HealthDecember 11, 2017

Critical care: New guidance for medication safety in the ICU

The Society of Critical Care Medicine (SCCM) is committed to “Right Care, Right Now.”

As part of this commitment, SCCM identifies patient care needs that require evidence-based best practice guidelines and works with experts to advance practices. Earlier this year, we published ”Clinical Practice Guidelines for Safe Medication Use in the ICU.”

Overall, safe and effective medication practices are discussed in several clinical practice guidelines. However, this recent publication was the first compilation of safe medication use practices for the critically ill. The breadth of data addressing the topic medication safety is substantial, and critically evaluating this literature was a highly involved process.

Why ICU-specific guidelines?

Critically ill patients are a population at high risk for more frequent and more severe medication-related events. Critically ill patients receive twice the number of medications that non-critically ill, hospitalized patients receive, thus increasing the opportunity for adverse drug events to occur. ICU patients are more likely to have drug-drug interactions, drug accumulation due to failing organs, and a sensitivity to drug responses resulting from their labile status. The complexity of the patient’s drug regimens and the environment provide a risk for patient harm.

Critically ill patients are also more likely to develop drug-induced events such as acute kidney injury and coagulopathies.

Guideline highlights

The critical care guidelines are composed of two primary sections: process and surveillance.

When it came to process, the SCCM safe medication use taskforce proposed PICO (population, intervention, comparator, outcome) questions per the GRADE criteria for the guidelines. We took a comprehensive approach to considering each step of the medication use process including prescribing, dispensing, administration and monitoring.

Additionally, we knew that an active medication surveillance program provides a continuous evaluation and awareness of ongoing safety issues and that a detailed set of standards needed to be outlined for institutions to follow.

The guidelines also incorporate key medication safety best practices that have been developed over the years, such as:

  • Standardizing intravenous medication concentrations
  • Preventing mixing of medication in the ICU and making premade products available
  • Implementation of technology, including
    • Robots for filling medications
    • Computerized prescriber order entry
    • Clinical decision support
    • Bar code medication administration
    • Advanced infusion pumps
  • Promoting and encouraging a culture of patient safety

Patient care requires a team that includes the patient. Therefore, another important feature of the guidelines is the emphasis they place on patient and caregiver reporting of symptoms. Engaging patients in their own care is consistent with SCCM’s belief in and commitment to “Right Care.” Patients are the people that healthcare providers serve, and engagement stimulates successful outcomes.

Patient-reported outcomes provide insight that may not be usually observed by healthcare professionals. Some adverse drug reactions such as headaches, nausea, and confusion are only detectable through conversations with the patient. In the ICU, critical care patients are often unable to articulate their own concerns, so a patient’s caregiver’s insight becomes essential for providing useful context for ongoing processes. For example, if a patient appears to be having cognitive status impairment, it is difficult to understand what type of improvement would be expected without understanding their baseline cognitive status. That requires consulting their caregiver.

CDS in the ICU

The SCCM guidelines evaluated the impact of clinical decision support (CDS) on medication error and adverse drug event reduction. While we noted a lack of evidence suggesting that clinical decision support reduces medication errors and ADEs specific to critically ill patients, we still support the value of adoption of CDS.

There are drawbacks to incorporating technology into patient care practices, which is why thoughtful preparation is required. While medication safety technology can decrease errors, new errors can sometimes be caused by the technology. These outcomes need to considered and balanced.

One significant drawback to incorporating clinical decision support is the risk of alert fatigue. Alert fatigue is the overexposure to alerts resulting in clinician desensitization, increasing the possibility of a professional overlooking a clinically relevant alert. Managing alert fatigue requires an active surveillance quality improvement program to evaluate the achieved, intended value of the clinical decision support, the need for modifications, and the usefulness/priority of the alert in the context of other alerts.

The Safe Medication Use Clinical Practice Guidelines emphasize important best practices. Ensuring optimal medication safety by incorporating the guidelines’ recommendations requires a commitment of the hospital’s administration and the clinicians. Also, discussed in the guidelines is the need for future research in areas such as medication reconciliation, hand-off communication techniques, impact of point-of-care testing, double checks during medication administration, and the safety impact of adopting technologies.

To learn more, visit the Society of Critical Care Medicine.

Sandra L. Kane-Gill, PharmD, MS, FCCM, FCCP, is Associate Professor of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy. She has secondary appointments in the School of Medicine in the Clinical Translational Science Institute, Department of Critical Care Medicine and the Department of Biomedical Informatics. Dr. Kane-Gill is also a Critical Care Medication Safety Pharmacist at UPMC. Her research focuses on effective approaches for the detection, prevention, and management of medication errors and adverse drug events.

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