It’s safe to say that nearly every US hospital system and medical center strives every day to enhance patient outcomes and provide exceptional care while managing health care costs. In the intensive care unit (ICU), there is an advanced level of care that can have a considerable impact on health care spending; this makes the ICU an ideal setting for health systems to address inefficiencies. When implemented successfully, improvement efforts in the ICU can improve patient outcomes and lead to significant cost savings.
One strategy available to health systems to address ICU inefficiencies and identify potential cost savings is by bringing critical care pharmacists into the ICU. These pharmacists can help hospitals overcome barriers to improvement while achieving a substantial return on investment in the process.
An Evolving Role in the Hospital
Up until the late 1970s, hospital pharmacists verified and dispensed medication from a centralized location with minimal patient interaction and limited collaboration with other health care team members. However, the introduction of the residency accreditation standards by the American Society of Health-System Pharmacists (ASHP) in 1980 marked the beginning of formal training in clinical practice and specialty areas, forging a path for pharmacists to display their clinical capabilities.1,2 As pharmacists engaged more directly with physicians, nurses, and other specialists, institutions began to recognize the value of integrating them into the multidisciplinary team of health care professionals. Subsequently, the role of hospital pharmacists expanded significantly, encompassing specialties such as critical care, primary care, pediatrics, transplant, oncology, infectious disease, and psychiatry.
Interest in critical care pharmacy is at an all-time high, making it one of the fastest-growing specialties. Between 2016 to 2020, the number of board-certified critical care pharmacists surged from 532 to 2873—with projections indicating the number will nearly double by 2025 as critical care PGY2 programs continue to expand. In 2019, there were 143 critical care PGY2 programs nationwide, and by October 2023, the ASHP directory listed 173 active programs—a remarkable 20% increase in just 4 years.3
Despite the growth in programs and the number of board-certified critical care pharmacists, job opportunities in the specialty space are not keeping pace.4 Consequently, many board-certified clinicians take non-ICU jobs or hybrid roles, where they round with the ICU team but are also inundated with off-unit staffing assignments and administrative tasks. A 2021 survey revealed that 401 critical care pharmacists consistently managed more patients than the ICU census at their facilities, indicating a need for increased critical care pharmacist coverage in the ICU.4 Literature also strongly supports this need.
A landmark investigation by Leape et al published in JAMA demonstrated that adding a rounding pharmacist to the ICU team reduced preventable adverse drug events (ADEs) by 66%.5 This was further substantiated by a 2019 meta-analysis, showing reductions of ADEs by 74%, mortality by 22%, and ICU length of stay by 1.33 days.6,7 Yet, despite the compelling evidence, only 70% of ICUs have a decentralized pharmacist on their multidisciplinary team of health care professionals, with pharmacist participation in weekend rounds occurring in just 15% of institutions.7 With ADEs adding over $1.5 billion to health care spending in the United States, this is simply unacceptable.8,9 To overcome this common challenge, we must advocate for hospital systems to leverage the evolving role of pharmacists, particularly in the ICU.
The Decentralized Model
The decentralized pharmacist model involves pharmacists being located on the ward rather than in the central pharmacy, taking responsibility for all medication-related issues for patients in their unit or service. This model is preferred for providing inpatient pharmacy services as it is associated with increased patient safety and greater efficiency in delivering care.10 However, due to increasing pressures to do more with less, many hospitals adopt variations of the decentralized model, collectively referred to this as a hybrid model.
When pharmacists are decentralized and able to collaborate in an interdisciplinary fashion, they are vastly more effective as clinicians. Instead of providing generalized recommendations by phone, a decentralized pharmacist attending rounds is privy to discussion details not available in the chart, allowing them to provide real-time recommendations and to make crucial interventions without delay. Additionally, their presence fosters a more trust-based relationship with physicians. Rather than a distant voice questioning the doctor’s medication order, the pharmacist and physician can engage in conversations that consider both their expertise and the patient’s medical history to ensure the best possible care plan.
In contrast to the traditional model of reviewing orders remotely from the central pharmacy, the decentralized model encourages pharmacists to build relationships with patients and their caretakers. Obtaining a medication history directly from the patient—or a loved one if the patient is unable—is far more efficient and accurate than relying on incomplete medical records and poorly-completed medication histories. With their expertise, diligence, and unique access to resources, pharmacists bring unmatched accuracy and detail to this vital step of patient care. A 2019 systematic review and meta-analysis of 8 studies found that pharmacy-led medication reconciliation reduced the number of medication discrepancies by a remarkable 68%.11 A separate review of 56 articles reported that pharmacy involvement in transition-of-care services was associated with a 32% reduction in the odds of 30-day hospital readmissions.12 These findings demonstrate that increasing pharmacy services, especially in the ICU, can lead not only to improved patient outcomes but also significant cost savings.
If the Data Is so Strong, Why is There Still Reluctance?
