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Position Paper on Critical Care Pharmacy Services: 2020 Update

Lat, Ishaq PharmD, FCCM, FCCP1; Paciullo, Christopher PharmD, FCCM, FCCP, BCCCP2; Daley, Mitchell J. PharmD, FCCM, BCPS3,4; MacLaren, Robert PharmD, MPH, FCCM, FCCP5; Bolesta, Scott PharmD, FCCM, FCCP, BCPS6; McCann, Jennifer PharmD, BCCCP7; Stollings, Joanna L. PharmD, FCCM, FCCP, BCCCP, BCPS8,9; Gross, Kendall PharmD, BCPS, BCCCP10; Foos, Sarah A. PharmD, BCCCP11; Roberts, Russel J. PharmD, FCCM, BCCCP, BCPS12; Acquisto, Nicole M. PharmD, FCCP, BCCCP13,14; Taylor, Scott PharmD, MS, BCPS15; Bentley, Michael PharmD, FCCM, FCCP16,17; Jacobi, Judith PharmD, MCCM, FCCP, BCCCP18; Meyer, Tricia A. PharmD, MS, FASHP, FTSHP19,20

Author Information
doi: 10.1097/CCM.0000000000004437

Abstract

Since the formation of the first ICU in the 1930s to present day, the field of critical care medicine has evolved and increased in complexity (1). In parallel, clinical pharmacy practice advanced from a dispensary role to one primarily of medication management. In the 1940s, pharmacists began attending interprofessional rounds and became more involved in the clinical aspects of care (2). In the intervening decades, critical care pharmacy developed into a distinct subspecialty within pharmacy practice, with specialized training and credentials. As the subspecialty evolved so too did the need for practice standards. The first position paper on critical care pharmacy services was published in 2000 and described pharmacy services that were foundational, desirable, and optimal (3). A subsequent survey of 1,034 ICUs to evaluate critical care pharmacy services found lower level services were commonly provided but desirable or optimal activities were inconsistent (4). Rapid progress in the field of pharmacotherapy, improvement in the application of technology, workforce trends, and evolution of healthcare delivery necessitate a continual assessment of practice standards in an effort to best serve patients. Since that first position paper, critical care medicine has continued to progress to the extent that the recommendation statements from the original position paper may no longer apply or need revision to be relevant for the current practice environment.

The purpose of this position paper is to delineate the activities of a critical care pharmacist and the scope of pharmacy services within the ICU. Critical care pharmacist activities and pharmacy services are categorized by the level of critical care services offered. We aim to provide recommendations on pharmacy practice for the current critical care environment. With an increasing emphasis placed on value in healthcare, a secondary objective of this position paper is to provide the means to demonstrate the value of a critical care pharmacist by describing activities that can be used by pharmacy administrators and hospital executives to measure and report. Finally, this position paper intends to serve as a guideline for critical care pharmacy practice for the coming decade.

The task force determined that guideline recommendations should be inclusive of pharmacy services across the continuum of critical illness. Therefore, the position paper addresses activities of the individual critical care pharmacist and those best served by pharmacy administrators. These individuals and members of the multiprofessional team should design comprehensive pharmacy services that meet the pharmacotherapy needs of the critically ill patient. The success of the multiprofessional critical care team is contingent on the support of administrators and executives. This model relies on collaborative engagement in care delivery designed to best serve patients, while promoting the needs of patients and staff to improve institutional performance.

METHODS

A task force was created in January 2015 to review, and revise, the existing position paper on critical care pharmacy services. The Society of Critical Care Medicine (SCCM), American College of Clinical Pharmacy (ACCP) Critical Care Practice and Research Network, and the American Society of Health-System Pharmacists (ASHP) were contacted to support this work. The task force included 15 members representing a broad cross-section of critical care pharmacy practice (hospital, academia, administration, urban, rural, and clinical practice setting) and the membership of SCCM, ACCP, and ASHP. Task force members convened in-person at the SCCM Annual Congress in February 2016 and subsequently held a series of conference calls to vote on statements using a modified Delphi method, refine verbiage, and generate the article text.

There are three notable modifications in this article that differ from the previous recommendations (3). The first is a simplification from three levels of recommendations (fundamental, desirable, and optimal) to two (foundational and desirable). The task force felt this was necessary to improve interpretation and implementation of these recommendations. Consistent with the original position paper, foundational activities are those services or activities deemed essential to critical care practice. Therefore, foundational services should be interpreted not as the minimum level of service or activities, but rather, those activities that serve as the core of critical care pharmacy services and provide the underpinning of care from which to expand pharmacy services. Additionally, desirable services or activities are those deemed to be “value added”; they are not as essential but extend the scope of practice toward a higher level. The second modification to this position paper was to use existing guidance for delivery of critical care services and assign recommendations to each level of ICU service (5). Level I critical care services are defined as ICUs that provide complete care for a wide range of disorders requiring intensive care, deliver comprehensive support services, and generally fulfill an academic mission. Level II critical care services provide comprehensive care but may not have the resources to care for specific populations and may not have an academic mission. Level III critical care services provide initial stabilization of critically ill patients, but do not offer comprehensive critical care. In recognition of the varying levels of critical care services, some activities are not possible, or needed, at all types of healthcare systems. Similarly, pharmacy departments for institutions with some level II and likely all level III ICUs are not staffed with the same number of personnel. In this way, the task force sought to provide recommendations that were specific to the level of resources available at each institution and are immediately relevant to practitioners, administrators, and executives. Throughout the article, the terms “critical care pharmacist,” “pharmacist,” and “designee” are used. The “critical care pharmacist” is intended to denote the pharmacist who is specialty trained and dedicated as a resource to delivering critical care pharmacy services. The “pharmacist” is intended to denote a generalist pharmacist who provides prospective order review and clinical services within their scope and expertise when a critical care pharmacist is not present. In those instances where the services of a “critical care pharmacist” may not be available, the statement would default to “pharmacist.” The “designee” is intended to denote a pharmacy resident or student pharmacist completing a practice experience under the supervision of the critical care pharmacist or pharmacist. It is not intended to suggest that such activities can or should be carried out solely by designees without a supervising pharmacist.

The task force identified five domains to describe critical care pharmacy services: 1) patient care; 2) quality improvement; 3) research and scholarship; 4) training and education; and 5) professional development. The task force co-chairs (I.L., C.P.) completed an initial literature review using PubMed with relevant search terms (“critical care,” “pharmacy,” and “pharmacotherapy”), collated references by section, and provided them to the task force to review. The literature review was broad and inclusive as the purpose was to ensure that all task force members were aware of current critical care pharmacy practices. The body of literature was expanded by members of the task force. Due to the lack of strong evidence, the task force sought to make recommendations using a modified Delphi method. All task force members were considered pharmacy experts and the co-chairs acted as facilitators, circulating anonymized responses and comments after each round of voting. There were no predefined stopping criteria. Voting continued until consensus was reached on a specific guideline statement, or it was retired. Experts rated statements on a 1–9 Likert scale, with a score of 1 indicating strong disagreement and 9 indicating strong agreement, with incremental levels of agreement in between. The scores were then grouped into tertiles, with the score range of 1–3 indicating disagreement, 4–6 indicating neutral, and 7–9 indicating agreement. Consensus was defined as greater than 66% of task force members agreeing on each statement and recommendation level according to the level of critical care services (I, II, or III). Task force co-chairs initiated the first phase of voting by circulating previously published guideline statements to determine if existing recommendation statements required revision or no longer applied in the current healthcare environment and, therefore, should be retired. If a consensus was reached on the need for revision, the task force chairs revised statements and proposed additional rounds of voting until consensus was reached by the task force. If consensus was reached determining retirement of a previously published statement with greater than 66% of the Task Force voting to “retire,” the statement was excluded from new guidelines. Reasons for retiring a statement were primarily based on the consensus that the statement no longer applied to the current practice environment either due to regulatory requirements or technologic advancement. Once previous recommendation statements were either retired or revised, co-chairs moved to phase 2 by soliciting new guideline recommendations from panel experts. New recommendations were grouped by domain. If two or more new recommendation statements submitted by task force members were similar, the phrasing of these statements was revised by the facilitators for another round of voting. Consensus was reached on all statements following the second round of voting. In the third round, recommendation statements were approved as “foundational” or “desirable” and assigned level of critical care services. Each domain was then organized into written statement recommendations followed by brief discussion, supported by evidence, when available, from additional literature searches. The deliberations and voting from the Task Force resulted in 82 recommendation statements and eight recommendation statements from the previous position paper.

