Pharmacy Research at University Hospitals Enhances ICU Safety, Efficiency

Innovations in Pulmonology, Critical Care & Sleep Medicine | Fall 2024

Therapeutic management in the critical care setting requires providers to treat high-acuity patients who often experience sudden status changes and involves the use of multiple complex medication regimens. At University Hospitals (UH) Cleveland Medical Center, ongoing pharmacy research initiatives help optimize patient care and outcomes across the health system’s intensive care units, ensuring that all critically ill patients receive the most advanced, cutting-edge therapies in a highest-quality care environment.

Andreea Popa, PharmD, BCPS, BCCCP

“In my role as a critical care pharmacist, my colleagues and I collaborate on projects that aim to standardize medication safety processes, optimize therapeutic efficacy of evidence-proven regimens and identify treatment-related adverse effects,” says Andreea Popa, PharmD, BCPS, BCCCP, Clinical Pharmacy Specialist in the Medical Intensive Care Unit at UH Cleveland Medical Center.

Dr. Popa is also the director of UH Cleveland Medical Center’s PGY2 Critical Care Pharmacy Residency Program. Over the past decade, residents have had the opportunity to participate in research projects and present their findings at national meetings, including the Society of Critical Care Medicine and the American Society of Health-System Pharmacists. Critical care fellows and medical residents also gain experience and perspective by participating in these pharmacy research initiatives.

“One of the best aspects of my job is working with our attending physicians to determine what questions we are interested in answering,” Dr. Popa says. “Each year, we focus on two or three medications, critical care processes or disease states.” She and her partner, Maribel Llamas Rangel, PharmD, BCCCP, work with physicians from multiple specialties to design research projects aimed at improving best practices.

Medication Studies

“The medications we are using have been therapeutically established,” Dr. Popa says. “While we know these drugs are beneficial, our research is focused on quality outcomes to ensure we are using them appropriately and not seeing adverse effects in our patient population.”

The team is currently evaluating thrombolytic therapy administered during cardiac arrest or for the management of hemodynamically unstable pulmonary embolism. “This is a very high-risk, high-cost medication,” Dr. Popa says. “Treatment can lead to serious adverse effects, but it can also save lives.”

Another ongoing pharmacy resident-led project is a retrospective review of septic shock patients managed with angiotensin II. Obtaining more information on this therapy will not only add to the limited current body of knowledge regarding this drug’s role in the management of septic shock, it will also help manage future patients at University Hospitals.

Other medications that the team focused on in recent years have included sedatives, such as ketamine and dexmedetomidine, pulmonary hypertension medications, paralytics and COVID-19 therapies.

Optimizing Care

A single dose of an ICU medication may cost $20,000 or more. According to the National Institutes of Health (NIH), ICU drugs contribute to almost one-third of hospital drug expenditures. While cost should not be the deciding factor in prescribing critical care medications, careful stewardship of pharmaceutical dollars is a crucial component of health care utilization. 

When a manufacturer of an expensive and frequently used vasopressor repackaged the drug, concerns about medication waste arose. “This is an emergency medication that nurses were able to compound at bedside,” Dr. Popa says. “We looked at 200 patients and determined the average amount of drug we were using per patient. Changing the concentration in each bag led to a significant decrease in waste.” The project also led to a pharmacy process change that involved storing the premixed medication in dispensing cabinets on the units for nurses to access quickly.

“Identifying ways to provide cost-effective care allows us to better care for our patients,” Dr. Popa says. “For example, helping with the development of an indication-driven order set for albumin in our EMR led to considerable cost savings across the health system.”

Switching from the use of inhaled nitric oxide to epoprostenol for the management of postoperative pulmonary hypertension and acute respiratory distress syndrome is another example of an extensive collaboration among the pharmacy team, respiratory therapy and ICU providers that led to significant cost savings for the entire system. “This project was completed over two years, providing enough time to ensure the safety and efficacy of our intervention,” Dr. Popa says.

In another project, the team is looking at aminoglycosides, a group of antibiotics that have the potential to cause renal injury. Current guidelines recommend these medications for patients in septic shock. “These are critically ill patients in ICU,” Dr. Popa says. “In this retrospective study involving aminoglycosides, we are hoping to see that by choosing the right patients and dosing optimally, we are not causing further harm.” 

Standardizing Practices

The team’s findings often lead to the development of new guidelines that help standardize care across the institution. Many practitioners provide care in the ICU, including physicians, physician assistants, nurse practitioners and nurses. Medical and pharmacy residents also train on the unit.

“It is important to ensure everyone is on the same page,” Dr. Popa says. “The more we foster consistency in practice and adherence to evidence-based guidelines — while still making sure to individualize care tailored to patients’ specific needs — the more we are able to improve safety and patient outcomes.”

For more information, contact Dr. Popa at Andreea.Popa@UHhospitals.org.

Contributing Expert:
Andreea Popa, PharmD, BCPS, BCCCP
Clinical Pharmacy Specialist, Medical Intensive Care Unit
PGY2 Critical Care Pharmacy Residency Program Director
University Hospitals Cleveland Medical Center 
Assistant Professor of Pulmonary and Critical Care Medicine
Case Western Reserve University School of Medicine