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Clinical pharmacy services in the critical care setting have expanded dramatically and include assisting

physicians in pharmacotherapy decision making, providing pharmacokinetic consultations, monitoring patients for

drug efficacy and safety, providing drug information, and offering medical education to physicians, nurses, and

patients. Measurable clinical effects of these services include reduced drug errors and adverse drug events,

decreased morbidity and mortality rates, and a positive pharmacoeconomic impact by decreasing overall health

care costs.

The profession of pharmacy evolved over the last century from a discipline that focused on pharmaceutical

products into one that primarily focuses on the patient and the optimal delivery of pharmaceutical care. The

curricula in most pharmacy colleges and universities has changed significantly to reflect this transformation.

Courses in pharmacotherapeutics, pharmacokinetics, pathophysiology, human anatomy and physiology, physicalassessment, and pharmacoeconomics have been added to prepare graduates for careers as clinicians.

Furthermore, pharmacy graduates can pursue additional training by completing residencies or fellowships in their

areas of interests, which can include critical care.

Critical care medicine has evolved into a multidisciplinary profession requiring highly trained, specialized

clinicians. Many pharmacists work in a critical care setting as part of a health care team. Their services may

include but are not limited to assisting physicians in pharmacotherapy decision making, providing

pharmacokinetic consultations, monitoring patients for drug efficacy and safety, providing drug information, and

offering medical education to physicians, nurses, and patients. These services are important in an intensive care

unit (ICU) because critically ill patients receive complex pharmaceutical regimens, are prone to drug-drug and

drug-nutrient interactions, have an increased frequency of adverse drug events, and have altered pharmacokinetic

parameters.

Pharmacists have been performing clinical services for more than 3 decades. [1] Numerous research articles and

several surveys have identified areas in which critical care pharmacists make significant contributions to patient

care.[1-10] Most of this literature describes the role and responsibilities of these pharmacists on multidisciplinary

health care teams as follows: drug-use evaluation programs, drug error management, in-service education,

pharmacokinetic consults, drug therapy monitoring, nutrition team participation, patient drug counseling, adverse

drug reaction programs, written drug histories, cardiopulmonary resuscitation (CPR) team participation, drug

information services, multidisciplinary medical rounds, written documentation in medical records, and clinical

research. Activities specific to the CPR team are as follows: provide artificial respiration, administer chestcompressions, prepare drugs, administer drugs, record drug administration, provide drug information, calculate

dosages and infusion rates, and set up or operate intravenous pump devices.

Guidelines and position statements stress the importance of continued growth of ICU clinical pharmacy services.

The American College of Critical Care Medicine of the Society of Critical Care Medicine published

recommendations for critical care services and personnel[11] in which it stressed the importance of clinical

pharmacy services, such as monitoring drug dosing and administration, adverse drug events (ADEs), drug-drug

interactions, and cost containment issues. In addition, clinical pharmacists with knowledge in CPR, nutrition

support, and clinical research are essential for level I ICUs with academic affiliations.

Altered organ function and polypharmacy clearly contribute to ADEs in patients requiring intensive medical care.[9]

Despite attempts of several authors to determine the cost of ADEs, it is difficult to estimate the financial,

emotional, and overall impact of an ADE. In an environment in which many drugs are administered, a critical care

pharmacist with thorough knowledge of clinical management of ADEs, pharmacokinetics, pharmacodynamics,

drug-drug interactions, and drug-nutrient interactions would be an important member of the health care team.

The Critical Care Pharmacist: An Essential Intensive CarePractitioner John Papadopoulos, Pharm.D., Jill A. Rebuck, Pharm.D., Cheryl Lober, Pharm.D., Steven E. Pass, Pharm.D., Edward C.

Seidl, Pharm.D., Rina A. Shah, Pharm.D., Deb S. Sherman, Pharm.D.

