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

The association of a critical care electronic prescribing system with the quality of patient care provided by clinical pharmacists - a prospective, observational cohort study

BACKGROUND

Despite the strong face validity of electronic prescribing (EP), the empiric data in support of improved patient safety is sparse. The objective of this study was to compare the clinical significance of pharmacist contributions between an established EP and paper-based prescribing (PBP) system in the intensive care unit (ICU) to understand the EP impact on the quality of patient care.

MATERIALS AND METHODS

We conducted a prospective longitudinal study in two 18-bed ICUs; one with EP and the other, PBP. Pharmacist contributions were analysed over three months. Demographic, clinical and adjunctive intervention data were also collected. A multilevel ordinal logistic regression model was used and patients were followed up for 28 days. The primary outcome was the distribution of clinical significance levels of pharmacist contributions.

RESULTS

There were 303 patients admitted to the ICU between April 1st and June 30th 2018. EP was used in 171 patients and PBP in 132 patients. 1658 contributions were analysed. There were 14.9% highly clinically significant contributions with EP compared to 44.6% with PBP. The EP group had lower odds (OR 0.05, 95% CI 0.02-0.12) for a higher clinical significance contribution compared to the PBP group, but this changed over the admission and differed between groups, with decreasing odds of a higher-level clinical contribution for each additional admission day with PBP (OR 0.57, 95%CI 0.42-0.78).

CONCLUSION

This study showed a significant difference in the distribution of pharmacist contributions made over time, with clinical significance levels remaining stable in the EP group at low severity, as opposed to PBP which were initially high and then gradually decreased in severity over time. This contemporaneous controlled study found that the EP system required less significant input both in the severity and frequency of pharmacist contributions to maintain patient safety.

Clinical pharmacy services in critical care: results of an observational study comparing ward-based with remote pharmacy services

BACKGROUND

Pharmacists are essential team members in critical care and contribute to the safety of pharmacotherapy for this vulnerable group of patients, but little is known about remote pharmacy services in intensive care units (ICU).

AIM

We compared the acceptance of pharmacist interventions (PI) in ICU patients working remotely with ward-based service. We evaluated both pharmacy services, including further information on PI, including reasons, actions and impact.

METHOD

Over 5 months, a prospective single-centre observational study divided into two sequential phases (remote and ward-based) was performed on two ICU wards at a university hospital. After a structured medication review, PI identified were addressed to healthcare professionals. For documentation, the national database (ADKA-DokuPIK) was used. Acceptance was used as the primary endpoint. All data were analysed using descriptive methods.

RESULTS

In total, 605 PI resulted from 1023 medication reviews. Acceptance was 75% (228/304) for remote and 88% (265/301; p < 0.001) for ward-based services. Non-inferiority was not demonstrated. Most commonly, drug- (44% and 36%) and dose-related (36% and 35%) reasons were documented. Frequently, drugs were stopped/paused (31% and 29%) and dosage changed (31% and 30%). PI were classified as "error, no harm" (National Coordinating Council for Medication Error Reporting and Prevention [NCC MERP] categories B to D; 83% and 81%). The severity and clinical relevance were at least ranked as "significant" (68% and 66%) and at least as "important" for patients (77% and 83%).

CONCLUSION

The way pharmacy services are provided influences the acceptance of PI. Remote pharmacy services may be seen as an addition, but acceptance rates in remote services failed to show non-inferiority.

Development, implementation and evaluation of a seven-day clinical pharmacy service in a tertiary referral teaching hospital during surge-2 of the COVID-19 pandemic

BACKGROUND

Seven-day clinical pharmacy services in the acute sector of the National Health Service are limited. There is a paucity of evidential patient benefit. This limits investment and infrastructure, despite United Kingdom wide calls.

AIM

To optimise medicines seven-days a week during surge-2 of the COVID-19 pandemic through implementation of a seven-day clinical pharmacy service. This paper describes service development, evaluation and sustainability.

SETTING

A tertiary-referral teaching hospital, London, United Kingdom.

DEVELOPMENT

The seven-day clinical pharmacy service was developed to critical care, acute and general medical patients. Clinical leads developed the service specification and defined priorities, targeting complex patients and transfer of care. Contributing staff were briefed and training materials developed.

IMPLEMENTATION

The service was implemented in January 2021 for 11 weeks. Multidisciplinary team communication brought challenges; strategies were employed to overcome these.

EVALUATION

A prospective observational study was conducted in intervention wards over two weekends in February 2021. 1584 beds were occupied and 602 patients included. 346 interventions were reported and rated; 85.6% had high or moderate impact; 56.7% were time-critical. The proportion of medicines reconciliation within 24-h of admission was analysed across the hospital between November 2020 and May 2021. During implementation, patients admitted Friday-Sunday were more likely to receive medicines reconciliation within 24-h (RR 1.41 (95% CI 1.34-1.47), p < 0.001). Rostered services were delivered sustainably in terms of shift-fill rate and medicines reconciliation outcome.

CONCLUSION

Seven-day clinical pharmacy services benefit patient outcome through early medicines reconciliation and intervention. Investment to permanently embed the service was sustained.

Critical care pharmacy workforce: a 2020 re-evaluation of the UK deployment and characteristics

INTRODUCTION

Critical care pharmacists improve the quality and efficiency of medication therapy whilst reducing treatment costs where they are available. UK critical care pharmacist deployment was described in 2015, highlighting a deficit in numbers, experience level, and critical care access to pharmacy services over the 7-day week. Since then, national workforce standards have been emphasised, quality indicators published, and service commissioning documents produced, reinforced by care quality assessments. Whether these initiatives have resulted in further development of the UK critical care pharmacy workforce is unknown. This evaluation provides a 2020 status update.

