Clinical pharmacists involved in many ICUs
Clinical pharmacists are directly involved as caregivers in nearly two-thirds of U.S. ICUs. Research conducted by Robert MacLaren, PharmD, an assistant professor at the University of Colorado Health Sciences Center School of Pharmacy, found that although clinical pharmacists provide a range of clinical and administrative services, involvement in educational and scholarly activities varies. He says the level of services provided is consistent with the criteria deemed fundamental for improving patient care, and higher-order services are far less likely to be provided.
MacLaren tells Drug Formulary Review his survey was conducted by a multidisciplinary task force of the Society of Critical Care Medicine that is examining the level of care provided by professionals in critical care settings and the nature of staff shortages.
He says he expected to find, as he did, that clinical pharmacists are providing the fundamental services that are necessary, but was surprised at the lack of educational and research services.
The survey report, published in the Annals of Pharmacotherapy, says pharmacists are assuming greater roles and responsibilities for ICU patient care and are integral members of ICU teams. Involvement of critical care pharmacists has been shown to decrease drug-related costs, prevent adverse drug events, and reduce patient morbidity.
The Society of Critical Care Medicine and other physician organizations have said pharmacists are an essential component for providing quality care to critically ill patients. In 2000, the society and the American College of Clinical Pharmacy published a position paper defining the scope of critical care pharmacy services. That report covered clinical and nonclinical pharmacy services and stratified levels of service as fundamental, desirable, or optimal to improving patient care.
MacLaren says the current level and scope of pharmacy services in U.S. hospital ICUs has not been well established and thus his survey was intended to characterize pharmacy services provided in ICUs. Some 3,238 hospitals listed by the American Hospital Association as having an ICU were sent surveys in two mailings. Surveys were received back from 382 hospitals or 11.8% of those contacted.
Nearly two-thirds of respondents (62.2%) provided direct ICU pharmacy services compared with indirect care (37.8%). Direct services were defined as at least part of a full-time equivalent (FTE) pharmacist's time being specifically devoted to the ICU (for example, decentralized staffing, pharmacist present for patient bedside care, pharmacist available via telepharmacy). Indirect services were defined as no portion of an FTE pharmacist's time being specifically devoted to the ICU. However, services may have been provided in another manner such as centralized staffing or pharmacy consult.
Variety of clinical activities
The type and extent of clinical activities provided to ICUs varied considerably. MacLaren reports that fundamental activities were more commonly provided than activities deemed desirable or optimal. Clinical activities were more likely to be available on weekends than around the clock.
Nearly all respondents (92.5%) documented clinical services provided, using either a centralized computer tracking system, a paper tracking system, or a handheld/laptop computer tracking system. The types of services commonly documented were changing drug therapy (90.6%), monitoring therapy (87.1%), order clarification (77.9%), preventing adverse drug events (77.5%), providing drug information (71.1%), cost savings (69.2%), and educational activities (53.2%). While 75% of documentation programs attached clinical significance to the service, only 21.6% attached economic impact. Most respondents (93.4%) indicated that patient-specific information was relayed to other pharmacists through verbal communication (80.9%), paper documentation (69.5%), centralized computer system (45.5%), and handheld/laptop computer system (5.2%).
The type and extent of pharmacist educational activities also varied considerably. The most common information sources available to pharmacists included the Internet or intranet references (99.2%), primary references (91.9%), and tertiary references (86.4%). Reimbursement was provided for professional development activities, such as attending national (74.8%) or local (54.4%) meetings, cardiopulmonary resuscitation or advanced cardiac life support certification (48.5%), organization membership (39.1%), and board certification (32.6%).
Many respondents were involved in committee service, with most pharmacists (95.1%) involved with developing and implementing ICU policies and protocols, 65.9% responsible for designing new pharmacy programs specifically for ICU patients, and 56.1% evaluating these initiatives. Adverse drug events were reported by 98% of pharmacists. The level of involvement with monitoring adverse drug events in the ICU included documentation (86.4%), assessment (75.5%), prevention (61.7%), and developing policies and procedures to prevent occurrence (51.5%).
Nearly half of the respondents (45.5%) indicated they were involved in research, with responsibility for data collection (75.7%), patient screening (52.5%), protocol design (51.5%), data analyses (40.6%), coordination (34.7%), manuscript preparation (34.7%), procuring funding (12.9%), and laboratory analyses (11.9%).
Growth in preparing parenteral products
Commenting on the results, MacLaren noted that two fundamental aspects of critical care dispensing are providing unit dose packaged medication and preparing all parenteral products. Both this survey and a 1988 survey of critical care pharmacy services found that nearly all institutions provided unit dose distribution to ICU patients. In contrast, the ability to prepare parenteral products for ICU patients has increased from 65.5% of institutions to 93.2% since 1988. MacLaren says this may be due to the doubling of the number of ICU satellite pharmacies as well as recognition that parenteral product services is a fundamental activity.
Despite a lack of residency training experience, more than 62% of respondents provided direct patient care. However, the definition of direct care included primary providing distribution functions in a satellite ICU pharmacy. Despite this limitation, MacLaren says, a response rate of 62% represents substantial growth since the 1988 survey, when most respondents were unsure of the role of the ICU pharmacist with direct patient care responsibilities, and pharmacists were only moderately involved in activities considered to be fundamental by today's practice.
"The participation of clinical pharmacists in the ICU has been shown to lower drug and ICU costs while improving patient outcomes," MacLaren reports. "Clinical pharmacy services, in general, are economically beneficial. Several national organizations recognize that pharmacists devoted to patient care as a component of multidisciplinary teams are essential for providing and delivering quality care. A continuing dilemma is the question of how to enhance the provision of direct patient care services and increase the level of these services so that many more patients receive those pharmacy activities deemed to be desirable and optimal. At present, these pharmacy services are usually only offered as a method of cost containment. Additional studies are needed to document the impact of direct pharmacy services on clinical and economic patient outcomes and the interactions that pharmacists have with other ICU health care professionals. Comparisons need to be made to establish which services provide the greatest benefit and what level of practice needs to be maintained to optimize these benefits."
He tells DFR his object in publishing the survey results was to get information out so people could see how their ICU compares with others. The next step, he says, will be to attach outcome data to the services provided, such as readmission rates and length of stay. Another likely follow-up will be a paper on best practices on training critical care pharmacists.
[Editor's note: Contact Dr. MacLaren at (303) 315-4772 or e-mail [email protected].]
Clinical pharmacists are directly involved as caregivers in nearly two-thirds of U.S. ICUs. Research conducted by Robert MacLaren, PharmD, an assistant professor at the University of Colorado Health Sciences Center School of Pharmacy, found that although clinical pharmacists provide a range of clinical and administrative services, involvement in educational and scholarly activities varies.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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