Pharmacotherapy. 2002;22(11)

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Several studies show that clinical pharmacists can reduce drug errors and ADEs in a hospital setting.[9, 12-14]

The only prospective study evaluating the impact of a clinical pharmacist in a medical ICU had two phases,

baseline and intervention.[9] It compared the ICU with a pharmacist rounding and intervening with a control

coronary care unit. Within 9 months, a 66% reduction in preventable ADEs from 10.4/1000 patient-days before the

intervention to 3.5/1000 patient-days after the intervention was observed in the study unit in comparison with the

control unit. In addition, 99% of recommendations made by the clinical pharmacist were accepted by physicians.

Many studies have documented cost-effective care related to pharmacist intervention in the acute care setting.[15-22] Clinical pharmacists can affect clinical end points, such as minimizing fluid intake in fluid-restricted patients in

the ICU or providing a positive impact in the management of streptococcal pneumonia by orchestrating optimal

antimicrobial selection.[15, 16] Individual monitoring of aminoglycoside therapy by clinical pharmacists minimizes

the frequency of associated nephrotoxicity, with a resultant decrease in cost of over $90,000/100 patients studied.[17] Pharmacists must provide value-added services such as identifying appropriate indicators to ensure that drug

therapy leads to a measurable patient outcome.[18]

A prospective study compared multidisciplinary medical and surgical teams with respect to the presence or

absence of a clinical pharmacist.[19] Pharmacist members of health care teams developed pharmaceutical care

plans, provided drug monitoring, and assisted in discharge planning. Care managed by teams that included a

clinical pharmacist led to shorter hospital stays and a benefit:cost ratio of 6:1. [19] Furthermore, a lower

percentage of medical patients required transfer back into the ICU, suggesting that pharmacists prevent transfer of

patients to more resource-intensive areas of the hospital, further decreasing health care costs.[19]

Pharmacy characteristics, specifically the number of pharmacists/average daily census and combined

hospitalwide clinical pharmacy services, were associated with a decrease in patient mortality.[20] Factors that

contributed to this association included the presence of pharmacists in patient-care areas and participation on

medical rounds, availability of therapeutic drug and ADE monitoring, pharmacokinetic services, patient drug

counseling, nutrition recommendations, admission histories, clinical research, and drug information services. This

study was the first to reveal a statistically significant association between pharmacists and a reduction in overall

hospital mortality rates.

Patient mortality rates decrease as pharmacy staffing/occupied bed increases,[21] with specific services having

greatest impact in improving health care by reducing hospital mortality. In an evaluation of the association

between such services and mortality in 1029 hospitals adjusted for severity of illness, participation of a pharmacist

on medical rounds and on CPR teams was associated with lower mortality compared with hospitals without these

services, with an absolute reduction in mortality of 40,000 patients.[22] Additional studies are necessary to

determine the clinical impact of critical care pharmacists on multidisciplinary ICU teams.

In an era of cost containment, each medical discipline must cost-justify its services and work collectively to

decrease medical costs. Many authors have assessed the positive economic impact pharmacists have in this

area.[10, 23-41]

A study in 934 United States hospitals tested direct relationships and associations among 14 pharmacy services,

staffing, and severity of illness-adjusted drug costs.[23] The services were divided into two categories: centrally

delivered and patient-specific clinical pharmacy services. Centrally delivered services referred to drug-use

evaluations, in-service education, drug and toxicologic information, and clinical research. Patient-specific services

were pharmacokinetic consultations, therapeutic drug monitoring, CPR team participation, drug protocol

management, ADE monitoring, medical and nutrition rounds, drug counseling, and admission drug histories.

Pharmacy staffing data and inpatient drug costs also were collected. Four pharmacy services (in-service

education, drug information, drug protocol management, admission drug histories) led to a statistically significant

decrease in drug costs, whereas other services showed a nonstatis tically significant trend ( ).

