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research-article2013

AOPXXX10.1177/1060028013504086Annals of PharmacotherapyBlum et al

Research Report

Implementation of a Dexmedetomidine Stewardship Program at a Tertiary Academic Medical Center

Annals of Pharmacotherapy 47(11) 1400­–1405 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1060028013504086 aop.sagepub.com

Rachel M. Blum, PharmD, BCPS1, Craig A. Stevens, PharmD, BCPS1, Danielle M. Carter, PharmD, BCPS1, Aaron P. Hussey, PharmD, BCPS1, Kathleen A. Marquis, PharmD, BCPS1, Heather Torbic, PharmD, BCPS1, Robert A. Southard, PharmD, BCPS2, and Paul M. Szumita, PharmD, BCPS1

Abstract Background: Brigham and Women’s Hospital implemented a dexmedetomidine stewardship program in October 2010 beginning with an institution-specific prescribing guideline. To ensure continued adherence to the prescribing guideline, a pharmacist-driven quality assurance program was implemented in November 2011. Objective: The primary objective of this study is to describe the role and impact of a dexmedetomidine stewardship program on dexmedetomidine use at a tertiary academic medical center. Methods: This is a prospective descriptive analysis of a dexmedetomidine stewardship program. Dexmedetomidine stewardship data were collected prospectively from January 2012 through June 2012, in all intensive care units (ICUs) at a single academic medical center. Adult patients (>18 years old) receiving dexmedetomidine therapy continuously for sedation and in the ICU were included in the analysis. Results: A total of 99 patients were identified during the study time frame, during which 71 (71.7%) were identified as compliant with the institutional guideline. The total number of patients receiving dexmedetomidine for greater than 24 hours was 13 (13.1%), of whom 10 (76.9%) received targeted interventions; 15 (15.2%) targeted interventions were made on all patients receiving dexmedetomidine during the study time frame. The total use of dexmedetomidine during the study period was 1310 vials, compared with 5404 vials during the equivalent time frame in 2010—a 76% reduction. Conclusions: A dexmedetomidine stewardship program, including an institution-specific prescribing guideline and a pharmacist-driven quality assurance program may ensure guideline compliance and decreased use of dexmedetomidine at an academic medical center. Keywords dexmedetomidine, intensive care unit, sedation, pain, agitation, delirium Received August 07, 2013; accepted August 14, 2013

Introduction Dexmedetomidine is a selective α-2 adrenoreceptor agonist, which is approved by the FDA for sedation in intubated and nonintubated patients.1 Dexmedetomidine reduces sympathetic drive, maintains an “arousable” level of sedation, provides analgesia, and does not suppress respiratory drive.2-6 These attributes are likely the reason for increased use of dexmedetomidine for pain, agitation, and delirium (PAD) nationally over recent years.7,8 Dexmedetomidine use steadily increased at our institution, reaching a peak in fiscal year (FY) 2010 of more than 10 000 vials. The role of pharmacists in medication stewardship has long been established in antimicrobial literature. Involving pharmacists in antimicrobial stewardship programs (ASPs) has demonstrated both clinical and economic benefits.9-11

ASPs are known to reduce antimicrobial use by almost 40% and decrease hospital costs by anywhere from $200 000 to $900 000.10 There is little published data available to guide institutions on the best practice of how to implement a prescribing guideline for intensive care unit (ICU) sedation and ensure adherence.12 At our institution, a dexmedetomidine stewardship program was implemented in an effort to decrease off-guideline use of this medication and ensure compliance with regard to indication and duration. 1

Brigham and Women’s Hospital, Boston, MA, USA Northwestern Memorial Hospital, Chicago, IL, USA

2

Corresponding Author: Paul M. Szumita, PharmD, BCPS, Department of Pharmacy, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA. Email: [email protected]

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Figure 1.  Abbreviated prescribing guidelines.

Abbreviation: BWH, Brigham and Women’s Hospital.

The primary objective of this study was to describe the role and impact of a dexmedetomidine stewardship program on dexmedetomidine use at a tertiary academic medical center.