METHODS

The 2015 electronic data entry tool was updated and circulated for completion by UK critical care pharmacists. The tool captured workforce data disposition as it was just prior to the COVID-19 pandemic, at critical care unit level.

MAIN FINDINGS

Data were received for 334 critical care units from 203 organisations (96% of UK critical care units). Overall, 98.2% of UK critical care units had specific clinical pharmacist time dedicated to the unit. The median weekday pharmacist input to each level 3 equivalent bed was 0.066 (0.043-0.088) whole time equivalents, a significant increase from the median position in 2015 (+ 0.021, p < 0.0001). Despite this progress, pharmacist availability remains below national minimum standards (0.1/level 3 equivalent bed). Most units (71.9%) had access to prescribing pharmacists. Geographical variation in pharmacist staffing levels were evident, and weekend services remain extremely limited.

CONCLUSIONS

Availability of clinical pharmacists in UK adult critical care units is improving. However, national standards are not routinely met despite widely publicised quality indicators, commissioning specifications, and assessments. Additional measures are needed to address persistent deficits and realise gains in organisational and patient-level outcomes. These measures must include promotion of cross-professional collaborative working, adjusted funding models, and a nationally recognised training pathway for critical care pharmacists.

[Drug therapy safety supported by interprofessional collaboration between ICU physicians and clinical pharmacists in critical care units in Germany : Results of a survey]

BACKGROUND

Critically ill patients are particularly susceptible to adverse drug events. International studies show that pharmaceutical care has a positive impact on patient and drug therapy safety. Nationally, the integration of pharmacists into the multidisciplinary team and participation in ward rounds is required. The aim of this work is to assess the scope and extent of pharmaceutical care in intensive care units (ICU) in Germany.

METHOD

In a literature and database search, 13 relevant pharmaceutical activities were identified. Based on this, an online survey with 27 questions on the implementation of pharmaceutical care in ICU was prepared by a panel of experts. The survey was sent to heads of German ICUs.

RESULTS

Of the participants, 35.3% (59/167) have established regular pharmaceutical care. Drug information (89.7% [52/58]), pharmaceutical interventions with change of therapy (e.g., ward rounds; 67,2% [39/58]), regular evaluation of prescriptions (medication analysis; 65.5% [38/58]) as well as the monitoring of medication (e.g., side effects, effectiveness, costs; 63.8% [37/58]) were most frequently mentioned. The participants with pharmaceutical care (58/168) graded 7 of 13 but those without (104/168) only two  activities as 'essential/indispensable'.

CONCLUSION

Only a few ICU in Germany have already integrated ward pharmacists into the multidisciplinary team. Once a pharmaceutical service has been established, a greater role/importance is assigned to several pharmaceutical activities.

Assessment of the implementation of safe medication practices in Intensive Medicine Units

OBJECTIVE

To assess the level of implementation of medication safety practices in Intensive Care Units (ICUs) and to identify opportunities for improvement.

DESIGN

A descriptive multicenter study was carried out.

SETTING

Intensive Care Units.

PARTICIPANTS/PROCEDURE

A total of 40 ICUs voluntarily completed the "Medication use-system safety self-assessment for Intensive Care Units" between March and September 2020. The survey comprised 147 items for evaluation grouped into 10 key elements.

MAIN VARIABLES

Calculation was made of the mean scores and mean percentages based on the maximum possible values for the overall survey, referred to the key elements and to each individual item for evaluation.

RESULTS

The mean score of the overall questionnaire among the participating ICUs was 436.8 (49.2% of the maximum possible score). No differences were found according to functional dependence, size of the hospital or type of ICU. The key elements referred to the incorporation of clinical pharmacists in these Units, as well as the competence and training of the professionals in safety practices yielded the lowest values (31.2% and 33.2%, respectively). Three other key elements related to accessibility to information about patients and medicines; to the standardization, storage and distribution of medicines; and to the quality and risk management programs, yielded percentages <50%.

CONCLUSIONS

Numerous effective safety medication practices have been identified with a low level of implementation in ICUs. This situation must be addressed in order to reduce medication errors in critically ill patients.

Burnout among pharmacy professionals in Qatar: A cross-sectional study

Background

Pharmacists’ roles and responsibilities have expanded in the modern pharmacy profession, and the expectations from pharmacists have increased. This has been associated with new psychological challenges and emotional stress that can induce burnout.

Objective

To determine the prevalence of burnout syndrome and factors associated with burnout among pharmacy professionals in the healthcare system in Qatar.

Methods

This institutional-based cross-sectional study was conducted on 850 pharmacy professionals within Hamad Medical Corporation (HMC) in Qatar. Convenience sampling was followed. The survey utilized the Maslach Burnout Inventory (MBI) Toolkit™ for Medical Personnel and a modified version of the Astudillo and Mendinueta questionnaire. Statistical analyses were performed using Stata version 16 for Windows and SAS Studio 3.8 (Enterprise Edition). P-value of less than 0.05 was considered significant.

Results

One hundred ninety-four pharmacy professionals (23%) responded to the survey. The prevalence of burnout was 19.7% [95% Confidence interval (CI); 13.8% - 26.8%] among 142 respondents who completed MBI questionnaire and 17.3% [95% CI; 11.7%-24.2%] among 139 respondents who completed Astudillo Mendinueta questionnaire. The most commonly reported factors that may lead to burnout were: tension and lack of organization in teamwork (59.6%), lack of recognition of or indifference to effort from patients, superiors, and colleagues (58.2%), and demanding and challenging patients and family members (56.7%). Multiple regression analysis showed that overtime working hours per month is independently associated with a higher risk of burnout [odds ratio (OR), 1.57; 95% CI, 1.15–2.14 for each 10-hours increase in monthly overtime, P = 0.005], while non-Arab ethnicity is associated with lower risk of burnout [OR, 0.27; 95% CI, 0.1–0.75; P = 0.012].

