During the coronavirus disease (COVID-19) global pandemic, urgent strategies to alleviate shortages are required. Evaluation of the feasibility, practicality, and value of drug conservation strategies and therapeutic alternatives requires a collaborative approach at the provincial level. The Ontario COVID-19 ICU Drug Task Force was directed to create recommendations suggesting drug conservation strategies and therapeutic alternatives for essential drugs at risk of shortage in the intensive care unit during the COVID-19 pandemic. Recommendations were rapidly developed using a modified Delphi method and evaluated on their ease of implementation, feasibility, and supportive evidence. This article describes the recommendations for drug conservation strategies and therapeutic alternatives for drugs at risk of shortage that are commonly used in the care of critically ill patients. Recommendations are identified as preferred and secondary ones that might be less desirable. Although the impetus for generating this document was the COVID-19 pandemic, recommendations should also be applicable for mitigating drug shortages outside of a pandemic. Proposed provincial strategies for drug conservation and therapeutic alternatives may not all be appropriate for every institution. Local implementation will require consultation from end-users and hospital administrators. Competing equipment shortages and available resources should be considered when evaluating the appropriateness of each strategy.

BackgroundThe layered learning practice model (LLPM), within which a pharmacist supervises both a pharmacy resident and a student, mitigates the growing demand for clinical rotations that has accompanied national expansion of Doctor of Pharmacy programs. A Canadian collaborative of hospital pharmacists established consensus on 8 clinical pharmacy key performance indicators (cpKPIs), activities associated with improved patient outcomes. Increased implementation of the LLPM alongside cpKPI measurement offers opportunities to compare the LLPM with standard practice in terms of pharmaceutical care delivery.ObjectiveTo quantify clinical productivity, as measured by proportions of eligible patients receiving cpKPIs and absolute numbers of completed cpKPIs, across scenarios involving pharmacists working with and without pharmacy learners.MethodsIn this retrospective observational study, pharmacy students, pharmacy residents, and pharmacists recorded completion of 7 cpKPIs for oncology inpatients over a total of 6 months in 2017 and 2018. Clinical productivity was described across the following 3 scenarios: presence of one or more pharmacists with one resident and one or more students (P-R-S); presence of one or more pharmacists with one or more students (P-S); and presence of one or more pharmacists only (P; standard practice).ResultsDuring the study, there were 685 recorded admissions to the inpatient oncology service. Generally, the proportions of patients who received cpKPIs were similar for scenarios with and without pharmacy learners present. Standardized to 20 pharmacist workdays, the total number of cpKPIs 1, 2, 3, 5, 6, and 7 (255 with P-R-S scenario, 281 with P-S scenario, and 258 with P scenario) and the total number of drug therapy problems resolved (i.e., cpKPI 3; 153 with P-R-S scenario, 180 with P-S scenario, and 149 with P scenario) were similar across the scenarios. Scenario P had fewer admitted patients per pharmacist workday (3.2) than scenarios P-S and P-R-S (3.4 and 3.7, respectively), which may have contributed to a trend toward greater proportions of patients receiving cpKPIs under scenario P.ConclusionsCompared with standard practice, integration of pharmacy learners within an oncology unit did not appear to impair clinical productivity, as demonstrated by the comparable proportions of patients receiving cpKPIs and the total number of completed cpKPIs.

ObjectivesThe 2013 clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the ICU suggest that pain be routinely assessed using a validated pain assessment tool. Currently available tools have only been evaluated in nondelirious critically ill patients, yet delirium can affect as many as 80% of ICU patients. The validated pain assessment tool adopted by our institution is the Critical Care Pain Observation Tool, and the objective of this study was to investigate the validity of this tool in patients with evidence of delirium. Design:Prospective cohort study. Setting:Two ICUs within a Canadian tertiary healthcare center. Patients:Forty consecutive adult patients deemed delirious on the day of enrollment using the Confusion Assessment Method for ICU. Measurements and Main Results:Serial Critical Care Pain Observation Tool assessments were conducted simultaneously by study personnel and objective nurses at baseline and after nonpainful and painful stimuli. Subjective opinions about pain and objective physical variables (including mean arterial pressure, heart rate, respiratory rate, and oxygen saturation) were collected at the same time points. Discriminant validity was described using paired t tests, whereas internal consistency was described using the Cronbach &agr; statistic. Responsiveness of the Critical Care Pain Observation Tool was measured by effect size, and reliability was described as the agreement between raters. Comparisons between the Critical Care Pain Observation Tool and the subjective assessments and objective measurements were based on positive and negative percent agreement. Critical Care Pain Observation Tool demonstrated excellent discriminant validity as evidenced by a highly statistically and clinically significant change in mean Critical Care Pain Observation Tool scores between baseline and painful procedures (mean difference, 3.13 ± 1.56; p < 0.001; Cohen D, 2.0). Interrater agreement was also excellent (&kgr; > 0.6), and scores between raters were highly correlated (r = 0.957). The Critical Care Pain Observation Tool possessed a high level of internal consistency (overall Cronbach &agr;, 0.778). Percent agreement was found to be greater between the Critical Care Pain Observation Tool and the nurse’s subjective opinion of the presence or absence of pain when compared with that between the Critical Care Pain Observation Tool and physiologic variables (80.5% vs 67.5%, respectively). Conclusions:The Critical Care Pain Observation Tool is a valid pain assessment tool in noncomatose, delirious adult ICU patients who are unable to reliably self-report the presence or absence of pain.

