Quality evaluation of clinical pharmacy services in an intensive care unit

Abstract

Due to complex pharmacotherapy often involving high-risk medications, critically ill patients are more vulnerable to adverse drug events. Pharmacists’ participation in Intensive Care Units (ICUs) has been shown to improve patient outcomes, and it is important to ensure that the service provided is of quality and is effective to actually achieve these outcomes. This study aims to develop and implement a quality system for pharmaceutical service provision within the ICU and evaluate the activities of clinical pharmacists in intensive care by assessing the impact of pharmaceutical interventions on surrogate clinical outcomes. The first phase of the study included consideration of current practices within the ICU to propose a hospital policy based on the Pharmacists’ Patient Care Process to provide a structured framework and standardise the provision of clinical pharmacy services in the ICU. The policy was reviewed by an expert panel through a multi-level approach. During the second phase, a data collection tool was developed and validated to capture and classify drug-related problems (DRPs) and pharmaceutical interventions (PIs) suggested by pharmacists in the ICU. Data on PIs recommended by a team of clinical pharmacists over three months were recorded in the data collection tool and categorised. PIs were classified according to their impact on surrogate patient outcomes and retrospectively evaluated by an expert panel to assess the probability of a potential adverse drug event (ADE) occurring in the absence of the PI. The developed policy includes responsibilities and comprises 11 main practices of the ICU pharmacy team related to direct patient care and indirect patient care. Over three months, the ICU pharmacist-patient profiles of 164 patients were considered, where 484 DRPs were identified in 135 patients; 38% (n=186) were related to dose selection, 24% (n=115) involved drug selection, and 13% (n=65) were related to monitoring. Most suggested PIs were related to change in dose 40% (n=193) and addition of medication 17% (n=80). Anti-infectives for systemic use were the most common group of medications identified in DRPs (41%). Pharmacists assisted in optimising fluid management for 17 patients, which involved hidden fluids. Therapeutic drug monitoring was recommended for 43 patients with subsequent dose adjustments to achieve therapeutic serum concentrations for medications with a narrow therapeutic range. Expert panel evaluation of PIs in relation to preventing a potential ADE resulted in 5 (1%) being of high probability, 124 (25.6%) being of medium probability, and 274 (56.6%) being of low probability. The remaining 81 (16.7%) had a very low or zero probability of preventing a potential ADE. This study aids in standardising clinical pharmacists' participation in the ICU and harmonises the quality of services. The study has indicated that pharmacists’ interventions in the ICU are effective in reducing the risk of occurrence of potential ADEs. Whilst the risk impact was estimated to range between high to very low, a key aspect of patient-centric care is providing optimised pharmacotherapy to mitigate individual patient risks as a result of medication use.