Conclusions

There is a relatively low prevalence of burnout syndrome among health-system pharmacy professionals in Qatar. Overtime working hours and Arab ethnicity are independently associated with burnout.

Assessment of the implementation of safe medication practices in Intensive Medicine Units

OBJECTIVE

To assess the level of implementation of medication safety practices in Intensive Care Units (ICUs) and to identify opportunities for improvement.

DESIGN

A descriptive multicenter study was carried out.

SETTING

Intensive Care Units.

PARTICIPANTS/PROCEDURE

A total of 40 ICUs voluntarily completed the "Medication use-system safety self-assessment for Intensive Care Units" between March and September 2020. The survey comprised 147 items for evaluation grouped into 10 key elements.

MAIN VARIABLES

Calculation was made of the mean scores and mean percentages based on the maximum possible values for the overall survey, for the key elements and for each individual item for evaluation.

RESULTS

The mean score of the overall questionnaire among the participating ICUs was 436.8 (49.2% of the maximum possible score). No differences were found according to functional dependence, size of the hospital or type of ICU. The key elements referred to the incorporation of clinical pharmacists in these units, as well as the competence and training of the professionals in safety practices yielded the lowest values (31.2% and 33.2%, respectively). Three other key elements related to accessibility to information about patients and medicines; to the standardization, storage and distribution of medicines; and to the quality and risk management programs, yielded percentages below 50%.

CONCLUSIONS

Numerous effective safety medication practices have been identified with a low level of implementation in ICUs. This situation must be addressed in order to reduce medication errors in critically ill patients.

A clinical pharmacist-led integrated approach for evaluation of medication errors among medical intensive care unit patients

AIM

Medication errors jeopardize the safety of critically ill patients. Using only one method for the detection of medication errors may not reflect an existing picture of patient safety accurately. Therefore, we designed a clinical pharmacist-led integrated approach to evaluate incidence rate, type, and severity of medication errors and preventable adverse drug events (ADEs) and to assess the impact of the implementation of interventions recommended by the clinical pharmacist.

METHODS

A prospective study was conducted from November 2017 to January 2019 in the medical ICU. The clinical pharmacist performed a combination of medication error detection methods, which included medication chart review, patient monitoring until discharge/death, and attending medical rounds. Detected medication errors were intervened with prescribers. Based on the prescribers' decision on delivered interventions, patients were divided into two groups: A (clinical pharmacist's interventions were implemented), and B (clinical pharmacist's interventions were not implemented). We compared patients' outcomes obtained from study groups to evaluate the impact of the implementation of interventions performed by the clinical pharmacist.

RESULTS

A total of 271 medication errors (122.62 per 1000 patient hospital-days) were detected among the study patients (n = 228). Drug-drug interactions (70, 25.8%), guideline nonconformity (51, 18.8%), and inadequate drug monitoring (29, 11%) were the most common types of detected medication errors. Eighty-six percentage of the clinical pharmacist's interventions were implemented by prescribers. Approximately half of medication errors were intercepted before reaching to patients who received the clinical pharmacist's interventions (group A). Overall, medication errors induced 33 preventable ADEs (14.93 per 1000 patient hospital-days), of which the number of preventable ADEs was significantly greater in group B (P < 0.0001). Significantly in group B, detected medication errors initiated chains of consecutive errors when the clinical pharmacist's interventions were not accepted. Also, this group had significantly increased length of stay (P < 0.0001), number of deaths (P = 0.0312), and more than a three-fold greater number of patients intratransferring to higher levels of care (P = 0.0235; odds ratio, 3.41; 95% confidence interval, 1.08-10.8).

CONCLUSION

The clinical pharmacist-led integrated approach revealed that medication errors commonly occurred among critically ill patients, and the clinical pharmacist's interventions intercepted the majority of these medication errors. The number of preventable ADEs was significantly fewer in a group of patients who received these interventions. However, medication errors formed chains of errors that adversely affected patients' investigated outcomes in the study group with no implementation of the clinical pharmacist interventions.

Position Paper on Critical Care Pharmacy Services: 2020 Update

OBJECTIVES

To provide a multiorganizational statement to update recommendations for critical care pharmacy practice and make recommendations for future practice. A position paper outlining critical care pharmacist activities was last published in 2000. Since that time, significant changes in healthcare and critical care have occurred.

DESIGN

The Society of Critical Care Medicine, American College of Clinical Pharmacy Critical Care Practice and Research Network, and the American Society of Health-Systems Pharmacists convened a joint task force of 15 pharmacists representing a broad cross-section of critical care pharmacy practice and pharmacy administration, inclusive of geography, critical care practice setting, and roles. The Task Force chairs reviewed and organized primary literature, outlined topic domains, and prepared the methodology for group review and consensus. A modified Delphi method was used until consensus (> 66% agreement) was reached for each practice recommendation. Previous position statement recommendations were reviewed and voted to either retain, revise, or retire. Recommendations were categorized by level of ICU service to be applicable by setting and grouped into five domains: patient care, quality improvement, research and scholarship, training and education, and professional development.

MAIN RESULTS

There are 82 recommendation statements: 44 original recommendations and 38 new recommendation statements. Thirty-four recommendations represent the domain of patient care, primarily relating to critical care pharmacist duties and pharmacy services. In the quality improvement domain, 21 recommendations address the role of the critical care pharmacist in patient and medication safety, clinical quality programs, and analytics. Nine recommendations were made in the domain of research and scholarship. Ten recommendations were made in the domain of training and education and eight recommendations regarding professional development.

CONCLUSIONS

Critical care pharmacists are essential members of the multiprofessional critical care team. The statements recommended by this taskforce delineate the activities of a critical care pharmacist and the scope of pharmacy services within the ICU. Effort should be made from all stakeholders to implement the recommendations provided, with continuous effort toward improving the delivery of care for critically ill patients.

