Evaluation of Critical Care Pharmacist Evening Services at an Academic Medical Center

Abstract

Purpose: Critical care pharmacists are considered essential members of the healthcare team; however, justification and recruitment of new positions, especially in the evening or weekend shifts, remains a significant challenge. The purpose of this study was to investigate the number of interventions, type of interventions, and associated cost savings with the addition of 1 board certified critical care clinical pharmacist to evening shift. Methods: This was a prospective collection and characterization of 1 evening shift critical care pharmacist’s clinical interventions over a 12-week period. Interventions were collected and categorized daily from 13:00 to 22:00 Monday through Friday. After collection was complete, cost savings estimates were calculated using pharmacy wholesaler acquisition cost. Results: Interventions were collected on 52 of 60 weekdays. A total of 510 interventions were collected with an average of 9.8 interventions accepted per day. The most common interventions included transitions of care, medication dose adjustment, and antibiotic de-escalation and the highest proportion of interventions occurred in the medical intensive care unit. An estimated associated cost avoidance of $66 537.80 was calculated for an average of $1279.57 saved per day. Additionally, 22 (4.1%) of interventions were considered high yield interventions upon independent review by 2 pharmacists. Conclusion: The addition of 1 board-certified critical care pharmacist to evening shift resulted in multiple interventions across several categories and a significant cost avoidance when calculated using conservative measures.

Introduction

Critical care pharmacists are essential members of the interprofessional healthcare team in the intensive care unit (ICU) providing both direct and non-direct patient care services.^1,2 Studies have demonstrated benefit of clinical services provided by critical care pharmacists including reduction of preventable adverse drug events, decreased hospital readmissions, and decreased emergency department visits.^3,4 In many institutional staffing models these pharmacy services are scaled down on evening and weekend shifts due to staffing constraints, potentially exposing patients to poorer outcomes.^1,2 Significant challenges prevent improvement of evening and weekend shift staffing ratios including justification and recruitment of new positions.^2,5

Weekend and evening shifts are more poorly staffed across multiple healthcare professions, and pharmacy-specific surveys corroborate this trend.^6,7 While many institutions have adopted practice models with fewer pharmacists on weekends and overnight, evidence suggests patients admitted to the hospital during these shifts are exposed to higher rates of medication errors. ⁸ Additionally, lack of evening shift clinical pharmacists has been recognized as an important gap in current standard of care. ⁹ Several studies have suggested that expanding clinical pharmacy services during “off hours” may mitigate these outcomes in select patient populations. ⁵ For example, when pharmacy-driven antimicrobial stewardship services were expanded to weekends in a cohort of medicine patients, a decreased time to both escalation and de-escalation of antimicrobials was achieved. ¹⁰ Studies assessing the impact of expanding emergency department pharmacy services to 24 hours have reported decreased medication errors, improvement in medication reconciliations, improved staff satisfaction, and increased cost savings.^11,12 Multiple studies have also demonstrated improved perceptions of quality of care when evening shift pharmacist are included.^13,14

Though evidence of benefit for evening shift pharmacist services exists, there is little evidence in a critical care-specific population. Due to the intensity of interventions and complex medical treatment of these patients, this population is also likely to derive benefit. The purpose of this evaluation was to report our institution’s experience with the addition of 1 board certified critical care pharmacist on weekday evening shifts and to characterize the clinical and financial benefit associated with this addition. Clinical benefit was measured by number and category of accepted interventions, and conservative cost avoidance estimates were evaluated.

Methods

This was a single center, prospective, observational evaluation of interventions made by an evening shift, board-certified critical care pharmacist at an academic medical center. The primary purpose was to determine the number of daily interventions made by the pharmacist. Other outcomes include characterization and cost avoidance associated with the interventions made. Interventions were collected on adult patients admitted to all adult ICUs. Accepted clinical interventions were identified by prospective order verification, consultation, and in person identification, then documented and characterized daily for a period of 12 weeks. Items documented included a description of the intervention, the date of occurrence, intervention category, doses of drug prevented, and drug involved. To conservatively calculate the number of doses prevented, an assumption was made that the morning shift unit-based pharmacist would achieve the same intervention by 8:00 the following morning. For example, if vancomycin was scheduled every 8 hours at 00:00, 8:00, and 16:00, and was discontinued by the evening pharmacist at 13:30, then 2 doses were considered prevented.

