Critical Care Pharmacy Services in United States Hospitals

Discussion

As of March 10, 2006, this is the first survey to describe the scope of critical care pharmacy services since the publication of the SCCM/ACCP position paper in 2000.^[16] Major findings include the following: pharmacists provided direct patient care to nearly two-thirds of ICUs in the US; ICU pharmacists were predominantly involved in providing patient care and administrative functions, but less frequently involved in educational activities of trainees and in scholarly activities; and although ICU pharmacists frequently provided services deemed fundamental by the position paper, they were far less likely to conduct activities deemed desirable or optimal across all service domains (ie, distributive, clinical, educational, administrative, scholarly).

Two fundamental aspects of critical care dispensing are providing unit dose packaged medication and preparing all parenteral products. Both our survey and the 1988 survey of critical care pharmacy services found that nearly all institutions provided unit dose distribution to ICU patients.^[25] In contrast, the ability to prepare parenteral products for ICU patients has increased from 65.5% to 93.2% of institutions since 1988. This may be due to the doubling of the number of ICU satellite pharmacies (from 19.5% in 1988 to 40.3% of institutions) as well as the recognition that parenteral product services is a fundamental activity.^[16]

Despite a lack of residency training experience, more than 62% of respondents provided direct patient care. However, the definition of direct care included primarily providing distribution functions in a satellite ICU pharmacy. Despite this limitation, a response rate of 62% represents substantial growth since 1988, 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.^[16,25]

Our survey found that fundamental clinical services were provided more regularly than services deemed desirable or optimal ( Table 2 ). Six of the 8 clinical activities deemed to be fundamental^[16] were provided more than 70% of patient ICU days, while only 2 higher-level services exceeded 50%. In surveys of pharmacy practice at the institutional level, clinical activities routinely provided consistently rank in the top 5 activities of our survey.^{[17,18,19,20]} Documentation of clinical service is considered a fundamental activity.^[16] Nearly all respondents completed the documentation necessary to be deemed fundamental, and many established this as a desirable activity by attaching clinical significance. Few pharmacists attached an economic impact to their interventions, despite data indicating that potential cost savings may justify clinical pharmacy programs.^[19]

There has been a substantial increase since 1988 in the provision of inservice-like programs, a fundamental educational activity.^[25] Almost all respondents frequently provided inservice training. The frequency with which critical care pharmacists precept students, however, has changed little over the past 20 years. The provision of educational activities deemed to be desirable or optimal was variable ( Table 3 ).^[16]

Almost all respondents were involved with committees, most commonly ICU- or pharmacy-specific committees ( Table 4 ). The critical care pharmacist was less likely to be involved with hospital-wide committees. Consistent with the results of a national survey of hospital-wide pharmacy practices, most respondents of this survey developed or implemented ICU policies and protocols, but only half evaluated these initiatives.^[19] The results of other national surveys indicated that pharmacists frequently evaluate potential adverse drug events and are more likely to report their findings to an internal agency than to an external entity.^[19,20] Similarly, almost all respondents of this survey reported adverse events, most commonly to an internal committee.

Any involvement of critical care pharmacists in scholarly activities is considered desirable or optimal.^[16] Slightly less than half the respondents indicated that they were involved with ICU research. Of these respondents, most performed desirable functions, but few engaged in optimal activities, such as funding procurement. Even fewer respondents have contributed to the medical literature in the past 5 years. A 1998 survey of clinical services found similar results, as 14% of hospitals had pharmacists that performed clinical research.^[20] Of note, only slightly more than half the institutions responding to our survey had a pharmacist responsible for handling investigational drugs, an activity deemed fundamental by the position paper.^[16]

The participation of clinical pharmacists in the ICU has been shown to lower drug and ICU costs while improving patient outcomes.^{[1,2,7,8,9,10,11,12,13,14]} Clinical pharmacy services, in general, are economically beneficial.^[28] Several national organizations recognize that pharmacists devoted to patient care as a component of multidisciplinary teams are essential for providing and delivering quality care.^[5,6,15] 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.^[4,29,30] 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 healthcare 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. The outcomes should address medical, economic, psychosocial/ethical, and institutional parameters.^[31]

Several limitations of this study deserve mention. The data were obtained from hospitals reported by the AHA to have an ICU and should not be extrapolated to other types of hospitals or non-ICU pharmacy services. All data were self-reported and no attempts were made to verify them. Although the response rate was low at 11.8%, geographic regions and characterizing variables between respondent and nonrespondent hospitals were similar. Therefore, we believe the results may be generally extrapolated to represent ICU pharmacy services at US institutions. Despite the fact that the survey was pretested, some definitions and questions may have generated inconsistent responses due to variability in question interpretation. Pharmacy systems (eg, physician order entry, automated dispensing, technician staffing) were not evaluated, so we were unable to assess whether the provision of a specific system alters the scope of services provided; however, it is anticipated that pharmacists would have more time for direct patient care activities as distributive functions are allocated elsewhere.^[22] In addition, we were unable to document what, if any, practice change occurred as a result of the position paper or whether the description of services in the position paper accurately reflects different levels of service. However, the fact that the provision of services for all pharmacy practice activities declined as the level of services progressed from fundamental to desirable to optimal supports the discretion of the levels presented in the position paper.^[16]

The Annals of Pharmacotherapy. 2006;40(4):612-618. © 2006 Harvey Whitney Books Company

Cite this: Critical Care Pharmacy Services in United States Hospitals - Medscape - Apr 01, 2006.