Q&A: New ICU Guidelines Highlight, Confirm Role of Critical Care Pharmacists

For patients experiencing emergency situations in the intensive care unit (ICU), critical care pharmacists are essential team members that have the ability to significantly improve patient outcomes.

“Pharmacists are one of the few things that really reduces adverse drug events and improves medication safety [in the ICU],” Andrea Sikora, PharmD, MSCR, FCCM, FCCP, BCCCP, associate professor of biomedical informatics at the University of Colorado School of Medicine, told Drug Topics. “The idea that we're going to make sure that every patient receives the care of a critical care pharmacist, I think that is going to be associated with improvements in patient-centered outcomes, like mortality and length of stay, but also institutional outcomes, because we often find that the best quality of care is also the most cost-effective care.”

Learn about Sikora’s role on the committee and the ways in which her team was able to champion for critical care pharmacists. | image credit: Felippe Lopes / stock.adobe.com

While Sikora recently chaired a committee exploring the role of pharmacists in ICUs across the country, critical care pharmacists have been operating in emergency situations for multiple decades. According to Sikora, however, her and her team’s guidelines are more of a confirmation of pharmacists’ roles in the ICU, offering industry-wide acceptance of pharmacists as knowledgeable providers in ICUs.

Learn about Sikora’s role on the committee and the ways in which her team was able to champion for critical care pharmacists.

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Drug Topics: Can you summarize the most recent developments regarding ICU pharmacists and your involvement in this process?

Andrea Sikora: There has been a lot of excitement in critical care pharmacy over the past few months. I think it's pretty incredible to think we’re about 20 years from the first endorsed position statement stating the essential nature of having critical care pharmacists on the ICU team. But given that we said that they were essential, we've really run into issues where about 30% of ICUs still don't have a critical care pharmacist, and only about 15% have someone available on weekends or holidays. As you might imagine, sick patients are also sick on Saturday and Sunday.

About 5 years ago, there was a meta-analysis that showed that critical care pharmacists reduced adverse drug events in the ICU by about 70% and that this was associated with a reduction in the odds of mortality of about 20%, which is quite a bit. The big issue that's facing pharmacy has been far more about this workload conversation of ‘How do we get pharmacists in the right place at the right time?’ One of the issues we faced is that almost every study you find, it shows that one pharmacist is better than no pharmacists; not a surprising outcome, right? It's like a placebo control, where you have a sugar pill versus an active ingredient. The problem there is that we don't really know what is the safe workload.

The excitement that we've seen recently is that there was a study that came out that showed, using causal inference methods, when you had a pharmacist there and they did more interventions, or had more ability to be with those patients, they reduced mortality. That's a pretty powerful outcome. There's also been a study that's been recently finished that had 70 centers and over 30,000 patients, called the OPTIM study. I've been involved with that, and I can tell you, the preliminary results are very exciting. We're seeing that if you have a high pharmacist-to-patient ratio, like you're taking care of too many patients, that's bad for patient care. It increases in mortality risk and increases in length of stay.

These things are really exciting. I think where all of this has been leading is that we need better guidelines and better consensus recommendations to basically enact how we're going to put pharmacists in the ICU. I had the honor of serving as the chair of this committee. It was originally through [the American College of Clinical Pharmacy’s] (ACCP) Critical Care [Practice and Research Network], but we got to work with SCCM, which is the Society of Critical Care Medicine, the American Critical Care Nursing Association, representatives from the Joint Commission and [the US Department of Health and Human Services], as well as endorsements from the American Society of Health-System Pharmacists, ACCP, and the Institute for Safe Medication Practices. It’s a pretty neat document that we've put together.

Drug Topics: How are these new guidelines expected to impact the greater pharmacy industry and the millions of patients that require intensive care?

Andrea Sikora: One of the things that I'm excited about with these guidelines is, although they are specific to critical care pharmacists, I do think that these recommendations can be readily transferred to other domains—so oncology, pediatrics, internal medicine. Obviously you're going to look at a few things that are really specific to the ICU. But some of the recommendations, like the fact that pharmacists play an integral role in quality improvement and improving the quality and processes of health care, that's true across the board, not just in the ICU. I really do see this as, I'm hoping, a template for the profession and anyone that is involved in clinical pharmacy.

It is millions of patients that are in the ICU every year. About 5 million patients will go through an ICU just in a year; pretty staggering numbers. Every patient that goes into the ICU is expected to have at least one medication error. The rates of adverse drug events are significantly higher in the ICU compared to other areas. Pharmacists are one of the few things that really reduces adverse drug events and improves medication safety. The idea that we're going to make sure that every patient receives the care of a critical care pharmacist, I think that is going to be associated with improvements in patient-centered outcomes, like mortality and length of stay, but also institutional outcomes, because we often find that the best quality of care is also the most cost-effective care.

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