Common Interventions in Critical Care Pharmacy

Critical care pharmacists ensure optimal pharmaceutical care in critically ill patients. Studies have shown that critical care pharmacists reduce medication errors, reduce cost, and improve patient outcomes.¹ I recently had the opportunity to spend a week training with pharmacists in the intensive care unit. I hope to share what I learned about how pharmacy can improve outcomes in this patient population.

Below are just a few of the interventions critical care pharmacists make to enhance patient care:

• DVT prophylaxis: Limitations in mobility lead to an increased risk of developing deep vein thrombosis (DVT). DVT prophylaxis is an aspect of supportive care where pharmacists play a key role. At our facility, we were able to run a VTE prophylaxis report with the most recent DVT prophylaxis ordered for a patient, including sequential compression devices, enoxaparin, or unfractionated heparin. Pharmacists review the patient’s INR, platelet count, hemoglobin, and hematocrit to assess appropriateness of chemical prophylaxis. The general chief complaint or reason for admission can also indicate whether a patient may be a candidate for chemical prophylaxis. For example, chemical prophylaxis may not be the best choice in a patient who has received a thrombolytic within the past 24 hours. If anticoagulation is suspended for this reason, pharmacists may review follow-up CT scans, and consult with the neurologist on the plan for DVT prophylaxis going forward.

• Stress ulcer prophylaxis: Critical care pharmacists determine whether patients are appropriate candidates for stress ulcer prophylaxis, and make recommendations to order or discontinue such therapy as necessary. Currently, guidelines recommend the use of stress ulcer prophylaxis in patients with mechanical ventilation for >48 hours or nonintentional coagulopathy. Prophylaxis is also recommended in patients with a history of GI bleed within 1 year of admission or who meet 2 or more minor criteria, which are detailed in the ASHP Guidelines on Stress Ulcer Prophylaxis.² Pharmacists continue to monitor these patients, and recommend discontinuation of stress ulcer prophylaxis if the patient no longer meets the requirements for therapy.

• Antimicrobial Stewardship: Antimicrobial stewardship is a critical component of patient care and an initiative that can prevent the development of resistant microorganisms. Pharmacists ensure that there is an antibiotic for every appropriate indication (or every organism identified), and an appropriate indication for every antibiotic. Empiric therapy is often initiated before cultures return. When a patient is being treated empirically, pharmacists consider which organisms are most likely to cause the current condition, and ensure that the recommended drug is effective against those pathogens. Available cultures should always be reviewed to determine whether a change in therapy is warranted. Cultures may identify the causative pathogen and permit de-escalation from a broad spectrum agent to a narrow spectrum agent targeting the identified microorganism. Alternatively, a change from a narrow spectrum to a broad spectrum agent may be warranted if growth of a new organism is detected. Assessing sensitivity results, and facility antibiograms is another component of antimicrobial stewardship. Pharmacists also evaluate whether there is a need for continued antibiotic therapy, particularly if treatment has been ongoing for 5 days or greater.

• IV to PO conversion: Pharmacists in the intensive care unit routinely assess the route of therapy for appropriateness. Patients who are intubated or are otherwise NPO are appropriate candidates for IV therapy. However, patients with a functioning GI tract, who are eating a regular diet, or who are successfully taking other oral medications may be candidates for IV to PO conversion.

• Renal monitoring: Urine output, and serum creatine are two important indicators of renal function. Critically ill patients often have dynamic renal function, and changes in urine output may occur first. Serum creatinine is used to estimate a patient’s creatinine clearance, which is the parameter used to dose most renally adjusted medications. Renally adjusted medications may need a dose reduction if renal function worsens, or a dose increase if renal function improves. Therefore, pharmacists review a patient’s medication profile after significant improvements or declines in renal function to ensure patients are receiving the appropriate dose considering their renal function at that time.

The interventions listed above are only a few of many responsibilities of a critical care pharmacist. These pharmacists may also work up patients, and round with the multidisciplinary team. In addition, critical care pharmacists communicate current drug shortages and substitutions to the team on their unit. Overall, working in the intensive care unit appears to provide critical care pharmacists the opportunity to use their clinical knowledge to enhance patient care as a valued member of the interprofessional team.

References

• Chant C. How Critical Are Critical Care Pharmacists? The Canadian Journal of Hospital Pharmacy. 2012;65(1):5-6.
• ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis. Am J Health Syst Pharm. 1999;56:347-379.