Elsevier

Journal of Critical Care

Volume 30, Issue 4, August 2015, Pages 808-813
Journal of Critical Care

Delirium
Pharmacist’s review and outcomes: Treatment-enhancing contributions tallied, evaluated, and documented (PROTECTED-UK)

https://doi.org/10.1016/j.jcrc.2015.04.008Get rights and content

Abstract

Purpose

The purpose was to describe clinical pharmacist interventions across a range of critical care units (CCUs) throughout the United Kingdom, to identify CCU medication error rate and prescription optimization, and to identify the type and impact of each intervention in the prevention of harm and improvement of patient therapy.

Materials and methods

A prospective observational study was undertaken in 21 UK CCUs from November 5 to 18, 2012. A data collection web portal was designed where the specialist critical care pharmacist reported all interventions at their site. Each intervention was classified as medication error, optimization, or consult. In addition, a clinical impact scale was used to code the interventions. Interventions were scored as low impact, moderate impact, high impact, and life saving. The final coding was moderated by blinded independent multidisciplinary trialists.

Results

A total of 20 517 prescriptions were reviewed with 3294 interventions recorded during the weekdays. This resulted in an overall intervention rate of 16.1%: 6.8% were classified as medication errors, 8.3% optimizations, and 1.0% consults. The interventions were classified as low impact (34.0%), moderate impact (46.7%), and high impact (19.3%); and 1 case was life saving. Almost three quarters of interventions were to optimize the effectiveness of and improve safety of pharmacotherapy.

Conclusions

This observational study demonstrated that both medication error resolution and pharmacist-led optimization rates were substantial. Almost 1 in 6 prescriptions required an intervention from the clinical pharmacist. The error rate was slightly lower than an earlier UK prescribing error study (EQUIP). Two thirds of the interventions were of moderate to high impact.

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

References (33)

  • K.A. Mergenhagen et al.

    Pharmacist- versus physician-initiated admission medication reconciliation: impact on adverse drug events

    Am J Geriatr Pharmacother

    (2012)
  • J.M. Rothschild et al.

    The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care

    Crit Care Med

    (2005)
  • J.A. Roberts et al.

    DALI: defining antibiotic levels in intensive care unit patients: are current beta-lactam antibiotic doses sufficient for critically ill patients?

    Clin Infect Dis

    (2014)
  • E. Manias et al.

    Interventions to reduce medication errors in adult intensive care: a systematic review

    Br J Clin Pharmacol

    (2012)
  • C.I. Miyagawa et al.

    Effect of pharmacist interventions on drug therapy costs in a surgical intensive-care unit

    Am J Hosp Pharm

    (1986)
  • J.M. LeBlanc et al.

    International critical care hospital pharmacist activities

    Intensive Care Med

    (2008)
  • J.W. Devlin et al.

    Reversing oversedation in the intensive care unit: the role of pharmacists in energizing guideline efforts and overcoming protocol fatigue

    Crit Care Med

    (2008)
  • R. MacLaren et al.

    Clinical and economic outcomes of involving pharmacists in the direct care of critically ill patients with infections

    Crit Care Med

    (2008)
  • J.E. Klopotowska et al.

    On-ward participation of a hospital pharmacist in a Dutch intensive care unit reduces prescribing errors and related patient harm: an intervention study

    Crit Care

    (2010)
  • R. MacLaren et al.

    Effects of pharmacist participation in intensive care units on clinical and economic outcomes of critically ill patients with thromboembolic or infarction-related events

    Pharmacotherapy

    (2009)
  • N.G. Hunfeld et al.

    Pharmacist clinical interventions in the ICU (abs)

    Crit Care

    (2010)
  • R.S. Bourne et al.

    Pharmacist proactive medication recommendations using electronic documentation in a UK general critical care unit

    Int J Clin Pharm

    (2012)
  • R. MacLaren et al.

    Critical care pharmacy services in United States hospitals

    Ann Pharmacother

    (2006)
  • A. Rivkin et al.

    Evaluation of the role of the critical care pharmacist in identifying and avoiding or minimizing significant drug-drug interactions in medical intensive care patients

    J Crit Care

    (2011)
  • B.J. Kopp et al.

    Cost implications of and potential adverse events prevented by interventions of a critical care pharmacist

    Am J Health Syst Pharm

    (2007)
  • R.S. Bourne et al.

    Proactive clinical pharmacist interventions in critical care: effect of unit speciality and other factors

    Int J Pharm Pract

    (2014)
  • Cited by (44)

    • Is ward round participation by clinical pharmacists a valuable use of time and money? A time and motion study

      2020, Research in Social and Administrative Pharmacy
      Citation Excerpt :

      The overall breakdown of reasons for interventions was similar to that of a previous large-scale Australian study by Dooley et al.,7 suggesting that the interventions performed in this study are representative of Australian clinical pharmacy practice. The majority of interventions recorded overall were of minor significance, in contrast to previous studies which have found that the majority of pharmacist interventions are of moderate significance.4,7,24–26 This may be explained by variations in the definitions of significance used by these studies.

    • Clinical Pharmacy Considerations in ICU

      2019, Encyclopedia of Pharmacy Practice and Clinical Pharmacy: Volumes 1-3
    View all citing articles on Scopus

    Conflict of interest: The authors declare that they have no conflict of interest.

    View full text