This program is music to ears of hospital ICUs

How much difference can pharmacists really make in the critical care unit? A group of R.Ph.s from two neighboring states set out to prove they could accomplish just about anything.

Eleven hospitals from New Jersey and Pennsylvania worked with VHA Inc. to implement the Medication Use Strategies in Critical Care (MUSIC) program. "MUSIC was designed to be a collaborative, evidence-based approach to cost-effective medication use in critical care," said VHA Pharmacy Manager Gregory Susla, Pharm.D. The program has helped make significant drug utilization improvements in areas such as sedation, stress ulcer prophylaxis, and volume expanders. By making these changes, hospitals in the initiative have saved $440,000 in pharmacy drug costs alone since the program's inception in January 2005.

Prior to program implementation, all the participating hospitals underwent careful evaluation of their ICU drug expenditures and reviewed ICU-related policies and therapeutic protocols to identify areas needing improvement. Since the 11 sites had different problem areas, they selected individual "targets" for the initiative. This was one of the strengths of the program, said Susla, "allowing each hospital to identify and address its specific needs to optimize medication use in its ICU, rather than forcing all of the hospitals to duplicate the same programs at each of the institutions."

The revised sedation protocol, making "wake-ups" standard, "provided specific guidelines to ensure consistent practices," said Liza Barbarello, Pharm.D., BCPS, who led the initiative at Capital Health System in Trenton, N.J. By switching to goal-directed therapy with propofol, hospitals were able to wake patients faster and avoid more complications. They saw significant reductions in the average number of ventilator days, and at one of the sites, they saw a decrease in ICU length of stay from 4.4 days to 3.6 days, as well as a complete eradication of VAP cases.

Despite slight increases in pharmacy acquisition costs due to the higher price tag for propofol, the costs are more than offset by the projected financial improvement of over $2.2 million for the year for Capital Health alone, thanks to the decreased ICU stay. Capital Health also targeted improvements in the use of proton pump inhibitors, albumin, and erythropoietin. According to Barbarello, using communication forms for pharmacy staff and student recommendations resulted in great acceptance rates. The forms, using a "Dear Doctor" format, cited published studies to support the recommendations. As a result, there has been significant reduction in the use of pantoprazole, albumin, and erythropoietin.

"The biggest challenges of the initiative were getting the evidence-based data out to the physicians and having all practitioners integrate them into their daily practice," she said.

Other participating hospitals have utilized a number of approaches, including the use of automatic stop orders and therapeutic substitutions, to minimize inappropriate use of such medications as nesiritide, levalbuterol, vancomycin, and ceftazidime. Significant strides have also been made in therapeutic areas such as deep vein thrombosis (DVT) prophylaxis and improved glycemic control. Such strides are in accordance with recommendations from organizations such as the American College of Chest Physicians, which has long recommended that hospitals institute formal strategies for DVT prophylaxis.

Hospitals in the initiative used various strategies to accomplish their goals, with a focus on evidence-based practice, open communication with the physicians, and pharmacy decentralization. Each participating hospital was able to accomplish a wide range of goals, and one hospital was even able to document enough savings to justify the addition of an ICU pharmacist. In addition, Susla noted, the program has led to "enhanced working relationships between pharmacists and other critical care practitioners in selecting the most appropriate medications for their critically ill patients."

THE AUTHOR is a writer based in New Jersey.