PATIENT CARE

Recommendations

  1. The critical care pharmacist regularly makes rounds as a member of the interdisciplinary critical care team to provide comprehensive medication management (CMM) for all ICU patients.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  2. As part of the interdisciplinary team, the critical care pharmacist assists healthcare professionals in discussions with patients and/or family members to help make informed decisions regarding pharmacotherapy options.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  3. The critical care pharmacist provides pertinent, comprehensive drug information to the critical care team.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  4. The critical care pharmacist provides drug therapy–related education to critical care team members.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  5. The pharmacist collaborates with the healthcare team to prevent potentially inappropriate drug therapy.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  6. The critical care pharmacist provides clinical consultation to the care team, both within and outside the ICU, for pharmacotherapeutic issues related to critical illness.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  7. Medication-related consults (i.e., pharmacotherapeutic and pharmacokinetic) are available 24 hr/d, 7 d/wk to all critically ill patients.
    • Level I: Foundational
    • Level II: Desirable
    • Level III: Desirable
  8. The critical care pharmacist provides pharmacokinetic monitoring and therapeutic adjustments when a targeted drug is prescribed.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  9. The critical care pharmacist reviews the medication history to determine which maintenance medications should be continued during the acute illness.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  10. The pharmacist assists with medication reconciliation for ICU patients at the time of ICU admission, transfer from the ICU to the ward, or discharge to home or facility.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  11. When reviewing orders for verification, the critical care pharmacist prospectively evaluates all drug therapy for appropriate indication, dose, drug interactions, drug allergies, and monitors the patient’s pharmacotherapeutic regimen for effectiveness and adverse drug events (ADEs), and intervenes as needed.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  12. The critical care pharmacist educates patients and/or patients’ care givers regarding medication therapies used to treat patients during and after acute illness, as appropriate.
    • Level I: Foundational
    • Level II: Foundational.
    • Level III: Desirable
  13. The pharmacist performs independent patient assessment (e.g., pain/agitation/delirium, nutrition).
    • Level I: Foundational
    • Level II: Desirable
    • Level III: Desirable
  14. A pharmacist certified in advanced cardiac life support (ACLS; or pediatric advanced life support [PALS]) responds to all resuscitation events in the hospital 24 hr/d, 7 d/wk.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  15. The pharmacist responds, or coordinates pharmacist response to all resuscitation and time-dependent emergencies in the hospital, including, but not limited to cardiac arrest, rapid response, trauma response, hemorrhagic shock, sepsis response, and acute neurologic life support.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  16. The pharmacist provides routine stewardship activities targeted at anti-infectives and other medications, including those that may be high risk for adverse events, high-cost concerns, and inappropriate utilization (e.g., factor products, anticoagulants, sedatives, acid-suppressive therapies).
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  17. The critical care pharmacist collaborates with other pharmacists (e.g., emergency medicine, infectious diseases, transplant, oncology), as needed, to address patient- and disease-specific therapeutic issues.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  18. In conjunction with the clinical dietitian, the critical care pharmacist reviews the nutrition therapy plan and recommends modifications as indicated to optimize the nutritional regimen.
    • Level I: Foundational
    • Level II: Desirable
    • Level III: Desirable
  19. The critical care pharmacist uses the medical record as one means to communicate with other healthcare professionals, and/or to document specific pharmacotherapeutic recommendations or activities.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  20. The critical care pharmacist uses appropriate documentation tools to demonstrate their impact on patient care and economic value.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  21. Critical care pharmacists document pertinent collaborative medication management problems and progress notes daily.
    • Level I: Desirable
    • Level II: Desirable
    • Level III: Desirable
  22. The critical care pharmacist documents clinical activities that include, but are not limited to, disease state management, general pharmacotherapeutic monitoring, pharmacokinetic monitoring, ADEs, education, and other patient care activities.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  23. The critical care pharmacist acts as a liaison between the pharmacy department and the interdisciplinary team to educate health professionals regarding current drug-related policies, procedures, guidelines, and pathways.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  24. The critical care pharmacist uses pharmacoeconomic analyses in conjunction with the interdisciplinary team to evaluate existing/new pharmacy services and the place of new drugs in critical care pharmacotherapy.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  25. The critical care pharmacist is proactive in designing, prioritizing, and promoting new clinical pharmacy programs and services.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  26. Pharmacy administrators evaluate clinical programs/services for stakeholder satisfaction, significance, and economic value.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  27. The critical care pharmacist prepares and presents drug therapy monographs and formulary reviews to the Pharmacy and Therapeutics committee for medications used in the care of critically ill patients.
    • Level I: Desirable
    • Level II: Desirable
    • Level III: Desirable
  28. The pharmacist should participate in planning and implementation of processes for disaster, or mass causalities, scenarios as applicable to the critically ill patient.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  29. The majority of the critical care pharmacist’s time is dedicated to critical care services, with few commitments, outside of critical care activities.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  30. Critical care pharmacists will have the majority of their clinical activity focused in the care of the critically ill population.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  31. Decentralized clinical pharmacy services in the ICU should include routine and consistent patient care coverage, inclusive of day, evening, and weekend coverage.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  32. Critical care pharmacy services are developed as “teams,” with multiple critical care pharmacists available, to deliver consistent and quality collaborative medication management.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  33. In the absence of an onsite critical care pharmacist, CMM may be supplemented through telemedicine.
    • Level I: Desirable
    • Level II: Desirable
    • Level III: Desirable
  34. The ICU pharmacist-to-patient ratio is defined based on patient acuity and complexity in addition to the scope of clinical and operational services provided.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable

Discussion

The value of the critical care clinical pharmacist-to-patient care is well established (6–9). Medication management is the most frequent decision category on patient care rounds; therefore, pharmacists on rounds have the opportunity to facilitate CMM and prevent ADEs (10). An ADE is defined as an injury resulting from the use of a drug and can result in a wide range of consequences. A landmark trial justified the presence of a critical care pharmacist on rounds by reducing rates of preventable ADEs by 66% with a 99% acceptance rate for medication management recommendations (11). An observational multicenter study in the United Kingdom identified approximately one of every six medication orders in the ICU required an intervention from a pharmacist, with two thirds rated as moderate to high impact (12). Specifically, available evidence suggests enhanced patient safety and clinical outcomes with involvement of a pharmacist in the management of the following therapeutic domains: antimicrobial therapy, anticoagulation, pharmacokinetic dosing, pain/agitation/delirium, and emergency response (13–31). Application of activities generally considered foundational has been shown to reduce overall hospital mortality across 885 hospitals (32). Evolving evidence continues to support the benefit of a critical care pharmacist internationally with a broadening scope of practice in adult/PICUs and within various subspecialty critical care practices or post-ICU care clinics (9,12,33–38). In the era of value-based care with rapidly rising medication costs, the economic impact of the critical care pharmacist has also been described (11,19,22,39–41). It has been estimated that the return on investment of a critical care pharmacist approaches 25:1 in patients with infection (19). Decentralized critical care pharmacists may achieve cost avoidance in excess of $200,000 per year when compared with centralized practice models (40). A more conservative estimate of benefit up to $5 per $1 in labor costs would still represent a substantial benefit, considering the high cost of medications in critical care, averaging 31% of a hospital’s total drug cost (42,43). Evolving literature over the last several decades has demonstrated the clinical and pharmacoeconomic impact the critical care pharmacist has when providing direct patient care. As a result, the critical care pharmacist is recognized as an essential member of the interdisciplinary team by pharmacy and interprofessional organizations (3,5,44–48).

