Richard S. Bourne MSc, MRPharmS
Lead Critical Care Pharmacist Sheffield Teaching Hospitals, UK
New legislation and national standards in the UK promote the role of the critical care clinical pharmacist towards integration in the critical care teamand improving patient care.
Traditionally, critical care clinical pharmacy services have often been developed in response to requirements to improve cost effective use of medicines and/or reduce medicine risk.While these aspects of medicine management remain paramount, there is increasing recognition of the skills clinical pharmacists contribute to the care of the critically ill patient (Intensive Care Society 1997).
Critical care pharmacists reduce adverse drug reactions, optimise medicine utilisation, improve fluid management, and reduce patient morbidity and mortality as well as having a positive pharmacoeconomic impact (Kane 2003; Papadopoulos et al. 2002). These results are achieved by integration within the critical care multidisciplinary team. Pharmacists attend medical ward rounds, review individual patient's medication, develop drug guidelines, educate staff, and manage therapeutic drug monitoring (TDM), medication risk, and medicine audit and research.
Appropriate use of pharmacy technicians for roles such as medicines management, drug audit and drug expenditure reporting enable clinical pharmacists to spend more time on clinical care as recommended in A Spoonful of Sugar (Audit Commission 2001).
A major difficulty for clinical pharmacy services for critical care in the UK has been the lack of national standards, demonstrated in the variation in practice and service provision (Timmins 2000). Some critical care areas had no pharmacist input; others had newly qualified, inexperienced pharmacists clearly attempting to practice beyond their current capability, while others had teams of experienced critical care pharmacists (Department of Health 2004). Predictably the perceived value of critical care clinical pharmacy services fluctuates widely from hospital to hospital accordingly. The recent development of national recommendations for both critical care pharmacist staffing levels and experience required, has gone some way to correcting this variation (Department of Health 2003).
Developments in Clinical Pharmacy
As the role of the critical care pharmacist gains further national recognition, it underlines the need to make further improvements in the standardisation of services which units receive. In the UK, we have made some significant developments in this area and now have national recommendations for core knowledge standards for specialist critical care pharmacists. A career framework for clinical pharmacists within critical care has been established including the competencies required for these positions (Department of Health 2005a).
Consultant pharmacist posts have been established and will be expected to provide significant leadership, research and educational roles, in addition to expert clinical practice. Importantly, these standards have been produced in conjunction with a new pay scheme affecting pharmacists, in which they must demonstrate the necessary competencies and experience (i) to take up a post and (ii) to progress along the pay scale within that post. In spring 2006, accredited pharmacists will be able to prescribe medication independently for the first time. This legislation provides a huge opportunity for clinical pharmacists to take even greater responsibility for individual patient care within the multidisciplinary team. It will allow pharmacists, for example to undertake TDM, dose alterations in multiorgan failure, parenteral nutrition and optimise antimicrobial therapy.
Nationally, the current pharmacy workforce is lacking the numbers of pharmacists with appropriate critical care experience, as demonstrated by particular difficulties in recruitment to these positions. It is therefore paramount that larger critical care units and pharmacy departments have recognised rotations for clinical pharmacists, thereby increasing their skills and fostering an interest in a critical care career. It is only in this way that we can hope to meet the needs of the 24/7 activity of critical care (Department of Health 2005b).While some centres have achieved positive steps to address these needs, this is not the norm. Clearly, the future workforce development plan needs a national accreditation system that incorporates these requirements.
Clinical pharmacy services are not alone in experiencing the challenges of funding their activity. It is hoped that national acceptance of staffing levels in addition to agreed staff skills and experience will ease the incorporation of clinical pharmacy costs in any critical care expansions.
Clinical pharmacy services are accepted as integral to national recommendations for critical care. The challenges ahead include reducing national variations and developing a skilled pharmacy workforce not only capable of meeting the service needs of this specialty, but also to contribute to the clinical, audit and research agendas to improve the future care of the critically ill patient.