The need for pharmaceutical care in an intensive care unit at a teaching hospital in South Africa
1 Department of Pharmacy, University of Limpopo, Medunsa Campus, Ga-rankuwa, South Africa
2 Department of Critical Care, Medical School, Faculty of Health Sciences, University of Pretoria; and Steve Biko Academic Hospital, Pretoria, South Africa
Background. The role of the pharmacist has evolved over the last 2 decades beyond traditional functions such as stock control and dispensing.
Objectives. To describe the functions performed by a clinical pharmacist while based in a surgical and trauma intensive care unit of a teaching hospital.
Methods. An operational research study that included indications of programme success was conducted. Interventions to assess therapy and achieve definite outcomes to satisfy patients’ medicine needs were documented for 51 patients over a study period of 8 weeks.
Results. A total of 181 interventions were suggested by the pharmacist, with 127 (70%) accepted and implemented by the medical and nursing staff of the unit. The most frequent interventions were related to: untreated medical conditions (15.5%), appropriate therapy or course (13.8%), investigations indicated or outstanding (12.2%), and inappropriate doses and dosing frequency (11%). Interventions were also made regularly to address system errors or non-compliance and factors hindering therapeutic effect. Of the 250 h the pharmacist spent in the ward, most time was used for pharmaceutical care (28%) and ward rounds (21%) with members of the multidisciplinary team.
Conclusions. The study results demonstrated that a clinical pharmacist’s contribution to patient care at ward level resulted in improved monitoring of pharmacotherapy. Medicine-related problems were identified and addressed.
Afr J Crit Care
Pharmacy entered the 20th century in the social role of the apothecary, i.e. preparing and selling medicinal drugs. A pharmacist’s main obligation was to ensure that the medicines he or she sold were pure, and to provide a good service to customers.1
Clinical pharmacy practice was born in the 1960s and evolved to the responsible provision of medicine-related patient care in the 1980s. 2 The act of performing clinical pharmaceutical interventions by the pharmacist as part of a healthcare team is called pharmaceutical care. 3 Clinical pharmacy interventions and pharmaceutical care can be defined as the process of identifying a medicine-related problem and making a recommendation in an attempt to prevent or resolve it.
According to the Minnesota model, the first step for pharmaceutical care is to identify a patient’s medicine-related needs.4 Categories of medicine-related needs or potential pharmaceutical interventions included are as follows:4
• New medicine therapy needed
• Unnecessary or wrong medicine therapy
• Dosage too low/high
• Adverse medicine reaction
• Compliance problem.
The effects or benefits of the provision of pharmaceutical care are measured to see whether a positive difference is made to the patient’s clinical, human rights and economic outcomes.5 Benefits of pharmaceutical care can be derived by the patient, the healthcare team, the pharmacy profession and the health system.5
Currently in South Africa (SA), according to Schellack and Gous,6 for a pharmacist to be effective in a healthcare team, he or she must move into the wards where drugs are prescribed and administered. They also noted that doctors’ ward rounds were a good training ground for ward pharmacists and an effective way of building relationships with prescribers. Through pharmaceutical care, the clinical pharmacist can play a role in concurrent review of prescribing patterns, providing feedback to the prescriber and educating providers and the public.7
Many pharmacy managers see ward rounds as time consuming and taking the pharmacist away from the dispensing practice.6 Combined with the low staff levels of pharmacists, suboptimal use of technical support staff and a lack of trained pharmacists, a low pharmacist presence in the wards has resulted.6
At the time of the current research, a clinical
pharmacist was not part of routine care in medication
monitoring to evaluate prescribing patterns or identify
potential or actual medication errors in the surgical and
trauma intensive care unit (ICU) at Steve Biko Academic
Hospital. The study was initiated to address the need for
pharmaceutical care and to evaluate the effect
of the presence of a pharmacist in the ICU.
The study was conducted at Steve Biko Academic Hospital, an 832-bed hospital with 53 ICU beds and 21 high-care beds, in Pretoria, Gauteng. The study site was the 12-bed surgical and trauma ICU. All the patients admitted to the unit during the 8-week study period, from Monday to Friday, were included in the study.
This was a cross-sectional, operational
research study. Indicators of programme success, such as
improving the quality of service by monitoring medication
errors and adverse effects, and adding new service components
such as antimicrobial stewardship and drafting and
implementation of antimicrobial guidelines, was an important
part of the study design. The data were collected
prospectively for 8 weeks.
