Critical Care Pharmacy Research Articles

Critical care pharmacy practice advancement recommendations on direct patient care activities: An opinion of the American College of Clinical Pharmacy Critical Care Practice and Research Network

AbstractAn updated position paper on critical care pharmacy services recommends the development of new clinical programs. However, proposed pragmatic strategies for critical care pharmacy practice advancement are lacking. The purpose of this position paper is to develop consensus recommendations aimed at direct patient care activities for the advancement of critical care pharmacy practice. A 24‐member task force of critical care pharmacists, physicians, and nurses participated in a Recommendation Development Phase and Consensus‐building Phase (using a Delphi method) to produce the final critical care practice advancement recommendations. Proposed recommendations of pragmatic medication management opportunities with an advanced scope of practice involving pharmacist prescriptive authority for initiating, modifying, or discontinuing drug therapy and medication monitoring were developed. Task force participants anonymously voted on each proposed recommendation using a five‐point Likert scale (1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree, and 5 = strongly disagree). Recommendations failing to achieve consensus (≥70% agreement on “strongly agree”/“agree” votes) were revised for subsequent voting. Task force response rates during the first and second voting rounds were 71% (n = 17) and 79% (n = 19), respectively. A total of 57 (93.4%) of the 61 proposed practice advancement recommendations achieved consensus of which 88.5% (n = 54) met consensus after the first round. Consensus recommendations involved the critical care pharmacist initiating (n = 15), modifying (n = 22), or discontinuing (n = 9) drug therapy, and ordering relevant laboratory values or tests to optimize drug therapy (n = 11). One recommendation failing consensus was not revised for additional voting given the impracticality of achieving agreement. Fifty‐seven of the proposed 61 recommendation statements (93%) achieved the consensus threshold after two rounds of voting by an interprofessional expert panel. These recommendations provide a conceptual framework for promoting novel critical care pharmacist prescriptive authority over specific aspects of direct patient care. Implementation challenges and barriers, further described in this paper, must be explored at the institutional level for acceptance.

The Role of a Pharmacy Administration and Leadership Rotation within Postgraduate Year Two Critical Care Residency Training.

The job of a critical care pharmacy specialist has evolved to include quality improvement and administrative tasks. As such, the American Society of Health-System Pharmacists (ASHP) highlights specific goals and objectives to ensure post-graduate year two (PGY2) critical care residents are sufficiently trained to perform these tasks. The PGY2 critical care pharmacy residency leadership at the University of Kentucky sought to develop a four-week learning experience entitled, "Critical Care Administration / Medication Use Quality & Outcomes," as a unique rotation to capture these requirements and activities. The focus of this commentary is to serve as a guide for other residency programs to develop such a rotation, highlight resulting resident contributions to the department, describe perceived benefits of this rotation for residents, and highlight how this rotation impacted graduated residents' early years as practitioners. This learning experience is pivotal to providing a more balanced view of the entire medication use process and the healthcare ecosystem during a specialty residency. PGY2 critical care residents can gain valuable experiences away from the bedside that better prepare them for future tasks in addition to patient care that will be expected of them as clinical pharmacists.

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

IntroductionCritical 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.MethodsThe 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 findingsData 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.ConclusionsAvailability 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.

A survey of critical care pharmacists on venous thromboembolism prophylaxis dosing practices with enoxaparin in adult trauma patients