After the intervention collection period, interventions were reviewed to calculate cost avoidance and to dichotomize the interventions into “high yield interventions” or not. Cost avoidance was calculated by multiplying the doses prevented by the pharmacy wholesaler acquisition cost, not including labor, diluents, or delivery cost. Intangible costs and costs of the addition of an omitted therapy were not considered. High yield interventions were considered interventions that avoided $500 or more or had the potential to prevent patient harm. A threshold of $500 was chosen as this is the rough cost per day of the evening ICU pharmacist. To determine interventions that prevented patient harm, all interventions were independently reviewed by 2 critical care pharmacists and dichotomized. Descriptive statistics were performed on all variables. This study was approved by the Institutional Review Board (Project 1733467) and supported by a Board of Pharmacy Specialties grant.

Practice Model

The practice model at the study institution includes decentralized, board-certified critical care clinical pharmacists who perform order verification, round with the interprofessional team, conduct research and scholarship, engage in teaching and precepting, complete quality improvement initiatives, and provide other administrative duties. There are 6 medical teams rounding in the adult ICUs, each having its own board-certified critical care pharmacist during dayshift, weekday hours: cardiovascular, medical (2 teams), neurosciences, surgical, and trauma. In general, these pharmacists’ work hours are 07:00 to 15:30. Critical care clinical pharmacy services are condensed even further over night and on weekends and were not evaluated as part of this current study. The evening shift critical care pharmacist’s work hours are 13:30 to 22:00 with typical office hours from 13:30 to 15:00. From 15:00 to 22:00, the evening pharmacist circulates through each ICU and clinically reviews patients. The pharmacist is contacted by nurses, providers, and pharmacy staff via institutional cell phone, secure messenger, or person while in the unit. Between the overlap period (13:30-15:30) for day and evening shift, verbal and/or written handoff is given from the day shift pharmacists to the evening shift pharmacist. Examples of the types of information that is handed off between shifts include but are not limited to: anticipated culture results, complex patients, high cost or restricted medication use, and transitions in care. The evening shift critical care pharmacist communicates interventions made during the evening shift to the day shift pharmacists via Theradoc^®.

Results

A total of 510 interventions were collected during the 12-week data collection period. Out of the 60 weekdays in this 12-week period, interventions were collected on 52 days (86.7%) due to absence of the evening ICU pharmacist. An average of 9.8 interventions were accepted per day with a range of 2 to 25 interventions per day. The most common intervention was discontinuation of ICU level treatment upon admission to the floor (transition of care), followed by correction of medication dose, intravenous to oral formulation conversion, antibiotic de-escalation, and addition of indicated drugs not ordered (ie, prophylaxis). A full characterization of the interventions can be found in Table 1. Interventions were most reported in the medical ICU (369), followed by surgical (42), trauma (38), cardiac (33), neuroscience (20), and emergency department (8) ICUs.

Table 1.

Intervention Characterization and Associated Cost.

Intervention category	Intervention count, n (%)	Cost avoidance, $ (% of total cost)
Transition of care	91 (17.9)	0 (0)
Incorrect dose	59 (11.6)	49.36 (0.07)
IV to PO transition	58 (11.4)	703.2 (1.06)
Antibiotic de-escalation	46 (9.0)	3719.76 (5.59)
Dose optimization	28 (5.5)	79.44 (0.12)
Drug omission	27 (5.3)	0 (0)
Not indicated	26 (5.1)	6023.76 (9.05)
Lab discontinuation	25 (4.9)	2408 (3.62)
Home medications	20 (3.9)	0 (0)
Insulin intervention	17 (3.3)	0 (0)
Anticoagulation intervention	15 (2.9)	17.23 (0.03)
Duplication of therapy	12 (2.4)	544.32 (0.82)
Fluid stewardship	12 (2.4)	308.05 (0.46)
Antibiotic escalation	10 (2.0)	98.78 (0.15)
Sedation weaning	9 (1.8)	0 (0)
Drug does not meet institutional criteria	8 (1.6)	2506.16 (3.77)
Missing medication prevention	7 (1.4)	1431.12 (2.15)
Recommended lab monitoring	7 (1.4)	0 (0)
Code response	6 (1.2)	0 (0)
Factor product intervention	6 (1.2)	48 651.62 (73.12)
Pain regimen optimization	5 (0.9)	0 (0)
Incorrect formulation ordered	2 (0.4)	0 (0)
Order placed on incorrect patient	2 (0.4)	0 (0)
Other	12 (2.4)	0 (0)
Total	510	$66 537.8

Note. IV = intravenous; PO = per os or by mouth.