Quantitative aspects included patient demographics, clinical
data, the number of different types of interventions as
portrayed in the pharmaceutical care problem list, time spent
on activities at ward level, the cost implications of
pharmaceutical care interventions, and prescribing patterns of
Data collection instrument
The data collection instrument comprised
a validated pharmaceutical care form, which has been used in
multiple previous clinical studies in SA.8-10
The form contained a patient database sheet to collect
demographic data and a section to evaluate the patient’s
medication therapy, and to identify potential and actual
Data collection process
Pharmaceutical care was rendered on a daily basis to all patients admitted to the ICU. Patient prescriptions and clinical data were evaluated by the pharmacist, whereafter necessary interventions were discussed with doctors during the daily ward rounds. The interventions and whether they were successful or not were recorded on the pharmaceutical care form. Interventions included discontinuation of antibiotics after completing a course, or reducing the antibiotic dose according to guidelines.
Medicine cost was calculated by
determining the difference between the cost of
medication used the day before and the day after an
intervention. This amount was a direct calculation and only for
the cost of one day after the intervention was performed. No
calculations were made for indirect cost implications or length
of ICU stay.
Validity and reliability
A pilot study was conducted prior to the
main study to verify the appropriateness of the data
collection instrument, in order to further enhance
the reliability and validity of the data
collection. Interventions towards patient therapy were based
on the literature and discussed with medical practitioners to
eliminate researcher bias.
Permission to conduct the study was
obtained from the hospital management and institutional ethics
review boards of the University of Limpopo (Medunsa campus) (MREC/H/15/2011)
and the University of Pretoria (226/2010). Informed consent
was obtained from patients, family members or legal guardians.
A total of 51 patients was included in the study.
Of the 51 study patients, 35 were male
and 16 female. The age of the patients ranged from 12 to 86
years, with a mean of 44.9 years.
The average length of stay (LOS) in the ICU was 8.7 days
(range 1 - 46). Patients older than 60 years had
a longer LOS (10 - 12 days) in the ICU compared with patients younger than 30 years (1
- 3 days). Only 13 (26%) of
the 51 study patients’ HIV status was known; 6 were
HIV-positive, while 7 were HIV-negative. Of the 6 patients who
were HIV-positive, 3 were previously receiving antiretroviral
treatment, while 2 were prescribed antiretroviral treatment
while admitted. One patient did not want her status disclosed
and therefore could not be treated.
A total of 71 diagnoses were recorded, with a mean of 1.4 (standard deviation 0.6) diagnoses per patient. It was noted that more than one diagnosis may apply to a single patient.
Trauma was the diagnosis most commonly encountered (n=21), including motor vehicle accidents and gunshot wounds. The injuries ranged from fractures to soft-tissue lacerations and abdominal wounds obtained from gunshot wounds or blunt-force trauma. Most trauma patients admitted also had skeletal or gastrointestinal involvement. Another common diagnosis was gastrointestinal sepsis (n=11) after general surgery.
The diagnosis of infection was made secondary to the admission
diagnosis in 14 of the 15 (93%) cases. This included
ventilator-associated pneumonia as well as surgical wound
The medication used was classified
according to the Anatomical Therapeutic Chemical (ATC)
classification system. A total of 529 medicines
were prescribed (Table 1). An average of 12 medicines was
prescribed per patient. Medicines most
frequently used were for the alimentary tract
(174 items (according to the ATC
system); 30%), the anti-infective system (124
items; 21%) and cardiovascular system (31 items; 54%).
Medicine from the blood and blood-forming organ system, namely
enoxaparin, was prescribed for 49 (8.5%)
A total of 181 interventions was
suggested for the 51 study patients (median 4; range 1 - 28
interventions per patient). A total of 127
interventions was accepted and implemented by medical and
nursing staff in the unit (Table 2). ‘Untreated medical
conditions’ were addressed most frequently (28
interventions, of which 9 were accepted; 15.5%). Reminding
doctors to prescribe patients’ chronic medications, e.g.
antihypertensives, and suggesting antidepressants
for long-term patients were included in this category.
This was followed by ‘length of course or therapy appropriate’ (25 interventions, of which 20 were accepted; 13.8%). This category included discontinuing antibiotics after completing the course, stopping antibiotic prophylaxis after 24 h and stopping pantoprasole continuous infusion for gastric bleeding after 72 h, as per hospital protocol.
‘Investigations outstanding’ made up 22 (12.2%) interventions. Only seven of the interventions were successful, because some culture results were never received from the laboratory. Some patients were discharged from the unit before results for serum concentrations of phenytoin were received.
Interventions made to address system errors or
non-compliance and factors hindering therapeutic effect
totalled 10 (5.5%) and 5 (2.125%), respectively.
These included medicine not received from the pharmacy because
of out-of-stock situations, and incorrect doses or medicine
not administered to the patient by the nursing staff. Interventions
were made during ward rounds with the
treating doctors. The pharmacist did
a pharmaceutical care round before the ward round, to
familiarise herself with the clinical status of each patient.
