Expanding the Reach of Critical Care Pharmacists Globally*

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Excerpt

Drug therapy plays a key role in treating critical illness; the average ICU patient receives more than 30 different medications (1). Critical care clinicians are faced with numerous decisions each day regarding drug selection, dosing, administration, availability, cost, and monitoring. A failure to appropriately manage these complex issues increases the risk for patient harm. The intensivist-led, multidisciplinary team (MDT) has been embraced as a model of care for the critically ill by clinicians, hospitals, and outside stakeholders (2).
The role of the specialist critical care pharmacist (SCCP) has evolved since the early 1980s to the point where the SCCP is deemed an essential part of the ICU MDT (3, 4). The SCCP is well established at most hospitals in North America, the United Kingdom, and Australia (5–8). In most other countries, a SCCP is present at only select institutions (9–12). Multiple studies demonstrate that a SCCP directly involved in bedside care will reduce medication-associated harm and cost and improve the appropriateness of critical care pharmacotherapy. These efforts have been shown to reduce time spent in the ICU and hospital and lower ICU mortality (6, 13, 14). Society of Critical Care Medicine (SCCM) guideline’s advocate that hospital critical care services include a SCCP who can prospectively monitor, ideally at the ICU bedside, medication regimens for dosing appropriateness, adverse reactions, drug-drug interactions, and cost optimization (3, 4). Similar guidelines exist in the United Kingdom (15). The SCCM and U.K. guidelines also highlight the important role of the SCCP in teaching, research, and quality improvement activities (4, 15).
In this issue of Critical Care Medicine, Leguelinel-Blache et al (16) evaluate the impact one SCCP had on boosting compliance to six ICU clinical bundles in a medical and surgical ICU at one French teaching hospital, a country where SCCPs are uncommon. This SCCP made at least one intervention to the ICU team (when bundle noncompliance was detected) on 65% of 1,062 patient days. When compared with a historic control period (during which the SCCP was not involved in ICU care), patients in the intervention group required 1.2 fewer days of mechanical ventilation and spent 1.4 and 3.7 less days in the ICU and hospital, respectively. Per patient, hospital costs were reduced, on average, by € 3,137. These reported differences were greater for patients with a higher baseline severity of illness. Hospital mortality rate remained unchanged. The physician acceptance rate for the interventions made by the SCCP was not reported.
This study (16) is noteworthy in a number of ways. It represents one of the first reports demonstrating the value of the SCCP in France. Although the SCCP had consulted with ICU clinicians on a biweekly basis in meetings outside the ICU for 10 years, she had not previously provided direct ICU patient care. This study (16) demonstrates that a SCCP can quickly assimilate with an intensivist-led MDT not used to working with a SCCP and improve patient outcome. It also further builds the case that a SCCP can boost compliance to institutional protocols not solely focused on medication therapy (17, 18). Importantly, the salary to support this SCCP over the 18-month intervention period was only 25% of the € 195,000 in-hospital cost savings realized, a return on investment similar to that demonstrated in other studies, including one from the Netherlands (12, 19).
Despite the well-established clinical and economic impact of the SCCP, barriers to their expanded role exist in many countries (20). A critical care setting where an intensivist-led MDT does not exist may hinder the ability of the SCCP to make change.
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