Article

Clinical and Financial Impact of Pharmacy Services in the Intensive Care Unit: Pharmacist and Prescriber Perceptions

Authors:
  • Research in Real Life
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Study objective: To compare pharmacist and prescriber perceptions of the clinical and financial outcomes of pharmacy services in the intensive care unit (ICU). Design: ICU pharmacists were invited to participate in the survey and were asked to invite two ICU prescriber colleagues to complete questionnaires. Setting: ICUs with clinical pharmacy services. Methods: The questionnaires were designed to solicit frequency, efficiency, and perceptions about the clinical and financial impact (on a 10-point scale) of pharmacy services including patient care (eight functions), education (three functions), administration (three functions), and scholarship (four functions). Basic services were defined as fundamental, and higher-level services were categorized as desirable or optimal. Respondents were asked to suggest possible sources of funding and reimbursement for ICU pharmacy services. Results: Eighty packets containing one 26-item pharmacy questionnaire and two 16-item prescriber questionnaires were distributed to ICU pharmacists. Forty-one pharmacists (51%) and 46 prescribers (29%) returned questionnaires. Pharmacists had worked in the ICU for 8.3 ± 6.4 years and devoted 50.3 ± 18.7% of their efforts to clinical practice. Prescribers generally rated the impact of pharmacy services more favorably than pharmacists. Fundamental services were provided more frequently and were rated more positively than desirable or optimal services across both groups. The percent efficiencies of providing services without the pharmacist ranged between 40% and 65%. Both groups indicated that salary support for the pharmacist should come from hospital departments of pharmacy or critical care or colleges of pharmacy. Prescribers were more likely to consider other sources of funding for pharmacist salaries. Both groups supported reimbursement of clinical pharmacy services. Conclusion: Critical care pharmacy activities were associated with perceptions of beneficial clinical and financial outcomes. Prescribers valued most services more than pharmacists. Fundamental services were viewed more favorably than desirable or optimal services, possibly because they occurred more frequently or were required for safe patient care. Substantial inefficiencies may occur if pharmacy services disappeared. Considerable support existed for funding and reimbursement of critical care pharmacy services.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... [1][2][3][4][5] While literature describes hospital and health system pharmacy models that expand pharmacist roles to include greater clinical patient care activities, the extent of clinical pharmacist services allocation varies based on operational workflow and resources. [6][7][8][9] In 2020, the ASHP Pharmacy Forecast provid-ed strategic recommendations for leaders to advance pharmacy practice through center of excellence recognition. 5 It is anticipated that designation as a pharmacy services center of excellence may improve organizational branding and recruitment of the best talent. ...
... Pharmacist-delivered patient care improves patient outcomes, increases cost efficiency and alleviates pressures on the healthcare system. 8,9 However, competing priorities and responsi-bilities coupled with inefficient processes and workflow can dramatically reduce the amount of time pharmacists are able to dedicate to comprehensive patient-centered care. Traditional pharmacist-to-patient ratios have been reported as ranging from 1:50 to 1:100, with suggested ratios of 1:20 (ICU specific) to 1:30 for optimal care. ...
... Hospitals with residency programs employed significantly more pharmacists statistically with advanced training or board-certification, which supports continued development of innovative models that promote the pharmacist's role in an advanced level of practice. 6,9,[15][16][17][18][19] Pharmacy practice models vary by organization, hospital and services offered, and direct clinical patient care continues to expand to pharmacist credentialing and privileging. 6,7,[20][21][22][23][24][25] In 2018, 32.3% of 811 surveyed hospitals reported pharmacist privileged activities that included prescribing medications pursuant to diagnosis of a medical disease or condition. ...
... The types of respondent ICUs were 126 medical (25.6%), 103 surgical (20.9%), 84 mixed (17%), 48 cardiovascular (9.7%), 34 neurosurgical (6.9%), 30 cardiothoracic (6.1%), 24 trauma (4.9%), 18 pediatric (3.7%), 11 burn (2.2%), six neonatal (1.2%), and nine other (1.8%). Daily census across all ICUs was 12 (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20) occupied beds. The physician model was described ...
... In the 2004 survey, 62.2% of respondents provided direct services and 37.8% provided indirect services (combination was not an option). The type and extent of clinical activities are described in Table 2. Pharmacists attended patient care rounds 5 days (4-5 d) per week and cared for 17 (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26) total patients daily. In terms of pharmacist provider models, 41.4% of respondents indicated they had dependent prescriptive authority (e.g., they required approval from another entity or via collaborative practice agreement or protocol), but for only certain medications or classes of medications, 35.5% of respondents indicated no prescriptive authority was available, 11% of respondents indicated they had independent or autonomous prescriptive authority, but for only certain medications or classes of medications, 9.7% of respondents indicated they had dependent prescriptive authority (e.g., they required approval from another entity or via collaborative practice agreement or protocol) for almost all medications or classes of medications, and 2.4% of respondents indicated they had independent or autonomous prescriptive authority for almost all medications or classes of medications. ...
... Pharmacists continue to justify their value by documenting their services. Given the beneficial patient outcomes associated with direct critical care pharmacy services and the incorporation of the pharmacist into the educational and scholarly missions of the ICU, the return on investment of the ICU pharmacist's salary is almost certainly favorable (16)(17)(18). Some have suggested that the time has come to discard the need for ICU pharmacists to justify their value and instead for ICUs and patients to expect the presence of direct pharmacy services either through accreditation standards or reimbursement (19). ...
Article
Full-text available
Involvement of clinical pharmacists in the ICU attenuates costs, avoids adverse drug events, and reduces morbidity and mortality. This survey assessed services and activities of ICU pharmacists. Design: A 27-question, pretested survey. Setting: 1,220 U.S. institutions. Subjects: Critical care pharmacists. Interventions: Electronic questionnaire of pharmacy services and activities across clinical practice, education, scholarship, and administration. Measurements and main results: A total of 401 (response rate of 35.4%) surveys representing 493 ICUs were completed. Median daily ICU census was 12 (interquartile range, 6-20) beds with 1 (interquartile range, 1-1.5) pharmacist full-time equivalent per ICU. Direct clinical ICU pharmacy services were available in 70.8% of ICUs. Pharmacists attended rounds 5 days (interquartile range, 4-5 d) per week with a median patient-to-pharmacist ratio of 17 (interquartile range, 12-26). The typical workweek consisted of 50% (interquartile range, 40-60%) direct ICU patient care, 10% (interquartile range, 8-16%) teaching, 8% (interquartile range, 5-18%) order processing, 5% (interquartile range, 0-20%) direct non-ICU patient care, 5% (interquartile range, 2-10%) administration, 5% (interquartile range, 0-10%) scholarship, and 0% (interquartile range, 0-5%) drug distribution. Common clinical activities as a percentage of the workweek were reviewing drug histories (28.5%); assessing adverse events (27.6%); and evaluating (26.1%), monitoring (23.8%), and managing (21.4%) drug therapies. Services were less likely to occur overnight or on weekends. Telemedicine was rarely employed. Dependent prescriptive authority (per protocol or via practice agreements) was available to 51.1% of pharmacists and independent prescriptive authority was provided by 13.4% of pharmacists. Educational services most frequently provided were inservices (97.6%) and experiential training of students or residents (89%). Education of ICU healthcare members was provided at a median of 5 times/mo (interquartile range, 3-15 times/mo). Most respondents were involved with ICU or departmental policies/guidelines (84-86.8%) and 65.7% conducted some form of scholarship. Conclusions: ICU pharmacists have diverse and versatile responsibilities and provide several key clinical and nonclinical services. Initiatives to increase the availability of services are warranted.