The implementation of pharmaceutical services in public hospitals in Mexico: an analysis of the legal framework and organizational practice

BACKGROUND

The implementation of pharmaceutical services in hospitals contributes to the appropriate use of medicines and patient safety. However, the relationship of implementation with the legal framework and organizational practice has not been studied in depth. The objective of this research is to determine the role of these two factors (the legal framework and organizational practice) in the implementation of pharmaceutical services in public hospitals of the Ministry of Health of Mexico.

METHODS

Semi-structured interviews were conducted with four groups of actors involved. The analysis focused on the legal framework, defined as the rules, laws and regulations, and on organizational practice, defined as the implementation of the legal framework by related individuals, that is, how they put it into practice.

RESULTS

The main problems identified were the lack of alignment between the rules and the incentives for compliance. Decision-makers identified the lack of managerial capacity in hospitals as the main implementation barrier, while hospital pharmacists pointed to poor regulation and the lack of clarity of the legal framework as the problems to consider.

CONCLUSIONS

Although the legal framework related to hospital pharmaceutical services in Mexico is inadequate, organizational factors (such as adequate skills of professional pharmacists and the support of the hospital director) have facilitated gradual implementation. To improve implementation, priority should be given to evaluation and modification of the current legislation along with the development of an official minimum standard for activities and services in hospital pharmacies.

The role of pharmacists in the renal multidisciplinary team at a tertiary hospital in South Africa: Strategies to increase participation of pharmacists

Background

Pharmacists are often marginalised from participating fully in a Multidisciplinary Team (MDT). Pharmacists can contribute in the renal MDT by minimising drug-related problems and optimising therapy.

Aim

The study aimed to explore the current role of pharmacists in renal care at a tertiary hospital in South Africa, and to recommend strategies to improve their participation in the renal MDT.

Method

An exploratory descriptive qualitative study was conducted using semi-structured interviews. The participants were selected using purposive sampling. The audiotaped interviews were transcribed exactly as spoken and analysed using thematic content analysis.

Results

Three themes emerged from the analysis: pharmacist’s current scope of practice within the renal MDT, potential future roles of pharmacists, and perceived barriers to participation of pharmacists within the renal MDT. Furthermore, participants provided recommendations to increase pharmacist’s participation in the renal MDT: that is standardisation of practice, skills development of both pharmacist and pharmacist assistants and recognition of pharmacist services in the wards.

Conclusion

The role of pharmacists at Pietersburg Hospital is the official name of the hospital is confined to stock management and dispensing. Efforts should be made to improve the participation of pharmacists in the MDTs with the intention to standardise the practice of pharmacists in the wards, equip both pharmacists and pharmacist assistants with the necessary skills and recognise pharmacist’s services in the wards.

Voluntarily reported prescribing, monitoring and medication transfer errors in intensive care units in The Netherlands

Background Medication errors occur frequently in intensive care units (ICU). Voluntarily reported medication errors form an easily available source of information. Objective This study aimed to characterize prescribing, monitoring and medication transfer errors that were voluntarily reported in the ICU, in order to reveal medication safety issues. Setting This retrospective data analysis study included reports of medication errors from eleven Dutch ICU's from January 2016 to December 2017. Method We used data extractions from the incident reporting systems of the participating ICU's. The reports were transferred into one database and categorized into type of error, cause, medication (groups), and patient harm. Descriptive statistics were used to calculate the proportion of medication errors and the distribution of subcategories. Based on the analysis, ICU medication safety issues were revealed. Main outcome measure The main outcome measure was the proportion of prescribing, monitoring and medication transfer error reports. Results Prescribing errors were reported most frequently (n = 233, 33%), followed by medication transfer errors (n = 85, 12%) and monitoring errors (n = 27, 4%). Other findings were: medication transfer errors frequently caused serious harm, especially the omission of home medication involving the central nervous system and proton pump inhibitors; omissions and dosing errors occurred most frequently; protocol problems caused a quarter of the medication errors; and medications needing blood level monitoring (e.g. tacrolimus, vancomycin, heparin and insulin) were frequently involved. Conclusion This analysis of voluntarily reported prescribing, monitoring and medication transfer errors warrants several improvement measures in these processes, which may help to increase medication safety in the ICU.

Assessment of burnout within a health-system pharmacy department

Purpose

Workplace-related burnout is a state of mental and physical exhaustion caused by one’s professional life. Literature demonstrates the link between physician burnout and serious consequences (reduced productivity, medical errors, and clinician suicide), but assessment of burnout in other healthcare professions is limited, especially in pharmacy. A quality improvement study was conducted to quantify burnout in a diverse health-system pharmacy department and identify potential strategies to improve well-being.

Methods

A survey was distributed to assess the perception and drivers of burnout within a health-system pharmacy. All associates received a survey comprised of the Maslach Burnout Inventory (MBI), demographic questions, and items affording respondents the opportunity to list stressors and potential solutions. Email reminders were sent weekly and site visits were conducted to encourage survey completion. Results were analyzed via descriptive statistics.

Results

Two hundred seventy-seven associates completed the survey (response rate, 40.5%). Seventy percent of those participants were experiencing moderate to high levels of burnout, with survey results indicating moderate levels of personal accomplishment and emotional exhaustion and low levels of depersonalization; there were no statistically significant differences in mean MBI scores by shift type, hours worked per week, or years of service. There were statistically significant differences in scores for personal accomplishment between males and females, as well as among positions and regions (P &lt; 0.05). Participants identified issues related to workflow, control, and community as the greatest contributors to stress.