Interventions on drug therapy problems could then be discussed
with the treating doctor during ward rounds. The interventions
were either accepted or rejected immediately. Interventions
made by the pharmacist concerning problems with the pharmacy
or counselling of patients or nursing staff occurred after the
Time spent providi ng pharmaceutical care services
The total time spent providing
pharmaceutical care services to the ICU was 250
h. Fig. 1 depicts the
specific time spent on different activities in the ward. Pharmaceutical
care rounds included reviewing the patient’s prescription
chart, vital signs and laboratory results. This took up the
majority of time in the ward (71 h; 28.5%). Using
information obtained during the pharmaceutical care rounds,
interventions were suggested on the ward rounds. In some
instances, more than one ward round was done per day because
of different specialties doing rounds. Ward rounds took up
21.7% (54 h) of the pharmacist’s time.
Fig. 1. Percentage of time spent in the ward, total 250 h.
Medication reconciliation (45 h) was done by evaluating the patient’s prescription chart, and monitoring the medication orders from the pharmacy and the dosing of the different medicines. The pharmacist checked that the correct medicine was received from the pharmacy, and that administration to the patient was correct.
A direct cost saving due to interventions made
by the clinical pharmacist was calculated as R14 353. Having a
pharmacist as a permanent member of the multidisciplinary team
may be a cost-saving opportunity for the unit.
The male/female ratio in the ICU was 2.18:1, which was not a reflection of the general population. According to Statistics SA,11 the male/female ratio in 2011 was 0.94:1. The mean age of patients admitted to the surgical ICU was 44.92 years, which is lower than that in the USA or the UK.12
Trauma, including gunshot and motor vehicle accident injuries, comprised the most frequent diagnoses. This was expected, since it is a surgical and trauma ICU. Nosocomial pneumonia and surgical wound infections were also prevalent as secondary diagnoses. Nosocomial pneumonia has been confirmed in the literature as common in patients undergoing mechanical ventilation.13
As there was a variety of medications used in the ICU, prescribed from short to more extensive periods, there were many opportunities for the clinical pharmacist to provide pharmaceutical care. The functions that the researcher performed correlated with the scope of a clinical pharmacist in a similar study by Bates et al.14 Interventions were made regularly to address a variety of medicine-related problems, inappropriate dose or dosing frequency, relative safety of chosen medicine and other factors hindering achievement of therapeutic effect, such as non-compliance and system errors. Similar studies performed in SA also highlighted the abovementioned interventions as being made most frequently by the clinical pharmacist.9 , 10 , 15
The cost of antibiotics and other medicines used by patients the day before and the day after an intervention was calculated. Interventions made included discontinuation of antibiotics after completing a course, or reducing the dose of antibiotics according to guidelines. This amount was a direct calculation and only for the cost of one day after the intervention was performed. No calculations were made for indirect cost implications or length of ICU stay. The cost saving during the study period added up to R14 353, but potentially could be more. Begley15 described the practice of pharmaceutical care as having benefits for the healthcare system, including cost saving. Having a pharmacist as a permanent member of the multidisciplinary team may be both a cost-saving and extra quality assurance opportunity for the unit.11
The study period was very short and
considerable time was used to become familiar with the
surroundings and routines in the unit. More time was
also needed to establish good relationships with attending
physicians and medical staff. Pharmaceutical services were rendered
only from Monday to Friday, so patients admitted over weekends
were not enrolled.
The study focused on the provision of pharmaceutical care in an ICU and the role of the pharmacist in assessing prescribing patterns, recognising and recording drug-related interventions and the time needed to provide pharmaceutical care.
Interventions were required across a broad spectrum of drug-related problems. Interventions suggested during ward rounds supplied a good platform for discussions regarding the use of antimicrobials and other medicines, or specific doses of medicine.
The number of medicines prescribed to the patients admitted to the unit during the study period provided an opportunity for the pharmacist to perform numerous interventions, and the conclusion can be made that the continued presence of a pharmacist in the ward would be beneficial to patient outcomes. The provision of pharmaceutical care has the potential to improve the quality of pharmacotherapy and save medicine costs.
After a 2-month period, it was established that there were
enough tasks to warrant a full-time position for a clinical
pharmacist in the ICU setting.
A permanent pharmacist should be appointed to the unit to be able to provide a consistent level of care to patients in the ward. A resident clinical pharmacist may also assist in the development and implementation of guidelines for the ward.
Acknowledgements. The authors would like to acknowledge Prof. Herman Schoeman for the statistical analysis of the data and the Department of Pharmacy, Medunsa campus, for financial and logistical support.
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