that when pharmacists were choosing the dose based on underlying renal function or based on previous exposure, we were more effective than probably previously seen, and so we didn't need as frequent dosing. We were able to kind of extend that out to every eight hours and so forth. We also slightly modified our hold parameters to just, you know, decrease the amount of confusion on nurses and bedside staff. And looking at what we were able to accomplish with our specific unit-based protocol, our first aim for this project was, of course, our post-shock fluid balance, and we saw to the left, you'll see the standard pre-protocolized group, the fluid balance at 24, 48, and 72 hours, and then to the right, you see the fluid balances that we saw while utilizing our protocol. So, significant across, you know, the 72-hour time frame, both 24, 48, and then again at the 72-hour time frame. So, definitely an improvement in overall volume status. We also wanted to look at ventilator-free days. Statistically, these were not different. We did see 48 hours longer, so we spared 48 hours in the ventilator, or it correlated with 48 hours longer ventilator-free time with the protocol, but again, this was not statistically significant. A couple other stats that we pulled or identified were amount of time from pure cement initiation to extubation, and then ICU-free days, both pre- and post-protocol with this that demonstrated on the bottom two lines on the top graph there. Some of the other outcomes are along the bottom of the screen. So, ventilator-free days, again, with the P-values all listed there, direct extubation, ICU-free days, and then we also reported reintubation rates to make sure there wasn't a significant difference between the two groups. So, moving right along, our last outcome that we wanted to make sure that we were looking at were adverse event rates, and we actually saw a higher amount of adverse event rates with our protocol. We realized kind of after the fact that we had, one, started a new electrolyte protocol during the time frame with initiation, which actually increased the amount of monitoring electrolytes, which was a great thing for patient care and definitely helped us evaluate electrolytes and overcome electrolyte abnormalities a lot quicker, but we were having more lab draws that were unrelated to the protocol. So, we were catching more instances specifically of hyponatremia, which really drove this number, or hypernatremia, I'm sorry, and hypokalemia. So, we were seeing more adverse effects probably because we were evaluating these numbers more, but nonetheless, we did see a difference in adverse event rates. And in looking at hospital mortality, we did see a significant decrease after the use of this protocol, which wasn't an outcome that we were hoping to modify, but nonetheless, I reported it there. So, again, that's just a small, I guess, snapshot of just one area that we were able to ingrain pharmacy practice in our intensive care unit population and outcomes that we were able to see because of it. Now, I will pass it along to Dr. Stallings to take over for post-intensive care clinics. Thank you, Brittany, for that introduction. Thank everybody for tuning into our webcast today. So, the objectives of my part of this presentation are going to be to define post-intensive care syndrome or PICS clinics, to describe a pharmacist's role in a PICS clinic, to define post-acute COVID-19 syndrome, and to discuss sequelae patient's experience with PICS. So, post-intensive care syndrome, if you're not familiar with it, is a term that was initially put together by Dale Needham and a group of other individuals that convened at a meeting in 2010. And essentially, they came up with a definition that described patients that were trapped in this cycle, recurrent critical illness. So, essentially, they were discharged from the ICU and eventually home, but unfortunately, they continued to get readmitted, and they never really fully recovered to their baseline. So, when we think about post-intensive care syndrome or PICS, there's really three different areas of impairment that patients can have. The first being physical. So, maybe like an impaired six-minute walk test, if you're not familiar with that, that takes into account a patient's age, weight, height, and sex. And so, there's normal values based on those four numbers. And so, you would determine how far away they are from that value. Then, also, another physical impairment that you might see is lung impairment. So, patients that do not, unfortunately, have their pulmonary function test do not return to baseline at one year out, or unfortunately, even at five years out. When we think about mental health, patients might be depressed, they might be anxious, they might have post-traumatic stress disorder. And then, we think about cognitive impairments. This is primarily functional impairment. So, the patients can't do things that they used to do, like maybe balance their checkbook. So, this, unfortunately, not only affects patients, but it can also affect family members. So, if it affects a family member, it's called PICS-F. So, when you think about a PICS or post-ICU clinic, this is the workflow that we use in our clinic at Vanderbilt. So, generally, the patients check in. Like I said before, they have pulmonary function tests, so they have spirometry. They go to an examination room, and then the