Full text of DOI:10.1592/phco.22.16.1484.33694

P RA C TIC E I N S IG H TS
The Critical Care Pharmacist:
An Essential Intensive Care Practitioner
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., and
Deb S. Sherman, Pharm.D.
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.
(
Pharmacotherapy 2002;22(11):1484–1488)
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, pharmaco-
kinetics, pathophysiology, human anatomy and
physiology, physical assessment, and pharmaco-
economics 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 pharmaco-
therapy decision making, providing pharmaco-
kinetic 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.
From the Arnold and Marie Schwartz College of
Pharmacy and Health Sciences, Brooklyn, New York, and
New York University Medical Center, New York, New York
Clinical Pharmacy Services
(
Dr. Papadopoulos); Fletcher Allen Health Care, Burlington,
Pharmacists have been performing clinical
services for more than 3 decades. Numerous
research articles and several surveys have
identified areas in which critical care pharmacists
make significant contributions to patient care.
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, pharmaco-
kinetic consults, drug therapy monitoring,
1
Vermont (Dr. Rebuck); Cleveland Clinic Foundation,
Cleveland, Ohio (Dr. Lober); University Hospital and
University of Cincinnati College of Pharmacy, Cincinnati,
Ohio (Dr. Pass); Allegheny General Hospital and Duquesne
University, Mylan School of Pharmacy, Pittsburgh,
Pennsylvania (Dr. Seidl); University Hospital of Cleveland,
Cleveland, Ohio (Dr. Shah); and St. Vincent Hospital,
Indianapolis, Indiana (Dr. Sherman).
1
–10
Address reprint requests to John Papadopoulos,
Pharm.D., Arnold and Marie Schwartz College of Pharmacy
and Health Sciences, 75 DeKalb Avenue, Brooklyn, NY
1
1201-5497.

THE CRITICAL CARE PHARMACIST Papadopoulos et al
1485
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 chest compressions,
prepare drugs, administer drugs, record drug
administration, provide drug information,
calculate dosages and infusion rates, and set up
or operate intravenous pump devices.
addition, 99% of recommendations made by the
clinical pharmacist were accepted by physicians.
Morbidity and Mortality Outcomes
Many studies have documented cost-effective
care related to pharmacist intervention in the
1
5–22
acute care setting.
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 manage-
ment of streptococcal pneumonia by orchestrating
1
5, 16
optimal antimicrobial selection.
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
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
1
7
studied. Pharmacists must provide value-added
services such as identifying appropriate
indicators to ensure that drug therapy leads to a
1
1
critical care services and personnel 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.
1
8
measurable patient outcome.
prospective study
A
compared
multidisciplinary medical and surgical teams
with respect to the presence or absence of a
1
9
clinical pharmacist. 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
Reductions in Adverse Drug Events
1
9
hospital stays and a benefit:cost ratio of 6:1.
Altered organ function and polypharmacy
clearly contribute to ADEs in patients requiring
intensive medical care. Despite attempts of
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
9
several authors to determine the cost of ADEs, it
is difficult to estimate the financial, emotional,
and overall impact of an ADE. In an environ-
ment 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. Several studies show that clinical
pharmacists can reduce drug errors and ADEs in
1
9
hospital, further decreasing health care costs.
Pharmacy characteristics, specifically the
number of pharmacists/average daily census and
combined hospitalwide clinical pharmacy
services, were associated with a decrease in
2
0
patient mortality. Factors that contributed to
this association included the presence of
pharmacists in patient-care areas and partici-
pation on medical rounds, availability of
therapeutic drug and ADE monitoring, phar-
macokinetic 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.
9
, 12–14
a hospital setting.
The only prospective study evaluating the
impact of a clinical pharmacist in a medical ICU
9
had two phases, baseline and intervention. 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
Patient mortality rates decrease as pharmacy
2
1
staffing/occupied bed increases, with specific
services having greatest impact in improving
health care by reducing hospital mortality. In an
evaluation of the association between such

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486
PHARMACOTHERAPY Volume 22, Number 11, 2002
2
3
Table 1. Cost Savings for Four Clinical Pharmacy Services
Savings/Occupied
Total
Service
Bed/Year ($)
Savings/Hospital ($)
In-service education
Drug information
Drug protocol management
Admission drug histories
460.96
1961.55
578.71
742.84
77,879.19
430,579.84
137,333.67
213,388.21
2
4
Table 2. Clinical Interventions and Cost Avoidance in an Intensive Care Unit
No. of
Net Cost
Potential Annual Cost
Category
Interventions
Avoidance ($)
Avoidance ($)
Drug therapy discontinuation
Changes in drug therapy
Nonformulary drug request challenges
Adverse drug event avoidance
133
98/107
13/29
30/59
3338
10,647
1977
13,355
42,589
7906
a
a
a
1988
7952
Totals
17,950
71,802
a
Number of interventions that had a positive effect on cost avoidance/total number of interventions.
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. Additional studies are necessary to
determine the clinical impact of critical care
pharmacists on multidisciplinary ICU teams.
service education, drug information, drug
protocol management, admission drug histories)
led to a statistically significant decrease in drug
costs, whereas other services showed a
nonstatistically significant trend (Table 1).
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
2
2
2
4
(Table 2). A total of 328 interventions were
performed in four categories, and cost avoidance
was calculated for each intervention.
Pharmacoeconomic Impact
A prospective, control-group, randomized
evaluation of pharmacist-initiated interventions
at a 1200-bed teaching hospital involved six
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
25
clinical pharmacists. Five clinical pharmacists
attended ICU rounds, and the sixth 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 not randomized 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
1
0, 23–41
impact pharmacists have in this area.
A study in 934 United States hospitals tested
direct relationships and associations among 14
pharmacy services, staffing, and severity of
2
3
illness-adjusted drug costs. 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-

THE CRITICAL CARE PHARMACIST Papadopoulos et al
1487
2
5
Table 3. Patient Outcomes and Cost Savings of Pharmacist-Initiated Interventions
Control Group
n=133)
73.75 (50.51–97.00)
2.4 (1.9–2.9)
9.7 (7.2–12.3)
21 (16)
Intervention Group
(n=126)
43.50 (29.81–59.99)
0.4 (0.1–0.6)
8.9 (6.9–10.8)
12 (10)
(
p Value
a
Total drug costs ($)
Duration of therapy (days)
<0.001
<0.001
0.57
a
a
Postrandomization length of stay (days)
In-hospital mortality, no. (%)
0.13
Required readministration of target agent, no. (%)
Intensive care unit 30-day readmission, no. (%)
Data are mean (range) values.
11 (8)
22 (17)
11 (9)
25 (20)
0.89
0.49
a
miscellaneous agents.
Acknowledgments
A total of 5590 drug profiles were reviewed and
226 interventions identified. Nine hundred
The authors thank Drs. John Devlin and Eric T.
Wittbrodt for their critical review of this manuscript.
1
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 recommen-
dations was distributed evenly and well accepted
by physicians.
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