Conclusion

The diverse staff of a health-system pharmacy department reported a moderate amount of burnout, with the greatest variation in the dimension of personal accomplishment. The mitigation strategies most commonly cited were staffing/workflow adjustments and creating a culture of well-being.

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

BACKGROUND

While the benefits of multidisciplinary ward round (WR) participation by clinical pharmacists have been demonstrated, it can be time-consuming. No previous studies have compared the specific benefits of WR participation and other clinical activities.

OBJECTIVES

To assess the clinical impact of different clinical pharmacist activities and analyse patterns of practice based on WR involvement and timing and significance of clinical interventions.

METHODS

In a prospective, observational time and motion study, clinical pharmacists servicing 6 unmatched specialty areas in a major quaternary public hospital were observed and their activities documented. Pharmacists' self-recorded interventions underwent expert panel assessment for significance and potential cost savings. Workflows and interventions were analysed for the 4 pharmacists involved in WRs ('WR pharmacists') during their time 'on' and 'off' rounds and for 2 pharmacists not involved in WRs ('non-WR pharmacists') using chi-square analyses.

RESULTS

During 170 h of observation, 267 clinical interventions (53.9% minor, 40.1% moderate, 6.0% major) were recorded. WR pharmacists spent 24.3% of their time on rounds, and 64.8% of interventions were made during this time (intervention rates: 4.5/hour on WR vs. 0.8/hour off WR vs. 1.3/hour for non-WR pharmacists). Differences in WR and non-WR pharmacists' workflows were observed, although there was no difference in time spent on clinical/patient-centred activities (p = 0.70). WR involvement was associated with significantly quicker interventions (p < 0.001). All major interventions were made by WR pharmacists; 80% were made on rounds. Major interventions were estimated to have decreased lengths of stay, intensive care requirements and procedure costs.

CONCLUSIONS

Clinical pharmacists focussed on patient-centred activities, regardless of WR involvement. Notwithstanding differences in the WR and non-WR specialty areas, WR participation was associated with more significant and timely interventions and potential cost savings. Coupled with the subjective benefits of WR participation observed, these findings support the potential value of clinical pharmacist WR participation.

Integrating a pharmacist into an anaesthesiology and critical care department: Is this worthwhile?

Background Operating rooms and Intensive Care Units are places where an optimal management of drugs and medical devices is required. Objective To evaluate the impact of a dedicated pharmacist in an academic Anaesthesiology and Critical Care Department. Setting This study was conducted in the Anaesthesiology and Critical Care Department of Grenoble University Hospital. Method Between November 2013 and June 2017, the drug-related problems occurring in three Intensive Care Units and their corrections by a full-time clinical pharmacist were analyzed using a structured order review instrument. Pharmaceutical costs in the Anaesthesiology and Critical Care Department were analyzed over a 7 year period (2010-2016), during which automated dispensing systems and recurrent meetings to review indications of medications and medical devices were implemented in the department. Main outcome measure Analysis of two issues: correcting drug-related problems and containing pharmaceutical costs. Results A total of 324 drug-related problems were identified. The most frequent problem concerned anti-infective agents (45%), and this was mainly due to the over-dosage of drugs (30%). Dosage adjustments were the most frequent interventions performed by the pharmacist (43%). Over the 7 year period, pharmaceutical costs decreased by 9% (€365,469), while the care activity of the department increased by 55% (+ 12,022 surgical procedures and + 1424 admissions in the ICU). Conclusion Integrating a pharmacist into the Anaesthesiology and Critical Care Department was associated with interventions to correct drug-related problems and containing pharmaceutical costs. Pharmacists should play a central role in such medical environments, to optimize the use of drugs and medical devices.

Impact of a pharmacist intervention at an intensive care rehabilitation clinic

Objective

While disruptions in medications are common among patients who survive critical illness, there is limited information about specific medication-related problems among survivors of critical care. This study sought to determine the prevalence of specific medication-related problems detected in patients, seen after critical care discharge.

Design

Consecutive patients attending an intensive care unit (ICU) follow-up programme were included in this single-centre service evaluation.

Setting

Tertiary care regional centre in Scotland (UK).

Participants

47 patients reviewed after critical care discharge at an ICU follow-up programme.

Interventions

Pharmacists conducted a full medication review, including: medicines reconciliation, assessing the appropriateness of each prescribed medication, identification of any medication-related problems and checking adherence.

Measurements

Medication-related problems in patients following critical care discharge. Interventions and medication-related problems were systematically graded and risk factors were identified using an adapted version of the National Patient Safety Agency Risk Matrix.

Main results

69 medication-related problems were identified in 38 (81%) of the 47 patients. The most common documented problem was drug omission (29%). 64% of the medication-related problems identified were classified as either moderate or major. The number of pain medications prescribed at discharge from intensive care was predictive of medication-related problems (OR 2.02, 95% CI 1.14 to 4.26, p=0.03).

Conclusions

Medication problems are common following critical care. Better communication of medication changes both to patients and their ongoing care providers may be beneficial following a critical care admission. In the absence of highly effective communication, a pharmacy intervention may contribute substantially to an intensive care rehabilitation or recovery programme.

Positive Pressure Ventilation in the Cardiac Intensive Care Unit

Contemporary cardiac intensive care units (CICUs) provide care for an aging and increasingly complex patient population. The medical complexity of this population is partly driven by an increased proportion of patients with respiratory failure needing noninvasive or invasive positive pressure ventilation (PPV). PPV often plays an important role in the management of patients with cardiogenic pulmonary edema, cardiogenic shock, or cardiac arrest, and those undergoing mechanical circulatory support. Noninvasive PPV, when appropriately applied to selected patients, may reduce the need for invasive mechanical PPV and improve survival. Invasive PPV can be lifesaving, but has both favorable and unfavorable interactions with left and right ventricular physiology and carries a risk of complications that influence CICU mortality. Effective implementation of PPV requires an understanding of the underlying cardiac and pulmonary pathophysiology. Cardiologists who practice in the CICU should be proficient with the indications, appropriate selection, potential cardiopulmonary interactions, and complications of PPV.

