Rutgers' simple solution for improving pharmacist coverage of the ICU

Liza Barbarello Andrews is a clinical associate professor at Rutgers’ Ernest Mario School of Pharmacy and critical care pharmacy specialist at Robert Wood Johnson University Hospital. (Rutgers)

Many hospital ICUs do not have enough pharmacy specialists on staff to be present in the ICU at all times. That can lead to longer-than-necessary wait times for critically ill patients.

Now Rutgers and RWJBarnabas Health System are testing a team-based model for intensive care unit (ICU) pharmacists they say shows promise for tackling that problem.

In a clinical trial at the Robert Wood Johnson University Hospital Hamilton, researchers found that empowering in-hospital pharmacists with training and confidence to make specialist decisions improved the process for ICU drug distribution and care.

According to a report on the trial published this week in the Journal of Clinical Outcomes Management, researchers tested the training of several nonspecialist pharmacies for six months on specific needs such as mechanical ventilators, infectious disease risk and blood flow management. These Critical Care Pharmacist Teams (CCPTs) were soon able to step in to help the ICU pharmacy specialist to make important decisions.

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Results included an improvement in the quality of pharmacy services provided to patients in the ICU and a greater sense of professional satisfaction for staff that voluntarily underwent the training.

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The solution was developed by lead researcher Liza Barbarello Andrews, an associate professor at Rutgers’ Ernest Mario School of Pharmacy and sole critical care pharmacy specialist at Robert Wood Johnson University Hospital Hamilton.

“Before we tried this model, the non-specialty pharmacists in the ICU were often uncomfortable with clinical issues, which sometimes meant going to the bedside to assess the situation. As a result, relatively minor issues were frequently escalated with a call to the specialist, who was not always readily available,” Andrews said in a statement. “Our new model effectively empowers all of our pharmacists to act as specialists.”

Beyond just testing out a new ICU care model, the program’s goal was to get cultural acceptance of the model in order to achieve sustainability.

Training for the CCPT team included education in a classroom, bedside and practice modeling. The study then assessed interventions performed by pharmacists before and after implementation to gauge the success.

“CCPT members felt empowered, as reflected by self-directed enrollment in PharmD programs and/or obtaining board certification. This success subsequently served to improve the culture of cooperation and spark similar evolution of other disciplines,” the study noted.

Originally, the 20-bed ICU unit at the Hamilton hospital had variable pharmaceutical care depending on who was on duty. Weekday ICU pharmacy services were provided by general practice staff pharmacists across two shifts. The main job of this team was to review drugs ordered, evaluate therapy and identify adverse drug events. Also, a hospital-based residency-trained pharmacist did rounds three days a week.

When the program began, intensive learning was applied for the first three months, followed by patient bedside care for another three months. Over time, the pharmacist accompanied the specialist during morning bedside evaluations to increase confidence.

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And beyond standardizing the team, a routine assessment criteria was established during this pilot. Along with daily protocols of what information to chart, monthly meetings were established for strategic development and to go over difficult cases.

All members of the ICU pharmacy program reported feeling better prepared and more confident in caring for critically ill patients and felt that the team and its standardized approach enhanced medication safety.

There were, however, some challenges in setting up the program. Andrews notes that during the training phase, it could be challenging for the specialist to dedicate the time to individualize training. 

"The first several months of the program require a commitment from the specialist to take routine off-hours calls from the team to discuss individual cases as they build their confidence and skills; being sufficiently supported is key to ensuring members evolve into the role," Andrews told FierceHealthcare. "In the long term, all team members must feel they have an active voice on the team, remain valued and help guide the continued development and evolution of pharmacy services in critical care."

Beyond training and development, some additional environmental challenges may present depending on the culture of the organization. In the pilot test, for example, some physicians initially pushed back on interacting with new team members, being accustomed to receiving recommendations only from the specialist. 

"Consistency from us rapidly resolved this; physicians quickly gained confidence in the team as we required interaction with the team member present," Andrews said.

Moving forward, Andrews is confident that the model is sustainable in other ICUs. It is important for there to be administrative buy-in to ensure things such as consistent scheduling of team members to critical care, and equally important is that members have a sense of professional satisfaction associated with their participation. Finally, a strong team leader is key to addressing the occasional challenges faced by the team or its members.

"Therefore, with administrative support, a dedicated team leader and motivated members, the model can be adapted to multiple ICU environments," Andrews said.

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