rital signs are checked by a nurse. They do the six-minute walk test. They go back to their exam room. Then, that's what I usually see the patient first, as the pharmacist, and do a very formalized medication reconciliation, find out what meds are on at home, make sure they're compliant with them, look for over-the-counter meds and herbal medications. I find out about their immunizations, and really just find out if they're having problems obtaining their meds from a cost standpoint. And then, the next thing that would happen is either a physician or an advanced practice provider would go in and perform a medical history and examination. And then, the next provider that would go in to see the patient is our neuropsychologist, and he would go in and provide an evaluation to determine if the patient has anxiety, or depression, or post-traumatic stress disorder, or cognitive impairment. Then, a case manager would go see the patient if there are any things that we have identified that need to be evaluated, or that a case management can potentially assess with. So then, we discuss with the patient the plan, and we also talk to the family members, obviously, to make sure they're on board with the plan as well. And so, really, just getting the team together in a conference-style format so that each of us can kind of give the input that we have found through our individual examination. And so then, our primary lead for the clinic, in my case, it's Dr. Carla Steven, who's our pulmonologist. She prepares a letter and would send this to the patient's primary care provider. So, our next polling question is, does a pharmacist work in the post-ICU clinic at your institution? So it looks like that in 79% of cases there is not a pharmacist that works in the post ICU clinic and in 21% of cases there are. So hopefully by the time that I finish this presentation that you will be convinced that you want to have a pharmacist to come work in your post ICU clinic at your institution and if you don't have a post ICU clinic hopefully you'll be convinced that you want to start one. Okay so this is some of the data specific to pharmacists and that we collected in our first 62 patients that we saw at our post ICU clinic here at Vanderbilt. So this is a number of adverse drug events where preventive measures were implemented and treated at our ICU RC. So the yellow is where preventive measures were implemented and the blue indicates where adverse drug events were treated. So we prevented constipation in a number of patients that came in on opiates and needed to have bowel regimens started. We helped with dizziness, hypoglycemia, and patients that are on numerous meds for diabetes that maybe weren't indicated anymore. We started calcium supplementation. We potentially prevented overdose, over sedation, photosensitivity, thrombosis, and then thrush. So making sure that patients wash their mouth out if they were on inhaled corticosteroids. Then with regards to what adverse drug events that were treated, so constipation, emesis, fatigue, hallucinations, hypoglycemia, insomnia, nausea, over sedation, peripheral edema, by stopping someone that was on amlodipine, and then also thrush. So this is a graph that looks at medications that were discontinued at the ICU RC. So as you can see here, if you look to the right side of this graph, the most common medications that were discontinued, I don't think will surprise anyone in this webcast, but proton pump inhibitors. This is one of the most common medications that are continued after people leave the ICU. And so we do a pretty good job, I think, of trying to get rid of those before they leave, but sometimes they unfortunately get restarted on the floor, or a lot of times these get restarted when patients go to facilities. So we stopped steroids, H2 blockers, bronchodilators, antibiotics, some vitamins and minerals, sedatives, some alkalizing agents, people went home on Bicarb, believe it or not, laxatives, leukotriene receptor antagonists, insulin, antipsychotics, another big agent that people unfortunately sometimes get sent out on, and antiplatelet and antifungal. So believe it or not, sometimes we need to start medications in the ICU recovery center. So some of the most common medications we started were H2 blockers to decrease the utilization of proton pump inhibitors, non-steroidal agents to decrease use of opiates, H1 blockers, meds for constipation. As you can see here, there's a number of other medications that we started as well. So some of the other things that I did as a pharmacist in our ICU recovery center is increasing doses, decreasing doses, giving people pillboxes to help them to increase compliance with their medication use, and then something that we were really surprised to see, but we really helped with administering vaccines. So when we initially conducted this study, and this was pre-COVID times, that's why this is not listed here, but definitely every patient that we see, we're always making sure that they have had their flu shot that year, and if they haven't, we can give it right there in the clinic. The same thing for pneumococcal vaccine, if that is appropriate, and the same thing now for COVID vaccines, just really encouraging patients to get these vaccinations when they're indicated. So we also did some basic laboratory tests, so just basic metabolic panel, potassium liver function tests, complete blood count, and