Many services that were deemed “desirable” in the recommendations published in 2000 are now considered foundational activities, reflecting the progression of the profession in general and the growing body of literature that supports the role of a critical care pharmacist to positively affect therapy. Active participation of a critical care pharmacist in patient care rounds and within an interprofessional team is foundational at level I and II institutions (statement 1). Participation in rounds facilitates provision of CMM through review of medication orders for appropriateness and safety (statements 9–11), allows collaboration and communication of recommendations regarding the therapy plan (statements 5, 6, 17–21), and provides drug information (statements 2, 3, 12) and education to the interdisciplinary critical care team (statement 4, 23). Institutions with level III critical care services may not have formal rounds, but the critical care pharmacist or pharmacist should strive to review individual patient care plans and make recommendations, provide drug information, and educate the critical care staff.

Given that critical care pharmacists have demonstrated improvements in clinical and economic outcomes, it is essential that they are optimally deployed to maximize their benefit for the care of critically ill patients, such as the management of drugs with therapeutic monitoring to achieve pharmacologic endpoints (statements 7, 8, 13–16) (6–9,11,19,22,39,40,47). The critical care pharmacist thoroughly reviews individual patient pharmacotherapy needs, inclusive of prior to critical illness and postdischarge, and communicates recommendations to the critical care team to facilitate transitions of care (statements 9 and 10). The role of the critical care pharmacist continues to evolve since its transition from a pure dispensing role to clinical or hybrid clinical-operational roles, including involvement in multidisciplinary rounds, CMM, medication safety, quality improvement, protocol development, transitions of care, emergency response/resuscitation, patient and family communication, education, management of drug shortages and recalls, research, disaster preparedness, and prescribing once a diagnosis is made (statements 22, 24, 25, 27, 28) (3,8,10,47,49–58).

The ASHP Practice Advancement Initiative (PAI) recommends institutions to determine drug therapy management services for consistent delivery by pharmacists, devote resources to the provision of those services, and assign pharmacists to patient care units (47). At the very least, it is deemed foundational at level I and II institutions that the majority of a critical care pharmacist’s time is dedicated to the ICU and focused on clinical activities, and that the staffing model provides consistent critical care pharmacist coverage (statements 29, 30). Recent surveys report that only 43.5–62.2% of ICUs have pharmacists assigned to care for ICU patients along with significant variability in clinical activities, institutional type, and ICU bed allocation (4,59). Ideally, critical care pharmacist coverage would be available 24 hr/d, 7 d/wk (statement 31). However, since economic and personnel constraints limit many institutions, it is recommended that institutions prioritize critical care pharmacy services to patients with the highest acuity and extend daily coverage to evening hours at a minimum (60,61).

One approach to facilitate consistent coverage (foundational activity at level I and II institutions) is to develop teams of critical care pharmacists (statement 32) (3,60). As critical care pharmacy services expand to include the development of critical care pharmacist teams, it may be prudent to create critical care team leadership positions. The team leader can ensure establishment of cohesive and best practice pharmacy services, mentor the team of pharmacists, and lead the critical care pharmacy team in creation of clinical programs and development of team goals to optimize critical care pharmacy services. Pharmacy services may be designed to align with subspecialty critical care services in hospitals (e.g., medical, surgical, neuro, cardiac, trauma, burn) necessitating pharmacists with differing daily responsibilities to provide patient-centered care. Academic critical care pharmacists especially benefit from a team of pharmacists and designees to maintain consistent services. Additionally, resource-limited ICUs may choose to supplement coverage with critical care pharmacist participation through telemedicine services (statement 33). Recent reports have highlighted critical care pharmacist involvement in telepharmacy services and demonstrated that their involvement contributes to improved scores on process measures (29,62,63). Establishing appropriate ICU pharmacist-to-patient ratios is foundational at level I and II institutions (statement 34). Bond and Raehl (32) described an association between clinical pharmacist-to-occupied bed ratio and lower mortality, but limited data are available to guide optimal ratios. Critical care pharmacist-to-patient ratios have been suggested in literature, although evidence is sparse and further research is needed (8,64). Determinations regarding coverage and service design should be based on patient acuity and complexity and the scope of pharmacist services to ensure that critical care pharmacists are allocated time to perform the full range of patient care and other services associated with improved outcomes.

Although a single model will not meet the needs of all critical care practice settings, key components of ideal practice models outlined in the PAI and the literature can apply across practice settings (10,47,48,53,54,61,65–70). It is recommended that each site determines how to best incorporate these recommendations such that every ICU patient receives CMM by a critical care pharmacist (statement 26).

QUALITY IMPROVEMENT

Recommendations

  1. The critical care pharmacist serves as the medication safety leader for critically ill patients by identifying potential ADEs, resolving existing ADEs, and improving medication use practices.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  2. The critical care pharmacist assists with the management of ADEs and develops process improvements to reduce and/or prevent medication errors.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  3. The critical care pharmacist participates in reporting ADEs to institutional committees and national programs (e.g., the Food and Drug Administration Medwatch program).
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  4. The critical care pharmacist is involved in continual evaluation of the availability of critical medications through optimization of automated dispensing cabinets.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  5. The critical care pharmacist should be involved as a team member in the design process for building a new or remodeling critical care area.
    • Level I: Desirable
    • Level II: Desirable
    • Level III: Desirable
  6. The critical care pharmacist implements and maintains departmental policies and procedures related to safe and effective use of medications in the ICU.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  7. The critical care pharmacist coordinates the development and implementation of ICU-focused drug therapy protocols, guidelines, order sets, and/or care pathways to maximize benefits of pharmacotherapy.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  8. The pharmacist independently investigates or collaborates with other critical care healthcare team members to evaluate the impact of drug therapy protocols, guidelines, order sets, and/or care pathways used in the ICU (e.g., drug administration, disease state management algorithms).
    • Level I: Foundational
    • Level II: Desirable
    • Level III: Desirable
  9. The critical care pharmacist leads or provides consultation to hospital committees when critical care pharmacotherapy issues are discussed.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  10. The critical care pharmacist serves on and provides consultation to hospital committees when critical care pharmacotherapy issues are discussed.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  11. The critical care pharmacist contributes to the hospital newsletter and drug monographs, on issues related to medication use in the ICU.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  12. The critical care pharmacist identifies and evaluates drug cost minimization opportunities and implements cost containment measures.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  13. The critical care pharmacist is involved in identifying local quality metrics for continuous quality improvement (e.g., risk-adjusted mortality, medication errors per medications ordered/dispensed, mechanical ventilation duration, delirium, mobilization).
    • Level I: Foundational
    • Level II: Desirable
    • Level III: Desirable
  14. The critical care pharmacist participates in quality assurance programs to enhance collaborative medication management, minimize costs, provide ongoing evaluation of current processes, and identify the need for new programs/processes.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  15. The critical care pharmacist shares responsibility for hospital performance for quality and process measure compliance, such as core measures and other hospital metrics (e.g., Clostridium difficile infection rates, vaccinations, patient satisfaction surveys), as it relates to critical care patients.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  16. The critical care pharmacist collaborates with medical staff, nursing, other members of the healthcare team, and hospital administration to prepare the ICU for accreditation and to address any deficiencies identified.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  17. Pharmacy space and facilities in the ICU are regularly assessed to determine whether efficiency can be improved, where applicable.
    • Level I: Foundational
    • Level II: Desirable
    • Level III: Desirable
  18. Real-time dashboard, or analytics monitoring, of quality metrics and drug utilization are available for the pharmacist to review for patient care and research.
    • Level I: Desirable
    • Level II: Desirable
    • Level III: Desirable
  19. Safety technology is implemented, inclusive of bedside barcode scanning, clinical decision support systems, and intelligent IV infusion devices in the routine care of critically ill patients.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  20. Medication use systems have the ability to:
    • i. create and maintain patient medication profiles;
    • ii. interface with patient laboratory data and other relevant test results;
    • iii. interface with patient charts (medication profiles) from other health systems and outpatient clinics;
    • iv. alert users to drug allergies;
    • v. alert users to medication maximum dose limits;
    • vi. alert users to medications prior to admission;
    • vii. alert users to diagnoses;
    • viii. alert users to drug-drug and drug-food/nutrient interactions;
    • ix. alert users to formulary and nonformulary medications as well as approved substitutions;
    • x. alert users to pertinent medication shortages; and
    • xi. provide live, real-time data that can be incorporated in pharmacotherapy decision-making.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  21. The hospital information management system is computerized, is able to comply with those requirements listed for medication use processes, and has the ability to:
    • i. allow direct provider order entry;
    • ii. interface with bedside clinical information systems in real time;
    • iii. alert users to disease state-drug and drug-drug interactions;
    • iv. provide IV admixture information (e.g., compatibility, stability, preparation);
    • v. provide medication information via references or internal guidelines/documents;
    • vi. allow documentation of pharmacy patient care interventions;
    • vii. provide benchmarking and quality data;
    • viii. access to policies and procedures related to medications;
    • ix. interface with mobile devices; and
    • x. provide patient-specific treatment algorithms.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational

Discussion

As many as 98,000 people die in hospitals each year due to preventable medical errors (71). In the ICU, medication errors represent the most common type of medical error and often lead to ADEs (72,73). When compared with non-ICUs, the rate of preventable and potential ADEs occur twice as often in critical care settings (74). More worrisome is that for every fifth dose of administered medications, one preventable error will occur, most commonly due to dose omission, incorrect dose, incorrect drug or technique, or interaction (75). Only recently, guidelines for the safe use of medication in the ICU have been introduced (76). Our recommendation regarding implementation of barcode medication administration provides the same intent as these guidelines while noting the weak nature of the existing evidence.

Optimizing safe medication use requires involvement of the critical care pharmacist throughout the entire medication use process (statements 2, 3, 6). Whether by rounding with the ICU team or developing ICU-focused policies and procedures, protocols, guidelines, order sets, and pathways, these functions are considered foundational for critical care pharmacists (statements 7, 8, 20). Other areas of pharmacist involvement include the implementation and maintenance of safe medication technologies (e.g., bedside barcode scanning, computerized prescriber order entry, and intelligent IV infusion devices), clinical decision support, and surveillance programs (statements 19, 21) (77–79). Given that most errors in the ICU are medication related, pharmacists are uniquely positioned to lead the healthcare team in preventing, identifying, and investigate the cause of errors and make recommendations to prevent future events from occurring (statements 1, 9–11).

Stemming from involvement in institutional committees and from the pharmacist’s role on the interprofessional team, critical care pharmacists have become involved in quality improvement initiatives, assisted in determining and meeting various quality metrics and performance measures, and promoted adherence to guidelines and protocols (statements 4, 8, 13, 18). Numerous studies have demonstrated the critical care pharmacist’s role in implementation and maintenance of compliance with various quality improvement initiatives (25,26,30,80–84). Additionally, pharmacists have promoted appropriate utilization of stress ulcer prophylaxis (85,86), adherence to a vasopressin protocol (87), reduction of door to needle time for tissue plasminogen activator (88), reduction in ADEs (11), reducing the risk of QTc interval prolongation (89), improvement in patient safety (90), and a decrease in drug-drug interactions (91). Similarly, committee involvement and clinical practice experience enable critical care pharmacists to facilitate rapid access to critical medications for emergency scenarios (statements 5, 16, 17) (5,92). Pharmacist participation in accreditation surveys is necessary to fulfill certain regulatory standards (statement 15).

One of the principle responsibilities of critical care pharmacists regarding quality improvement is assurance of high-quality cost-effective care (statements 12–14). The American College of Critical Care Medicine critical care services and personnel guidelines recommend pharmacists implement and maintain policies and procedures regarding safe and effective medication use (5). It has been found that critical care pharmacists reduce medication cost while maintaining appropriate treatment (19,22,38,87,93–96). Critical care pharmacists are equipped with select knowledge and skills useful in determining the most cost-effective use of medications in the ICU, while still maintaining quality of care and patient outcomes (97).

RESEARCH/SCHOLARSHIP

Recommendations

  1. The pharmacist is actively involved in critical care pharmacotherapy research, including, but not limited to, developing and reviewing study proposals, screening and/or enrollment of patients, publication of study results, and serving as a Principal Investigator, co-investigator, study coordinator, or contact person, where applicable.
    • Level I: Desirable
    • Level II: Desirable
    • Level III: Desirable
  2. The pharmacist contributes to the pharmacy and medical literature (e.g., case reports, letters to the editor, and therapeutic, pharmacokinetic, and pharmacoeconomic reports).
    • Level I: Desirable
    • Level II: Desirable
    • Level III: Desirable
  3. The pharmacist reports research results to the pharmacy and medical community at regional, national, and international meetings.
    • Level I: Desirable
    • Level II: Desirable
    • Level III: Desirable
  4. The pharmacist participates in research design and data analysis.
    • Level I: Desirable
    • Level II: Desirable
    • Level III: Desirable
  5. The pharmacist secures funds for conducting research.
    • Level I: Desirable
    • Level II: Desirable
    • Level III: Desirable
  6. The critical care pharmacist participates as a key investigator for critical care research.
    • Level I: Foundational
    • Level II: Desirable
    • Level III: Desirable
  7. Critical care pharmacists are actively involved in collaborating in multicenter research projects.
    • Level I: Desirable
    • Level II: Desirable
    • Level III: Desirable
  8. The profession of pharmacy is represented on the Institutional Review Board and/or Scientific Review Board, as applicable.
    • Level I: Foundational
    • Level II: Desirable
    • Level III: Desirable
  9. The pharmacist contributes to the medical literature as a peer reviewer.
    • Level I: Desirable
    • Level II: Desirable
    • Level III: Desirable

Discussion

In contrast to many of the clinical pharmacy services that are rated by the taskforce as foundational, those involving research/scholarship are considered desirable across all ICU levels of services for eight of nine statements. This suggests that the scope of activities provided by the pharmacist should extend beyond clinical services, many of which are now engrained in patient care, to functions that include research/scholarship, especially at level I ICUs (7).

The two research/scholarship functions that are rated as “foundational” are representation of the pharmacist on the Institutional/Scientific Review Board and participation of the pharmacist as a key investigator, both only at level I ICUs (statements 6 and 8). The only function related to research/scholarship that was rated as “foundational” in the position paper published in 2000 was the representation of a pharmacist on the Institutional/Scientific Review Board (3). It should be noted that unlike the 2000 paper, the current taskforce did not address the role of the pharmacist in providing Investigational Drug Services, as these functions are carried out in accordance with the Good Clinical Practice Guidelines as mandated by the Code of Federal Regulations and should be “foundational” activities at all institutions (98).