Methods Prior to data collection, this study received approval from the Institutional Review Board and Brigham and Women’s Hospital Pharmacy Peer Review Committee. A dexmedetomidine stewardship program was created to oversee the design, creation, and implementation of a prescribing guideline and to monitor the sustainability of guideline compliance. In October 2010, the dexmedetomidine stewardship group worked with a multidisciplinary task force to create a prescribing guideline to define appropriate indications for the use of dexmedetomidine (Figure 1), which was implemented shortly thereafter. Prior to roll-out of the guideline, institution-wide educational efforts were undertaken for all disciplines, including pharmacists, physicians, and nurses. In November 2011, a pharmacist-driven quality assurance program was implemented to ensure continued compliance with the prescribing guideline. The dexmedetomidine stewardship pharmacists were a small group of senior critical care pharmacy specialists who accepted stewardship

responsibilities in addition to their regular daily roles. Each morning, the dexmedetomidine stewardship pharmacist identified all patients with a current order for dexmedetomidine using a report generated from our electronic system and sent to all pharmacists by e-mail prior to the commencement of the first shift. The clinical pharmacist then assessed the appropriateness of dexmedetomidine based on the prescribing guideline and discussed the PAD management plan with the primary ICU team. The dexmedetomidine stewardship pharmacist served as a resource to the clinical pharmacist to discuss patient cases and make recommendations on PAD management as needed. Dexmedetomidine stewardship pharmacists also served as resources for ongoing education regarding PAD management for pharmacists, physicians, and nurses as the need arose. Clinical pharmacy services are provided in each of the 9 adult ICUs as a presence on multidisciplinary rounds on Mondays through Fridays. There is reduced staffing on evenings, nights, and weekends. Although pharmacists continue to assess patients, there is no specific pharmacist dedicated to each of the adult ICUs during these times. This is a prospective descriptive analysis of a dexmedetomidine stewardship program. Dexmedetomidine sustainability data were collected prospectively from January 2012 through June 2012. The primary end point of this analysis was compliance with the prescribing guideline during this

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time frame. Secondary end points included dexmedetomidine use described as the total use of dexmedetomidine during the study period compared with the equivalent time frame in 2010, indications for initiation of dexmedetomidine, patient location, duration of dexmedetomidine infusion, number of patients receiving dexmedetomidine, number of patients receiving dexmedetomidine for greater than 24 hours, clinical pharmacist interventions, and total number of targeted interventions by the stewardship group during the study time frame. Integrated clinical pharmacists rounded on multidisciplinary teams in each of the 9 adult ICUs and used the prescribing guideline to help assess and ensure appropriate use of dexmedetomidine. Clinical pharmacist interventions were defined as the documentation of the discussion between the clinical pharmacist and the primary ICU team regarding indications that were noncompliant with the institutional guideline and discussing alternative therapeutic options to transition off from a dexmedetomidine infusion. Targeted stewardship interventions were defined as the stewardship pharmacist and the clinical pharmacist having a highlevel discussion regarding a patient’s care. Independent of the single-arm sustainability analysis, total hospital-wide dexmedetomidine use data were retrospectively retrieved from January 2005 through September 2012. To ensure that the use of dexmedetomidine, via stewardship, did not negatively affect duration of mechanical ventilation (MV), hospitalwide duration of MV data were retrieved for FY 2010 and FY 2012. Medians and interquartile ranges (IQRs) were used to describe the duration of infusion per patient.

Table 1.  Baseline Demographics. Variable

Total, n = 99

Indication, n (%)   Extubation facilitation   Fast-track cardiac surgery, extubation  Nonintubated/Agitation  Other Identified as compliant to guideline, n (%) Service, n (%)   Cardiothoracic ICU   Burn/Trauma and surgical ICU   Thoracic ICU   Medical ICU   Neuroscience ICU Dexmedetomidine use, n (%)   Dexmedetomidine, 48 hours Clinical pharmacist interventions. n (%) Number of stewardship interventions, n (%)  Total  Patients receiving >24 hours of   dexmedetomidine, n = 13 Infusion   Total duration (hours)   Median duration, IQR (hours)

39 (39.4) 33 (33.3) 17 (17.2) 10 (10.1) 71 (71.7) 64 (64.6) 16 (16.2) 12 (12.1) 5 (5.1) 2 (2) 86 (86.9) 12 (12.1) 1 (1) 67 (67.7) 15 (15.2) 10 (76.9)

1564 12 (10-24)

Abbreviations: ICU, intensive care unit; IQR, interquartile range.