thyroid stimulating hormone. We had a lot of patients that had hair loss just from being so stressed from critical illness, and so thyroid stimulating hormone was something that we had to check from time to time in our patients. So this is really a summary of all the data demonstrating pharmacists' roles in the post-ICU clinic. So the first by Pamela McTavish, and so this is out of the UK, and essentially showed that at their clinic, a pharmacist made a lot of different interventions with regards to dose adjustments, stopping therapy in a fairly large patient population. She did a further study in 2020, not looking at just her center, but all the different hospitals within her group, and once again showing what a huge role that pharmacists have with regards to shortening duration and counseling as well. The next study was in a different patient population. We really hadn't looked at a post-intensive care clinic, the role of a pharmacist in primarily seeing trauma patients. So Janelle Pointe was one of the authors on this study, and she did a full medication review on 78 patients, and as you can see here, made dosage adjustments, stopping meds, starting meds, counseling, etc. And then the last is from the University of Michigan, so Rima Mohammed, and so looking at for medication related problems in just over 50 patients, and really discovering a lot of different medication related problems in this patient population. So we now, and I'll show you a map of this in a moment, have, so at my institution was really the first institution to have a post-ICU clinic, and the first to have one that had a pharmacist. So now there are over 40 different institutions that have a pharmacist that works in the post-ICU clinic. So we actually published a position paper in the Journal of the American College of Clinical Pharmacy in 2020, just to really, and to state our opinion about the importance of a role, of the role of a critical care pharmacist in the post-ICU clinic. So what are some of the activities to initiate and sustain pharmacy services? This is one of the most common questions that I get. So first you really have to get like the support of your manager, and then really determine how to manage your schedule. So like in my instance, I only work, I work like two times a month for three hours a piece, so not that much, but really just trying to figure out how I can be covered when I'm not in the ICU to take care of those patients as well. Create a list of questions for the patients and the family, just to make sure that you're consistent about asking the same questions about medications. Developing a data collection tool, and then really seeking feedback from the interdisciplinary team as to how we can best be utilized within that setting. So this was a testimonial that I had permission to use that I wanted to share with you from a patient that I had seen in our post-ICU recovery center. So when I got home from the hospital, I was shocked to realize that I had 11 prescriptions for a total of 24 pills a day. I kept asking my wife what all these pills were for and if I really needed them. The staff had gone over all these medications with my wife, but I knew nothing about it, and the pharmacist of the post-ICU recovery center at Vanderbilt reviewed my medications with me and helped me feel better about it. So once again, highlighting what an important role that pharmacists have within this specific role. So as I mentioned before, like how do you coordinate all of this? How does a pharmacist work in the ICU and then also work in a post-ICU recovery center? We're busy people, and this is just a picture I put together like what's my typical day. So I round with three different teams and maybe there's a code. I'm getting asked questions by multiple different providers. I'm trying to follow up on SATs and SBTs and attending things for our pharmacy residents like journal clubs or case presentations. I'm giving talks like this one. I'm going over patients with a student or resident. I'm assessing for penicillin allergies and trying to get rid of those if they're inappropriate. And then following up with the other team that I didn't specifically round with and then trying to get to our post-ICU recovery center twice a month while still getting questions from providers. So it can be a lot to manage. So I'm going to go through like some recommendations that I have as to how to make this happen. So one of the biggest challenges is time, as you might have noted from the prior slide. So really just using layered learning. So using your students and residents to help really facilitate this and make this happen. With regards to order verification, asking like Central Pharmacy to verify orders during your clinic time. It can be hard to not have physical presence in the ICU while in the clinic. So giving out my phone number or your phone number to make sure that we're readily accessible and while we're not there. For code response, asking another ICU pharmacist or critical care pharmacy resident to cover. And also the lack of experience in outpatient setting. Absolutely, I've had to ask for help from our outpatient pulmonary pharmacist a lot with regards to insurance, etc. And she's been absolutely a delight to work with. So as I alluded to earlier, this is a map I had put together to really show how much we've grown over the years. And those three pills that on the far right