AbstractEnoxaparin is the preferred treatment for venous thromboembolism (VTE) prophylaxis in trauma patients, but timing of initiation, optimal dosing, and therapeutic drug monitoring remain controversial. The objective of this study was to evaluate enoxaparin VTE prophylaxis practices in adult trauma patients across trauma centers in the United States and compare results to current guideline recommendations. An online survey designed by the study investigators was sent to pharmacist members of the American College of Clinical Pharmacy (ACCP) Critical Care Practice Research Network (PRN) and residency directors of institutions with accredited Critical Care Pharmacy Residency programs in the fall of 2021. This survey queried pharmacists' self‐reported practices regarding enoxaparin dosing and monitoring in trauma patients. One hundred five responses were collected with an estimated response rate of 5.3%. Most respondents reported using a standard enoxaparin dose of 30 mg subcutaneously (SUBQ) every 12 h (67%; 70/104) in trauma patients with normal renal function and higher initial dosing for obese trauma patients (75%; 78/104). The most common body mass index (BMI) threshold for dose adjustments in obesity was a BMI ≥40 kg/m2; whereas 100 kg or more was commonly reported for a weight threshold. Multiple alternative enoxaparin dosing regimens were reported for obese and overweight patients. Of respondents who monitor anti‐Factor Xa (anti‐Xa) levels, 84% (61/73) reported monitoring peak levels with 47% (29/61) targeting a peak anti‐Xa goal of 0.2–0.4 units/ml. Seventy‐five percent (51/68) of respondents who adjust enoxaparin dosing based on anti‐Xa level monitoring reported adjusting doses by increments of 10 mg SUBQ every 12 h, and 41% (28/68) indicated having a pharmacist‐driven protocol for dose adjustments. Significant variation exists in enoxaparin dosing and monitoring strategies for VTE prophylaxis. Consensus among clinical practice guidelines is needed to standardize practice nationally.

Development of a critical care pharmacist career coaching and professional development program at an academic medical center

AbstractContinuing professional development is a lifelong process that is multifaceted, holistic, self‐directed, and is not a replacement for continuing education. Through ongoing professional development, pharmacists can improve their skill set in a broad range of clinical, educational, research, and administrative activities. Not only does development of this growth benefit the individual pharmacist, but also the institution and pharmacy profession. In 2020, the American College of Clinical Pharmacy, the Society of Critical Care Medicine, and the American Society of Health‐System Pharmacists published an updated position paper on critical care pharmacy services. A new recommendation in the update was to create mechanisms for critical care pharmacists to develop their career and professional development. Herein, we describe our experience with the development and implementation of a critical care pharmacy career professional development program using peer‐to‐peer coaching within a large academic medical center. Professional development is not a one size fits all and should be individualized. We initially focused on developing research skills based on initial surveys. Afterwards professional development was varied we created new resources such as journal referee “how‐to” and teaching in a flipped classroom.

Publication rate and impact stratified by gender among pharmacists designated Fellow in the American College of Critical Care Medicine

BackgroundThere are approximately 352,000 pharmacists practicing in the United States, with most (59%) being female. Editorial board membership and publications with a female as the first author in selected pharmacy journals has increased in the past 2 decades. This study determined whether these positive trends are also occurring in critical care pharmacy. ObjectiveTo report publication rate and publication impact stratified by male and female gender among pharmacists designated Fellow of Critical Care Medicine (FCCM). MethodsPharmacists designated FCCM from inception through the 2020 convocation year were identified in January 2021 using a list provided by the Society of Critical Care Medicine. Pharmacists were excluded if they were designated Master of Critical Care Medicine, did not have an active pharmacist license, or did not have data in the Scopus database. Data were collected in February 2021 including year of first publication, total number of publications, citations, and Hirsch index (h-index). ResultsA total of 134 pharmacists were evaluable, including 76 males (57%) and 58 females (43%). Males had an earlier first publication year than females (2005 vs. 2010; P < 0.001). Males have produced a higher number of publications per individual pharmacist (29 vs. 13; P = 0.002) and a similar number of publications per year (2 vs. 1; P = 0.05). When comparing publication impact, males generated more citations (384 vs. 139; P = 0.001) and had a higher h-index (10 vs. 6, P < 0.001). These trends persisted when data from only the past 5 years were used. ConclusionThere is statistically significant gender disparity in publication rate and impact. However, this disparity seems to be decreasing with time as the rate of females designated FCCM is increasing. This is consistent with an overall increase in the proportion of pharmacists who are female and deserves further exploration.