Many pharmacists already actively engage in research/scholarship, so it is not surprising that the taskforce recognized the pharmacist as a key investigator as a foundational service, albeit only at level I ICUs. The term “key investigator” in this sense is meant to describe the investigator who conceived the project and is responsible for its completion. In many cases, project results may never be disseminated beyond the home institution, so presenting at scientific meetings or contributing to the medical literature are considered “desirable” activities. The results of a survey of ICU pharmacy functions conducted over a decade ago showed nearly half (45.5%) of pharmacists engage in research in high-level roles (4). However, many of the pharmacists responding to this survey practiced in level I ICUs, so it is not evident that these services are commonly provided across all ICUs. Many granting agencies and research practices promote multidisciplinary involvement in research/scholarship. Therefore, it is highly likely in the future that the level and scope of pharmacy services related to research/scholarship will continue to expand to the extent that many more activities will become foundational across all ICUs.

It is expected that demand by other healthcare disciplines for pharmacists to directly engage in functions involving research/scholarship will increase as pharmacists possess unique knowledge and skills about study design, data analyses, and pharmacotherapy application in research (99). The results of another survey of ICU providers and pharmacists showed nonpharmacist providers consistently valued the clinical and financial impact of all pharmacy services, including those involving research/scholarship (100). It will be incumbent on the profession of pharmacy to ensure that critical care pharmacists are appropriately trained to deliver the functions of research/scholarship across all ICUs.

TRAINING/EDUCATION

Recommendations

  1. The critical care pharmacist provides an interprofessional experience in training and mentoring pharmacy students, residents, and fellows through experiential critical care rotations.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  2. The critical care pharmacist supports postgraduate residencies and/or fellowship training in critical care pharmacy practice.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  3. Critical care pharmacy trainees should be evaluated on educational outcomes and documented experiences to demonstrate competence for a given subject.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Foundational
  4. The pharmacist participates in the education of pharmacy students, residents, and/or fellows by serving as a project advisor.
    • Level I: Desirable
    • Level II: Desirable
    • Level III: Desirable
  5. The critical care pharmacist provides education to health professional students and trainees pertinent to critical care pharmacotherapy.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  6. The critical care pharmacist provides formal accredited interprofessional educational sessions (such as medical grand rounds or intensive care rounds).
    • Level I: Desirable
    • Level II: Desirable
    • Level III: Desirable
  7. The pharmacist has an active role in interdisciplinary simulation activities.
    • Level I: Desirable
    • Level II: Desirable
    • Level III: Desirable
  8. The critical care pharmacist is a certified instructor and provides certification classes to other healthcare providers (ACLS, PALS, emergency neurologic life support [ENLS], as applicable)
    • Level I: Desirable
    • Level II: Desirable
    • Level III: Desirable
  9. The pharmacist develops and implements training programs for personnel working in the ICU.
    • Level I: Foundational
    • Level II: Desirable
    • Level III: Desirable
  10. The pharmacist identifies and educates medical and community groups about the role of pharmacists as part of the interdisciplinary healthcare team in the ICU.
    • Level I: Desirable
    • Level II: Desirable
    • Level III: Desirable

Discussion

An interdisciplinary, collaborative approach to patient care is necessary as the complexity of healthcare expands, especially in the critical care population. Consequently, education of healthcare professions should be interprofessional to foster interactions that enhance the practice of each individual discipline within the team (statements 1, 4). The ACCP position statement on interprofessional education and practice supports interprofessional learning and skills development, an understanding of respective disciplinary roles, mutual respect, and a sustained commitment to interprofessional learning and patient care (101). Therefore, the critical care pharmacist should be deeply involved in interprofessional training and these activities are considered foundational for critical care pharmacists practicing in level I ICUs and foundational or desirable for level II and III ICUs (statements 1–4, 8). Direct patient care experience for trainees provides invaluable opportunity to develop and refine problem-solving abilities, accountability, efficiency, build confidence, understand clinical disease and pharmacotherapy, and to mature professionally. Practical skills training is foundational, as opposed to didactic education (statement 4, 5, 10) (102). Trainees can facilitate expansion of clinical services or support clinical programs in areas that are underserved, and critical care pharmacist participation in training programs is considered foundational for level I and II ICUs (statement 3). The fact that many of these educational services are deemed “foundational” represents advancements in practice as all educational and training activities were considered desirable or optimal services in the recommendations published in 2000 (3).

The critical care pharmacist should provide interprofessional experiences to trainees but also create and deliver education to all members of the team. As highlighted in the statements (statements 6–9), this may include the interdisciplinary critical care team, other community healthcare members, or through certification classes or simulation activities. These activities are considered desirable, in addition to the core foundational activities recommended above. The ACCP white paper on interprofessional education provides environment specific models, assessment methods, and important implications and barriers to the application of interprofessional education for the clinical pharmacist (103).

Finally, to accomplish the vision of ACCP and ASHP that all entry-level hospital pharmacists will complete postgraduate residency training, or have sufficient hospital experience, prior to entering practice, the critical care pharmacist should develop opportunities and support the infrastructure of first- and second-year residency programs and fellowships (statement 3) (104,105).

PROFESSIONAL DEVELOPMENT

Recommendations

  1. The pharmacist maintains a mastery of knowledge related to current resources and primary literature pertinent to critical care pharmacotherapy.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  2. The pharmacist maintains certification in available life-support courses (e.g., ACLS, PALS, ENLS, advanced trauma life support [ATLS—audit], and advanced burn life support [ABLS]), as applicable to practice.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  3. Pharmacists practicing extensively in critical care will seek board certification in critical care pharmacy when eligible.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  4. The pharmacist is involved in non–patient care activities, including interdisciplinary committees and educational lectures.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  5. The pharmacist provides formal accredited educational sessions at local, regional, state, and national meetings.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  6. The critical care pharmacist is a member of a professional critical care organization, in addition to pharmacy organizations.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable
  7. Pharmacy administrators should provide protected time for critical care pharmacists to facilitate education, administrative, research, and scholarly activities.
    • Level I: Foundational
    • Level II: Desirable
    • Level III: Desirable
  8. Pharmacy administrators should create mechanisms for critical care pharmacists to develop their career and professional role within a health system.
    • Level I: Foundational
    • Level II: Foundational
    • Level III: Desirable

Discussion

To provide CMM to their patients, critical care pharmacists require appropriate preparation (statement 1). The goals and objectives of a postgraduate year 2 critical care pharmacy residency are a starting point, along with basic credentials such as the life-support certifications (e.g., ACLS, PALS, ENLS, ATLS, and ABLS) for any practitioner who participates in resuscitation activities (statements 2–3). Required competency of a clinical pharmacist has been defined and includes six essential domains, including board certification (106). Thus, board certification in critical care pharmacotherapy is a foundational credential for critical care pharmacists in level I and II settings, and board certification in general pharmacotherapy is a desirable competency for any pharmacist practicing direct patient care in the hospital (statement 3). Board certification ensures high-quality–continuing education, provides a recognized minimum credential for direct patient care, and is becoming a required credential in hospitals (107). Board certification may increase pharmacist credibility within the critical care team, as a parallel to the medical model. The Board of Pharmacy Specialties credential of Board Certified Critical Care Pharmacist is most applicable. However, alternative or additional board certifications may be appropriate for a critical care pharmacist practicing in subspecialized areas (e.g., pediatrics, nutritional support).

