Saint Luke's Hospital of Kansas City is a tertiary care hospital is located at 4401 Wornall Road in Kansas City, Missouri. It is part of the Saint Luke's Health System.
Purpose To investigate the impact of an overnight critical care pharmacist shift on pharmacy services in a quality improvement initiative.Methods The department of pharmacy implemented an overnight critical care pharmacist shift in October 2023 to better align with recommendations for critical care pharmacy services from the Society of Critical Care Medicine, American College of Clinical Pharmacy, and American Society of Health-System Pharmacy. This initiative focused on patient care services and aimed to increase compliance from 6.2% to 75% during overnight hours by May 2024. Characterization of the impact included time to order verification, time to administration, and number and type of pharmacist interventions. Plan-Do-Study-Act (PDSA) cycles were utilized to measure changes over time.Results Shift initiation (PDSA cycle 1) resulted in a mean time to order verification of 9.4 minutes (SD, 24.7 minutes) compared to 7.4 minutes (SD, 13.9 minutes) before initiation. There was no difference in the mean time to order verification of stat medications. Pharmacists documented an average of 214 interventions per month compared to 84 before initiation. For PDSA cycle 2, patient profile reviews of newly admitted patients occurred during 60 of 60 (100%) shifts, with an average of 9 patients reviewed per shift. Prospective profile review led to interventions for 93.3% of shifts.Conclusion This initiative increased institutional compliance with foundational patient care recommendations from 6.2% to 67.2%. Implementation of overnight critical care pharmacists led to an increase in the number of interventions documented over time without a significant corresponding increase in the time to order verification and administration. Opportunities exist for further optimization of clinical activities during the overnight hours.
Introduction: Published data investigating a time-dependent effect of initiation of antiarrhythmic therapy for shockable in-hospital cardiac arrest (IHCA) is lacking. We aimed to evaluate the association between time of intravenous amiodarone or lidocaine administration and return of spontaneous circulation (ROSC) in patients with IHCA caused by ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT). Methods: This was a retrospective, multi-center, single health system, observational cohort study of patients with an IHCA caused by VF/pVT and who received amiodarone or lidocaine during 2014-2024. The primary outcome was ROSC, and the secondary outcome was survival to hospital discharge. A multivariable logistic regression model was constructed to evaluate the association between (1) time to drug administration and (2) drug administration prior to the second defibrillator shock on both survival outcomes. Results: A total of 88 patients with a shockable IHCA were identified. Longer time to amiodarone or lidocaine administration was associated with lower likelihood of ROSC (adjusted odds ratio [aOR] 0.91; 95% CI: 0.83-0.99, P = 0.04) but not with survival to discharge (aOR 0.99; CI 0.90-1. 10P = 0.90). Administration of antiarrhythmic therapy prior to the second defibrillator shock was associated with higher likelihood of ROSC (aOR 6.48; CI 2.08-20.21, P = 0.001) and survival to discharge (aOR 2.82; CI 1.03-7.77, P = 0.04). Conclusion: Early administration of amiodarone or lidocaine, particularly prior to the second defibrillator shock, was associated with an increased odds of survival outcomes in IHCA with shockable rhythms.
Rationale Multiple risk factors have been associated with adverse outcomes in acute pulmonary embolism (aPE), such as hemodynamic instability, right ventricle (RV) dysfunction, and others. Less attention has been focused on kidney dysfunction; an end-organ susceptible to injury in aPE. We aim to describe the prevalence, risk factors, and outcomes associated with acute kidney injury (AKI) among aPE patients. Methods and statistical analysis This is a retrospective single-center study of patients diagnosed with aPE from 2011 to 2022. We identified patients with PE using the international classification of diseases ninth and tenth revisions. The diagnosis of aPE was confirmed by computed tomography pulmonary angiogram. Data were stratified by the presence of AKI. AKI was defined as an increase in serum creatinine on admission of ≥1.5 times compared to baseline or an increase in serum creatinine of ≥0.3 mg/dl compared to admission. We performed a multivariable logistic regression analysis to determine the clinical factors associated with AKI adjusting for demographic variables (age, race, sex, and body mass index [BMI]) and clinical variables with p-values of <0.20 between groups. To determine if AKI was associated with a composite outcome of inpatient mortality, vasopressor use, and mechanical ventilation, a multivariable logistic regression analysis was done adjusting for demographics, comorbidities, and surrogates of aPE severity (including RV dysfunction on echocardiography and simplified pulmonary embolism severity index). We provide odd ratios (OR) with confidence intervals (CI). A p-value of <0.05 was considered statistically significant. Results Of 1157 patients with aPE analyzed, 29% (n=336) developed AKI. The median age of the AKI group was 66 years (IQR 57-75), 53% (n=180) were females, and mostly were African Americans (79%, n=264). On multivariable analysis, male sex (OR=1.53, CI:1.08-2.15, p=0.015), hypertension (OR=1.91, CI:1.23-2.95, p=0.004), left ventricle ejection fraction (LVEF) (OR=1.01, CI:1.00-1.03, p=0.015), RV dysfunction (OR=1.87, CI:1.17-2.99, p=0.008), and white blood cell count (WBC) (OR=1.06, CI:1.02-1.09, p<0.0001) were independently associated with AKI. In terms of outcomes, a composite outcome of mechanical ventilation, vasopressor use, and inpatient mortality was seen in 41% (n=137) of the AKI group. The AKI group had more composite outcome (41% vs. 11%, p<0.0001). On multivariable analysis, AKI was independently associated with the composite outcome (OR=5.58, CI:4.01-7.77, p<0.0001). Conclusion Among aPE patients, AKI was a prevalent complication. Male sex, chronic hypertension, higher LVEF, RV dysfunction, and higher WBC count were independently associated with AKI. Meanwhile, AKI was independently associated with adverse outcomes in aPE.