Implementation of a unique mass casualty and emergency preparedness longitudinal learning experience for postgraduate year 2 pharmacy residents

Background and purposeThe American Society of Health-System Pharmacists (ASHP) postgraduate year 2 (PGY2) critical care pharmacy residency program offers an elective competency area, E3: Mass Casualty. Similar elective competencies are also available for PGY2 emergency medicine and postgraduate year 1/2 pharmacotherapy programs. Because of the COVID-19 pandemic, pharmacist proficiency in the management of disasters is even more urgent. However, few residency programs require or include a specific learning experience to achieve this competency. This article provides examples of opportunities that residency programs can implement to offer an Emergency Preparedness/Mass Casualty (EP/MC) learning experience. Educational activity and settingA longitudinal EP/MC learning experience was integrated into a PGY2 critical care program. FindingsA longitudinal EP/MC learning experience within the PGY2 critical care, emergency medicine, and pharmacotherapy residency program curricula is achievable and promotes resident development. Learning experience components included topic discussions, participation on local and state-level emergency preparedness (EP) committees, completion of certification programs, projects, and participation on statewide emergency response teams. SummaryImplementation of a longitudinal EP/MC learning experience formalizes topics and activities that support achievement of the ASHP elective competency area of Mass Casualty for PGY2 residency programs. EP/MC goals and objectives should be a requirement for critical care, emergency medicine, pharmacotherapy, and health-system pharmacy administration and leadership PGY2 programs. By formalizing training, pharmacists can be better prepared for EP and more integrated into multidisciplinary disaster response teams.

Critical Care Pharmacy Program Accreditation Standards Framework and Core Competencies in Saudi Arabia

Clinical pharmacy services in Saudi Arabia are expanding steadily, particularly with notable developments in critical care pharmacy services and training programs, including four critical care residency programs localized in Riyadh and one program in Jeddah. The Scientific Council of Pharmacy leads extensive efforts to advance clinical pharmacy practice and training under the Saudi Commission for Health Specialties (SCFHS), the accrediting body for critical care training programs and all other specialties. Despite launching critical care pharmacy programs in 2013, currently available accreditation standards and competency assessments for specialized residency programs in critical care were established in 2020. These accreditation standards and competency assessment modalities have been found to have significant areas of improvement based on the feedback of practicing critical care pharmacy residency program directors and trainees over the past few years. This is an opinion paper based on a consensus of critical care and emergency medicine pharmacy experts which recommends updating the current accreditation standards framework and competency assessment blueprint for specialized critical care pharmacy programs. Additionally, it highlights the need to modify the accreditation standards framework for critical care pharmacy programs. Further evaluation of these modalities can be revised as deemed reasonable by governmental authorities by recruiting practicing critical care clinical pharmacy experts.

Lean into Clinical Pharmacy: An Experience in Implementing Key Performance Indicators and Gemba Walks into Clinical Pharmacy Services.

Purpose: The Lean methodology was applied to clinical metrics by a critical care pharmacy team. The experiences associated with the development and implementation of clinical metrics and their impact on daily workflow are described. Summary: The Lean methodology has been introduced into the healthcare system as a means of process improvement, which can eliminate waste through appropriate medication utilization. At OhioHealth Riverside Methodist Hospital, the department of pharmacy was tasked with the development of clinical metrics after a health system wide Gemba walk was initiated. The pharmacy department's critical care team developed a strategy identifying and evaluating clinical metrics pertaining to their everyday workflow. Each clinical metric was evaluated in accordance with a pre-defined goal. Metrics requiring heavy documentation and those in which the pharmacist does not have autonomous authority to manage were often challenging to implement and were less successful. Throughout this process, the lessons learned focused on generating ideas that were easily documented, evidence-based, and department specific. The critical care team discovered that the outcome of the most successful metrics highlighted clinical pharmacist value and data generated could be used to support funding for additional resources. Conclusion: The critical care pharmacy team developed a streamlined process to implement clinical metrics as means of identifying areas for improvement using the Lean methodology.