PURPOSE:To determine the proportion of critically ill adults developing impaired gastrointestinal transit (IGT) using a clinically pragmatic definition, its associated morbidity and risk factors.MATERIALS AND METHODS:Critically ill adult patients receiving enteral nutrition for ≥ 72 hours and mechanically ventilated for ≥ 48 hours were prospectively identified. IGT was defined as absence of a bowel movement for ≥ 3 days, treatment for constipation, and one of the following: (1) radiologic confirmed ileus, (2) feed intolerance, (3) abdominal distention, or (4) gastric decompression.RESULTS:One thousand patients were screened, and 248 were included for analysis. Fifty patients (20.1%; 95% confidence interval, 15.1-25.6%) developed IGT persisting for 6.5 ± 2.5 days. Patients with IGT had longer lengths of intensive care unit stay and were less likely to reach nutrition targets compared to patients without IGT or traditional definitions of constipation. Daily opioid use and pharmacological constipation prophylaxis were identified risk factors for IGT.CONCLUSION:Traditional definitions of constipation or ileus in intensive care unit patients are simplistic and lack clinical relevance. Pragmatically defined IGT is a common complication of critical illness and is associated with significant morbidity. Future interventional studies for IGT in critically ill adults should use a more clinically relevant definition and evaluate energy deficits and lengths of stay as clinically relevant outcomes.

Digitalis toxicity produces a toxidrome characterized by gastrointestinal, neurologic, electrolyte, and nonspecific cardiac manifestations. Chronic toxicity remains much more difficult to recognize compared with an acute presentation because of the nonspecific manifestations; therefore, serum glycoside levels are essential for diagnosis in this population. The mainstay of management continues to be rapid toxidrome identification followed by digoxin-specific antibody fragment therapy with supportive care. Several controversies still remain, including therapy for patients dependent on hemodialysis, appropriateness of calcium therapy for hyperkalemia, ideal agents for arrhythmia therapy, and the potential utility of plasmapheresis for removal of bound digoxin-antibody fragment complexes.

PURPOSEThe 24-hour stability of a levothyroxine solution admixed and stored in three common infusion containers and infused through polyvinyl chloride (PVC) tubing was evaluated.METHODSLevothyroxine sodium 1-μg/mL injection prepared in glass bottles and PVC and polyolefin bags were assayed using high-performance liquid chromatography at 0, 1, 3, 6, 12, and 24 hours; samples drawn directly from the containers, as well as from the distal end of attached PVC tubing, were assayed. The area under the time-versus-concentration curve (AUC) for predicted and delivered doses was calculated; analysis of variance was used for comparison of the percentages of predicted and actual AUC values.RESULTSThe levothyroxine concentration was stable in glass bottles and polyolefin bags through 24 hours (mean ± S.D. percentage of initial concentration remaining, 103.5% ± 2.5% and 100.0% ± 2.9%, respectively). In the PVC infusion bags, the amount of drug decreased to 90% of the initial concentration within 1 hour and then rose and remained within acceptability limits. The levothyroxine concentration of the samples infused through PVC line from glass and polyolefin containers decreased after 1 hour by about 13%; the loss of the drug from the samples infused from PVC bags was higher (18%), presumably due to additive adsorptive effects. In all samples tested, the drug concentration rebounded and remained above 90% to the end of the study.CONCLUSIONLevothyroxine sodium 1-μg/mL solution was stable for 24 hours in glass bottles and polyolefin bags but when stored in PVC bags, the concentration decreased by 10% after 1 hour.

The role of clinical pharmacy services in acute care settings such as the emergency department and the intensive care unit (ICU) has been documented since the 1970s. These studies have demonstrated that the participation by pharmacists in direct patient care exerts a positive influence on patient outcomes, cost containment, and prevention of adverse drug reactions.1-10 In comparison, pharmacy-managed consult services in acute care settings are less common, and the few that have been described in published reports appear to have been limited to the monitoring of specific therapeutic drugs, medication history-taking, and the provision of drug information.5,7,8