Results During the 6-month sustainability data time frame, a total of 99 patients were identified. A summary of characteristics can be found in Table 1. Of the 99 patients started on dexmedetomidine, 71 (71.7%) were identified as compliant with the institutional guideline. The total use of dexmedetomidine during the study period was 1310 vials, compared with 5404 vials during the equivalent time frame in 2010—a 76% reduction. The trend in total hospital-wide dexmedetomidine use from 2005 to 2012 can be seen in Figure 2. The primary indications for initiation of dexmedetomidine were for the facilitation of extubation 39 (39.4%) and for facilitation of extubation in fast-track cardiac surgery patients 33 (33%). Patients were primarily admitted to the cardiothoracic ICU, with 64 (64.6%) patients, followed by the burn/trauma and surgical ICU, thoracic ICU, medical ICU, and neuroscience ICU—16 (16.2%), 12 (12.1%), 5 (5.1%), and 2 (2%) patients, respectively. The median duration of infusion was 12 hours per patient (IQR = 10-24). During the sustainability study period, a total of 86 (86.9%) patients received dexmedetomidine for less than 24 hours, 13 (13.1%) patients received dexmedetomidine

Figure 2.  Dexmedetomidine use.

for greater than 24 hours, and only 1 (1%) patient received an infusion for greater than 48 hours. Overall, the total duration of dexmedetomidine infusion was 1564 hours. Of the 13 patients receiving dexmedetomidine for greater than 24 hours, 10 (76.9%) received targeted interventions. Also, 67 (67.7%) clinical pharmacist interventions and 15 (15.1%) targeted stewardship interventions were made on all patients receiving dexmedetomidine during the study time frame. The mean duration of MV for FY 2010 was 102.1 hours per patient compared with the median duration of MV for

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Discussion A dexmedetomidine stewardship program at a tertiary academic medical center resulted in sustained compliance with an institutional guideline. This study also demonstrates the feasibility of producing stewardship programs outside of the long-established ASPs, moving into the area of PAD stewardship. To our knowledge, this is the first study evaluating the implementation of a dexmedetomidine stewardship program. The 2013 clinical practice guidelines for the management of PAD in adults in the ICU focus on patients’ alertness, preferentially recommending nonbenzodiazepine sedation over continuous infusion benzodiazepines.13,14 Selecting a PAD management strategy can be controversial and often requires a clinical discussion when caring for ICU patients. The challenge for critical care clinicians regarding the use of sedatives is to provide comfort and safety without increased morbidity, mortality, or cost. Institutions may develop initiatives to improve clinical outcomes for patients and compliance with institution-specific guidelines. The general approach to PAD management at our institution is in alignment with the 2013 clinical practice guidelines for the management of PAD in adults in the ICU. As shown in Figure 1, first-line therapy for fast-track cardiac surgery patients is propofol, and patients can receive dexmedetomidine if a propofol wean fails. In all other patients, dexmedetomidine may be initiated in patients failing standard PAD management, including a pain-first approach, bolus therapy, and nonbenzodiazepine management of agitation. Although PAD stewardship programs are not well described in the literature, the foundation of a dexmedetomidine-specific stewardship program can be derived from the long-established ASPs. The primary objectives of ASPs are to encourage the proper use of antimicrobials; including the right selection, duration, dose, and route of administration.15 ASPs focus on the appropriate use of antimicrobials, which have demonstrated positive results, including decreased adverse drug events and decreased health care costs.9,15,16 A dexmedetomidine stewardship program was developed at our institution to achieve similar positive outcomes. Our dexmedetomidine prescribing guideline was created and approved by a multidisciplinary team of physicians, nurses, pharmacists, and hospital administration personnel. The key element to the eventual success of the guideline was the continued collaboration among all bedside clinicians. One barrier that the stewardship program faced was a lack of consensus on PAD management strategies across all ICUs. This barrier was overcome with multidisciplinary discussion and decision making. This was demonstrated in