Table 1. Cost Savings for Four Clinical Pharmacy Services[23]

Savings/Occupied





Service Bed/Year ($) Total Savings/Hospital ($)

In-service education 460.96 77,879.19

Drug information 1961.55 430,579.84

Drug protocol management 578.71 137,333.67

Admission drug histories 742.84 213,388.21

The cost-saving effects of a clinical pharmacist in a 14-bed surgical ICU at a 550-bed university teaching hospital

were determined over 13 weeks ( ). [24] A total of 328 interventions were performed in four categories, and cost

avoidance was calculated for each intervention.

Table 2. Clinical Interventions and Cost Avoidance in an Intensive Care Unit[24]

Category

No. of

Interventions

Net Cost Avoidance

($)

Potential Annual Cost

Avoidance ($)

Drug therapy discontinuation 133 3338 13,355

Changes in drug therapy 98/107a 10,647 42,589

Nonformulary drug request

challenges

13/29a 1977 7906

Adverse drug event avoidance 30/59a 1988 7952

Totals 17,950 71,802

A prospective, control-group, randomized evaluation of pharmacist-initiated interventions at a 1200-bed teaching

hospital involved six clinical pharmacists.[25] Five clinical pharmacists attended ICU rounds, and the s ixth

assessed antibiotic orders by a 24-hour approval pager. All interventions were recorded over 30 days and were

characterized as either quality of care or cost saving. Quality-of-care interventions were carried out but notrandomized due to the potential to compromise care. All other interventions were randomized into an intervention

group and a control group. A separate investigator was contacted for each potential cost-saving intervention.

Interventions randomized into the intervention group prompted a telephone call to the physician, whereas those

randomized to control were observed only after consultation. Cost-saving interventions were stratified into six

categories -- antiinfective, gastrointestinal, cardiovascular, central nervous system, autonomic, and miscellaneous

agents.

A total of 5590 drug profiles were reviewed and 1226 interventions identified. Nine hundred sixty-seven (79%) were

classified as improving quality of care, including adjustments for organ dysfunction, recommendations to

discontinue or add drugs, and provision of drug information to patients and health care providers. Two hundred fifty-

nine interventions (21%) were classified as potential cost savings and were randomized into the intervention (126)

and control (133) groups, respectively. The distribution of recommendations was distributed evenly and well

accepted by physicians.

The mean duration of treatment with targeted agents was 2.4 days (range 1.9-2.9 days) in the control group

compared with 0.4 days (range 0.1-0.6 days) in the intervention group (p<0.001). Patients randomized into the

intervention group had 41% lower drug costs than those in the control group (mean $73.75 vs $43.40, p<0.001; ).

It was concluded that an approximate savings of $7900 would have been achieved if all interventions were acted on

(95% confidence interval [CI] $900-14,800), which would have extrapolated to an annual savings of $113,000 (95%

CI $13,000-212,000) based on 80,000 patient-days in those areas in 1997.

Table 3. Patient Outcomes and Cost Savings of Pharmacist-Initiated Interventions[25]

Control Group

(n=133)

Intervention Group

(n=126)

p

Value





Total drug costs ($)a 73.75 (50.51-97.00) 43.50 (29.81-59.99) <0.001

Duration of therapy (days)a 2.4 (1.9-2.9) 0.4 (0.1-0.6) <0.001

Postrandomization length of stay (days)a 9.7 (7.2-12.3) 8.9 (6.9-10.8) 0.57

In-hospital mortality, no. (%) 21 (16) 12 (10) 0.13

Required readministration of target agent, no.

(%)

11 (8) 11 (9) 0.89

Intensive care unit 30-day readmission, no. (%) 22 (17) 25 (20) 0.49

Pharmacy has evolved into a profession that clearly complements the practice of medicine. Critical care

pharmacists can have a positive impact in the ICU by decreasing ADEs, improving morbidity and mortality rates,

and decreasing overall health care costs. The education and training that pharmacists receive prepare these

clinicians to be valuable members of multidisciplinary health care teams.

References

1. Hatoum HT, Catizone C, Hutchinson RA, et al. An eleven-year review of the pharmacy literature:

documentation of the value and acceptance of clinical pharmacy. Drug Intell Clin Pharm 1986;20:33-48.