Employers benefit from highly competent staff and should facilitate the development process and create privileging standards and rewards (107). A career recognition process with medical staff/hospital privileging creates a standardized platform for “top of the license” practice and allows for prescribing and other practice benefits in a variety of practice settings (51). Pharmacy department leaders will need to demonstrate strong leadership and advocacy to achieve a credentialing and privileging process. A standard template for evaluation of the many practice-related, educational, and scholarly activities of a clinical pharmacist should be implemented (108). Professionalism and scholarly activity can be further encouraged through the provision of protected time to attend meetings and participate in scholarly activities as a component of critical care pharmacist career development and is a foundational need in level I settings (statements 4–8). Ensuring ongoing competence and professional development is essential to ensure ongoing high-quality practice and is foundational in level I and II settings. Membership in critical care organizations creates opportunities for foundational, high-level professional education (statement 6).

The completion of tasks related to professional development will increase visibility of the pharmacist and their employer and facilitates peer recognition both within and outside of pharmacy (statement 5, 7–8). Activities can include scholarly efforts such as conducting research and publishing in respected journals. The pharmacist should be actively engaged in providing pharmacy and interdisciplinary education, further establishing one’s self as the medication expert at the local, regional, state, national, and international level. Active membership and involvement in critical care organizations and pharmacy-specific organizations are important and foundational for level I and II and can provide opportunities for education, appointment or election to offices, committee participation, and nominations for various awards and fellowship status. Although recognition enhances the image of the individual pharmacist, the opportunity to network and work to support the profession can enhance their effectiveness as a practitioner.

SUMMARY

Through multiorganizational collaboration among the SCCM, American Society of Health-Systems Pharmacists, and ACCP, this article provides an updated roadmap for establishing and refining critical care pharmacy services in the form of 82 statement recommendations. Informed by task force members from various critical care and administrative practice settings, these guidelines address the various domains of critical care pharmacy practice. Guideline recommendation statements were generated through a rigorous process of literature evaluation and debate.

Technology, regulation, and the services and role of pharmacists continue to evolve within the healthcare setting. Critical care pharmacists have been leaders in defining their roles and provided the framework for these statements. Although this is a potential limitation of this document, and may appear self-serving, it also creates a framework to stimulate self-reflection. This document is an important tool that critical care practitioners and administrators should use to evaluate progress toward the highest levels of activity within the realms of patient care, quality improvement, research and scholarship, training and education, and professional development. Although limited resources may impact optimal implementation within any setting, these statements can serve as a roadmap to the highest level of care. It is hoped that practitioners will continue to document their roles and impact on patient outcome to make this an ongoing process.

TABLE 1.
TABLE 1.:
Round 1 Task Force Panel Voting
TABLE 2.
TABLE 2.:
Round 2 Voting, With New Recommendation Statements

