Do we need a pharmacist in the ICU?

Abstract

On the surface, the answer to the question of the title of this editorial seemed to be a rhetorical and obvious yes. This is not because two pharmacists are involved in authoring this editorial, but because there is a substantial amount of literature-arguably more than which exists for any other clinical team member in the ICU and likely more than some of the standard-of-care interventions (such as mechanical ventilation)-which linked the presence of a pharmacist in an ICU to improved patient outcomes.Since the beginning of ICU clinical pharmacy services in the 1960s [1], the practice has matured along with the subspecialty of critical care medicine into one that has been considered by the Society of Critical Care Medicine (SCCM) as essential [2]. In fact, within the SCCM guidelines for best practice model and ICU staffing [2], pharmacist presence was considered as best practice supported by grade C evidence, the highest level of all recommendations in that document. A summary of the studies evaluating the impact of having a dedicated pharmacist in the ICU is shown in [3] clearly demonstrated that presence of pharmacists in a medical ICU reduced medication errors and cost. These benefits appear generalizable since the studies have been conducted in a variety of ICUs (e.g., medical, surgical, neurosurgical, cardiac, and pediatric) using different physician staffing models (e.g., open vs closed ICU), and date back to the early 1990s [13]. The majority of the studies have been conducted in North America, but similar beneficial results have been published from studies conducted in Asia [4,8,9], the Middle East [10], and Europe [11]. Provision of drug information, clarifying and correcting medication orders, identifying drug interactions as well as actual or potential adverse drug events, and recommending alternative therapies account for greater than 90 % of ICU pharmacists' activities [3,4,8,13,14]. 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].In addition to the clear benefits for the patients, ICU pharmacists can play a multitude of other roles [17] such as education of other team members, leadership or administrative roles in critical care committees, and in Intensive Care Med (2015) 41:1314-1320

Pharmacist prescribing in critical care: an evaluation of the introduction of pharmacist prescribing in a single large UK teaching hospital

“…Clinical pharmacists make an essential contribution to the safe and effective use of medicines in critically ill patients 1. Direct patient care via pharmacist medication review is an important resource for reducing medication errors and optimising medication use 2.…”

Reducing medication errors in critical care patients: pharmacist key resources and relationship with medicines optimisation

“…The e‐Delphi consensus process identified the perceived value by a UK critical care pharmacist group of some interventions/ resources commonly employed by critical care units. Healthcare staff are an effective barrier to medication errors in critical care units . The process recognised the importance of not only provision of clinical pharmacist activity, but also the need for specialist advanced‐level of pharmacists .…”

“…Healthcare staff are an effective barrier to medication errors in critical care units . The process recognised the importance of not only provision of clinical pharmacist activity, but also the need for specialist advanced‐level of pharmacists . The latter may reflect the combined direct clinical activity and professional support roles (clinical guidelines, education and participation in clinical incident review and response)…”

Infrastructure and Organization of Adult Intensive Care Units in Resource-Limited Settings

“…No studies have been published from resource-limited settings evaluating patient outcomes related to nurse-to-patient ratios. Evidence from resource-limited settings confirms the benefits of including pharmacists into the multidisciplinary ICU team on patient outcomes [17]. Studies from China, Thailand, Jordan, Egypt, and Vietnam demonstrated consistent reductions in medication costs [33][34][35] and adverse events [36] after involvement of a pharmacist in daily ICU practice.…”

“…Notably, a higher nurse-to-patient ratio prevents burnout of nurses [16]. Studies in resource-rich settings also suggest that the presence of allied healthcare professionals like pharmacists [17], respiratory or physical therapists [18], and dieticians [19] within a multidisciplinary ICU team improves patient outcomes [3]. Furthermore, proactive communications with infectious disease specialists or microbiologists favorably affect antibiotic use and costs [20].…”