Definitions: Dose optimization: increase or decrease in a currently ordered medication for organ function (not including renal dose adjustment), weight, or critical illness. Home medications: restarting or correcting home medications continued inpatient. Incorrect dose: incorrect dose for indication (not including renal dose adjustment or dose optimization categories). Transition of care: interventions associated with transition of an ICU patient to a ward unit (eg, discontinuation of ICU prophylaxis, conversion of IV antihypertensive PRN medications to PO as needed orders, etc.)

The overall cost savings calculated from documented interventions was $66 537.80 with an average daily cost avoidance of $1279.57 (maximum daily cost avoidance: $16 402, minimum: $0.00). Roughly 73% of cost avoidance was associated with prevention of inappropriate factor product use followed by discontinuation of non-indicated medications, antibiotic de-escalation, and discontinuation of drugs that do not meet criteria for use. Full cost savings data can be seen in Table 1. After independent review by 2 pharmacists, twenty-one interventions (4.1%) were scored as “high yield interventions.” Nine of these interventions were considered high yield due to cost avoidance of ≥$500 and 12 interventions were scored as high yield due to the potential harm prevented by the intervention. A brief description of each intervention considered to prevent potential harm is provided in Table 2.

Table 2.

Description of “High Yield Interventions” Considered to Prevent Potential Harm.

Prevented administration of polymyxin B to a patient with acute kidney injury and XDR Pseudomonas aeruginosa (resistant to every antimicrobial on formulary including ceftolozone-tazobactam and ceftazidime-avibactam). Discussed with the infectious disease team and coordinated borrowing cefidericol from hospital across the street within 1 h to avoid administration of potentially toxic antimicrobial. Send out susceptibilities returned susceptible to cefidericol.

Prevented vancomycin administration for a patient with severe AKI with vancomycin level of 48 µg/mL. The peak after administration of 1250 mg dose would have been estimated to be 69 µg/mL.

Prevented administration of therapeutic heparin drip in a patient with gunshot wound to head. The team intended to order heparin-papaverine for line patency. Order was corrected.

Prevented administration of 5000 unit heparin bolus to patient with 20 000 platelets/µL and current bleeding. The physician intended to order 500 units for port access. Order was corrected.

Patient with Escherichia coli bacteremia was to be deescalated to ceftriaxone from cefepime. The physician discontinued cefepime order, but ceftriaxone was omitted for several hours. Added ceftriaxone order to continue to treat patient.

Prevented administration of heparin DVT prophylaxis and recommended initiation of argatroban on patient with positive HIT antibody. HIT antibody was not acted upon for >6 h and the patient was scheduled to receive additional doses of heparin prophylaxis.

Prevented administration of 20 mEq IV potassium in a patient with potassium of 5.6 mEq/L and poor renal function preventing potential adverse event and potassium lowering therapy.

Prevented administration of cisatracurium infusion to patient with RASS > −4. Recommended increasing sedation and held paralytic until RASS at goal. The patient did not require cisatracurium after escalation of sedation.

Team initiated ampicillin for Enterococcus faecium blood stream infection. Recommended to escalate from ampicillin to vancomycin due to high likelihood of resistance. Susceptibilities later returned as ampicillin resistant.

Enterococcus faecium resulted in blood culture and was left untreated for several hours. Contacted physician and initiated daptomycin treatment.

Prevented enoxaparin 40 mg every 12 h from being administered to a 30 kg patient for prophylaxis. This dose would have resulted in full anticoagulation. Discussed with physician and decreased dose to 20 mg every 12 h for trauma prophylaxis dosing.

Patient with high suspicion of meningitis on ceftriaxone 1 gm every 24 h. Recommended increase to 2 g every 12 h for optimal dosing for CNS infection.

Note. AKI = acute kidney injury; CNS = central nervous system; DVT = deep vein thrombosis; HIT = heparin induced thrombocytopenia; IV = intravenous; RASS = Richmond Agitation Sedation Scale; XDR = extensively drug resistant.

Discussion

In this descriptive evaluation of a board-certified critical care clinical pharmacist’s interventions on weekday, evening shifts, we observed an average of 9.8 interventions per day. These interventions were associated with over $66 000 dollars of cost avoidance. Additionally, this data was effectively presented to the institutional full-time employee (FTE) committee to justify a second evening ICU float position and inform workflow design for this position. Extrapolating this 12-week period to 1 year (235 weekdays) would yield 2305 interventions, an associated cost avoidance of $300 698.95, and a cost avoidance to salary ratio of 2.3:1. Though the value of a clinical pharmacist is not explained by cost avoidance alone, this estimate may provide a conservative starting point with the assumption that there is additional benefit through clinical outcomes and non-patient care related activities.