side are really the three clinics that are in Europe. And then we have one in Canada. We have fewer clinics on the West Coast, but hopefully we're going to continue to grow those as well. So now we're going to move in and talk about post-acute COVID-19 syndrome or PACS. So when we think about organ systems that are affected by PACS, we think about hematologic. So patients having DVTs following COVID-19. Cardiovascular, maybe they have cardiomyopathy. GI and hepatobiliary, so maybe constipation or diarrhea. Neuropsychiatric, so maybe they have cognitive impairment or anxiety or depression. From a renal standpoint, maybe they have not acute renal failure anymore, but chronic renal failure. From a reproduction status, maybe they are having trouble producing, for one example, or they have impaired menstrual cycles. From an endocrine standpoint, new diabetes diagnosis were common. From a dermatologic standpoint, the diagnosis of COVID toes, where patients had these purple-like rashes on their toes. And then from a pulmonary status, what I've already talked about, so patients having impaired pulmonary function tests. So this just shows the prevalence of PACS. So this was in 277 patients, in which 182 were severe in-patients. And as you can see, PACS occurred in just over 50% of these patients with fatigue and dyspnea being very common in these patients. So I think it's important to note, as you can see here, we had our first, we developed a clinic in 2011, and these have continued to grow over the years. And I'm sure no one's surprised to see the spike in 2020 with COVID-19. And this next slide really shows not only ICU recovery center clinics, which are blue, but also COVID recovery clinics, which are red. So my specific instance, we actually see all the patients that have had COVID that survive in our post-ICU clinic. And so some of these are combined, but I do think it's important to show how these have grown over the years. So our third polling question, is there a PACS clinic at your institution? So, it looks like 93% do not have one and 7% do. So, hopefully, this is something that will continue to increase in number as this patient population, as I hope you're learning throughout this talk, really have a need for this service, for sure. So, in conclusion, PICS and PACS are common in many patients following critical illness. A pharmacist who works in the ICU and a PICS or a PACS clinic is key in aiding in the transitions of care. And a pharmacist is a key member of a PICS or PACS clinic team to help manage very complex medication regimens. So, thank you for tuning in today. So, now I'm going to hand the mic over to our next speaker, who is Keri Griffiths, and she's going to talk about telecritical care. Joanna, for that introduction, I'm so excited to be on this webcast today to talk about one of my passions, telecritical care and an area in which I practice, along with my colleagues, Sonia Everhart and Desiree Kosmicki. We're going to talk about the pharmacist's role in telecritical care and really try to give you some pointers on how to develop your own telecritical care service, or you can reach out to one of us, and we are happy to discuss that further with you. Our first polling question, are there telecritical care pharmacy services at your institution? So, it looks like there are some institutions, about 25% have services, but the majority of you all do not. With COVID, some of this has grown since the COVID pandemic. And then we'll move on to our next question. Do you practice as a critical care pharmacist? So trying to see the 35 of you out there listening, how many of you actually practice in this area? So there's a few of you out there with the majority of you probably in other units at the bedside. Hopefully, I can convince you that you want to be part of a very small cohort and work in a telecritical care setting, which is nice because we can also work from home. So I wanted to talk about the telecritical care pharmacist integration at Atrium Health because I feel that we have grown over the years that we have been doing this, as well as increased to increase our capacity. So in 2013, Atrium Health began its tele ICU virtual critical care services. And in 2015, we added pharmacy to the mix. And so we started with a second shift pharmacist from 3 to 11pm. And really what they were doing during that time was using a clinical decision support tool to really identify alerts for patients, such as electrolyte derangements, glucoses that were not at goal, and other things as well as looking at new patient evaluations for patients that were admitted during those hours that didn't have an intensivist at the bedside. So we really focused on our resource limited institutions. And then in 2017, I joined the team for a day shift coverage. And so my hours were Monday, Wednesday, Friday, 8 to noon. And so during that time, I began looking at facilities that not have a critical care trained pharmacist on site. So really looking at those resource limited facilities and how we could best optimize patient care at those facilities that didn't have a critical care trained pharmacist. I was rounding with three facilities at that time, between 2017 and 2020. And so following six facilities total, a total of 76 beds during that time. Now I will say that we had a lower census pre-COVID, so I wasn't necessarily looking at 76 patients a day. But it was more around 