our analysis by our 10 sustainability interventions that were made on patients receiving dexmedetomidine for greater than 24 hours by the stewardship pharmacist. These interventions included collaboration with physicians, nurses, and other pharmacists to promote compliance with the guideline. Dexmedetomidine was associated with a decreased duration of MV when compared with continuous infusion midazolam in both the SEDCOM and MIDEX trials.17,18 It is critical to note that the doses of midazolam were a mean of 0.056 mg/kg/h in SEDCOM and a median of 0.062 mg/ kg/h in MIDEX. Based on the weight of an average patient, this would be an equivalent of almost 5 mg/h. Not surprisingly, these considerable doses of midazolam led to an increased time between discontinuation of midazolam and patient extubation in both studies. Compared with our practice, patients with the goal to be awake and alert would generally not require such high doses. Although dexmedetomidine has been shown to decrease duration of MV in these 2 studies, non-medication-specific techniques have been shown to optimize patient outcomes, including decreased duration of MV, decreased hospital and ICU length of stay, decreased incidence of ventilator-associated pneumonia, decreased duration of delirium, and decreased coma.12,19-35 Techniques to achieve these important clinical outcomes include the following: systematic and frequent assessment of PAD to titrate agents to patient goal awake and alert, use of no sedation (analgosedation), decreased use of continuous infusions of sedatives, bolus dosing before initiating/increasing continuous infusions of sedatives, spontaneous awakening trials, spontaneous breathing trials paired with spontaneous awakening trials, and early mobilization.24-35 Guideline-based use of dexmedetomidine via stewardship did not appear to negatively affect duration of MV; however, we are not making an association between decreased dexmedetomidine use and length of MV. Our institution was at the height of dexmedetomidine use during the FY 2010, which correlated with a MV duration time of roughly 102 hours per patient. Interestingly, during the time of our dexmedetomidine stewardship program (FY 2012) the median duration of MV per patient was reduced to roughly 74 hours, despite a significant reduction in dexmedetomidine use and more reliance on alternative medications and non-medication-specific techniques. Our evaluation has a few important limitations worth mentioning. Although our institutional data revealed a correlation between reduction in duration of MV and decreased dexmedetomidine use, this cannot be attributed to dexmedetomidine stewardship alone. Several hospital-wide quality improvement initiatives aimed at improving the quality of care for the mechanically ventilated patient took place during this study period, including application of the “vent bundle,” with a focus on coordination of spontaneous

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awakening trials and spontaneous breathing trials. Although improvement in clinical outcomes such as duration of MV is ideal, our study was not powered to detect this.

Conclusions A dexmedetomidine stewardship program that includes an institution-specific prescribing guideline and a pharmacistdriven quality assurance program may ensure guideline compliance and decreased use of dexmedetomidine at an academic medical center. Acknowledgments We would like to acknowledge the following Brigham and Women’s Hospital clinicians and departments for their contributions to dexmedetomidine stewardship sustainability: drug policy executive committee, pharmacy and therapeutics committee, physician directors of the critical care units, nursing directors and educators of the critical care units, department of anesthesia, department of pharmacy services, and all bedside clinicians.

Declaration of Conflicting Interests The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Drs Blum, Stevens, Carter, Hussey, Marquis, Torbic, Southard, and Szumita report that they have no affiliation with or financial interest in a commercial organization that would pose a conflict of interest in regard to this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Implementation of a dexmedetomidine stewardship program at a tertiary academic medical center.

Brigham and Women's Hospital implemented a dexmedetomidine stewardship program in October 2010 beginning with an institution-specific prescribing guid...
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