... A clinical pharmacist involved in direct ICU patient management has been shown to improve patient safety and clinical outcomes in quaternary, tertiary, and community adult and PICUs (30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40). ...
... Consensus not met (73.5% agreement). Clinical pharmacists have become integral members of the multidisciplinary team in all PICUs and demonstrate increasing contributions to improving patient safety and clinical outcomes in adult and PICUs (30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40). ...
... All PICUs should have access to an on-site pediatric pharmacist who is available for daily rounds, pharmacy support, and ongoing educational activities. Although most respondents felt that the presence of an on-site pediatric pharmacist is important who participates in rounds and as stipulated provides education, this may not be feasible in many CMC PICUs (30,35). Kopp et al (35) documented the impact that a pediatric pharmacist can have on decreasing medication errors. ...
Article
Objectives: To update the American Academy of Pediatrics and Society of Critical Care Medicine's 2004 Guidelines and levels of care for PICU. Design: A task force was appointed by the American College of Critical Care Medicine to follow a standardized and systematic review of the literature using an evidence-based approach. The 2004 Admission, Discharge and Triage Guidelines served as the starting point, and searches in Medline (Ovid), Embase (Ovid), and PubMed resulted in 329 articles published from 2004 to 2016. Only 21 pediatric studies evaluating outcomes related to pediatric level of care, specialized PICU, patient volume, or personnel. Of these, 13 studies were large retrospective registry data analyses, six small single-center studies, and two multicenter survey analyses. Limited high-quality evidence was found, and therefore, a modified Delphi process was used. Liaisons from the American Academy of Pediatrics were included in the panel representing critical care, surgical, and hospital medicine expertise for the development of this practice guidance. The title was amended to "practice statement" and "guidance" because Grading of Recommendations, Assessment, Development, and Evaluation methodology was not possible in this administrative work and to align with requirements put forth by the American Academy of Pediatrics. Methods: The panel consisted of two groups: a voting group and a writing group. The panel used an iterative collaborative approach to formulate statements on the basis of the literature review and common practice of the pediatric critical care bedside experts and administrators on the task force. Statements were then formulated and presented via an online anonymous voting tool to a voting group using a three-cycle interactive forecasting Delphi method. With each cycle of voting, statements were refined on the basis of votes received and on comments. Voting was conducted between the months of January 2017 and March 2017. The consensus was deemed achieved once 80% or higher scores from the voting group were recorded on any given statement or where there was consensus upon review of comments provided by voters. The Voting Panel was required to vote in all three forecasting events for the final evaluation of the data and inclusion in this work. The writing panel developed admission recommendations by level of care on the basis of voting results. Results: The panel voted on 30 statements, five of which were multicomponent statements addressing characteristics specific to PICU level of care including team structure, technology, education and training, academic pursuits, and indications for transfer to tertiary or quaternary PICU. Of the remaining 25 statements, 17 reached consensus cutoff score. Following a review of the Delphi results and consensus, the recommendations were written. Conclusions: This practice statement and level of care guidance manuscript addresses important specifications for each PICU level of care, including the team structure and resources, technology and equipment, education and training, quality metrics, admission and discharge criteria, and indications for transfer to a higher level of care. The sparse high-quality evidence led the panel to use a modified Delphi process to seek expert opinion to develop consensus-based recommendations where gaps in the evidence exist. Despite this limitation, the members of the Task Force believe that these recommendations will provide guidance to practitioners in making informed decisions regarding pediatric admission or transfer to the appropriate level of care to achieve best outcomes.
... It also further builds the case that a SCCP can boost compliance to institutional protocols not solely focused on medication therapy (17,18). Importantly, the salary to support this SCCP over the 18-month intervention period was only 25% of the € 195,000 in-hospital cost savings realized, a return on investment similar to that demonstrated in other studies, including one from the Netherlands (12,19). ...
... The role of the SCCP in low-income countries may be of particular importance where medications may be scarce/hard to obtain, and intensivist resources are often stretched (22). As was done in this study (16), it is important for SCCP's to document their impact on both cost and patient outcome (6,13,14,19). Pharmacists who desire a SCCP role should seek out additional training, mentoring, and board-certification opportunities. Pharmacy managers should cultivate relationships with hospital administrators and ICU directors to establish new SCCP positions. ...
Article
Full-text available
EDITORIAL IN CCM
... Both groups recognised fundamental pharmacist activities such as provision of drug information, assessment of admission for causality, monitoring for safety, efficacy and pharmacokinetics and prospective evaluation of drug therapy. 34 Despite the lack of agreement seen in this study, there was a high rate of clinician acceptance of pharmacist interventions. Clinical pharmacy services appear to be valued by other health professionals, although pharmacists themselves often under-perceive the value of their own contributions to the team. ...
... Clinical pharmacy services appear to be valued by other health professionals, although pharmacists themselves often under-perceive the value of their own contributions to the team. 34 Despite the trend for increased reporting of medication-related incidents and ADRs seen in this study, the actual number of reports was low. However, analysis of the reports made showed only errors that had reached the patient had been reported, highlighting the underreporting of 'near-misses'. ...
Article
More than a quarter of reported incidents in hospitals are medication-related. The critically ill population is at greater risk of medication-related incidents due to a number of factors, including a higher number of drugs prescribed, lower physiological reserve and greater illness severity. Overseas studies have shown that the inclusion of on-ward clinical pharmacy support may attenuate these drug-related problems (DRPs); however, local evidence in regional Australian intensive care units (ICUs) is lacking.
... [18][19][20] However, these findings are not generalisable as such, since these studies were performed in North America and their setting is different from the European setting. Whereas the American pharmacists have been intensively involved in critical care for many years, 21 in Europe most hospital pharmacies do not have a clinical pharmacy service. As a result Europe has about 17 times less pharmacists, i.e. 1.1 hospital pharmacists/100 beds. ...
... Up to now, only a few European studies have calculated costs of interventions made by clinical pharmacists in the ICU. 16,21,24 All studies were single centre and the economic outcomes differed greatly between these studies. Therefore, a prospective quality improvement study was performed in two ICUs in the Netherlands with the primary aim to determine the proportion of pharmacist interventions accepted by physicians during ICU patient rounds. ...
Article
Full-text available
Introduction: The risk of prescribing errors and related adverse drug events (ADE) on the intensive care unit (ICU) is high. Based on studies carried out in North America or the UK, a clinical pharmacy service can reduce ADEs and lower overall costs. This study looks into the clinical and financial impact of interventions made by pharmacists during patient rounds in two ICU settings in the Netherlands. Materials and methods: A quality improvement study was performed in a general teaching hospital (GTH) and a university hospital (UH) in the Netherlands. The improvement consisted of a review of medication orders and participation in patient rounds by an ICU-trained pharmacist. The main outcome measure was the proportion of accepted pharmacist interventions. Secondary outcome measures were the clinical relevance of the accepted interventions, the proportion of prevented potential ADEs (pADE) and a cost-benefit ratio. Results: In the GTH 160 patients and in the UH 174 patients were included. A total of 332 and 280 interventions were analysed. Acceptance of the interventions was 67.3% in the GTH and 61.8% in the UH. The accepted interventions were mostly scored as clinically relevant, resulting in 0.16 and 0.11 prevented pADEs per patient. The cost benefit was €119 (GTH) and €136 (UH) per accepted intervention. Conclusion: This clinical pharmacy service in two ICUs resulted in high numbers of accepted and clinically relevant interventions. Our model appeared to be cost-effective in both ICU settings.
... For instance, in several countries, clinical services provided by pharmacists are not reimbursed. This discourages the pharmacists from providing these services [28,29]. Moreover, lack of information and understanding among physicians, other health professionals, and patients about how pharmacists can contribute to seizure control and quality of life of people with epilepsy can also hamper the deployment and implementation of pharmaceutical care services. ...