40 to 45. During COVID-19, our pharmacists tried to increase our day shift coverage to better collaborate with the bedside teams. So our second shift changed hours to have more of a first shift following to be able to better collaborate. This also decreased the number of facilities we were following because some of our larger institutions we no longer needed to follow because they had capacity at that time. Now post-COVID, all of our telecritical care pharmacists are on day shift. And we are currently rounding with two facilities. I round with one facility three days a week and my colleagues round with another facility five days a week. So looking at the pharmacist role as a telecritical care pharmacist, we really needed to define what our goal of the service was going to be. So as you're trying to think, how can I develop a critical care, telecritical care pharmacist role through my institution, what was your goal? So our goal is to provide critical care pharmacist services to our resource limited facilities where a critical care trained pharmacist is not available. Now during our second shift coverage, we were really providing a safety net to a lot of those facilities to make sure that patients were getting optimal care, even though a pharmacist was not on site. So your coverage, depending on the shift, you may provide overnight critical care pharmacist coverage for the institution that may not have 24 hour pharmacist coverage, or just being a resource to provide PRN coverage after hours. Now we focused on specific areas and here are just some examples, glucose management, electrolyte replacement, as well as looking at sedation and paralytics, and overall medication management. So this kind of is a catch all for those interventions and recommendations that didn't fit into other categories that we had already identified. And so interventions would consist of things like discontinuing or initiating vasopressors, IV fluids, updating RAS goals, if they're on a paralytic, off a paralytic, are they on all the necessary prophylaxis, those sorts of things. I will say that our first shift coverage did prospective chart reviews on all ICU level patients, which differed from our second shift coverage, because that was more alert driven by our clinical decision support system for things like glucose and electrolytes. And then they also did new patient evaluations. I'd like to talk about rounding a little bit, my colleagues and I do have some publications about rounding at one of our rural facilities, a 10 bed ICU, so feel free to check that out at your convenience. But with rounding technology, support is a big deal. And probably one of the most important things depending on the platform you decide to use. So our pharmacists that round five days a week use Microsoft Teams, because the team at the bedside crowds around the nursing station, they hop on the phone, everyone else on the team hops on Microsoft Teams, and they have rounds that way and go through every patient. I think their rounds last about 30 minutes, but eight to 10 bed ICU. And so it doesn't take very long. I currently round with a 14 bed ICU, which can take anywhere from 30 minutes to an hour. But we actually use a different platform where I'm actually on a rolling cart, where they can see my face and hear me and I can hear every single noise in the whole ICU, which makes it a little bit challenging at times if there's a lot of background noise. But that way we can all have in live discussions about the patients and be able to optimize care at that time. So you're probably thinking, well, what if the technology doesn't work? Because sometimes the cart doesn't get plugged in, or the internet goes out and you aren't able to, you know, round at the specified time for that team. And so, you know, using your in our system or making a phone call to discuss it with the provider or the APP or the nurse, even if you can get ahold of anyone else to find out what the plan is for the day and then making your recommendations. I think the biggest role here also for a lot of these resource limited facilities is us serving as the drug information resource for our teams, not only for the physicians, but also for the nurses. They'll reach out and say, hey, when do I stop the heparin drip as I start the apixaban? Or how long do I need to keep the insulin drip on? Or what orders did we talk about changing on rounds if, you know, they were having to deal with something else at the time? I think that's a really important area as pharmacists that we can provide. Now, I mentioned that my colleagues and I have published a couple papers discussing virtual rounds and the results. And, you know, the results of our interventions really showed that we made more interventions on first shift and especially when we rounded, looking at about seven and a half interventions per shift rounding on first shift versus two to two and a half interventions per patient for our second shift pharmacists. So that's a pretty significant difference there just looking at the numbers. So related to pharmacist hours. So this will also depend on the goal of your telecritical care service. Whether you want the pharmacist on first shift, second shift, or third shift. Now, I will say at Atrium we have not had any pharmacists on third shift for our telecritical care, right? We did a few weekends during COVID to help with just the acuity of the