The role of the pharmacist in the intensive care unit

The use of medication to support patients and optimise outcomes is a fundamental strand of care. Pharmacists provide a key role managing medication within the complexity of various routes of administration, severe and rapidly shifting pharmacokinetic and dynamic parameters, and extremes of physiology in critical illness. Pharmacists intercept and resolve medication errors, optimise medication therapy and undertake broader professional activities within the job role that contribute to the smooth running of ICU. These activities are associated with improved quality, reduced mortality and reduced costs.

Pharmacist Adscription To Intensive Care: Generating Synergies

OBJECTIVE

To evaluate incorporation of the hospital pharmacist to the routine activity of an Intensive Care Unit (ICU).

DESIGN

A prospective observational study was carried out to evaluate the impact of pharmacist interventions, made by a pharmacist temporarily assigned to the ICU, upon medical prescriptions.

SETTING

A medical and surgical ICU with 21 beds.

PATIENTS

Patients with at least one ICU stay were included, while patients with admission and discharge in periods when the pharmacist was not present were excluded.

INTERVENTIONS

The interventions were made after daily review of the prescriptions, and were communicated verbally or in writing to the supervising physician.

MAIN VARIABLES

Number of interventions, therapeutic group of the drugs involved, type of intervention and degree of acceptance.

RESULTS

A total of 194 interventions were made in 62 patients. The majority were related to safety aspects (33%) and the optimization of therapy (32%). The most frequent interventions were the administration of drugs via the nasogastric tube (19%) and pharmacokinetic monitoring (14.4%). The most frequently involved groups of drugs were anti-infectious agents (33%) and digestive system medications (27%). A total of 56.2% of the interventions were made verbally, and 80% were accepted.

CONCLUSIONS

Pharmacist adscription to an ICU and the implementation of interventions on prescriptions have allowed improvement of safety and the optimization of pharmacotherapy in more than 50% of the patients. The high rate of acceptance of these interventions would support the implementation of such programs in critical care units.

Pharmacist prescribing in critical care: an evaluation of the introduction of pharmacist prescribing in a single large UK teaching hospital

OBJECTIVES

To evaluate the introduction of pharmacist independent prescribing activity across three general critical care units within a single large UK teaching hospital. To identify the prescribing demographics including total of all prescriptions, number prescribed by pharmacists, reason for pharmacist prescription, range of medications prescribed, pharmacist prescribing error rate and the extent of pharmacist second 'clinical check'.

METHODS

Retrospective evaluation of e-prescribing across all general critical care units of a single large UK teaching hospital. All prescribing data were downloaded over a 1-month period (May to June 2016) with analysis of pharmacist prescribing activity including rate, indication, therapeutic class and error rate.

RESULTS

In total, 5374 medicines were prescribed in 193 patients during the evaluated period. Prescribing pharmacists were available on the units on 60.4% (58/96) of days, during their working hours and accounted for 576/5374 (10.7%) of medicines prescribed in 65.2% (126/193) of patients. The majority (342/576) of pharmacist prescriptions were for new medicines. Infections, central nervous system, and nutrition/blood were the top three British National Formulary (BNF) therapeutic categories, accounting for 63.4% (349/576) of all pharmacist prescriptions. The critical care pharmacist prescribing error rate was 0.18% (1/550).

CONCLUSIONS

Pharmacist independent prescribers demonstrated a high degree and wide-ranging scope of prescribing activity in general critical care patients. Pharmacists contributed a significant proportion of total prescribing, despite less than full service coverage. Prescribing activity was also safe with a very low error rate recorded.

Reducing medication errors in critical care patients: pharmacist key resources and relationship with medicines optimisation

BACKGROUND

Medication errors are the most common type of medical errors critical care patients experience. Critical care units utilise a variety of resources to reduce medication errors; it is unknown which resources or combinations thereof are most effective in improving medication safety.

OBJECTIVES

To obtain UK critical care pharmacist group consensus on the most important interventions/resources that reduce medication errors. To then classify units that participated in the PROTECTED UK study to investigate if there were significant differences in the reported pharmacist prescription intervention type, clinical impact and rates according to unit resource classification.

METHODS

An e-Delphi process (three rounds) obtained pharmacist consensus on which interventions/resources were most important in the reduction of medication errors in critical care patients. The 21 units involved in the PROTECTED UK study (multicentre study of UK critical care pharmacist medicines interventions), were categorised as high-, medium- and low-resource units based on routine delivery of the final Top 5 interventions/ resources. High and low units were compared according to type, clinical impact and rate of medication interventions reported during the PROTECTED UK study.

KEY FINDINGS

Consensus on the Top 5 combined medication error reduction resources was established: advanced-level clinical pharmacist embedded in critical care being ranked most important. Pharmacists working on units with high resources made significantly more clinically significant medicines optimisations compared to those on low-resourced units (OR 3.09; P = 0.035).

CONCLUSIONS

Critical care pharmacist group consensus on the most important medication error reduction resources was established. Pharmacists working on high-resourced units made more clinically significant medicines optimisations.

Reliability of clinical impact grading by healthcare professionals of common prescribing error and optimisation cases in critical care patients

Objective

To identify between and within profession-rater reliability of clinical impact grading for common critical care prescribing error and optimisation cases. To identify representative clinical impact grades for each individual case.

Design

Electronic questionnaire.

Setting

5 UK NHS Trusts.

Participants

30 Critical care healthcare professionals (doctors, pharmacists and nurses).

Intervention

Participants graded severity of clinical impact (5-point categorical scale) of 50 error and 55 optimisation cases.