About the Author
Michael Beshir, PharmD, is an assistant professor at Marshall B. Ketchum University in Fullerton, California. Beshir is an experienced clinician and academician with nearly a decade of inpatient service. With a background in Management Science and Economics, he earned his Doctor of Pharmacy degree from Midwestern University in Chicago in 2015. After completing PGY1 residency training at Rush University Medical Center, he served as Clinical Coordinator at Rush Oak Park Hospital, where he specialized in critical care, led clinical services, and precepted pharmacy students. His passion for formulary management and policy work led him to later pursue and complete PGY2 training in Drug Information at Kaiser Permanente in 2021, after which he returned to inpatient service at PIH Health and Harbor UCLA Medical Center. In March 2024, Beshir joined the Marshall B. Ketchum University College of Pharmacy where he serves as a faculty member in the Department of Pharmacy Practice.
Reluctance to widely adopt and expand the decentralized pharmacist model is multifaceted and warrants a closer examination of contributing factors. Some institutions may be unaware of just how much value decentralized pharmacists provide, although, this is becoming increasingly unlikely with the growing body of evidence. Others may recognize the advantages but prioritize immediate cost-cutting measures, such as negotiating better deals with drug suppliers or reducing their workforce. While these actions may offer short-term financial benefits, I believe them to be shortsighted in the long run. Hiring critical care pharmacists is a temporary investment that results in significant sustainable financial gains. Additionally, pharmacy is often underrepresented among stakeholders and decision-makers, with pharmacy leaders frequently tasked to minimize spending rather than being granted additional full-time equivalents. Addressing these barriers is essential to increasing pharmacist presence in the ICUs.
As of November 2022, there are approximately 500,000 nurses and 20,000 critical care physicians, compared to an estimated 3600 board-certified critical care pharmacists available for the nation’s nearly 100,000 ICU beds.7 While the number of PGY2 residency programs and board-certified critical care pharmacists is rapidly growing, employment opportunities remain stagnant—making it imperative to carefully consider and methodically address the identified barriers. A recent update to a position paper on critical care pharmacy services provides evidence-based guidance and can be a valuable resource for this endeavor. A joint task force, comprising of 15 pharmacists representing a wide array of organizations and regions, collaborated to skillfully outline roles and responsibilities for critical care pharmacists and standardize the practice. The publication also offers 82 recommendations aimed at improving critical care pharmacist representation and integration within interdisciplinary teams.13
This position paper is a great step in the right direction and similar efforts are needed. For proper integration and representation of critical care pharmacists, pharmacy leaders must have a greater presence on the boards of hospitals and medical centers. They must gain and maintain a seat at the table, finding creative ways to demonstrate the immense value of adding more decentralized pharmacists to ICU teams.
References
Horn E, Jacobi J. The critical care clinical pharmacist: Evolution of an essential team member. Critical Care Medicine. March 2006;34(3):S46-S51. doi:10.1097/01.CCM.0000199990.68341.33
Carter B. Evolution of Clinical Pharmacy in the USA and Future Directions for Patient Care. Drugs Aging. March 2016;33(3):169-77. doi:10.1007/s40266-016-0349-2
MacLaren R, Roberts RJ, Dzierba AL, Buckley M, Lat I, Lam SW. Characterizing Critical Care Pharmacy Services Across the United States. Crit Care Explor. 2021 Jan 8;3(1):e0323. doi:10.1097/CCE.0000000000000323
Leape L, Cullen D, Clapp M, al e. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;282:267–270.
Lee H, Ryu K, Sohn Y, Kim J, Suh G, Kim E. Impact on Patient Outcomes of Pharmacist Participation in Multidisciplinary Critical Care Teams: A Systematic Review and Meta-Analysis. Critical Care Medicine. 2019;47(9):1243-1250.
Sikora A, Martin GS. Critical Care Pharmacists: Improving Care by Increasing Access to Medication Expertise. Ann Am Thorac Soc. 2022 Nov;19(11):1796-1798. doi:10.1513/AnnalsATS.202206-502VP
Kane-Gill S, Kirisci L, Verrico M, Rothschild J. Analysis of risk factors for adverse drug events in critically ill patients. Crit Care Med. 2012;40:823-828.
Slight S, Seger D, Franz C, Wong A, DW. DB. The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States. J Am Med Inform Assoc. 2018;25:1183-88.
Lebras M, Maruyama A, Stacey D, Tataru A, Dalen D. Are Decentralized Pharmacy Services the Preferred Model of Pharmacy Service Delivery within a Hospital? Can J Hosp Pharm. Mar-Apr 2015;68 (2):168-71. doi:10.4212/cjhp.v68i2.1444
Choi Y, H HK. Effect of pharmacy‐led medication reconciliation in emergency departments: A systematic review and meta‐analysis. J Clin Pharm Ther. 2019;44(6):932-945.
Rodrigues CR, Harrington AR, Murdock N, Holmes JT, Borzadek EZ, Calabro K, Martin J, Slack MK. Effect of Pharmacy-Supported Transition-of-Care Interventions on 30-Day Readmissions: A Systematic Review and Meta-analysis. Ann Pharmacother. 2017 Oct;51(10):866-889. doi:10.1177/1060028017712725
Lat I, Paciullo C, Daley MJ, et al. Position Paper on Critical Care Pharmacy Services (Executive Summary): 2020 Update. American Journal of Health-System Pharmacy. 2020;77(19):1619-1624. doi:10.1093/ajhp/zxaa217
