DeliriumPharmacist’s review and outcomes: Treatment-enhancing contributions tallied, evaluated, and documented (PROTECTED-UK)☆
Introduction
The critically ill patient is at risk of medicines-related adverse events [1]; drug interactions; and, on some occasions, inadequate therapy [2]. This risk can be exacerbated by the presence of organ failure or by supportive therapies such as renal replacement therapy. Consequently, interventions to reduce medication errors and optimize therapy are an essential component of patient care. These include electronic prescribing, smart infusion pumps, medicines reconciliation, clinical guidelines, and services normally led by a specialist critical care pharmacist (SCCP) [3]. Improving the safety and efficacy of medication therapy in critical care patients is the cornerstone of SCCP activity. Since the first reports of clinical pharmacist interventions in critical care in the mid-1980s [4], there has been a gradual progression from those focused on financial savings in medicine use to reducing medication errors and, more recently, to the optimization of medication therapy [5]. Clinical pharmacists have been reported to improve medicines-related patient outcomes in the use of sedation [6], antimicrobial therapy [7], therapeutic drug monitoring [8], and management of thromboembolism/ infarction [9]. Medicines optimizations by addition or adjustment of pharmacotherapy are becoming more dominant practices [10], [11]. Furthermore, proactive interventions, such as SCCP-initiated recommendations made as part of their individual patient review or attendance in multidisciplinary ward rounds, now comprise the majority of medicines interventions made by SCCPs [11], [12].
Despite almost 3 decades of reports of clinical pharmacist in critical care unit (CCU) activity, many important questions remain unanswered. Firstly, the current evidence base is composed of mainly North American reports and focuses on single centers and often specific intervention types, for example, drug-drug interactions [13] or adverse drug events [14]. As such, how transferable is the existing evidence base to UK or indeed European practice, how do single-site reports reflect wider practice, and what is the scope of direct patient care delivered by clinical pharmacy teams? Although European publications on SCCP in critical care are on the increase [8], [10], [11], [15], [16], variations in clinical pharmacy standards and services are pronounced [5], [17], [18]. The importance of SCCP services in critically ill patients are recognized in national UK intensive care standards [18]. These standards include recommendations for staff skill mix (pharmacist and pharmacy technicians) and recommend that clinical pharmacy services are best delivered using a team approach. More data are required to inform how these clinical pharmacy services should be configured and delivered to support resource decisions.
The speciality of critical care and patient-related factors affect the types of interventions clinical pharmacist make [15]. In addition, the knowledge, skills, and level of practice of the clinical pharmacist [19] are important factors likely to affect the clinical impact of the direct patient care provided. Data on the clinical significance of these SCCP-led direct care activities need to be better described if we are to ascertain the true patient value of the services provided.
To begin to answer some of these questions, we conducted a prospective multicenter service evaluation of clinical pharmacist interventions across UK intensive care units (ICUs). The aim of the study was to describe, quantify, and assess the clinical importance of direct patient care activities of critical care clinical pharmacy teams.
Section snippets
Design
This prospective observational study was conducted in 21 adult CCUs across the United Kingdom over a 14-day period from November 5 to 18, 2012. A pilot test run was undertaken prior to this to test the data collection Web portal and to support SCCP familiarity with the categories and methodology. All SCCPs were members of the United Kingdom Clinical Pharmacy Association Critical Care Group Expert Group. These members were the site coordinators of their base hospital’s pharmacy team. The study
Results
Clinical pharmacy teams from 21 CCUs participated. The demographics of the units and pharmacy teams are described in Table 1. The CCUs comprised of general or specialist ICUs, high-dependency units (HDUs; including single-organ support and postoperative care), and mixed ICU/HDUs. There were differences in the composition of the pharmacy teams in terms of pharmacist to patient ratio, pharmacist experience, independent prescriber status, team members’ role, and grading. There were 13 independent
Discussion
To our knowledge, this is the first multicenter study describing clinical pharmacist contribution to the care of the critically ill patient. Overall, clinical pharmacists made interventions in almost 1 (16.1% of prescribed items) in 6 prescribed medications; and more than 60% of the interventions were of at least moderate impact. Medication errors were found in 6.8% of all prescribed items, which is slightly lower than the 8.9% rate identified by the EQUIP study [25] that specifically examined
Conclusion
We have described a multicenter study undertaken over a number of CCUs in the United Kingdom that identified the high frequency and clinical importance of medication interventions made by clinical pharmacists. These results underline the importance of the direct patient care clinical pharmacists, including SCCPs. The study also informs our understanding on the difference between levels of clinical pharmacist, from junior to consultant SCCP, and the likely clinical impact of their practice in
Acknowledgments
United Kingdom Clinical Pharmacy Association.
The National Institute for Health Research, Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust.
PROTECTED-UK GROUP who have collected data and served as scientific advisors: Dr Rob Shulman, Dr Cathy McKenzie, June Landa Alberdi, Dr Richard Bourne, Dr Mark Tomlin, Dr Andy Jones, Prof Ian Bates, David West, Dr Yogini Jani, David Sapsford, Helen McHale, Jane Hylands, Emma Graham-Clarke, Nicola Rudall, Brit Cadman, Greg Barton, Ruth
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Conflict of interest: The authors declare that they have no conflict of interest.