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
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
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
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
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
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
Clinical Pharmacy Services in
Intensive Care
 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
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
The evidence
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.

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 < 0.001)
 Duration of both ICU and hospital stays were also significantly reduced in
the post-intervention group

Critical Care Medicine 2008, Marshall J.

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.

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 < 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.

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.

Impact on drug therapy costs (2)

 Before-after comparative study

 Al-Hussein Hospital’s 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.

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.

Interventions In Mubarak Al-
Kabeer Hospital Intensive
Care Unit
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%
Interventions made (cont’d)

 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)
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
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