... Although there is some literature about other health care professionals' opinions of clinical pharmacy services, few studies have included hospital pharmacists' perceptions of their own role. 11,[16][17][18] Even less has been published on hospital pharmacists' perspectives on expanding scopes of practice. [19][20][21] However, the survey tools used in these previous studies were not validated for internal consistency or reliability. ...
Article
Full-text available
p> ABSTRACT Background: Pharmacists have made significant contributions to patient care and have been recognized as integral members of the interprofessional team. Health care professionals differ in their opinions and expectations of clinical pharmacy services. Very little has been published about health care professionals’ perspectives on advanced clinical pharmacy roles, such as prescriptive authority or administration of vaccines. In 2013, clinical pharmacy services were introduced in a vascular and general surgery ward where a pharmacist had not previously been assigned. Objectives: To explore surgical nurses’ and physicians’ opinions and expectations of clinical pharmacy services and to determine how these views changed over time; to compare pharmacists’ views of clinical pharmacy services with those of nurses and physicians; and to develop validated survey tools. Methods: Three survey tools were created and validated, one for each profession. Surveys were distributed to nurses and physicians assigned to the general and vascular surgery ward before introduction of clinical pharmacy services and 8 months after implementation. Hospital pharmacists were invited to complete the survey at one time point. Results: Differences existed in the opinions of nurses, physicians, and pharmacists about some traditional activities. Nurses and physicians indicated stronger agreement with pharmacists participating in medication reconciliation activities than did pharmacists (p < 0.001), whereas a greater proportion of pharmacists felt that they were the most appropriate health care professionals to provide medication discharge counselling, relative to nurses and physicians (p = 0.001). Respondents supported advanced roles for pharmacists, such as collaborative practice agreements, but there was less support for prescribing, physical assessments, and administration of vaccines. Nurses indicated the strongest agreement with pharmacist prescribing (82% versus 69% among pharmacists and 27% among physicians; p < 0.001). Nurses and physicians expressed strong endorsements of clinical pharmacy services in the surveys’ comment sections. Conclusions: The introduction of clinical pharmacy services to a surgical health care team resulted in high levels of satisfaction among nurses and physicians who responded to this survey. Differences in perceptions of traditional clinical pharmacy service activities and advanced practice roles need to be studied in more depth to better understand the factors influencing health care professionals’ views. RÉSUMÉ Contexte : Les pharmaciens ont fait d’importantes contributions aux soins aux patients et ils ont d’ailleurs été reconnus comme membres à part entière de l’équipe interprofessionnelle. Les professionnels de la santé ont des opinions et des attentes variées en ce qui concerne les services de pharmacie clinique. Or, il n’y a que très peu de documents publiés à propos des points de vue soutenus par les professionnels de la santé sur les rôles en pharmacie clinique avancée, notamment le droit de prescrire et l’administration de vaccins. En 2013, des services de pharmacie clinique ont fait leur entrée dans une unité de chirurgie générale et vasculaire où aucun pharmacien n’avait été affecté auparavant. Objectifs : Chercher à connaître l’opinion et les attentes du personnel médical et infirmier rattaché à une unité de chirurgie en ce qui concerne les services de pharmacie clinique et voir comment ces perceptions ont changé avec le temps; comparer les points de vue soutenus par les pharmaciens en ce qui concerne les services de pharmacie clinique à ceux du personnel médical et infirmier; et mettre au point des outils d’enquête validés. Méthodes : Trois outils d’enquête ont été créés et validés, un pour chaque profession. Les sondages ont été distribués au personnel médical et infirmier rattaché à l’unité de chirurgie générale et vasculaire avant l’introduction de services de pharmacie clinique, puis huit mois après la mise en place de ces services. Les pharmaciens d’hôpitaux ont été invités à répondre au sondage à un point dans le temps. Résultats : On a observé des différences entre les opinions du personnel infirmier, des médecins et des pharmaciens à propos de certaines activités traditionnelles. Le personnel infirmier et les médecins ont indiqué être plus fortement d’accord avec la participation des pharmaciens aux activités touchant le bilan comparatif des médicaments que ne l’ont signalé les pharmaciens ( p < 0,001), alors qu’une plus grande proportion de pharmaciens croyaient être les professionnels de la santé les mieux placés pour offrir des conseils sur les médicaments au moment du congé, comparativement au personnel infirmier et aux médecins ( p = 0,001). Les répondants étaient favorables aux rôles avancés pour les pharmaciens, comme les ententes de pratique en collaboration, mais ils l’étaient moins en ce qui touche à la prescription, à l’examen physique et à la vaccination. Le personnel infirmier était le plus d’accord avec le droit de prescrire des pharmaciens (82 % contre 69 % pour les pharmaciens et 27 % pour les médecins; p < 0,001). Le personnel infirmier et les médecins ont exprimé un fort appui pour les services de pharmacie clinique dans les sections du sondage réservées aux commentaires. Conclusions : La mise en place de services de pharmacie clinique dans une équipe de soins de santé en chirurgie s’est traduite par des niveaux élevés de satisfaction chez le personnel infirmier et les médecins ayant répondu à ce sondage. Les différences des perceptions à l’égard des activités traditionnelles de services de pharmacie clinique et les rôles de pratique avancée doivent être étudiées plus en profondeur afin de mieux comprendre les facteurs qui influencent les points de vue des professionnels de la santé.</p
... Higher volume of exposure leads to improved outcomes (22). The use of clinical pharmacists in daily rounds has previously been reported to improve outcomes and the study reviewed here supports the same (23)(24)(25). Staffing an oncological ICU with nurses and pharmacists focused on the concomitant oncology and critical care needs would likely have added benefit. ...
Article
Full-text available
Since the inception of critical care as a formal discipline in the late 1950s, we have seen rapid specialization to many types of intensive care units (ICUs) to accommodate evolving life support technologies and novel therapies in various disciplines of medicine. Indeed, the field has expanded such that specialized ICUs currently exist to address critical care problems in medicine, cardiology, neurology and neurosurgery, trauma, burns, organ transplant and cardiothoracic surgeries. Specialization does not only need new infrastructure, but also training and staffing of health care providers, ancillary staff, and development and implementation of processes of care. Oncology is another branch of medicine with growing ICU needs. Given the rise in cancer incidence worldwide and better survival rates alongside advances in chemotherapeutic and surgical options, more cancer patients are nowadays requiring advanced life support for cancer-related complications, treatmentrelated toxicities and severe infections. Here we provide a brief summary of the current evidence supporting the specialization of critical care and explore three different models of care for critically ill cancer patients, including the development of a specialized oncological ICU. Finally, we also discuss recently published and future research related to the care of critically ill cancer patients.
... 2,3 This is surprising, considering that many studies have described the positive impact that critical care pharmacists have on patient care, quality metrics, and financial goals for organizations. [4][5][6][7][8] Furthermore, the Society of Critical Care Medicine (SCCM) recognizes pharmacists as an integral part of the critical care team. 9 On the supply side, the pipeline of pharmacy school graduates pursuing a career in health system pharmacy has continued to increase over the years. ...
