Ginger Rouse, BCCCP, PharmD, BCPS,
Clinical Pharmacy Specialist II, Medical Intensive Care
Yale New Haven Hospital
New Haven, Connecticut
Disclosure information not submitted.
Aaron Knopp, PharmD, BCPS, BCCCP
Critical Care Clinical Pharmacy Specialist
Rhode Island Hospital
Providence, Rhode Island
Disclosure information not submitted.
Ashley West, BCCCP, BCPS, PharmD
Yale New Haven Health
New Haven, Connecticut
Disclosure information not submitted.
Bryan McGill, PharmD, BCPS, BCCCP
Senior Clinical Pharmacy Specialist, Critical Care
Yale New Haven Hospital, United States
Disclosure information not submitted.
Title: Implementation of a Pharmacist-Lead Albumin Stewardship Program
Introduction: The administration of fluids to impact intravascular volume remains common in ICUs. In patients with sepsis-induced hypoperfusion, IV crystalloids are the resuscitative fluid of choice. Guidelines recommend albumin in patients with end-stage liver disease after large-volume paracentesis, spontaneous bacterial peritonitis, or hepatorenal syndrome. After a medication use evaluation (MUE) conducted in 2017 showed 55% of albumin 25% orders did not meet established restriction criteria at our institution, ordering screens were optimized, requiring a reason for use and end times for select indications. An alert was also created to flag the pharmacist when a patient had a standing order for albumin 25% plus a serum albumin level of >3.5 mg/dL, which then allowed the pharmacist to discontinue the order for select indications per an established protocol.
Methods: A MUE of albumin 25% was conducted in January 2020. Patients were included if they received albumin 25% in inpatient units across our health-system. Patients were excluded if they were pregnant or < 18 years old. Additional data collected included unit, demographics, ordered dose and frequency, concomitantly administered crystalloids or diuretics, vasopressors within 24 hours preceding albumin administration, adherence to pharmacist discontinuation protocol, ordered indication, and chart-documented indication. The primary outcome was compliance to institution-specific restriction criteria.
Results: Out of orders reviewed, 211 (64.5%) orders reviewed did not meet restriction criteria. Similar to the 2017 MUE, most off-criteria use was for albumin-assisted diuresis (14%) and volume expansion in patients with shock (49%). Only 40 (38%) patients with shock had crystalloids administered in the 24 hours prior to albumin. Pharmacist adherence to the discontinuation protocol increased, with only 150 grams meeting criteria for pharmacist discontinuation compared to 3600 grams previously.
Conclusions: A pharmacist-led albumin stewardship team was formed and recommended transitioning to pharmacist-entry only ordering across the health-system, which was largely supported due to the continued off-criteria use despite prior optimizations. This team provided extensive education across the health-system and will continue to collect data on albumin utilization