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Background: Evidence suggests that poor sleep increases risk of delirium. Because delirium is associated with poor outcomes, institutions have developed protocols to improve sleep in critically ill patients., Objective: To assess the impact of implementing a multicomponent sleep protocol., Methods: In this prospective, preimplementation and postimplementation evaluation, adult patients admitted to the medical intensive care unit (ICU) over 42 days were included. Outcomes evaluated included median delirium-free days, median Richards-Campbell Sleep Questionnaire (RCSQ) score, median optimal sleep nights, duration of mechanical ventilation (MV), ICU and hospital length of stay (LOS), and in-hospital mortality., Results: The preimplementation group included 78 patients and postimplementation group, 84 patients. There was no difference in median delirium-free days (1 day [interquartile range, IQR, = 0-2.5] vs 1 day [IQR = 0-2]; P = 0.48), median RCSQ score (59.4 [IQR = 43.2-71.6] vs 61.2 [IQR = 49.9-75.5]; P = 0.20), median optimal sleep nights (1 night [IQR = 0-2] vs 1 night [IQR = 0-2]; P = 0.95), and in-hospital mortality (16.7% vs 17.9%, P = 1.00). Duration of MV (8 days [IQR = 4-10] vs 4 days [IQR = 2-7]; P = 0.03) and hospital LOS (13 days [IQR = 7-22.3] vs 8 days [IQR = 6-17]; P = 0.05) were shorter in the postimplementation group, but both were similar between groups after adjusting for age and severity of illness., Conclusions and Relevance: This report demonstrates that implementation of a multicomponent sleep protocol in everyday ICU care is feasible, but limitations exist when evaluating impact on measurable outcomes. Additional evaluations are needed to identify the most meaningful interventions and best practices for quantifying impact on patient outcomes.

Purpose: Obtaining an accurate medication history from patients on hospital admission is a priority in pharmacy practice. Timely and accurate histories are imperative as they may help determine the etiology of illness and prevent medication errors. We conducted a quality improvement project to assess the accuracy of alternate-source medication histories obtained for critically ill patients who were delirious or mechanically ventilated at the time of intensive care unit admission., Methods: Included patients were 18 years of age or older, admitted to the medical intensive care unit from August 2017 through January 2018, and had a medication history obtained from a family member or outpatient pharmacy due to active delirium or mechanical ventilation. Patients were directly interviewed after resolution of delirium or extubation. Discrepancies between the initial and follow-up histories were documented and categorized using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for Categorizing Medication Errors., Results: Forty patients were included. One hundred four discrepancies were documented, with a median of 2 discrepancies per patient. The most common types of discrepancies were addition (51.9%), followed by omission (24.0%). NCC MERP index category A (51%) was the most common error classification identified., Conclusion: Discrepancies between initial and follow-up medication histories occurred at a frequent rate in delirious or mechanically ventilated patients; however, these discrepancies tended to be of low risk severity., (© American Society of Health-System Pharmacists 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Health care facility-onset Clostridium difficile infections (HO-CDI) are an important national problem, causing increased morbidity and mortality. HO-CDI is an important metric for the Center for Medicare and Medicaid Service's (CMS) performance measures. Hospitals that fall into the worst-performing quartile in preventing hospital-acquired infections, including HO-CDI, may lose millions of dollars in reimbursement. Under pressure to reduce CDI and without a clear optimal method for C. difficile detection, health care facilities are questioning how best to use highly sensitive nucleic acid amplification tests (NAATs) to aid in the diagnosis of CDI. Our institution has used a two-step glutamate dehydrogenase (GDH)/toxin immunochromatographic assay/NAAT algorithm since 2009. In 2016, our institution set an organizational goal to reduce our CDI rates by 10% by July 2017. We achieved a statistically significant reduction of 42.7% in our HO-CDI rate by forming a multidisciplinary group to implement and monitor eight key categories of infection prevention interventions over a period of 13 months. Notably, we achieved this reduction without modifying our laboratory algorithm. Significant reductions in CDI rates can be achieved without altering sensitive laboratory testing methods., (Copyright © 2018 American Society for Microbiology.)