2. Crawford SY, Myers CE. ASHP national survey of hospital-based pharmaceutical services -- 1992. Am J

Hosp Pharm 1993;50:1371-404.

3. Bond CA, Raehl CL, Pitterle ME. 1992 National clinical pharmacy service study. Pharmacotherapy

1994;14:282-304.

4. Pedersen CA, Schneider PJ, Santell JP, et al. ASHP national survey of pharmacy practice in acute care

settings: monitoring, patient education, and wellness -- 2000. Am J Hosp Pharm 2000;57:2171-87.

5. Elenbaas RM. Pharmacist on a resuscitation team [letter]. N Engl J Med 1972;287:151.

6. Schwerman E, Schwartau N, Thompson CO, et al. The pharmacist as a member of the cardiopulmonary

resuscitation team. Drug Intell Clin Pharm 1973;7:298-308.

7. Shimp LA, Mason NA, Toedter NM, et al. Pharmacist participation in cardiopulmonary resuscitation. Am J

Hosp Pharm 1995;52:980-4.

8. Pratt SC. Pharmacist participation in cardiopulmonary resuscitation attempts. Am J Hosp Pharm

1986;43:1679-85.

9. Leape LL, Cullen DJ, Dempsey Clapp M, et al. Pharmacist participation on physician rounds and adversedrug events in the intensive care unit. JAMA 1999;282:267-70.

10. Montazeri M, Cook DJ. Impact of a clinical pharmacist in a multidisciplinary intensive care unit. Crit Care

Med 1994;22:1044-8.

11. American College of Critical Care Medicine of the Society of Critical Care Medicine. Critical care services

and personnel: recommendations based on a system of categorization into two levels of care. Crit Care

Med 1999;27:422-6.

12. Folli HL, Poole RL, Benitz WE, et al. Medication error prevention by clinical pharmacists in two children's

hospitals. Pediatrics 1987;79:718-22.

13. Kilroy RA, Iafrate RP. Provision of pharmaceutical care in the intensive care unit. Crit Care Nurs Clin North

Am 1993;5: 221-5.





14. McKenny JM, Wasserman AJ. Effect of advanced pharmaceutical services on the incidence of adverse

drug reactions. Am J Hosp Pharm 1979;36:1691-7.

15. Broyles JE, Brown RO, Vehe KL, et al. Pharmacist interventions improve fluid balance in fluid-restricted

patients requiring parenteral nutrition. Drug Intell Clin Pharm 1991;25:119-22.

16. Covinsky JO, Hamburger SC, Kelly KL, et al. The impact of the docent clinical pharmacist on the treatment

of streptococcal pneumonia. Drug Intell Clin Pharm 1982;16:587-91.

17. Streetman DS, Nafziger AN, Destache CJ, et al. Individualized pharmacokinetic monitoring results in less

aminoglycoside-associated nephrotoxicity and few associated costs. Pharmacotherapy 2001;21:443-51.

18. Hatoum HT, Vlasses PH. Patient outcome and the future practice of pharmacy. Drug Intell Clin Pharm

1991;25:208-10.

19. Bjornson DC, Hiner WO, Potyk RP, et al. Effect of pharmacists on health care outcomes in hospitalized

patients. Am J Hosp Pharm 1993;50:1875-84.

20. Pitterle ME, Bond CA, Raehl CL, et al. Hospital and pharmacy characteristics associated with mortality

rates in United States hospitals. Pharmacotherapy 1994;14:620-30.

21. Bond CA, Raehl CL, Pitterle ME, et al. Health care professional staffing, hospital characteristics, and

hospital mortality rates. Pharmacotherapy 1999;19:130-8.

22. Bond CA, Raehl CL, Franke T. Clinical pharmacy services and hospital mortality rates. Pharmacotherapy

1999;19:556-64.

23. Bond CA, Raehl CL, Franke T. Clinical pharmacy services, pharmacist staffing, and drug costs in United

States hospitals. Pharmacotherapy 1999;19:1354-62.