patients and the sheer number of the patients. But currently, we really only have data for first and second shift. And lastly, some logistics. So when you're thinking about service that you may want to start in the telecritical care world, how many pharmacists do you want or will you need for your service? Which shift are you going to be covering? And how many facilities will you and your team be covering? Right now, we cover seven facilities. Now, I will say that they vary from 10 to 18 beds. I think right now we have about a total of 76 beds that are split between the two of us that are on at one time. And so really, these are all questions you should ask yourself. You know, we're still asking ourselves as our health system grows and the number of facilities grow, do we need to add on more pharmacists? Now, the tricky part for pharmacists in the telecritical care realm is licensure. We do have multiple state licenses for our facilities for which we cover. But, you know, thinking about logistics for that and the cost and the time involved to take all of those law tests for every single state, at least currently, that may change in the next several years, I hope. But for some pharmacists, it may not be possible. So if you're like me and don't want to take more law tests, maybe this is not, you know, necessarily the realm that you want to pursue. However, hopefully, NABP will be changing some of those rules here in the near future for us to get a compact license, which would make it easier because telecritical care is so vital, especially for our rural facilities. So in conclusion, I just want to say that our telecritical care pharmacist group has grown over the last 10 years. Wow, it's been 10 years since we've been doing this, or around there, from second shift to adding day shift pharmacy coverage three days a week, and then our second shift moving their hours to first shift so that we're all on first shift now in order to collaborate with our bedside teams during those hours. Now I'm going to turn it over back to Paul. Thank you very much. Thank you, Dr. Griffith. We're going to start our Q&A session. Keep in mind that feel free to submit questions through the question box on the control panel. A quick question in terms of looking at that de-resuscitation protocol, was there any difference in the rates of shock? I think that's always the fear that people talk about. Do you mean like new shocks or like going into shock after? Yeah, re-initiation of vasopressor again. No, there was not any difference between groups. We had been extra cautious with that component too. We actually stopped diuresis, if any signs of hypotension, but there was no difference between the pre- and post-protocol groups. Great, thank you. In terms of thinking about the PICS clinic, what we consider as some of the biggest hurdles in terms of starting a PICS clinic outright? I think the two biggest hurdles are space and time. So space, like for example, our PICS clinic we meet at in our pulmonary clinic on Friday afternoon just because nobody wants to have clinic on Friday afternoons, to be frank. So a big way to get over that though, and we learned this worked during COVID is telehealth because then I can literally sit in my office, the pulmonologist can sit in their office, the neuropsychologist can sit in their office and see the patients. The other is time because essentially the pulmonologist can bill, the neuropsychologist can bill, and we in Tennessee, I am actually able to bill and that's something I'm working on with my boss, but we don't bill, right? And so it's just trying to, like I said in the presentation, like get it all done, be an ICU pharmacist, but twice a month go do this too. So those are definitely the two biggest limitations I think about. In terms of thinking about these telecritical care pharmacy service, what would you say some of those people out there who wants to set up a telecritical care pharmacy service, what would be some elements that would be needed to kind of set up on those services at their local hospital? Sure, that's a great question, Paul. So I think the biggest challenge is getting those FTEs from the pharmacy department or even trying to get the FTEs from the critical care service line if that's available. I think also showing your value and how you can save money for the pharmacy department and really optimizing patient care through interventions, stopping medications so that they don't show up in Joanna's clinic and she has to stop them, or even thinking about the number of pharmacists that are needed. I will say that all of our ICUs are also wired with technology and so that may be a barrier as well with respect to starting a tele-ICU practice. Thank you, everybody. I don't see any other questions on the box, so that's going to conclude our Q&A section. Thank you to Dr. Bissell, Dr. Stallings, and Dr. Griffiths for your time today. And thank you to all of you for attending our session today. Keep in mind, this webcast is being recorded. The recording will be available to everybody, attendees within 5-7 business day. Just log into the MySCCM.org and navigate to the MyLearnings tab to access the recordings. That concludes our presentation for today.

critical care pharmacists

telecritical care

PICS clinics

PACS clinics

diuresis protocols

pharmacist interventions

medication reconciliation

medication optimization

patient outcomes