How pharmacists can work with intensivists on ICUs

Working with intensivists in intensive care units, pharmacists can make significant contributions, including preventing drug errors, reducing costs, and improving care. That's according to experts in critical care medicine.

At this point, only 10% of hospitals have intensivist-directed ICU staffing. But this is expected to change thanks to pressure from the Leapfrog Group, a coalition of more than 100 large employers. It has pushed for a hospital standard called ICU Physician Staffing (IPS), an intensivist-led model of operation to boost patient safety.

Intensivists are physicians who specialize in critical care with the experience and skill required to detect and address changes in patients' clinical conditions, often before complications occur. Intensivists can be surgeons, anesthesiologists, internists, or pediatricians with additional training and board certification in critical care. They are often the ICU director and must have the ability to manage and coordinate care by a variety of clinicians.

Many studies have documented the advantages of having intensivists care for the critically ill, with a relative reduction in ICU mortality rates ranging from 15%-60%. Researchers conservatively estimate that more than 50,000 lives could be saved annually by implementing a change to intensivist-led ICU staffing across America. Currently, more than four million patients are admitted to ICUs and more than 500,000 die each year.

According to the Society of Critical Care Medicine (SCCM), a professional organization devoted to ensuring excellence in critical care, it is not only the presence of intensivists that makes a difference in the ICU, but rather the existence of a team of highly trained multidisciplinary health professionals, such as nurses, respiratory therapists, dietitians, and pharmacists.

Stephen O. Heard, director, surgical intensive care units, and professor of anesthesiology and surgery at the University of Massachusetts Memorial Medical Center in Worcester, works as an intensivist. "Our pharmacists routinely make rounds with the ICU team and provide recommendations about drug selection, dose, and frequency of dosing," he said. "They also remind us which route of administration is most economical, such as suggesting a change to the enteral form of a medication if the patient's condition allows," he added.

Heard's medical center has a relationship with the Massachusetts College of Pharmacy, where Pharm.D. residents rotate onto the ICU service under the direction of the attending Pharm.D. Although there are currently no standardized training requirements for a pharmacist aiming to work in the ICU, most have had some prior exposure to critical care in the form of a residency or clinical rotation.

"There is also evidence to support pharmacist participation on daily rounds in the ICU," stated Sean Berenholtz, M.D., assistant professor, departments of anesthesiology/critical care medicine and surgery, and intensivist for two adult ICUs at Johns Hopkins Hospital in Baltimore.

Berenholtz cited an article by Lucian Leape and others (JAMA, 1999), which found the presence of a pharmacist on rounds in the ICU was associated with a 66% reduction in adverse drug events. The pharmacist on Berenholtz's team performs daily rounds and remains available throughout the day for questions, providing real-time recommendations on drug dosing, drug-drug interactions, allergy and cost information, and antibiotic approval, he added.

According to Thomas G. Rainey, M.D., FCCM, director of critical care at Suburban Hospital in Bethesda, Md., and president of CriticalMed, a company that specializes in working with hospitals to institute organized intensive care, the presence of a pharmacist is integral to all of the activities in the ICU. For example, his team pharmacist has identified potential drug errors from mistakes made on medication administration records (MARs); suggested conversions from IV to oral therapy, thereby decreasing a patient's length of stay; and initiated the use of erythropoietin for a patient with a gastrointestinal bleed, avoiding a probable transfusion.

"Our pharmacist has become so integrated into the team that he has actually taken on the job of team leader on a palliative care project," Rainey said of Dan Albrandt, the pharmacist who will be the primary investigator for the project to be funded by the Robert Woods Johnson Foundation. He concluded, "There is tremendous satisfaction for a pharmacist to function as part of a team and be accepted as an important and integral member—as exemplified by this project, which he initiated and others have wholeheartedly supported."