Article
Background: While hospital beds continue to decline as patients previously treated as inpatients are stabilized in ambulatory settings, the number of critical care beds available in the United States continues to rise. Growth in pharmacy student graduation, postgraduate year 2 critical care (PGY2 CC) residency programs, and positions has also increased. There is a perception that the critical care trained pharmacist market is saturated, yet this has not been evaluated since the rise in pharmacy graduates and residency programs. Purpose: To describe the current perception of critical care residency program directors (CC RPDs) and directors of pharmacy (DOPs) on the critical care pharmacist job market and to evaluate critical care postresidency placement and anticipated changes in PGY2 CC programs. Methods: Two electronic surveys were distributed from October 2015 to November 2015 through Vizient/University HealthSystem Consortium, American Society of Health-System Pharmacists (ASHP), Society of Critical Care Medicine, and American College of Clinical Pharmacy listservs to target 2 groups of respondents: CC RPDs and DOPs. Questions were based on the ASHP Pharmacy Forecast and the Pharmacy Workforce Center’s Aggregate Demand Index and were intended to identify perceptions of the critical care market of the 2 groups. Results: Of 116 CC RPDs, there were 66 respondents (56.9% response rate). Respondents have observed an increase in applicants; however, they do not anticipate increasing the number of positions in the next 5 years. The overall perception is that there is a balance in supply and demand in the critical care trained pharmacist market. A total of 82 DOPs responded to the survey. Turnover of critical care pharmacists within respondent organizations is expected to be low. Although a majority of DOPs plan to expand residency training positions, only 9% expect to increase positions in critical care PGY2 training. Overall, DOP respondents indicated a balance of supply and demand in the critical care trained pharmacist market. In comparing RPD and DOP perceptions of the demand for critical care pharmacists, DOPs perceived demand to be higher than RPDs (mean, 3.2 vs 2.8; P = .032). Conclusion: Although there is a perception of the oversupply of critical care trained pharmacists, a survey of DOPs and CC RPDs found a market with positions available, rapid hiring, stable salaries, and plans for expanded hiring of critical care trained pharmacists.
... On one hand, in most nations, clinical services provided by pharmacists are not reimbursed, which discourages pharmacists from taking on this role. 26,27 On the other, the authors suggest this situation also may reflect pharmacists' knowledge gaps that would inhibit them from performing clinical services. In a study centered in Aracaju, one of northwestern Brazil's largest cities, almost 80% of pharmacists working in community pharmacies were found to have insufficient knowledge to perform clinical services such as dispensing drugs. ...
Article
Full-text available
Objective: To identify studies about clinical services performed by pharmacists for patients with epilepsy (PWE) and the impact of these services on the health of PWE. Study Design: A systematic review of published studies describing clinical services performed by pharmacists for PWE. Methods: We performed a systematic review of studies published in PubMed, Scopus, and Lilacs databases prior to March 3, 2015. The inclusion criteria were (a) original, observational, or experimental studies available in full text; (b) published in English, Portu-guese, or Spanish language; and (c) described clinical services performed by pharmacists for PWE. The quality of the selected studies was evaluated using the Downs and Black checklist, and the systematic review was prepared in accordance with the recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Results: We identified 4463 studies; 5 were in accordance with inclusion criteria. The pharmaceutical contributions identified were registration of information related to the patient, health education, and counseling. The pharmacists' interventions were able to prevent problems related to the use of medicines, improve patients' knowledge about epilepsy, improve patients' quality of life and agility in daily activities, and increase medication adherence of PWE. Conclusions: Pharmacists are involved in clinical services that can improve the treatment outcomes and the epilepsy-related health of patients, but a limited number of articles in the scientific literature highlight these contributions. Am J Pharm Benefits. 2016;8(3):e55-e60
... PE classifications determined by a physician as in our study, could be different from classifications determined by pharmacists, as in the study by Klopotowska [1]. It has been shown that physicians tend to rate the impact of pharmacy services more favourably than do pharmacists themselves [15]. However, by requiring the physicians' approval, a clinically relevant study result was guaranteed. ...
Article
Full-text available
Background With a clinical pharmacists’ participation in an intensive care unit (ICU) previous international studies have shown a reduction of medication errors, drug costs and improvements of clinical outcomes. Still there is a lack of qualitative data on clinical pharmacists’ impact on prescribing error rates in the ICU. Therefore, a new approach was developed relating prescribing errors to the number of monitored medications including physicians’ approval on all prescribing errors. Objective This study investigates the influence of clinical pharmacists’ medication review on the prescribing error rate in an ICU. Setting A controlled interventional study was conducted in a surgical ICU with one control phase (P0) and two intervention phases (P1 and P2). Method The investigation aimed to determine if the medication review by clinical pharmacists results in a significant reduction of prescribing errors related to a control period. In contrast to previous studies, prescribing errors detected by the clinical pharmacists, were only taken into account, if consent with the physicians was achieved. Secondary outcomes were the reduction of potentially severe prescribing errors, the number of days without systemic anti-infective therapy and the ICU length of stay. Throughout P0 the data was collected retrospectively without any intervention. During the intervention periods P1 and P2, two clinical pharmacists screened the medical records for prescribing errors and discussed them with the senior physician in charge. During P2 one clinical pharmacist attended ward rounds additionally. Main Outcome Measure The main outcome measure of this study was the number of prescribing errors detected related to the number of monitored medications. Results The incidence of prescribing errors was significantly reduced from 1660 in P0 to 622 in P1 respectively 401 in P2 (P0 vs. P1/P2 respectively; both p < 0.001; Fisher’s Exact Test) in total, respective 14.12% in P0 vs. 5.13% in P1 and 3.25% in P2 related to the monitored medications (P0:11755; P1:12134; P2:12329). Conclusion Clinical pharmacists’ interventions led to a significant reduction of prescribing errors in the ICU, contributing to a safer medication process. We strongly recommend a broad implementation of clinical pharmacists in ICUs.
... 9,30 Moreover, in a recent survey, prescribers generally perceived greater clinical and financial impact of direct critical care pharmacy services than the pharmacist who provided these services. 33 As such, the leap of faith that administrators must take to justify critical care pharmacy services is worthwhile both financially and based on prescriber perceptions. ...
... The studies indicate that a large majority, and in most studies almost all, of pharmacists' recommendations are accepted by the physicians [3,4,[13][14][15]. These significant improvements in patient care afforded by the presence of dedicated pharmacists are clearly viewed as important by medical colleagues, as shown by a recent survey [16]. ...
... Process evaluations and other research involving multiprofessional collaboration including ward-based pharmacists often make use of surveys to study the views of the involved healthcare professionals [14][15][16][17][18][19]. These survey studies report that physicians and nurses generally are satisfied with the collaboration with the pharmacists and that an increase in the quality and safety of the patients' medication treatment is perceived. ...
Article
Full-text available
Purpose: There is a lack of knowledge about factors that influence the performance of comprehensive medication reviews (CMRs) by multiprofessional teams in hospital practice. This study aimed to explore the facilitators and barriers for performing CMRs and post-discharge follow-up in older hospitalised patients from the healthcare professional perspective. Methods: Physicians and ward-based pharmacists were recruited from an ongoing trial at four hospitals in Sweden. Semi-structured interviews were conducted with 16 physicians and 7 pharmacists. Interview topics were working processes, resources, competences, medication-related problems, intervention effects and collaboration. The interviews were audio-recorded, transcribed verbatim and thematically analysed using the Consolidated Framework for Implementation Research (CFIR). Identified subthemes were categorised as facilitators or barriers and grouped into overarching main themes. Results: In total, 21 facilitators and 25 barriers were identified across all CFIR domains and grouped in 6 main themes: (a) CMRs and follow-up are needed, but not in all patients; (b) there is a general belief in positive effects; (c) lack of resources is an issue, although the performance of CMRs may save time; (d) pharmacists' knowledge and skills are valuable, but they need more clinical competence; (e) compatibility with hospital practice is challenging, and roles and responsibilities are unclear and (f) personal contact at the ward is essential for physician-pharmacist collaboration. Conclusion: Multiple facilitators and barriers for performing CMRs and post-discharge follow-up in older hospitalised patients exist. These factors should be addressed in future initiatives with similar interventions by multiprofessional teams to ensure successful implementation and performance in hospital practice.
