Best Practice Spotlight: Multiple benefits to having pharmacist in ICU
Multiple benefits to having pharmacist in ICU
Hospitals surveyed nationally
A recent study provides hospital pharmacists with evidence that suggests having a pharmacist providing direct care to patients in the intensive care unit (ICU) can improve patient outcomes.1
"We surveyed as many intensive care units (ICUs) as possible to ask if they had pharmacy services and at what level," says Robert MacLaren, PharmD, FCCM, FCCP, an associate professor in the department of clinical pharmacy at the University of Colorado Denver School of Pharmacy in Aurora. MacLaren also works directly with patients in the medical ICU at the University of Colorado Hospital.
"Then we divided ICUs into those that had a pharmacist who directly cared for patients versus those that did not," MacLaren adds.
Using ICD-9 codes, investigators looked at three diseases, including health care-acquired pneumonia, community-acquired pneumonia, and sepsis.
"Then we used the Medicare database called MEDPAR [Medicare Provider Analysis and Review] to look at outcomes for patients within each ICU of each institution," MacLaren explains. "For those disease states, the trend was consistent, showing that providing pharmacy services directly to patients reduces mortality, length of stay [LOS], and charges."
The findings are associative, and researchers cannot say definitively that having pharmacists led to the better outcomes, he notes.
"But we feel the association is strong and robust," MacLaren says. "In terms of clinical practice, I've received numerous e-mails from pharmacists thanking me."
Since the study was published last year, a number of pharmacists have gone to their supervisors, hospital physicians, and ICU leadership, showing them the study as justification for providing pharmacist direct care in the ICU.
The findings were that mortality was reduced by 4.8% to 23.6%, depending on the type of infection, MacLaren says.
The LOS was shortened by 5.9% to 8.1%, and the total reduction in charges was about 12%, he adds.
The hospitals that did not have a pharmacist at bedside in the ICU had 671 additional deaths in 2004, which was the year studied, MacLaren says.
Also, the extra ICU days was 35,000, with a range of 9,000-54,000, depending on the type of infection, he adds.
The key is for the pharmacist to provide bedside care, MacLaren notes.
"It's not what you're doing as much as how you're doing it," he says. "I tell pharmacists that 90% of my interventions or practice issues are relatively minor."
The services are fundamental and include pharmacokinetic monitoring, adverse event monitoring, patient histories, order clarification, drug information, and staff education, he says.
"The key is that it's all at the bedside, and we're not in the basement somewhere or at a peripheral site," MacLaren explains. "We're at the bedside, helping with therapy decisions at the time decisions are made."
MacLaren is one of three ICU pharmacist specialists. They provide 24-hour ICU coverage, five days a week, and they're available by pager on the weekends.
The pharmacist ICU specialist's typical day might look like this:
- 6:30 a.m.: Go to the unit. Review patient profiles and histories and identify any issues, such as a dose that needs to be adjusted, a patient who requires daily awakening that's not being done, starting enteral nutrition, or adjusting an antibiotic dose.
- 8 a.m. to noon: Go on rounds with physicians. During bedside visits, the pharmacist might identify an issue that should be addressed and discuss things that have been missed.
- 12:00 noon-on: Handle follow-up calls and provide educational sessions for residents and others.
The ICU pharmacist specialists also assist with suggesting and changing or creating new protocols.
"Ultimately, any protocol that comes through the ICU, we're involved with," MacLaren says. "Pharmacists can't just do one thing — they have to do everything and be involved with the entire patient case, helping wherever they're needed."
Typically, new protocols are written when there's an issue with a patient or process in the ICU.
"It could be a sedation issue for a patient who is commonly uncomfortable or is oversedated or if they're waiting to wake the patient over three or four days," MacLaren says an example.
The issue in that example is that patients are staying in the ICU longer than necessary and are more uncomfortable than necessary because of the oversedation, he notes.
The next step is to check how frequently the issue comes up, making a landscape assessment, MacLaren says.
"Maybe the assessment shows that 30% of the time patients aren't waking up in two days," he says. "It could be a cost or adverse event issue."
Once it's clear that the issue needs addressing, the pharmacist will obtain buy-in from other health care professionals.
"I'll sell the idea of writing a new protocol and find a couple of champions for the protocol," MacLaren says. "It could be a physician or nurse."
If MacLaren develops the new protocol, he'll include all references and then send it out to the group of people he had initially contacted about the problem. He'll ask for their feedback, asking them the following:
- Is it something we can do?
- Does it need modification?
- Who needs to be consulted?
Then he'll start to arrange meetings to discuss changing, assessing, and implementing the new protocol.
The last step is to educate staff on how to make the change.
"I'll go bedside to bedside with nurses or a respiratory therapist and educate all employees on why we're doing it," MacLaren says.
"I'll say, 'We have a problem; we have buy-in from all of these people, so here's how it will change what you do now,'" MacLaren says.
Once the new protocol is implemented, the pharmacist will need to assess staff compliance and see whether the protocol has made a change and produced the expected positive outcomes.
"It's a continuous process of implementation, assessment, and modification," MacLaren says. "You need to make sure it's a culture change and that people are doing it because the ICU is going to do this."
What typically happens is that compliance is high at the start, and then it starts to drop off, so continual education and quality improvement measures are needed, he adds.
It's also important to conduct regular checks — perhaps annually, MacLaren says.
"We have an ICU outcomes/quality improvement nurse who does spot checks," he says. "She randomly checks 40 patients in a month and reports her findings."
1. MacLaren R, Bond CA, Martin SJ, et al. Clinical and economic outcomes of involving pharmacists in the direct care of critically ill patients with infections. Crit Care Med 2008;36:3184-3189.A recent study provides hospital pharmacists with evidence that suggests having a pharmacist providing direct care to patients in the intensive care unit (ICU) can improve patient outcomes.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.