Postoperative Delirium: A Literature Review of Management in Intensive Care Unit

Perioperative delirium is a wide-ranging problem that directly affects primary clinical results. The anesthesiologist must understand how to define and diagnose delirium, identify patients at high risk of delirium, identify predisposing factors to adjust the care plan appropriately, and manage delirium in the acute postoperative period. Delirium is an organ dysfunction in critically ill patients, independently associated with improved morbidity. Research on delirium in hospitalized patients (including critically ill patients) has increased exponentially in the last decade. This study emphasizes the need for a mechanistic explanation of delirium to help advance the research that ultimately leads to its prevention and treatment. In this study, multinational and multidisciplinary clinicians, and researchers from the fields of critical care medicine, psychiatry, anesthesiology, neurology, and pharmacy sought to collaborate in the management of delirium in the intensive care unit (ICU).

Prospective Observational Evaluation of Predatory Journals in Critical Care Pharmacy Practice: Defining Characteristics Associated With Receiving Unsolicited Invitations to Publish

Open-access publishing promotes accessibility to scholarly research at no cost to the reader. The emergence of predatory publishers, which exploit the author-pay model by charging substantial publication fees for publication in journals with questionable publishing processes, is on the rise. Authors are solicited through aggressive marketing tactics, though who is targeted is not well described. The purpose of this study was to identify characteristics associated with critical care pharmacists that make them targets of unsolicited invitations to publish. A prospective, observational study of critical care pharmacists was performed. Participants archived emails received by their professional email that were unsolicited invitations to submit their original work for publication in a journal (unsolicited journals). Variables were evaluated to determine which were associated with unsolicited invitations; these were compared to legitimate journals, defined as all PubMed-indexed journals in which the participants were previously published. Twenty-three pharmacist participants were included, all of whom were residency and/or fellowship trained and practicing in an academic medical center. Participants had a median of 7 years of experience since their post-graduate training, 6 years since their last change in professional email address, and 2 years since their first PubMed-indexed publication. From these participants, 136 unsolicited and 59 legitimate journals were included. The average number of invitations increased 1.04 (95% CI, 1.02–1.05) times for every additional PubMed-indexed publication (P < .001). Most unsolicited journals were considered predatory. Legitimate and unsolicited journals differed significantly. The number of previous PubMed-indexed publications strongly correlates with the likelihood of critical care pharmacists receiving unsolicited publication invitations, often from predatory journal.

Critical care pharmacy in Saudi Arabia: Historical evolution and future directions—A review by the Critical Care and Emergency Medicine Pharmacy Specialty Network at the Saudi Society of Clinical Pharmacy

AbstractBackgroundClinical pharmacy services in Saudi Arabia (SA) have improved over the past few years, leading to improved patient‐centered outcomes. Clinical pharmacy services have been steadily incorporating critical care (CC) services in the country since the 1980s with a sustained growth in this field over the last few years.AimsThis review aims to describe CC pharmacy services in Saudi Arabia by exploring the historical evolution of patient care, education, research, and leadership, including challenges and opportunities for professional advancement.Materials and methodologyWe reviewed existing literature regarding CC pharmacy services in SA in addition to documented phone interviews with CC pharmacy pioneers in SA.ResultsCritical care pharmacy services improved in many facets. We identified possible areas for improvement and suggested an action plan for other countries to expand their CC pharmacy services.ConclusionIn Saudi Arabia, clinical pharmacy services are growing with sustained growth in CC pharmacy services.