... It is expected that demand by other healthcare disciplines for pharmacists to directly engage in functions involving research/scholarship will increase as pharmacists possess unique knowledge and skills about study design, data analyses, and pharmacotherapy application in research (99). The results of another survey of ICU providers and pharmacists showed nonpharmacist providers consistently valued the clinical and financial impact of all pharmacy services, including those involving research/scholarship (100). It will be incumbent on the profession of pharmacy to ensure that critical care pharmacists are appropriately trained to deliver the functions of research/scholarship across all ICUs. . ...
Article
Objectives: Provide a multiorganizational statement to update the statement from a paper in 2000 about critical care pharmacy practice and makes recommendations for future practice. Design: The Society of Critical Care Medicine, American College of Clinical Pharmacy Critical Care Practice and Research Network, and the American Society of Health-Systems Pharmacists convened a joint task force of 15 pharmacists representing a broad cross-section of critical care pharmacy practice and pharmacy administration, inclusive of geography, critical care practice setting, and roles. The Task Force chairs reviewed and organized primary literature, outlined topic domains, and prepared the methodology for group review and consensus. A modified Delphi method was used until consensus (> 66% agreement) was reached for each practice recommendation. Previous position statement recommendations were reviewed and voted to either retain, revise, or retire. Recommendations were categorized by level of ICU service to be applicable by setting, and grouped into five domains: patient care, quality improvement, research and scholarship, training and education, and professional development. Main results: There are 82 recommendation statements: forty-four original recommendations and 38 new recommendation statements. Thirty-four recommendations were made for patient care, primarily relating to critical care pharmacist duties and pharmacy services. In the quality improvement domain, 21 recommendations address the role of the critical care pharmacist in patient and medication safety, clinical quality programs, and analytics. Nine recommendations were made in the domain of research and scholarship. Ten recommendations are in the domain of training and education and eight recommendations regarding professional development. Conclusions: The statements recommended by this taskforce delineate the activities of a critical care pharmacist and the scope of pharmacy services within the ICU. Effort should be made from all stakeholders to implement the recommendations provided, with continuous effort toward improving the delivery of care for critically ill patients.
... Fundamental services are viewed more favorably than desirable or optimal services, possibly because they are provided more frequently or are required for safe patient care. [7] Clinical pharmacy interventions could also decrease the cost of treatment in the ICUs. [8] Average number of interventions is also usually high in ICUs. ...
Article
Full-text available
Intensive care unit is a potential area for drug-related problems. As many of the patients treated are complex patients, clinical pharmacy intervention could find drug therapy problems. Drug information liaisons daily attended ward rounds with intensivists and screened the patient for drug therapy assessment using the American Society for Health-System Pharmacists clinical skills competition DTA format. This was a prospective study done for 6 months from August 2012 to January 2013. Simple statistics were used to tabulate the drug-related problems assessed. A total of 72 patients were screened for drug therapy problems, for which 947 drug doses were prescribed in the study period. The total number of prescriptions was 148. The average number of drugs per prescription was 6.39 and the average number of drugs per patient was 13.15. A total of 243 problems were identified; on an average, 1.67 problems were present per prescription. The total number of drug interactions identified was N = 192 (78.2%); majority of them (61.4%) were of type C (not serious). So, 55.73% of them were monitored and not stopped or substituted. The second type of problem was a correlation between drug therapy and medical problem (7.4%). Appropriate drug selection and drug regimen was the third problem, and the adverse drug reactions and therapeutic duplications accounted for approximately 2% of the drug-related problems identified. Drug interactions constituted the major problem of ICUs, but not many were serious or significant. Consensus in assessment of drug-related problems and convincing intensivists with good quality evidences are required for better acceptance of interventions.
... 20 These results are consistent with perceptions of nonpharmacist prescribers who perceive financial as well as clinically impactful services provided by ICU pharmacists. 21 ...
Article
Critical care medicine has grown from a small group of physicians participating in patient care rounds in surgical and medical intensive care units (ICUs) to a highly technical, interdisciplinary team. Pharmacy's growth in the area of critical care is as exponential. Today's ICU requires a comprehensive pharmaceutical service that includes both operational and clinical services to meet patient medication needs. This article provides the elements for a business plan to justify critical care pharmacy services by describing the pertinent background and benefit of ICU pharmacy services, detailing a current assessment of ICU pharmacy services, listing the essential ICU pharmacy services, describing service metrics, and delineating an appropriate timeline for implementing an ICU pharmacy service. The structure and approach of this business plan can be applied to a variety of pharmacy services. By following the format and information listed in this article, the pharmacy director can move closer to developing patient-centered pharmacy services for ICU patients. 2016
Article
Background: Reasons for suboptimal metformin prescribing are unclear, but may be due to perceived risk of lactic acidosis. The purpose of this study is to describe provider attitudes regarding metformin prescribing in various patient situations. Methods: An anonymous, electronic survey was distributed electronically to 76 health care providers across the nation. The 14-item survey contained demographic questions and questions related to prescribing of metformin for T2DM in various patient situations, including suboptimal glycemic control, alcohol use, history of lactic acidosis, and varying degrees of severity for certain health conditions, including renal and hepatic dysfunction, chronic obstructive pulmonary disease, and heart failure. Results: There were a total of 100 respondents. For suboptimal glycemic control, most providers (75%) would increase metformin from 1500 to 2000 mg daily; however, 25% would add an alternate agent, such as a sulfonylurea (18%) or dipeptidyl peptidase-4 inhibitor (7%). Although 51% of providers would stop metformin based on serum creatinine thresholds, the remainder would rely on glomerular filtration rate thresholds of <60 mL/min (15%), <30 mL/min (33%), or <15 mL/min (1%) to determine when to stop metformin. For heart failure, 45% of providers would continue metformin as currently prescribed regardless of severity. Most providers would adjust metformin for varying severity of hepatic dysfunction (74%) and alcohol abuse (40%). Conclusions: Despite evidence supporting the cardiovascular benefits of metformin, provider attitudes toward prescribing metformin are suboptimal in certain patient situations and vary greatly by provider.
Article
Today, many pharmacists identify themselves as critical care specialists, and some may assume that this specialty has always been in place. However, critical care pharmacy practice has formally existed for only about 35 years. The evolution of clinically oriented pharmacy practice in general
Article
Psychiatric pharmacists have specialized knowledge, skills, and training or substantial experience working with patients with psychiatric or neurologic disorders. As part of the collaborative team with a physician, psychiatric pharmacists can provide comprehensive medication management (CMM), a direct patient care service, to patients with psychiatric or neurologic disorders. CMM is a standard of care in which all medications for an individual patient are assessed to determine appropriateness, effectiveness, safety, and adherence. Studies have shown that when psychiatric pharmacists are included as part of the collaborative team with a physician, medication-related outcomes for patients with psychiatric or neurologic disorders improve. Despite the evidence supporting the value of psychiatric pharmacists as part of the health care team, the very limited mechanisms for compensation for CMM limit the numbers of patients with psychiatric or neurologic disorders who have access to services provided by a psychi...
Article
Full-text available
Objective. To summarize the effects of media methods used in continuing education (CE) programs on providing clinical community pharmacy services and the methods used to evaluate the effectiveness of these programs. Methods. A systematic review was performed using Medline, SciELO, and Scopus databases. The timeline of the search was 1990 to 2013. Searches were conducted in English, Portuguese, and Spanish. Results. Nineteen articles of 3990 were included. Fourteen studies used only one media method, and the live method (n511) was the most frequent (alone or in combination). Only two studies found that the CE program was ineffective or partially effective; these studies used only the live method. Most studies used nonrobust, nonvalidated, and nonstandardized methods to measure effectiveness. The majority of studies focused on the effect of the CE program on modifying the knowledge and skills of the pharmacists. One study assessed the CE program’s benefits to patients or clients. Conclusion. No evidence was obtained regarding which media methods are the most effective. Robust and validated methods, as well as assessment standardization, are required to clearly determine whether a particular media method is effective. © 2016, American Association of Colleges of Pharmacy. All rights reserved.