Main Outcome Measures

Case between and within profession-rater reliability and modal clinical impact grading.

Methods

Between and within profession rater reliability analysis used linear mixed model and intraclass correlation, respectively.

Results

The majority of error and optimisation cases (both 76%) had a modal clinical severity grade of moderate or higher. Error cases: doctors graded clinical impact significantly lower than pharmacists (-0.25; P < 0.001) and nurses (-0.53; P < 0.001), with nurses significantly higher than pharmacists (0.28; P < 0.001). Optimisation cases: doctors graded clinical impact significantly lower than nurses and pharmacists (-0.39 and -0.5; P < 0.001, respectively). Within profession reliability grading was excellent for pharmacists (0.88 and 0.89; P < 0.001) and doctors (0.79 and 0.83; P < 0.001) but only fair to good for nurses (0.43 and 0.74; P < 0.001), for optimisation and error cases, respectively.

Conclusions

Representative clinical impact grades for over 100 common prescribing error and optimisation cases are reported for potential clinical practice and research application. The between professional variability highlights the importance of multidisciplinary perspectives in assessment of medication error and optimisation cases in clinical practice and research.

Critical care pharmacy workforce: UK deployment and characteristics in 2015

OBJECTIVE

Clinical pharmacists reduce medication errors and optimize the use of medication in critically ill patients, although actual staffing level and deployment of UK pharmacists is unknown. The primary aim was to investigate the UK deployment of the clinical pharmacy workforce in critical care and compare this with published standards.

METHODS

An electronic data entry tool was created and distributed for UK critical care pharmacy services to record their critical care workforce deployment data.

KEY FINDINGS

Data were received for 279 critical care units in 171 organizations. Clinical pharmacist input was identified for 98.6% of critical care units. The median weekday pharmacist input to critical care was 0.045 whole time equivalents per Level 3 (ICU) bed with significant interregional variation. Weekend services were sparse. Pharmacists spent 24.5% of time on the multidisciplinary team ward round, 58.5% of time on independent patient review and 17% of time on other critical care professional support activities. There is significant variation in staffing levels when services are stratified by highest level of competence of critical care pharmacist within an organization (P = 0.03), with significant differences in time spent on the multi-disciplinary ward round (P = 0.010) and on other critical care activities (P = 0.009), but not on independent patient review.

CONCLUSIONS

Investment in pharmacy services is required to improve access to clinical pharmacy expertise at weekends, on MDT ward rounds and for other critical care activities.

Factors Associated With Burnout Among US Hospital Clinical Pharmacy Practitioners: Results of a Nationwide Pilot Survey

Background: In health care, burnout has been defined as a psychological process whereby human service professionals attempting to positively impact the lives of others become overwhelmed and frustrated by unforeseen job stressors. Burnout among various physician groups who primarily practice in the hospital setting has been extensively studied; however, no evidence exists regarding burnout among hospital clinical pharmacists. Objective: The aim of this study was to characterize the level of and identify factors independently associated with burnout among clinical pharmacists practicing in an inpatient hospital setting within the United States. Methods: We conducted a prospective, cross-sectional pilot study utilizing an online, Qualtrics survey. Univariate analysis related to burnout was conducted, with multivariable logistic regression analysis used to identify factors independently associated with the burnout. Results: A total of 974 responses were analyzed (11.4% response rate). The majority were females who had practiced pharmacy for a median of 8 years. The burnout rate was high (61.2%) and largely driven by high emotional exhaustion. On multivariable analysis, we identified several subjective factors as being predictors of burnout, including inadequate administrative and teaching time, uncertainty of health care reform, too many nonclinical duties, difficult pharmacist colleagues, and feeling that contributions are underappreciated. Conclusions: The burnout rate of hospital clinical pharmacy providers was very high in this pilot survey. However, the overall response rate was low at 11.4%. The negative effects of burnout require further study and intervention to determine the influence of burnout on the lives of clinical pharmacists and on other health care-related outcomes.

A Mnemonic for Pharmacists to Ensure Optimal Monitoring and Safety of Total Parenteral Nutrition: I AM FULL

Objective: To present a guideline-derived mnemonic that provides a systematic monitoring process to increase pharmacists’ confidence in total parenteral nutrition (TPN) monitoring and improve safety and efficacy of TPN use. Data Sources: The American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines were reviewed. Additional resources included a literature search of PubMed (1980 to May 2016) using the search terms: total parenteral nutrition, mnemonic, indications, allergy, macronutrients, micronutrients, fluid, comorbidities, labs, peripheral line, and central line. Articles (English-language only) were evaluated for content, and additional references were identified from a review of literature citations. Study Selection and Data Extraction: All English-language observational studies, review articles, meta-analyses, guidelines, and randomized trials assessing monitoring parameters of TPN were evaluated. Data Synthesis: The ASPEN guidelines were referenced to develop key components of the mnemonic. Review articles, observational trials, meta-analyses, and randomized trials were reviewed in cases where guidelines did not adequately address these components. Conclusions: A guideline-derived mnemonic was developed to systematically and safely manage TPN therapy. The mnemonic combines 7 essential components of TPN use and monitoring: Indications, Allergies, Macro/Micro nutrients, Fluid, Underlying comorbidities, Labs, and Line type.

PROTECTED-UK - Clinical pharmacist interventions in the UK critical care unit: exploration of relationship between intervention, service characteristics and experience level

PURPOSE

Clinical pharmacist (CP) interventions from the PROTECTED-UK cohort, a multi-site critical care interventions study, were further analysed to assess effects of: time on critical care, number of interventions, CP expertise and days of week, on impact of intervention and ultimately contribution to patient care.