REFERENCES

1. Vincent JL. Critical care—where have we been and where are we going?. Crit Care. 2013; 17Suppl 1S2
2. Harvey AK, Whitney J, Nahata MC, et al. Francke’s legacy—40 years of clinical pharmacy. Ann Pharmacother. 2008; 42:121–126
3. Rudis MI, Brandl KM. Position paper on critical care pharmacy services. Society of Critical Care Medicine and American College of Clinical Pharmacy Task Force on critical care pharmacy services. Crit Care Med. 2000; 28:3746–3750
4. Maclaren R, Devlin JW, Martin SJ, et al. Critical care pharmacy services in United States hospitals. Ann Pharmacother. 2006; 40:612–618
5. Haupt MT, Bekes CE, Brilli RJ, et al.; Task Force of the American College of Critical Care Medicine, Society of Critical Care MedicineGuidelines on critical care services and personnel: Recommendations based on a system of categorization of three levels of care. Crit Care Med. 2003; 31:2677–2683
6. Dager W, Bolesta S, Brophy G, et al. An opinion paper outlining recommendations for training, credentialing, and documenting and justifying critical care pharmacy services. Pharmacotherapy. 2011; 31
7. Preslaski CR, Lat I, MacLaren R, et al. Pharmacist contributions as members of the multidisciplinary ICU team. Chest. 2013; 144:1687–1695
8. Horn E, Jacobi J. The critical care clinical pharmacist: Evolution of an essential team member. Crit Care Med. 2006; 34:S46–S51
9. McKenzie MS, Auriemma CL, Olenik J, et al. An observational study of decision making by medical intensivists. Crit Care Med. 2015; 43:1660–1668
10. Bauer SR, Kane-Gill SL. Outcome assessment of critical care pharmacist services. Hosp Pharm. 2016; 51:507–513
11. Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999; 282:267–270
12. Shulman R, McKenzie CA, Landa J, et al.; PROTECTED-UK GroupPharmacist’s review and outcomes: Treatment-enhancing contributions tallied, evaluated, and documented (PROTECTED-UK). J Crit Care. 2015; 30:808–813
13. Carver PL, Lin SW, DePestel DD, et al. Impact of mecA gene testing and intervention by infectious disease clinical pharmacists on time to optimal antimicrobial therapy for Staphylococcus aureus bacteremia at a university hospital. J Clin Microbiol. 2008; 46:2381–2383
14. Gentry CA, Greenfield RA, Slater LN, et al. Outcomes of an antimicrobial control program in a teaching hospital. Am J Health Syst Pharm. 2000; 57:268–274
15. Bond CA, Raehl CL. Clinical and economic outcomes of pharmacist-managed antimicrobial prophylaxis in surgical patients. Am J Health Syst Pharm. 2007; 64:1935–1942
16. Bond CA, Raehl CL. Clinical and economic outcomes of pharmacist-managed aminoglycoside or vancomycin therapy. Am J Health Syst Pharm. 2005; 62:1596–1605
17. Wade WE, McCall CY. Pharmacist-managed aminoglycoside therapy in combination with a beta-lactam agent in the treatment of nosocomial pneumonia in critically ill patients. Pharmacotherapy. 1995; 15:216–219
18. Streetman DS, Nafziger AN, Destache CJ, et al. Individualized pharmacokinetic monitoring results in less aminoglycoside-associated nephrotoxicity and fewer associated costs. Pharmacotherapy. 2001; 21:443–451
19. MacLaren R, Bond CA, Martin SJ, et al. Clinical and economic outcomes of involving pharmacists in the direct care of critically ill patients with infections. Crit Care Med. 2008; 36:3184–3189
20. Petitta A. Assessing the value of pharmacists’ health-systemwide services: Clinical pathways and treatment guidelines. Pharmacotherapy. 2000; 20:327S–332S
21. To L, Schillig JM, DeSmet BD, et al. Impact of a pharmacist-directed anticoagulation service on the quality and safety of heparin-induced thrombocytopenia management. Ann Pharmacother. 2011; 45:195–200
22. MacLaren R, Bond CA. Effects of pharmacist participation in intensive care units on clinical and economic outcomes of critically ill patients with thromboembolic or infarction-related events. Pharmacotherapy. 2009; 29:761–768
23. Bond CA, Raehl CL. Pharmacist-provided anticoagulation management in United States hospitals: Death rates, length of stay, Medicare charges, bleeding complications, and transfusions. Pharmacotherapy. 2004; 24:953–963
24. Dager WE, Branch JM, King JH, et al. Optimization of inpatient warfarin therapy: Impact of daily consultation by a pharmacist-managed anticoagulation service. Ann Pharmacother. 2000; 34:567–572
25. MacLaren R, Plamondon JM, Ramsay KB, et al. A prospective evaluation of empiric versus protocol-based sedation and analgesia. Pharmacotherapy. 2000; 20:662–672
26. Marshall J, Finn CA, Theodore AC. Impact of a clinical pharmacist-enforced intensive care unit sedation protocol on duration of mechanical ventilation and hospital stay. Crit Care Med. 2008; 36:427–433
27. Devlin JW, Nasraway SA Jr. Reversing oversedation in the intensive care unit: The role of pharmacists in energizing guideline efforts and overcoming protocol fatigue. Crit Care Med. 2008; 36:626–628
28. Devlin JW, Holbrook AM, Fuller HD. The effect of ICU sedation guidelines and pharmacist interventions on clinical outcomes and drug cost. Ann Pharmacother. 1997; 31:689–695
29. Forni A, Skehan N, Hartman CA, et al. Evaluation of the impact of a tele-ICU pharmacist on the management of sedation in critically ill mechanically ventilated patients. Ann Pharmacother. 2010; 44:432–438
30. Louzon P, Jennings H, Ali M, et al. Impact of pharmacist management of pain, agitation, and delirium in the intensive care unit through participation in multidisciplinary bundle rounds. Am J Health Syst Pharm. 2017; 74:253–262
31. Draper HM, Eppert JA. Association of pharmacist presence on compliance with advanced cardiac life support guidelines during in-hospital cardiac arrest. Ann Pharmacother. 2008; 42:469–474
32. Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and hospital mortality rates. Pharmacotherapy. 2007; 27:481–493
33. Tripathi S, Crabtree HM, Fryer KR, et al. Impact of clinical pharmacist on the pediatric intensive care practice: An 11-year tertiary center experience. J Pediatr Pharmacol Ther. 2015; 20:290–298
34. Beardsley JR, Jones CM, Williamson J, et al. Pharmacist involvement in a multidisciplinary initiative to reduce sepsis-related mortality. Am J Health Syst Pharm. 2016; 73:143–149
35. Michalets E, Creger J, Shillinglaw WR. Outcomes of expanded use of clinical pharmacist practitioners in addition to team-based care in a community health system intensive care unit. Am J Health Syst Pharm. 2015; 72:47–53
36. Jiang SP, Chen J, Zhang XG, et al. Implementation of pharmacists’ interventions and assessment of medication errors in an intensive care unit of a Chinese tertiary hospital. Ther Clin Risk Manag. 2014; 10:861–866
37. Fideles GM, de Alcântara-Neto JM, Peixoto Júnior AA, et al. Pharmacist recommendations in an intensive care unit: Three-year clinical activities. Rev Bras Ter Intensiva. 2015; 27:149–154
38. Montazeri M, Cook DJ. Impact of a clinical pharmacist in a multidisciplinary intensive care unit. Crit Care Med. 1994; 22:1044–1048
39. Stollings JL, Caylor MM. Postintensive care syndrome and the role of a follow-up clinic. Am J Health Syst Pharm. 2015; 72:1315–1323
40. Kopp BJ, Mrsan M, Erstad BL, et al. Cost implications of and potential adverse events prevented by interventions of a critical care pharmacist. Am J Health Syst Pharm. 2007; 64:2483–2487
41. Hammond DA, Flowers HJ, Meena N, et al. Cost avoidance associated with clinical pharmacist presence in a medical intensive care unit. J Am Coll Clin Pharm. 2019; 2:610–615
42. Haas CE, Vermeulen LC. Caution warranted when torturing data until they confess. J Am Coll Clin Pharm. 2019; 2:606–607
43. Altawalbeh SM, Saul MI, Seybert AL, et al. Intensive care unit drug costs in the context of total hospital drug expenditures with suggestions for targeted cost containment efforts. J Crit Care. 2018; 44:77–81
44. Brilli RJ, Spevetz A, Branson RD, et al.; American College of Critical Care Medicine Task Force on Models of Critical Care Delivery. The American College of Critical Care Medicine Guidelines for the Definition of an Intensivist and the Practice of Critical Care MedicineCritical care delivery in the intensive care unit: Defining clinical roles and the best practice model. Crit Care Med. 2001; 29:2007–2019
45. Dellit TH, Owens RC, McGowan JE Jr, et al.; Infectious Diseases Society of America; Society for Healthcare Epidemiology of AmericaInfectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007; 44:159–177
46. Doherty RB, Crowley RA; Health and Public Policy Committee of the American College of PhysiciansPrinciples supporting dynamic clinical care teams: An American College of Physicians position paper. Ann Intern Med. 2013; 159:620–626
47. The consensus of the pharmacy practice model summit. Am J Health Syst Pharm. 2011; 68:1148–1152
48. American College of Clinical PharmacyStandards of practice for clinical pharmacists. Pharmacotherapy. 2014; 34:794–797
49. International Pharmaceutical FederationThe Role of the Pharmacist in Crisis Management: Including Manmade and Natural Disasters and Pandemics.20051–4XXXAvailable at: http://www.fip.org/www/uploads/database_file.php?id=208&table_id
50. ASHP statement on the role of health-system pharmacists in emergency preparedness. Am J Health Syst Pharm. 2003; 60:1993–1995
51. Jordan TA, Hennenfent JA, Lewin JJ 3rd, et al. Elevating pharmacists’ scope of practice through a health-system clinical privileging process. Am J Health Syst Pharm. 2016; 73:1395–1405
52. Abramowitz PW, Thompson KK, Cobaugh DJ. The time has come: Increased prescribing authority for pharmacists. Am J Health Syst Pharm. 2016; 73:1386–1387