Postoperative Delirium: A Literature Review of Management in Intensive Care Unit

Perioperative delirium is a wide-ranging problem that directly affects primary clinical results. The anesthesiologist must understand how to define and diagnose delirium, identify patients at high risk of delirium, identify predisposing factors to adjust the care plan appropriately, and manage delirium in the acute postoperative period. Delirium is an organ dysfunction in critically ill patients, independently associated with improved morbidity. Research on delirium in hospitalized patients (including critically ill patients) has increased exponentially in the last decade. This study emphasizes the need for a mechanistic explanation of delirium to help advance the research that ultimately leads to its prevention and treatment. In this study, multinational and multidisciplinary clinicians, and researchers from the fields of critical care medicine, psychiatry, anesthesiology, neurology, and pharmacy sought to collaborate in the management of delirium in the intensive care unit (ICU).

Productivity Tracking: A Survey of Critical Care Pharmacist Practices and Satisfaction.

Introduction: The position paper on critical care pharmacy services describes two tiers of responsibilities: essential and desirable activities. Activities are categorized into five domains: patient care, quality improvement, research and scholarship, training and education, and professional development. Documentation of these activities can be important for justifying pharmacist positions, comparing pharmacy practice models, conducting performance evaluations, and tracking individual workload; however, limited recommendations are provided for standardized productivity tracking, and national practices remain largely uncharacterized. Objectives: The purpose of this survey was to describe documentation practices of critical care pharmacist activities. Methods: A cross-sectional survey was distributed via email to 1694 members of the ACCP critical care practice research network. The survey asked respondents to describe the methods used to document productivity as it relates to the 5 domains. Results: Seventy-nine (4.7%) critical care pharmacists from 63 institutions completed the survey. Intervention documentation was used for position justification and annual reviews among 54.4% and 44.1% of pharmacists, respectively. Pharmacists were routinely expected to perform additional responsibilities beyond patient care that contribute to overall productivity, but the percentage of institutions that track these activities as a measure of pharmacist productivity was relatively low: quality improvement (46%), research/scholarship (29%), training/education (38%), and professional development (27%). Documentation of these additional responsibilities and activities was primarily used for annual evaluations, but the majority of respondents answered that no standardized method for tracking activities existed. In multivariate regression, dedicated ICU pharmacists was a significant predictor for increased satisfaction (Exp(ß) 4.498, 95% CI 1.054-19.187, P = .042). Conclusion: Practice variation exists in how and for what intent critical care pharmacists track productivity. Further evaluation and standardization of productivity tracking may aid in position justification and practice model evaluation for dedicated ICU pharmacists in today's value-based era.

Optimization of critical care pharmacy clinical services: A gap analysis approach.

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

The standards treatment

The standards treatment

Prescribing and documentation by critical care clinical pharmacy specialists with around‐the‐clock staffing: A single‐center evaluation

AbstractIntroductionEvidence supports pharmacists as essential team members in the intensive care unit (ICU). Data are limited for pharmacist prescribing and documentation, ideal pharmacist staffing, and timing of clinical pharmacy activities in the ICU.ObjectiveThe purpose of this evaluation was to assess the frequency, timing, and most common areas of prescribing and documentation for critical care clinical pharmacy specialists (CPSs) in a single medical center with around‐the‐clock staffing.MethodsA Veterans Affairs (VA) medical center implemented a collaborative practice model in which CPSs provide direct ICU patient care around the clock. Direct patient care activities are provided for two ICUs with three multidisciplinary teams (medical, surgical, and cardiovascular), the nutrition support team, and emergency response teams. Documentation through an electronic health record progress note is required any time a CPS performs a patient encounter and uses prescriptive authority. A retrospective evaluation was performed to evaluate critical care CPS patient encounters and clinical interventions from October 1, 2016 through September 30, 2020.ResultsCumulatively, 78 622 CPS clinical interventions requiring prescriptive authority were made during 17 938 documented encounters. For clinical interventions, 40 897 (52.0%) were during daytime hours and 37 725 (48.0%) were after‐hours. Of the documented encounters, 10 461 (58.3%) were during daytime hours compared with 7477 (41.7%) after‐hours. Medication‐related prescribing interventions accounted for 57 400 (73.0%) of the interventions, while 6931 (8.8%) were nonpharmacologic and 14 291 (18.2%) were additional interventions. The most common disease states for prescribing interventions included Anticoagulation (13.8%), Infectious Diseases (13.1%), Cardiovascular (10.5%), Nutrition/Gastrointestinal (6.6%), Neuropsychiatric (5.3%), Endocrine (4.3%), Nephrology (3.5%), and Pulmonary (1%).ConclusionThis evaluation provides details of prescribing and documentation by critical care CPSs with an around‐the‐clock staffing model. This may be useful for ICU clinicians and administrators considering expanding critical care pharmacy services.