METHODS

Intervention data were collected from 21 adult critical care units over 14 days. Interventions could be error, optimisation or consults, and were blind-coded to ensure consistency, prior to bivariate analysis. Pharmacy service demographics were further collated by investigator survey.

KEY FINDINGS

Of the 20 758 prescriptions reviewed, 3375 interventions were made (intervention rate 16.1%). CPs spent 3.5 h per day (mean, ±SD 1.7) on direct patient care, reviewed 10.3 patients per day (±SD 4.2) and required 22.5 min (±SD 9.5) per review. Intervention rate had a moderate inverse correlation with the time the pharmacist spent on critical care (P = 0.05; r = 0.4). Optimisation rate had a strong inverse association with total number of prescriptions reviewed per day (P = 0.001; r = 0.7). A consultant CP had a moderate inverse correlation with number of errors identified (P = 0.008; r = 0.6). No correlation existed between the presence of electronic prescribing in critical care and any intervention rate. Few centres provided weekend services, although the intervention rate was significantly higher on weekends than weekdays.

CONCLUSIONS

A CP is essential for safe and optimised patient medication therapy; an extended and developed pharmacy service is expected to reduce errors. CP services should be adequately staffed to enable adequate time for prescription review and maximal therapy optimisation.

An integrative review of drug errors in critical care

Medication error is the commonest cause of medical error and the consequences can be grave. This integrative review was undertaken to critically appraise recent literature to further define prevalence, most frequently-implicated drugs and effects on patient morbidity and mortality in the critical care environment. Forty studies were compared revealing a markedly heterogeneous data set with significant variability in reported incidence. There is an important differentiation to be made between medication error (incidence 5.1-967 per 1000 patient days) and adverse drug event (incidence 1-96.5 per 1000 patient days) with significant ramifications for patient outcome and cost. The most commonly implicated drugs were cardiovascular, gastrointestinal, antimicrobial and hypoglycaemic agents. Beneficial interventions to reduce such errors include computerised prescribing, education and pharmacist input. The studies described provide insight into suboptimal management in the critical care environment and have implications for the development of specific improvement strategies and future training.

Advanced Level Practice Education: UK Critical Care Pharmacists' Opinions in 2015

National UK standards for critical care highlight the need for clinical pharmacists to practice at an advanced level and above. The aim of this research paper was to describe the views of UK critical care pharmacists on the current provision of Advanced Level Practice (ALP) education and accreditation. It sought to identify whether there is a need for a national or regional training programme. A questionnaire was delivered electronically targeting UK critical care pharmacists. Whilst the response rate was low at 40% (166/411); the views expressed were representative of UK practitioners with the majority of responders meeting the national specifications for clinical pharmacist staffing in critical care areas. The responses highlighted work-based learning as the main resource for developing ALP and a lack of suitable training packages. The vast majority of pharmacists identified that a national or regional training programme was required for ALP. The results also identified the main barriers to undertaking ALP accreditation were lack of time, uncertainty regarding the process and its professional benefits and a lack of education and training opportunities. In conclusion, the responses clearly indicated that, for the necessary progression of critical care pharmacists to ALP, a national or regional training programme is required.

Impact of the introduction of a specialist critical care pharmacist on the level of pharmaceutical care provided to the critical care unit

OBJECTIVES

To evaluate the impact of a dedicated specialist critical care pharmacist service on patient care at a UK critical care unit (CCU).

METHODS

Pharmacist intervention data was collected in two phases. Phase 1 was with the provision of a non-specialist pharmacist chart review service and Phase 2 was after the introduction of a specialist dedicated pharmacy service. Two CCUs with established critical care pharmacist services were used as controls. The impact of pharmacist interventions on optimising drug therapy or preventing harm from medication errors was rated on a 4-point scale.

KEY FINDINGS

There was an increase in the mean daily rate of pharmacist interventions after the introduction of the specialist critical care pharmacist (5.45 versus 2.69 per day, P < 0.0005). The critical care pharmacist intervened on more medication errors preventing potential harm and optimised more medications. There was no significant change to intervention rates at the control sites. Across all study sites the majority of pharmacist interventions were graded to have at least moderate impact on patient care.

CONCLUSION

The introduction of a specialist critical care pharmacist resulted in an increased rate of pharmacist interventions compared to a non-specialist pharmacist service thus improving the quality of patient care.

Pharmacist independent prescribing in critical care: results of a national questionnaire to establish the 2014 UK position

OBJECTIVES

Clinical pharmacist practice is well established in the safe and effective use of medicines in the critically ill patient. In the UK, independent pharmacist prescribers are generally recognised as a valuable and desirable resource. However, currently, there are only anecdotal reports of pharmacist-independent prescribing in critical care. The aim of this questionnaire was to determine the current and proposed future independent prescribing practice of UK clinical pharmacists working in adult critical care.

METHODS

The questionnaire was distributed electronically to UK Clinical Pharmacy Association members (closed August 2014).

KEY FINDINGS

There were 134 responses to the questionnaire (response rate at least 33%). Over a third of critical care pharmacists were practising independent prescribers in the specialty, and 70% intended to be prescribers within the next 3 years. Pharmacists with ≥5 years critical care experience (P < 0.001) or worked in a team (P = 0.005) were more likely to be practising independent prescribers. Pharmacists reported significant positives to the use of independent prescribing in critical care both in patient care and job satisfaction. Independently, prescribing was routine in: dose adjustment for multi-organ failure, change in route or formulation, correction prescribing errors, therapeutic drug monitoring and chronic medication. The majority of pharmacist prescribers reported they spent ≤5% of their clinical time prescribing and accounted for ≤5% of new prescriptions in critical care patients.

CONCLUSIONS

Most critical care pharmacists intend to be practising as independent prescribers within the next 3 years. The extent and scope of critical care pharmacist prescribing appear to be of relatively low volume and within niche prescribing areas.