53. Shane R. Critical requirements for health-system pharmacy practice models that achieve optimal use of medicines. Am J Health Syst Pharm. 2011; 68:1101–1111
54. Jacobi J, Ray S, Danelich I, et al. Impact of the pharmacy practice model initiative on clinical pharmacy specialist practice. Pharmacotherapy. 2016; 36:e40–e49
55. Feih J, Peppard WJ, Katz M. Pharmacist involvement on a rapid response team. Am J Health Syst Pharm. 2017; 74:S10–S16
56. Bauer SR, Abraham PE, Barletta JF, et al. Development of the Critical Care Pharmacotherapy Trials Network. Am J Health Syst Pharm. 2017; 74:287–293
57. Alkhalili M, Ma J, Grenier S. Defining roles for pharmacy personnel in disaster response and emergency preparedness. Disaster Med Public Health Prep. 2017; 11:496–504
58. Pincock LL, Montello MJ, Tarosky MJ, et al. Pharmacist readiness roles for emergency preparedness. Am J Health Syst Pharm. 2011; 68:620–623
59. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration–2011. Am J Health Syst Pharm. 2012; 69:768–785
60. Erstad BL. A primer on critical care pharmacy services. Ann Pharmacother. 2008; 42:1871–1881
61. Granko RP, Poppe LB, Savage SW, et al. Method to determine allocation of clinical pharmacist resources. Am J Health Syst Pharm. 2012; 69:1398–1404
62. Hassan E, Depietro M, Zubrow M, et al. Effect of sedation tapering as part of multiprofessional pain, agitation and delirium program on ICU outcomes. 2012In: American Society of Health System Pharmacists 47th Annual Midyear Clinical MeetingLas Vegas, NVA5–A050
63. Meidl TM, Woller TW, Iglar AM, et al. Implementation of pharmacy services in a telemedicine intensive care unit. Am J Health Syst Pharm. 2008; 65:1464–1469
64. SHPA Committee of Specialty Practice in Critical CareSHPA standards of practice for critical care pharmacy practice. J Pharm Pract Res. 2008; 38:58–60
65. Mason KC. Cutting-edge practice model: An integrated model within a large academic medical center. Am J Health Syst Pharm. 2011; 68:1112
66. Geiger BL. Cutting-edge practice model: Experience in a veterans affairs hospital. Am J Health Syst Pharm. 2011; 68:1112–1113
67. Berry R. Cutting-edge practice model: Experience in a small community hospital. Am J Health Syst Pharm. 2011; 68:1113
68. Pickette SG. Cutting-edge practice model: Experience in a community hospital system. Am J Health Syst Pharm. 2011; 68:1114
69. Berensen NM. Cutting-edge practice model: A mixed integrated and clinical specialist model in a large health system. Am J Health Syst Pharm. 2011; 68:1114–1115
70. Kucukarslan SN, Corpus K, Mehta N, et al. Evaluation of a dedicated pharmacist staffing model in the medical intensive care unit. Hosp Pharm. 2013; 48:922–930
71. Kohn LT, Corrigan JM, Molla S. To err is human. Medicine (Baltimore). 1999; 126:312
72. Hale GM, Kane-Gill SL, Groetzinger L, et al. An evaluation of adverse drug reactions associated with antipsychotic use for the treatment of delirium in the intensive care unit. J Pharm Pract. 2016; 29:355–360
73. Smithburger PL, Buckley MS, Culver MA, et al. A multicenter evaluation of off-label medication use and associated adverse drug reactions in adult medical ICUs. Crit Care Med. 2015; 43:1612–1621
74. Cullen DJ, Sweitzer BJ, Bates DW, et al. Preventable adverse drug events in hospitalized patients: A comparative study of intensive care and general care units. Crit Care Med. 1997; 25:1289–1297
75. Kopp BJ, Erstad BL, Allen ME, et al. Medication errors and adverse drug events in an intensive care unit: Direct observation approach for detection. Crit Care Med. 2006; 34:415–425
76. Kane-Gill SL, Dasta JF, Buckley MS, et al. Clinical practice guideline: Safe medication use in the ICU. Crit Care Med. 2017; 45:e877–e915
77. Smithburger PL, Buckley MS, Bejian S, et al. A critical evaluation of clinical decision support for the detection of drug-drug interactions. Expert Opin Drug Saf. 2011; 10:871–882
78. DiPoto JP, Buckley MS, Kane-Gill SL. Evaluation of an automated surveillance system using trigger alerts to prevent adverse drug events in the intensive care unit and general ward. Drug Saf. 2015; 38:311–317
79. Bickham P, Golembiewski J, Meyer T, et al. ASHP guidelines on perioperative pharmacy services. Am J Health Syst Pharm. 2019; 76:903–820
80. Devlin JW, Marquis F, Riker RR, et al. Combined didactic and scenario-based education improves the ability of intensive care unit staff to recognize delirium at the bedside. Crit Care. 2008; 12:R19
81. Stollings JL, Foss JJ, Ely EW, et al. Pharmacist leadership in ICU quality improvement: Coordinating spontaneous awakening and breathing trials. Ann Pharmacother. 2015; 49:883–891
82. Gesin G, Russell BB, Lin AP, et al. Impact of a delirium screening tool and multifaceted education on nurses’ knowledge of delirium and ability to evaluate it correctly. Am J Crit Care. 2012; 21:e1–e11
83. Swan JT. Decreasing inappropriate unable-to-assess ratings for the confusion assessment method for the intensive care unit. Am J Crit Care. 2014; 23:60–69
84. Marino J, Bucher D, Beach M, et al. Implementation of an intensive care unit delirium protocol: An interdisciplinary quality improvement project. Dimens Crit Care Nurs. 2015; 34:273–284
85. Tasaka CL, Burg C, VanOsdol SJ, et al. An interprofessional approach to reducing the overutilization of stress ulcer prophylaxis in adult medical and surgical intensive care units. Ann Pharmacother. 2014; 48:462–469
86. Buckley MS, Park AS, Anderson CS, et al. Impact of a clinical pharmacist stress ulcer prophylaxis management program on inappropriate use in hospitalized patients. Am J Med. 2015; 128:905–913
87. Wu JY, Stollings JL, Wheeler AP, et al. Efficacy and outcomes after vasopressin guideline implementation in septic shock. Ann Pharmacother. 2017; 51:13–20
88. Rech MA, Bennett S, Donahey E. Pharmacist participation in acute ischemic stroke decreases door-to-needle time to recombinant tissue plasminogen activator. Ann Pharmacother. 2017; 51:1084–1089
89. Ng TM, Bell AM, Hong C, et al. Pharmacist monitoring of QTc interval-prolonging medications in critically ill medical patients: A pilot study. Ann Pharmacother. 2008; 42:475–482
90. Buckley MS, Harinstein LM, Clark KB, et al. Impact of a clinical pharmacy admission medication reconciliation program on medication errors in “high-risk” patients. Ann Pharmacother. 2013; 47:1599–1610
91. Rivkin A, Yin H. Evaluation of the role of the critical care pharmacist in identifying and avoiding or minimizing significant drug-drug interactions in medical intensive care patients. J Crit Care. 2011; 26:104.e1–104.e6
92. Chapuis C, Roustit M, Bal G, et al. Automated drug dispensing system reduces medication errors in an intensive care setting. Crit Care Med. 2010; 38:2275–2281
93. Claus BO, Robays H, Decruyenaere J, et al. Expected net benefit of clinical pharmacy in intensive care medicine: A randomized interventional comparative trial with matched before-and-after groups. J Eval Clin Pract. 2014; 20:1172–1179
94. Weant KA, Armitstead JA, Ladha AM, et al. Cost effectiveness of a clinical pharmacist on a neurosurgical team. Neurosurgery. 2009; 65:946–950
95. Kane SL, Weber RJ, Dasta JF. The impact of critical care pharmacists on enhancing patient outcomes. Intensive Care Med. 2003; 29:691–698
96. Hamblin S, Rumbaugh K, Miller R. Prevention of adverse drug events and cost savings associated with PharmD interventions in an academic level I trauma center: An evidence-based approach. J Trauma Acute Care Surg. 2012; 73:1484–1490
97. Flannery AH, Pandya K, Laine ME, et al. Managing the rising costs and high drug expenditures in critical care pharmacy practice. Pharmacotherapy. 2017; 37:54–64
98. American Society of Health-System PharmacistsASHP guidelines on clinical drug research. Am J Heal Pharm. 1998; 55:369–376
99. American Society of Hospital PharmacistsASHP statement on pharmaceutical research in organized health-care settings. Am J Hosp Pharm. 1991; 48:1781
100. MacLaren R, Brett McQueen R, Campbell J. Clinical and financial impact of pharmacy services in the intensive care unit: Pharmacist and prescriber perceptions. Pharmacotherapy. 2013; 33:401–410
101. American College of Clinical PharmacyInterprofessional education and practice. Pharmacotherapy. 2009; 29:880–881
102. Rathbun RC, Hester EK, Arnold LM, et al. Importance of direct patient care in advanced pharmacy practice experiences. Pharmacotherapy. 2012; 32:e88–e97
103. Lee R, Ii P, Hume AL, et al. Interprofessional education: Principles and application. A framework for clinical pharmacy. Pharmacotherapy. 2009; 29:145e–164e
104. Murphy JE, Nappi JM, Bosso JA, et al.; American College of Clinical PharmacyAmerican College of Clinical Pharmacy’s vision of the future: Postgraduate pharmacy residency training as a prerequisite for direct patient care practice. Pharmacotherapy. 2006; 26:722–733
105. American Society of Health-System PharmacistsASHP long-range vision for the pharmacy work force in hospitals and health systems: Ensuring the best use of medicines in hospitals and health systems. Am J Heal Pharm. 2007; 64:1320–1330
106. Saseen JJ, Ripley TL, Bondi D, et al. ACCP clinical pharmacist competencies. Pharmacotherapy. 2017; 37:630–636
107. Hager DR, Hartkopf KJ, Koth SM, et al. Creation of a certification requirement for pharmacists in direct patient care roles. Am J Health Syst Pharm. 2017; 74:1584–1589
108. Lee M, Badowski ME, Acquisto NM, et al. ACCP template for evaluating a clinical pharmacist. Pharmacotherapy. 2017; 37:e21–e29
Keywords:

collaborative medication management; credentialing; critical care; pharmacy; professional development

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