Role of the Clinical Pharmacist in Intensive Care: Review of the Evidence

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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

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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

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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

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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

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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

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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

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• Clinical Pharmacy Services in Intensive Care

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• 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

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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

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• The evidence

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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.

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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 lt 0.001)
• Duration of both ICU and hospital stays were also
  significantly reduced in the post-intervention
  group
• Critical Care Medicine 2008, Marshall J.

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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.

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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 lt
  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.

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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.

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Impact on drug therapy costs (2)

• Before-after comparative study
• Al-Hussein Hospitals 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.

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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.

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• Interventions In Mubarak Al-Kabeer Hospital
  Intensive Care Unit

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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

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Interventions made (contd)

• 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)

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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

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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