Characterizing Critical Care Pharmacy Services Across the United States

A 27-question, pretested survey. 1,220 U.S. institutions. Critical care pharmacists. Electronic questionnaire of pharmacy services and activities across clinical practice, education, scholarship, and administration. A total of 401 (response rate of 35.4%) surveys representing 493 ICUs were completed. Median daily ICU census was 12 (interquartile range, 6-20) beds with 1 (interquartile range, 1-1.5) pharmacist full-time equivalent per ICU. Direct clinical ICU pharmacy services were available in 70.8% of ICUs. Pharmacists attended rounds 5 days (interquartile range, 4-5 d) per week with a median patient-to-pharmacist ratio of 17 (interquartile range, 12-26). The typical workweek consisted of 50% (interquartile range, 40-60%) direct ICU patient care, 10% (interquartile range, 8-16%) teaching, 8% (interquartile range, 5-18%) order processing, 5% (interquartile range, 0-20%) direct non-ICU patient care, 5% (interquartile range, 2-10%) administration, 5% (interquartile range, 0-10%) scholarship, and 0% (interquartile range, 0-5%) drug distribution. Common clinical activities as a percentage of the workweek were reviewing drug histories (28.5%); assessing adverse events (27.6%); and evaluating (26.1%), monitoring (23.8%), and managing (21.4%) drug therapies. Services were less likely to occur overnight or on weekends. Telemedicine was rarely employed. Dependent prescriptive authority (per protocol or via practice agreements) was available to 51.1% of pharmacists and independent prescriptive authority was provided by 13.4% of pharmacists. Educational services most frequently provided were inservices (97.6%) and experiential training of students or residents (89%). Education of ICU healthcare members was provided at a median of 5 times/mo (interquartile range, 3-15 times/mo). Most respondents were involved with ICU or departmental policies/guidelines (84-86.8%) and 65.7% conducted some form of scholarship. ICU pharmacists have diverse and versatile responsibilities and provide several key clinical and nonclinical services. Initiatives to increase the availability of services are warranted.

In-House Production of Dialysis Solutions to Overcome Challenges During the Coronavirus Disease 2019 Pandemic

In-House Production of Dialysis Solutions to Overcome Challenges During the Coronavirus Disease 2019 Pandemic

Scholastic synergy: A team prototype for pharmacy faculty engagement in education, research, and service

IntroductionMany clinical faculty members are challenged by competing factors of scholarly productivity, education, service obligations, and patient care. A team-based approach has the potential to synergistically increase productivity and mitigate factors associated with burnout. MethodsThe purpose of this report is to discuss a prototype for a small, team-based, practice-oriented collaborative approach to advancing critical care pharmacy practice through research and education. Productivity was evaluated in the areas of scholarship and teaching. ResultsThis team was formed in 2017 and includes five critical care faculty across four campuses from a single academic institution. This collaborative has published peer-reviewed articles, secured grant funding, and developed novel teaching modalities. ConclusionsChallenges encountered include timeline adherence, development of uniform data collection processes, clarifying roles and expectations for different projects, and authorship. This team may act as a prototype for clinical faculty teams to enhance engagement and scholarship productivity in a practice-based setting.