Article
Objectives: Surgical and medical ICU patients are at high risk of mortality and provide a significant cost to the healthcare system. The aim of this study is to describe the effect of pharmacist-led interventions on drug therapy and clinical strategies on ICU patient outcome and hospital costs. Design: Before and after study in two French ICUs (16 and 10 beds). Patients: ICU patients. Intervention: From January 1, 2013, to June 30, 2015, a pharmacist observation period was compared with an intervention period in which a critical care pharmacist provided recommendations to clinicians regarding sedative drugs and doses, choice of mechanical ventilation mode and related settings, antimicrobial de-escalation, and central venous and urinary catheters removal. Differences in ICU and hospital length of stay, duration of mechanical ventilation, mortality rate, and hospital costs per patient were quantified between groups with patients matched for severity of illness (Simplified Acute Physiology Score II) at admission. Measurements and main results: From the 1,519 and 1,268 admitted patients during the observation and intervention periods, respectively, 1,164 patients were evaluable in both groups after matching for Simplified Acute Physiology Score II score. The intervention period was associated with mean (95% CI) reductions in patient hospital length of stay (3.7 d [5.2-2.3 d]; p < 0.001), ICU length of stay (1.4 d [2.3-0.5 d]; p < 0.005), duration of mechanical ventilation (1.2 d [2.1-0.3 d]; p < 0.01), and hospital costs per stay (2,560 euros [3,728-1,392 euros]; p < 0.001). The overall cost savings were 10,840 euros (10,727-10,952 euros) per month, mostly due to reduced consumption of sedatives and antimicrobials. No impact on mortality rate was identified. Conclusions: Critical care pharmacist-led interventions were associated with decreases in ICU and hospital length of stays and ICU drug costs.
Article
Evidence supports pharmacists as essential team members in the intensive care unit (ICU). Data are limited for pharmacist prescribing and documentation, ideal pharmacist staffing, and timing of clinical pharmacy activities in the ICU. The purpose of this evaluation was to assess the frequency, timing, and most common areas of prescribing and documentation for critical care clinical pharmacy specialists (CPSs) in a single medical center with around‐the‐clock staffing. A Veterans Affairs (VA) medical center implemented a collaborative practice model in which CPSs provide direct ICU patient care around the clock. Direct patient care activities are provided for two ICUs with three multidisciplinary teams (medical, surgical, and cardiovascular), the nutrition support team, and emergency response teams. Documentation through an electronic health record progress note is required any time a CPS performs a patient encounter and uses prescriptive authority. A retrospective evaluation was performed to evaluate critical care CPS patient encounters and clinical interventions from October 1, 2016 through September 30, 2020. Cumulatively, 78 622 CPS clinical interventions requiring prescriptive authority were made during 17 938 documented encounters. For clinical interventions, 40 897 (52.0%) were during daytime hours and 37 725 (48.0%) were after‐hours. Of the documented encounters, 10 461 (58.3%) were during daytime hours compared with 7477 (41.7%) after‐hours. Medication‐related prescribing interventions accounted for 57 400 (73.0%) of the interventions, while 6931 (8.8%) were nonpharmacologic and 14 291 (18.2%) were additional interventions. The most common disease states for prescribing interventions included Anticoagulation (13.8%), Infectious Diseases (13.1%), Cardiovascular (10.5%), Nutrition/Gastrointestinal (6.6%), Neuropsychiatric (5.3%), Endocrine (4.3%), Nephrology (3.5%), and Pulmonary (1%). This evaluation provides details of prescribing and documentation by critical care CPSs with an around‐the‐clock staffing model. This may be useful for ICU clinicians and administrators considering expanding critical care pharmacy services.
Article
This article has been retracted: please see INNOVATIONS in pharmacy retraction policy (https://pubs.lib.umn.edu/index.php/innovations/policies). This article has been retracted by the Editor and Publisher due to the inappropriate use of previously published work. The beginnings of caring for critically ill patients date back to Florence Nightingale’s work during the Crimean War in 1854, but the subspecialty of critical care medicine is relatively young. The first US multidisciplinary intensive care unit (ICU) was established in 1958, and the American Board of Medical Subspecialties first recognized the subspecialty of critical care medicine in 1986. Critical care pharmacy services began around the 1970s, growing in the intervening 40 years to become one of the largest practice areas for clinical pharmacists, with its own section in the SCCM, the largest international professional organization in the field. During the next decade, pharmacy services expanded to various ICU settings (both adult and pediatric), the operating room, and the emergency department. In these settings, pharmacists established clinical practices consisting of therapeutic drug monitoring, nutrition support, and participation in patient care rounds. Pharmacists also developed efficient and safe drug delivery systems with the evolution of critical care pharmacy satellites and other innovative programs. In the 1980s, critical care pharmacists designed specialized training programs and increased participation in critical care organizations. The number of critical care residencies and fellowships doubled between the early 1980s and the late 1990s. Standards for critical care residency were developed, and directories of residencies and fellowships were published. In 1989, the Clinical Pharmacy and Pharmacology Section was formed within the Society of Critical Care Medicine, the largest international, multidisciplinary, multispecialty critical care organization. This recognition acknowledged that pharmacists are necessary and valuable members of the physician-led multidisciplinary team. The Society of Critical Care Medicine Guidelines for Critical Care Services and Personnel deem that pharmacists are essential for the delivery of quality care to critically ill patients. These guidelines recommend that a pharmacist monitor drug regimen for dosing, adverse reactions, drug-drug interactions, and cost optimization for all hospitals providing critical care services. The guidelines also advocate that a specialized, decentralized pharmacist provide expertise in nutrition support, cardiorespiratory resuscitation, and clinical research in academic medical centers providing comprehensive critical care. Article Type: Commentary
Article
Objectives: To provide a multiorganizational statement to update recommendations for critical care pharmacy practice and make recommendations for future practice. A position paper outlining critical care pharmacist activities was last published in 2000. Since that time, significant changes in healthcare and critical care have occurred. Design: The Society of Critical Care Medicine, American College of Clinical Pharmacy Critical Care Practice and Research Network, and the American Society of Health-Systems Pharmacists convened a joint task force of 15 pharmacists representing a broad cross-section of critical care pharmacy practice and pharmacy administration, inclusive of geography, critical care practice setting, and roles. The Task Force chairs reviewed and organized primary literature, outlined topic domains, and prepared the methodology for group review and consensus. A modified Delphi method was used until consensus (> 66% agreement) was reached for each practice recommendation. Previous position statement recommendations were reviewed and voted to either retain, revise, or retire. Recommendations were categorized by level of ICU service to be applicable by setting and grouped into five domains: patient care, quality improvement, research and scholarship, training and education, and professional development. Main results: There are 82 recommendation statements: 44 original recommendations and 38 new recommendation statements. Thirty-four recommendations represent the domain of patient care, primarily relating to critical care pharmacist duties and pharmacy services. In the quality improvement domain, 21 recommendations address the role of the critical care pharmacist in patient and medication safety, clinical quality programs, and analytics. Nine recommendations were made in the domain of research and scholarship. Ten recommendations were made in the domain of training and education and eight recommendations regarding professional development. Conclusions: Critical care pharmacists are essential members of the multiprofessional critical care team. The statements recommended by this taskforce delineate the activities of a critical care pharmacist and the scope of pharmacy services within the ICU. Effort should be made from all stakeholders to implement the recommendations provided, with continuous effort toward improving the delivery of care for critically ill patients.
