Role of the Clinical Pharmacist in Intensive Care: Review of the Evidence Adnan Hajjiah Critical Care Pharmacist MSc Clinical Pharmacy, MPharm Mubarak Al-Kabeer Hospital

Why the need for a clinical pharmacist in intensive care settings? Critically ill patients often have multisystem organ failure Multisystem organ failure along with polypharmacy predispose to medication toxicities Co-morbidities, altered drug pharmacokinetics and drug-drug interactions further enhance the risk for both overdosing and underdosing and adverse medication events including acute kidney injury, hepatotoxicity, neurological dysfunction and other end-organ disturbances

Why the need for a clinical pharmacist in intensive care settings? The dynamic nature of intensive care units involving healthcare professionals with different experiences and backgrounds allows for great variability in patient care Protocol development driven by clinical pharmacists can positively impact such variability

Clinical pharmacy services The profession of pharmacy has evolved over the past 50 years from focusing solely on pharmaceutical products into a discipline that is more patient-centered with special attention to optimal delivery of pharmaceutical care Curricula in most pharmacy colleges have changed significantly to include courses in pharmacotherapeutics, pharmacokinetics, pathophysiology, and Pharmacoeconomics to prepare graduates for careers as clinicians

Evolution of critical care pharmacy Clinical pharmacy services in critical care settings have expanded dramatically and include assisting physicians in pharmacotherapy decision making, providing pharmacokinetic consultations, monitoring patients for efficacy and safety and providing drug information During the 1980s, critical care pharmacists designed specialized training programs and increased participation in critical care organizations followed by developing standards for critical care residency Several professional pharmacy organizations formed specialty groups consisting of critical care pharmacists including: the American College of Clinical Pharmacy and American Society of Health-System Pharmacists

Evolution of critical care pharmacy In 1989, the Society of Critical Care Medicine acknowledged the necessity and value of pharmacists as members of physician-led multidisciplinary team In 2000, the SCCM along with ACCP developed a position paper that stratified clinical pharmacy services into three levels; namely fundamental, desired and optimal services

Clinical Pharmacy Services in Intensive Care

Numerous research articles have identified areas in which critical care pharmacists make significant contributions to patient care Most of this literature describes the responsibilities of these pharmacists as follows: Drug-use evaluation Drug error management In-service education Pharmacokinetic consultations Drug therapy monitoring Written drug histories Written documentation in medical records

Other activities Therapeutic drug monitoring Participation in patient care rounds Prevention of drug-drug interactions Prevention, minimization and management of ADRs Provision of drug information and therapeutic consultation Reduction in medication costs Education of ICU professionals regarding drug-related aspects Education of nursing staff for optimal administration/reconstitution Development of medication protocols and policies to minimize errors and improve outcomes

The evidence

Impact of clinical pharmacist in a cardiac-surgery intensive care unit Dec 2002 to May 2003 19-bed cardiac-surgery ICU at King Faisal Specialist Hospital and Research Centre, Riyadh The clinical pharmacist made 394 interventions (94% success rate) No medication prescribed for medical condition (33%) Inappropriate dosing regimen (28%) No indication for use (14%) Saudi Medical Journal 2008, Al-Jazairi AS et al.

Impact of clinical pharmacist-enforced sedation protocol on mechanical ventilation and hospital stay Before-after study (18 bed medical ICU) Mean duration of mechanical ventilation reduced from 14 days to 7.4 days in the post-intervention group (p < 0.001) Duration of both ICU and hospital stays were also significantly reduced in the post-intervention group Critical Care Medicine 2008, Marshall J.

Impact on preventable adverse drug events (1) Before-after comparison study Medical ICU (study unit), CCU (control) A senior pharmacist made rounds with the ICU team in the morning and was available on call throughout the day Within 9 months, the rate of preventable ADEs decreased by 66% from 10.4 per 1000 patient-days before the intervention to 3.5 following the intervention In the control groups, rate remained unchanged 366 recommendations were made by the pharmacists with 99% acceptance rate Journal of American Medical Association 1999, Leape LL et al.

Impact on preventable adverse drug events (2) Intervention study 8.5 months in an adult medical and surgical ICU, the Netherlands ICU hospital pharmacist made a total of 659 recommendations with consensus rate of 74% between the pharmacist and physicians Incidence of prescribing errors during intervention period was significantly lower than baseline (62.5 per 1000 monitored patient-days versus 190.5 per 1000 monitored patient-days, p < 0.0001) Preventable ADEs were reduced from 4.0 per 1000 monitored patient-days during baseline period to 1.0 per 1000 monitored patients-days during the intervention period (p = 0.25) Critical Care 2010, Klopotowska JE et al.

Impact on drug therapy costs (1) Tertiary care teaching hospital Over a 7 month period 117 recommendations were made (94% acceptance rate) Total net cost savings was USD 1796.73 Journal of Pharmacology and Pharmacotherapeutics 2012, Lucca JM et al.

Impact on drug therapy costs (2) Before-after comparative study Al-Hussein Hospital’s ICU, Jordan 10 months period Total reduction of drug therapy costs was USD 211574.9 representing an average of 35.8% reduction when compared to the first period Saudi Pharmaceutical Journal 2013, Aljbouri TM, et al.

Impact on drug therapy costs (3) Intervention study Surgical ICU Over 4.5 months A total of 129 interventions were documented Potential cost avoidance of documented interventions was USD 209,919 – 280,421 American Journal of Health-System Pharmacy 2007, Kopp BJ et al.

Interventions In Mubarak Al- Kabeer Hospital Intensive Care Unit

Interventions made In a random 52-week period, a total of 243 successful interventions were made Percentage of dose and frequency adjustments consisted of 40% of the total number of interventions Percentage of pharmaceutical consultation 54% Medication reviews and reconciliation 6%

Interventions made (cont’d) Interventions involving antibiotic therapy (including choice, dose, frequency, monitoring and duration of treatment) accounted for 30% of all interventions Antihypertensives and antifungals accounted for 10% of total interventions (choice, dose adjustments and switching between oral and intravenous formulations)

Recommendations Establishment of specialized clinical pharmacy programs in intensive care settings in collaboration between intensive care professionals and the pharmacy department Participation of dedicated pharmacists preferably with postgraduate training in clinical pharmacy services

Summary Critical care pharmacists are crucial members in the ICU multidisciplinary team Provided with adequate training, critical care pharmacists can reduce prescribing errors, preventable ADEs and medication costs with potential improvement in patient outcomes