24. Miyagawa CI, Rivera JO. Effect of pharmacist interventions on drug therapy costs in a surgical intensivecare unit. Am J Hosp Pharm 1986;43:3008-13.

25. McMullin ST, Hennenfent JA, Ritchie DJ, et al. A prospective, randomized trial to assess the cost impact

of pharmacist-initiated interventions. Arch Intern Med 1999;159:2306-9.

26. Katona BG, Ayd PR, Walters JK, et al. Effect of a pharmacist's and a nurse's interventions on cost of drug

therapy in a medical ICU. Am J Hosp Pharm 1989;46:1179-82.

27. Hadbavny AM, Hoyt JW. Promotion of cost-effective benzodiazepine sedation. Am J Hosp Pharm

1993;50:660-1.

28. Bearce WC, Willey GA, Fox RL, et al. Documentation of clinical interactions: quality of care issues and

economic considerations in critical care pharmacy. Hosp Pharm 1988;23:883-90.

29. Wilt JL, Johnson RF, Melby MS, et al. The cost effectiveness of a satellite pharmacy in the surgical

intensive care unit (SICU) [abstr]. Chest 1992;102:192S.

30. Levy DB. Documentation of clinical and cost saving pharmacy interventions in the emergency room. Hosp

Pharm 1993;28:624-53.

31. Hatoum HT, Hutchinson RA, Witte KW, et al. Evaluation of the contribution of clinical pharmacist: inpatient

care and cost reduction. Drug Intell Clin Pharm 1988;22:252-9.

32. Schumock GT, Meek PD, Ploetz PA, et al. Economic evaluations of clinical pharmacy services -- 1988-

1995. Pharmacotherapy 1996;16:1188-208.





Acknowledgments

The authors thank Drs. John Devlin and Eric T. Wittbrodt for their critical review of this manuscript.

Reprint Address

Address reprint requests to John Papadopoulos, Pharm.D., Arnold and Marie Schwartz College of Pharmacy andHealth Sciences, 75 DeKalb Avenue, Brooklyn, NY 11201-5497.

Pharmacotherapy. 2002;22(11) © 2002 Pharmacotherapy Publications

Copyright © 1999, Pharmacotherapy Publications, Inc., All rights reserved.

33. Chuang LC, Sutton JD, Henderson GT. Impact of a clinical pharmacist on cost saving and cost avoidance

in drug therapy in an intensive care unit. Hosp Pharm 1994;29:215-21.

34. Kelly WN, Meyer JD, Flatley CJ. Cost analysis of a satellite pharmacy. Am J Hosp Pharm 1986;43:1927-

30.

35. Willett MS, Bertch KE, Rich DE, et al. Prospectus on the economic value of clinical pharmacy services --

a position statement of the American College of Clinical Pharmacy. Pharmacotherapy 1989;9:45-56.

36. Bond CA, Raehl CL, Franke T. Clinical pharmacy services, pharmacy staffing, and the total cost of care in

United States hospitals. Pharmacotherapy 2000;20:609-21.

37. Mutchie KD, Smith KA, MacKay MW, et al. Pharmacist monitoring of parenteral nutrition: clinical and cost

effectiveness. Am J Hosp Pharm 1979;36:785-7.

38. Devlin JW, Holbrook AM, Fuller HD. The effect of ICU sedation guidelines and pharmacist interventions on

clinical outcome and drug costs. Ann Pharmacother 1997;31: 689-95.

39. Baldinger SL, Chow MSS, Gannon RH, et al. Cost savings from having a clinical pharmacy work part-time

in a medical intensive care unit. Am J Hosp Pharm 1997;54:2811-14.

40. Matuszewski KA, Vlasses PH. Survey results from academic health center intensive care units:

considerations for departments of pharmacy. Clin Ther 1995;17:517-25.

41. Gandhi PJ, Smith BS, Tataronis GR, et al. Impact of a pharmacist on drug costs in a coronary care unit.

Am J Hosp Pharm 2001;58:497-503.

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