Background: Funguria occurs often in hospitalized patients and is most commonly caused by Candida species. Fluconazole is the agent of choice for most Candida urinary tract infections. Amphotericin B bladder irrigations (ABBI) are an alternative treatment option., Objective: The purpose of this study is to assess the efficacy of ABBI compared to fluconazole for the treatment of candiduria in the intensive care unit (ICU) setting., Methods: We conducted a retrospective chart review of patients admitted to ICUs at our institution with a positive urine culture for Candida species between 2005 and 2012. All patients receiving ABBI were included; patients receiving fluconazole for treatment of candiduria were matched by year. The primary endpoint was achievement of cure., Results: There was no difference in cure between the ABBI and fluconazole groups (59.6% vs. 52.8%, p = 0.55). Clearance was higher in patients receiving ABBI (92.3% vs. 67.9%, p < 0.001). Logistic regression found that renal dysfunction predicted greater cure with ABBI therapy compared to fluconazole (OR 7.63, 95% CI 1.81-32.1)., Conclusion: ABBI was equally efficacious in achieving overall cure, and resulted in greater clearance of candiduria compared to fluconazole. ABBI may be considered an alternative to fluconazole for the treatment of candiduria and may be preferred over fluconazole in patients with renal dysfunction.

Objective: The economic implications of sedative choice in the management of patients receiving mechanical ventilation are unclear because of differences in costs and clinical outcomes associated with specific sedatives. Therefore, we aimed to determine the cost-effectiveness of the most commonly used sedatives prescribed for mechanically ventilated critically ill patients., Design, Setting, and Patients: Adopting the perspective of a hospital, we developed a probabilistic decision model to determine whether continuous propofol or intermittent lorazepam was associated with greater value when combined with daily awakenings. We also evaluated the comparative value of continuous midazolam in secondary analyses. We assumed that patients were managed in a medical intensive care unit and expected to require ventilation for > or = 48 hrs. Model inputs were derived from primary analysis of randomized controlled trial data, medical literature, Medicare reimbursement rates, pharmacy databases, and institutional data., Main Results: We measured cost-effectiveness as costs per mechanical ventilator-free day within the first 28 days after intubation. Our base-case probabilistic analysis demonstrated that propofol dominated lorazepam in 91% of simulations and, on average, was both $6,378 less costly per patient and associated with more than three additional mechanical ventilator-free days. The model did not reveal clinically meaningful differences between propofol and midazolam on costs or measures of effectiveness., Conclusion: Propofol has superior value compared with lorazepam when used for sedation among the critically ill who require mechanical ventilation when used in the setting of daily sedative interruption.

Objective: To describe delayed peak lithium concentrations after an overdose of extended-release lithium tablets., Case Summary: A patient with borderline personality disorder and depression ingested extended-release lithium approximately 20.25 g along with other agents. At presentation, the lithium concentration was 1.4 mEq/L. Significant enteral intake was initiated 27 hours after presentation and the lithium concentration 5 hours later increased to 3.2 mEq/L. A second lithium peak concentration of 5.0 mEq/L was noted 40 hours after presentation. Two hemodialysis sessions lasting 4 hours each were performed along with administration of sodium polystyrene sulfonate in sorbitol 20% to enhance lithium elimination and decrease absorption. Eighty-eight hours after presentation, the lithium concentration had decreased to 1.5 mEq/L., Discussion: Delayed and secondary peak lithium concentrations have been reported following an overdose with an extended-release product. Extended-release lithium may form an aggregate in the gastrointestinal tract and/or have delayed absorption secondary to coingested drugs. Toxicity may result if the patient begins enteral intake of drugs, fluids, or nutrition., Conclusions: Continued monitoring of lithium concentrations after an acute ingestion with an extended-release product are recommended until lithium concentrations are less than 1.5 mEq/L and there are no signs of toxicity, particularly once the patient begins significant enteral intake.