Article
Background: The involvement of pharmacists in the provision of specialised care to patients with epilepsy is poor. Objective: To evaluate the impact of pharmaceutical care services on the clinical outcomes of epilepsy. Setting: Two selected major referral epilepsy treatment centres in southern Nigeria were used for the study. Patients were recruited from the Neurology and Medical out-patient clinics of the hospitals. Method: An open randomised controlled study was carried out on epilepsy patients receiving clinical care at the selected hospitals. Patients in the intervention group were offered pharmaceutical care services. The impact of the pharmaceutical care services on the clinical outcomes of epilepsy (seizure frequency and severity) was evaluated. Main outcome measure: The effect of pharmaceutical care services on seizure frequency and severity in patients with epilepsy. Results: There was a statistically significant difference between the usual care (UC) and the pharmaceutical care (PC) group on the clinical outcomes of epilepsy post-PC intervention. Comparison between the groups (UC versus PC) revealed that patients in the PC group had a significantly lower seizure frequency score than those in the UC group at 3 months and 6 months-(pre-intervention: 3.09 versus 3.34; t = -1.685; p = 0.094) (3 months 2.45 versus 1.68; t = 4.494; p = 0.001), (6 months: 1.97 versus 0.92; t = -3.137; p = 0.001). Also, comparisons between the groups (UC versus PC) showed that patients in the PC group had a significantly lower seizure severity score than those in the UC group at 3 months and 6 months-(pre-intervention 18.46 versus 20.38; t = -3.102; p = 0.01) (3 months: 17.51 versus 14.79; t = 4.202; p = 0.001) (6 months 16.41 versus 11.66; t = 8.930; p = 0.001). Conclusion: Pharmaceutical care interventions may significantly reduce seizure frequency and severity in patients with epilepsy. Impact of findings on practice: These findings provide justification for the integration of pharmaceutical care services with other elements of health care for epilepsy patients.
Article
Critical care pharmacy services in the ICU have expanded from traditional dispensing responsibilities to being recognized as an essential component of multidisciplinary care for critically ill patients. Augmented by technology and resource utilization, this shift in roles has allowed pharmacists to provide valuable services in the form of assisting physicians and clinicians with pharmacotherapy decision-making, reducing medication errors, and improving medication safety systems to optimize patient outcomes. Documented improvements in the management of infections, anticoagulation therapy, sedation, and analgesia for patients receiving mechanical ventilation and in emergency response help to justify the need for clinical pharmacy services for critically ill patients. Contributions to quality improvement initiatives, scholarly and research activities, and the education and training of interdisciplinary personnel are also valued services offered by clinical pharmacists. Partnering with physician and nursing champions can garner support from hospital administrators for the addition of clinical pharmacy critical care services. The addition of a pharmacist to an interprofessional critical care team should be encouraged as health-care systems focus on improving the quality and efficiency of care delivered to improve patient outcomes.
Article
Full-text available
Critical care pharmacy activities have been described as fundamental, desirable, and optimal, but actual services provided have not been evaluated. To characterize the type and level of pharmacy services provided to intensive care units (ICUs). A 38 question survey was sent in 2 consecutive mailings to all US institutions (N = 3238) with an ICU. Questions were categorized according to clinical, educational, administrative, and scholarly activities, with levels of services stratified as fundamental, desirable, or optimal. Completed surveys were received from 382 (11.8%) institutions encompassing 1034 ICUs. Direct clinical pharmacy activities were provided at 62.2% of ICUs. The pharmacists in those programs attended rounds 4.4 +/- 1.5 days/wk, mean +/- SD, and had a workweek that consisted of patient care (43% of hours worked), drug distribution (26.2%), administration (12.6%), education (10.9%), and scholarly activities (7.3%). Fundamental clinical activities performed during at least 75% of patient ICU days were providing drug information, drug therapy evaluation, drug therapy intervention, and pharmacokinetic monitoring. Conducting in-services (92.8%), a fundamental service, was the only educational activity frequently provided. Most respondents were involved with at least one multidisciplinary committee, and 45.5% conducted scholarly activities. Desirable or optimal activities were not frequently provided across all service categories. Clinical pharmacists are directly involved as caregivers in nearly two-thirds of ICUs in the US. Although they provide a range of clinical and administrative services, involvement in educational and scholarly activities is variable. The level of services provided is consistent with the criteria deemed fundamental for improving patient care. Higher-order services are far less likely to be provided.
Conference Paper
Purpose: This study explores associations between the involvement of clinical pharmacists in the care of critically ill Medicare patients with thromboembolic events (TE) and mortality rates, length of intensive care unit (ICU) stay, Medicare charges, and drug charges. Outcomes of bleeding complications (BC) are also delineated according to the involvement of clinical pharmacists. Methods: ICU pharmacy services were obtained from a 2004 national survey. Clinical pharmacy service was defined as having some pharmacist time specifically devoted to the direct care of ICU patients. TE and BC were defined using ICD-9-CM codes. ICU outcome data were drawn from 2005 MEDPAR. Results: The involvement of clinical pharmacists was evaluated in 110,309 TE patients, accounting for 7987 BC. Mortality rates in ICUs that did not have clinical pharmacists were higher by 37% (odds ratio=1.41, 95% CI 1.36-1.46; 183 extra deaths) and 32% (odds ratio=1.35, 95% CI 1.13-1.61; 6 extra deaths) for TE and BC, respectively. Lengths of stay in ICUs without pharmacists were longer by 14.8% (7.28±8.17 vs. 6.34±7.80 days, p<0.0001; 59,429 extra ICU days) and 15.8% (12.4±13.28 vs. 10.71±9.53 days, p=0.008; 7478 extra ICU days) for TE and BC respectively. The absence of clinical pharmacists was associated with extra Medicare charges of $215,397,354 (p<0.001) and $63,175,725 (p<0.0001) for TE and BC, respectively. Extra drug charges were $26,363,674 (p<0.0001) and $2,610,750 (p<0.001), respectively. In the absence of clinical pharmacists, BC increased by 48% (odds ratio=1.53, 95% CI 1.46-1.60; 131 extra BC) resulting in 39% more patients with BC (odds ratio=1.47, 95% CI 1.28-1.69; 25 extra patients) receiving more transfusions (6.77±10.35 vs. 3.06±2.64 blood units/patient, p=0.006; 93 extra blood units). Conclusions: The involvement of clinical pharmacists in the care of critically ill Medicare patients with TE is associated with reduced mortality, improved clinical and economic outcomes, and fewer BC.
Article
This commentary from the 2010 Task Force on Acute Care Practice Model of the American College of Clinical Pharmacy was developed to compare and contrast the "unit-based" and "service-based" orientation of the clinical pharmacist within an acute care pharmacy practice model and to offer an informed opinion concerning which should be preferred. The clinical pharmacy practice model must facilitate patient-centered care and therefore must position the pharmacist to be an active member of the interprofessional team focused on providing high-quality pharmaceutical care to the patient. Although both models may have advantages and disadvantages, the most important distinction pertains to the patient care role of the clinical pharmacist. The unit-based pharmacist is often in a position of reacting to an established order or decision and frequently is focused on task-oriented clinical services. By definition, the service-based clinical pharmacist functions as a member of the interprofessional team. As a team member, the pharmacist proactively contributes to the decision-making process and the development of patient-centered care plans. The service-based orientation of the pharmacist is consistent with both the practice vision embraced by ACCP and its definition of clinical pharmacy. The task force strongly recommends that institutions pursue a service-based pharmacy practice model to optimally deploy their clinical pharmacists. Those who elect to adopt this recommendation will face challenges in overcoming several resource, technologic, regulatory, and accreditation barriers. However, such challenges must be confronted if clinical pharmacists are to contribute fully to achieving optimal patient outcomes.
