Elevating Critical Care Pharmacy Services in a Resource-Limited Environment Through Establishment of a Pharmacist Team

From Robert Wood Johnson University Hospital Hamilton, Hamilton, NJ.

Abstract

• Background: Critical care pharmacy services are often provided by clinical specialists during limited hours and, otherwise, by general practice pharmacists, leading to varied level, expertise, and multidisciplinary expectations of these services.
• Objective: Since no published descriptions of successful models sustaining routine, high-quality critical care pharmacy services in a community-based, resource-limited environment exist, a critical care pharmacist team (CCPT) was created to meet this goal. After successful launch, the initiative’s primary goal was to assess whether team formation indeed standardized and increased the level of pharmacy services routinely provided. The secondary goal was to demonstrate cultural acceptance, and thus sustainability, of the model.
• Methods: A CCPT was formed from existing pharmacist resources. A longitudinal educational plan, including classroom, bedside, and practice modeling, assured consistent skills, knowledge, and confidence. Interventions performed by pharmacists before and after implementation were assessed to determine whether the model standardized type and level of service. Surveys of the CCPT and multidisciplinary teams assessed perceptions of expertise, confidence, and value as surrogates for model success and sustainability.
• Results: Interventions after CCPT formation reflected elevated and standardized critical care pharmacy services that advanced the multidisciplinary team’s perception of the pharmacist as an integral, essential team member. CCPT members felt empowered, as reflected by self-directed enrollment in PharmD programs and/or obtaining board certification. This success subsequently served to improve the culture of cooperation and spark similar evolution of other disciplines.
• Conclusion: The standardization and optimization of pharmacy services through a dedicated CCPT improved continuity of care and standardized multidisciplinary team expectations.

Keywords: critical care; clinical pharmacist; pharmaceutical care; standards of practice.

There has been significant evolution in the role, training, and overall understanding of the impact of critical care pharmacists over the past 2 decades. The specialized knowledge and role of pharmacists make them essential links in the provision of quality critical care services.¹ The Society of Critical Care Medicine (SCCM) and the American College of Clinical Pharmacy (ACCP) have defined the level of clinical practice and specialized skills that characterize the critical care pharmacist and have made recommendations regarding both the personnel requirements for the provision of pharmaceutical care to critically ill patients and the fundamental, desirable, and optimal pharmacy services that should be provided to these patients (Table 1).² Despite this, only two-thirds of US intensive care units (ICUs) have clinical pharmacists/specialists (defined as spending at least 50% of their time providing clinical services), resulting in fundamental activities dominating routine pharmacist services.³ The clinical nature of most desirable and optimal activities, such as code response and pharmacist-driven protocol management, is limited, but these activities correlate with decreases in mortality across hospitalized populations.⁴

Despite their demonstrated benefit and recognized role, critical care pharmacists remain a limited resource with limited physical presence in ICUs.⁵ This presents hospital pharmacies with a real dilemma: given that clinical pharmacy specialists are often a limited resource, what services (fundamental, desirable, or optimal) should be provided by which pharmacists over what hours and on which days? For many hospitals, personnel resources allow for a clinical pharmacy specialist (either trained or with significant experience in critical care) to participate in multidisciplinary rounds, but do not allow a specialist to be present 7 days per week across all times of the day. As a result, routine services may be inconsistent and limited to activities that are fundamental-to-desirable, due to the varied educational and training backgrounds of pharmacists providing nonrounding services. Where gaps have been identified, remote (tele-health) provision of targeted ICU pharmacist services are beneficial.⁵

In our organization, we recognized the significant variation created by this resource-defined model and sought to develop a process to move closer to published best practice standards for quality services² through the creation of a formalized critical care pharmacist team (CCPT). This change was spurred by the transition of our organization’s clinical pharmacist to a board-certified, faculty-based specialist, which in turn spurred new focus on standardizing both the type and quality of services provided by the entire pharmacy team, targeting a higher, more consistent level of pharmacist care which better aligned with SCCM/ACCP-defined activities associated with quality services. The specialist proposed the formation of a CCPT, a process that involved targeted, intensive education and clinical skills development of a narrow pharmacist audience; administration approved this plan, provided that the CCPT arose from existing resources. This realignment focused on ensuring continuity of services across pharmacist roles (ie, rounding vs satellite) as well as across times (both days of the week and shifts). This report describes the methods used to recruit, train, and sustain a CCPT; the resulting changes observed in levels of pharmacy services after CCPT implementation; and the impressions of the CCPT members and the multidisciplinary team (physicians, nurses, dieticians, respiratory therapists, chaplains, and social workers in addition to the pharmacist), as cultural integration and perceived value are essential for sustainability and growth of the model.