Although pharmacists improve patient outcomes, pharmacist positions are frequently justified through cost avoidance measures. ¹⁵ The most notable study on this topic is the multicenter PHARM-CRIT study which evaluated critical care pharmacist interventions and associated cost avoidance. ¹⁶ In this study, investigators observed a potential cost avoidance to pharmacist salary ratio of 3.3:1 to 9.6:1, demonstrating the significant contribution pharmacists have on limiting costs. While the PHARM-CRIT investigators assigned monetary value to interventions based on existing cost avoidance literature, health systems and FTE committees may remain skeptical due to the high numbers. Anticipated cost avoidance based on perceived benefit to patients from an intervention (eg, addition of venous thromboembolism prophylaxis, code blue participation, and renal dose adjustment), while clinically and financially meaningful, is difficult to justify with objective data. This study demonstrates a lower cost avoidance to pharmacist ratio while only including tangible cost avoidance data. This complements the results of the PHARM-CRIT study while providing a more conservative starting point for those aiming to justify new positions.

Cost avoidance comprises only a small portion of pharmacist responsibilities. The 2020 position paper on critical care pharmacy services states that critical care pharmacists provide benefit through not only direct patient care, but also quality improvement, formulary management, research and scholarship, and education, affecting the health system in a more systematic way than simply individual patient interventions. ¹ The tracking of pharmacist impact on both patient care and non-patient care activities is notoriously difficult to ascertain, thus making it challenging to examine the full impact of critical care pharmacists within the health system. Forehand et al ¹⁷ sought to bridge this gap by examining documentation and tracking of the broad scope of pharmacist productivity through a recent survey. In addition to direct patient care activities, a large portion of survey respondents reported that non-patient care activities were encompassed in their job responsibilities, including quality improvement, education, and professional development. ¹⁷ However, significant practice variation was shown regarding productivity tracking and how the tracking is utilized in the annual review of pharmacists and justification of pharmacist positions. ¹⁷ While these non-patient care activities were expected of most pharmacists, many institutions lacked a standardized approach to the documentation of these activities and infrequently utilized these activities as justification for pharmacist positions. Incorporating standardized processes for tracking pharmacists’ activities, including not only interventions and cost-avoidance, but also non-patient care activities can aid in providing a more complete benefit evaluation of critical care pharmacy services.

While we found significant clinical and cost savings benefit to adding a critical care clinical pharmacist to our weekday, evening shift schedule, there are likely additional opportunities for improvement if these services were expanded to additional evening shift decentralized pharmacists, the addition of decentralized overnight pharmacists, and additional decentralized pharmacists on all shifts for weekends and holidays. Indeed, a recent exploratory analysis of the PHARM-CRIT database revealed that pharmacists who rounded with 1 service were more likely to attempt and have interventions accepted than those pharmacists who rounded with 2 or more or no services. Additional analysis of this database affirmed that as the patient to pharmacist ratio increases, the number of high intensity pharmacist interventions decreases. ¹⁸ Collectively, these data build an argument for additional board-certified critical care pharmacist FTEs on evening, night, weekend, and holiday shifts.

This evaluation has several limitations including its single-center, observational design, which precludes causal inference and lacks a comparator group. Moreover, this study evaluated a narrow metric of pharmacist workload (ie, interventions) and did not include the effect of these services on patient-centered outcomes; however, the purpose of this analysis was descriptive. In our study, 73% of cost savings were associated with inappropriate factor use. Our institution serves a large population of hemophilia and traumatic injury patients that require supplemental factors and anticoagulation reversal. This may limit cost-avoidance generalizability to institutions that serve smaller populations of these patients. Assuming no factor interventions, cost avoidance extrapolation for 1 year would yield a total savings of $81 188.71. Though interventions were collected prospectively, workload constraints prevent 100% collection of all interventions and cost avoidance was not calculated for interventions assumed to avoid less than $5.00. This likely underestimates the true number of interventions and associated cost avoidance. This study was completed at the initiation of this service, and we expect that evening pharmacist impact would increase over time, as the medical teams become more familiar with this resource. Larger, multi-center analyses specifically designed to understand how critical care pharmacist services affect outcomes are needed; however, this study may still serve as an important justification tool for those centers with critically ill patients that do not currently have evening shift critical care services provided.

Conclusion

In this evaluation of an evening shift critical care pharmacist’s interventions, the addition of a clinical pharmacist resulted in 510 accepted interventions with several potentially preventing patient harm. These interventions were associated with significant cost avoidance and complement previous cost-avoidance literature. These data highlight the benefits and feasibility of the addition of an evening shift critical care clinical pharmacist.