Article
Abstract In 2000, the Society of Critical Care Medicine (SCCM) and the American College of Clinical Pharmacy (ACCP) published a position paper that defined critical care pharmacy services as fundamental, desirable, and optimal. A task force was developed that included individuals who are members of the ACCP Critical Care Practice and Research Network, the SCCM clinical pharmacy and pharmacology section, and the American Society of Health-System Pharmacists to develop an opinion paper with three primary objectives: to provide recommendations for the level of preparation and training of pharmacists to practice in critical care, to develop recommendations for the credentialing of pharmacists providing critical care services, and to develop mechanisms for documenting and justifying intensive care unit (ICU) pharmacy services. Each objective was addressed to accommodate the levels of services defined as fundamental, desirable, or optimal, and are targeted at all pharmacists providing or wanting to provide pharmacy services to critically ill patients. The training and preparing of the pharmacist caring for critically ill patients is discussed in the context of the knowledge and skills required to provide pharmacy services in the ICU. Credentialing of the critical care pharmacist and the documentation of services take into account the various scopes of practice, and recommendations are based on current and idealistic mechanisms. A detailed outline is provided for the process of services justification. This paper provides a foundation that is focused on delivering direct and proactive patient care services, particularly at the desirable and optimal levels, with the ultimate goal of enhancing the level of pharmacy services provided to the care of critically ill patients. This commentary should be of interest to numerous stakeholders including pharmacists, other pharmacy department staff, other ICU health care professionals, hospital and academic administrators, accrediting agencies, government officials, and payers. The task force encourages the profession of pharmacy in general to incorporate key recommendations provided in this document with respect to specialized training, credentialing, and service justification.
Article
To assess the effects of clinical pharmacist participation in the care of critically ill Medicare patients with thromboembolic or infarction-related events (TIE) on clinical and economic outcomes. In this retrospective database review (September 1, 2004-August 31, 2005), patient data were retrieved from the 2004 Expanded Modified Medicare Provider Analysis and Review database. Outcomes data evaluated included mortality rates, length of intensive care unit (ICU) stay, total Medicare charges, drug and laboratory charges, and rates of bleeding complications. In addition, outcomes related to the bleeding complications (transfusions, mortality rate) were assessed. Patient outcomes in ICUs with clinical pharmacy services were compared with patient outcomes in ICUs without these services. Clinical pharmacy services were defined as direct patient care services provided by a pharmacist specifically devoted to the ICU; other services such as order processing or drug distribution were not part of these services. A description of ICU pharmacy services was obtained from a 2004 national survey. We identified 141,079 patients with TIE, of whom 7987 also had bleeding complications. In hospitals with ICU clinical pharmacy services, mortality rates in patients with TIE only and TIE with bleeding complications were higher by 37% (odds ratio [OR] 1.41, 95% confidence interval [CI] 1.36-1.46) and 31% (OR 1.35, 95% CI 1.13-1.61), respectively, than in ICUs with clinical pharmacy services. Lengths of ICU stay were longer by 14.8% (mean +/- SD 7.28 +/- 8.17 vs 6.34 +/- 7.80 days, p<0.0001) and 15.8% (12.4 +/- 13.28 vs 10.71 +/- 9.53 days, p=0.008), respectively. The lack of clinical pharmacist participation in a patient's care was associated with extra Medicare charges of $215,397,354 (p<0.001) and $63,175,725 (p<0.0001) and extra drug charges of $26,363,674 (p<0.0001) and $2,610,750 (p<0.001) for TIE only and TIE with bleeding complications, respectively. Without clinical pharmacy services, bleeding complications increased by 49% (OR 1.53, 95% CI 1.46-1.60), resulting in 39% more patients requiring transfusions (OR 1.47, 95% CI 1.28-1.69); these patients also received more blood products (mean +/- SD 6.8 +/- 10.4 vs 3.1 +/- 2.6 units/patient, p=0.006). Involving clinical pharmacists in the direct care of intensive care patients with TIE was associated with reduced mortality, improved clinical and charge outcomes, and fewer bleeding complications. Hospitals should promote direct involvement of pharmacists in the care of patients in the ICU.
Article
To determine whether the absence or presence of clinical pharmacists in intensive care units (ICUs) results in differences in mortality rates, length of ICU stay, and ICU charges for Medicare patients with nosocomial-acquired infections, community-acquired infections, and sepsis. The type and level of pharmacy services provided to ICUs were obtained from a 2004 national survey. Clinical pharmacy services were defined as having at least a partial pharmacist full-time equivalent specifically devoted to the ICU for the purpose of direct involvement in patient care. Infections were defined using International Classification of Diseases, Ninth Revision, Clinical Modification codes. ICU outcome data were drawn from the 2004 modified Medicare provider analysis and review. Depending on the infection studied, the involvement of clinical pharmacists was evaluated in 8,927-54,042 patients from 265 to 276 hospitals. None. Mortality rates, length of ICU stay, Medicare charges, drug charges, and laboratory charges for each of the infections categorized according to the absence or presence of clinical pharmacists. Compared to ICUs with clinical pharmacists, mortality rates in ICUs that did not have clinical pharmacists were higher by 23.6% (p < 0.001, 386 extra deaths), 16.2% (p = 0.008, 74 extra deaths), and 4.8% (p = 0.008, 211 extra deaths) for nosocomial-acquired infections, community-acquired infections, and sepsis, respectively. Similarly, ICU length of stay was longer by 7.9% (p < 0.001, 14,248 extra days), 5.9% (p = 0.03, 2855 extra days), and 8.1% (p < 0.001, 19,215 extra days) for nosocomial-acquired infections, community-acquired infections, and sepsis, respectively. ICUs that did not have clinical pharmacists had greater total Medicare billings of 12% (p < 0.001, $132,978,807 extra billing charges), 11.9% (p < 0.001, $32,240,378 extra billing charges), and 12.9% (p < 0.001, $224,694,784 extra billing charges) for nosocomial-acquired infections, community-acquired infections, and sepsis, respectively. Similar findings were observed for Medicare drug charges and laboratory charges. The involvement of clinical pharmacists in the care of critically ill Medicare patients with infections is associated with improved clinical and economic outcomes. Hospitals should consider employing clinical ICU pharmacists.
Article
The goal of the Task Force on Critical Care Pharmacy Services was to identify and describe the scope of practice that characterizes the critical care pharmacist and critical care pharmacy services. Specifically, the aims were to define the level of clinical practice and specialized skills characterizing the critical care pharmacist as clinician, educator, researcher, and manager; and to recommend fundamental, desirable, and optimal pharmacy services and personnel requirements for the provision of pharmaceutical care to critically ill patients. Hospitals having comprehensive resources as well as those with more limited resources were considered. Consensus opinion of critical care pharmacists from institutions of various sizes providing critical care services within several types of pharmacy practice models was obtained, including community-based and academic practice settings. Existing guidelines and literature describing pharmacy practice and medication use processes were reviewed and adapted for the critical care setting. By combining the strengths and expertise of critical care pharmacy specialists with existing supporting literature, these recommendations define the level of clinical practice and specialized skills that characterize the critical care pharmacist as clinician, educator, researcher, and manager. This Position Paper recommends fundamental, desirable, and optimal pharmacy services as well as personnel requirements for the provision of pharmaceutical care to critically ill patients.
credentialing, and documenting and justifying critical care pharmacy services
  • An opinion paper outlining recommendations for training