Effect of Inpatient Pharmacist-Led Medication Reconciliations on Medication-Related Interventions in Intensive Care Unit Recovery Centers

Abstract

Background: Critical care pharmacists complete comprehensive medication reviews in Post Intensive Care Syndrome (PICS) patients at Intensive Care Unit Recovery Centers (ICU-RCs) to optimize medication therapies after hospital discharge. Inpatient pharmacists often complete medication reconciliations prior to hospital discharge, which could affect interventions at an ICU-RC. However, this association remains ill-described. Objective: The purpose of this study was to, in patients with PICS, describe the effect of an inpatient, pharmacist-led medication reconciliation on the number of clinical pharmacist interventions at the first ICU-RC visit. Methods: This was a post-hoc subgroup analysis of an international, multicenter cohort study of adults who had a pharmacist-led comprehensive medication reconciliation conducted in 12 ICU-RCs. Only patients’ first ICU-RC visit was eligible for inclusion. The primary outcome was the number of medication interventions made at initial ICU-RC visit in PICS patients who had an inpatient, pharmacist-led medication reconciliation compared to those who did not. Results: Of 323 patients included, 83 received inpatient medication reconciliations and 240 did not. No difference was observed in the median number of medication interventions between groups (2 vs 2, p = .06). However, a higher incidence of any intervention (86.3% vs 78.3%, p = .09) and dose adjustment (20.4% vs 9.6%; p = .03) was observed in the no medication reconciliation group. Only ICU Sequential Organ Failure Assessment score was associated with an increased odds of medication intervention at ICU-RC visit (aOR 1.15, 95% CI 1.05-1.25, p < .01). Conclusion and Relevance: No difference in the total number of medication interventions made by ICU-RC clinical pharmacists was observed in patients who received an inpatient, pharmacist-led medication reconciliation before hospital discharge compared to those who did not. Still, clinical observations within this study highlight the continued importance and study of clinical pharmacist involvement during transitions of care, including ICU-RC visits.

Background

With continued advancements in care, Intensive care unit (ICU) survivorship has increased over time; however, many ICU survivors are left with long-lasting deficits in cognitive, physical, and mental health after hospital discharge.^1-3 To increase awareness, prompt additional research, and increase screening for new impairments after critical illness, a multi-national group of stakeholders convened by the Society of Critical Care Medicine in 2010 agreed upon the term Post Intensive Care Syndrome (PICS) to describe these lasting symptoms. ³ Data describing the presence of at least one PICS symptom suggest a prevalence of approximately 50% in intensive care unit survivors, though the exact prevalence is unknown.^4-6 Similarly, survivors of critical illness secondary to COVID-19 experience these impairments, often termed Post-Acute Sequelae of SARS-CoV-2 Infection (PASC) or Long COVID, at a similar estimated prevalence.^7,8

These findings are important in the context of data describing increased ICU survival and its impact on the healthcare sytem.^9-12 Survivors of critical illness have been reported to experience significantly higher rates of hospital readmission and a 1-year mortality rate that is nearly four times greater compared to patients admitted to non-ICU wards (14.3% vs 3.9%). ¹¹ Furthermore, in the setting of frequent readmissions and lasting deficits after ICU admission, these patients experience decreased quality of life and high healthcare resource utilization.^9-12

A systematic review and meta-analysis of 89 studies identified 60 risk factors for the development of PICS. ¹³ While many identified risk factors were non-modifiable, pharmacy effort directed toward modifiable risk factors may be warranted. For example, critical care pharmacists are well positioned to contribute to reduced rates of ICU delirium by assisting with appropriate medication selection and limiting the use of medications associated with ICU delirium daily and during transitions of care.^14-16 Indeed, studies of pharmacist involvement at various transitions of care have reported improvements in preventable adverse drug events (ADE), medication errors, and medication discrepancies.^17-26 Pharmacist medication reconciliation prior to hospital discharge provide a key opportunity to address medication-related issues that may contribute to PICS symptoms.

The role of the pharmacist in the care of survivors of critical illness has expanded beyond hospital admission. The advent of ICU recovery centers (ICU-RCs) added another means to treat PICS, added a novel transition of care for survivors of critical illness, and provided an opportunity for pharmacist intervention.^27-31 ICU-RCs are outpatient clinics typically supported by an interdisciplinary group of providers including physicians, pharmacists, nurses, respiratory and occupational therapists, and social workers designed to address lasting complications of critical illness.^28,32 Critical care pharmacists have been integrated into many ICU-RCs to complete comprehensive medication reconciliations due to the frequency of ADEs, unnecessary medication continuation, and failure to resume maintenance medications at various transitions of care.^31,33-44 Observational data have described the role critical care pharmacists play in identification and/or reconciliation of these and other medication-related problems in ICU-RCs.^32,45,46 The interplay between inpatient pharmacist interventions, such as medication reconciliation, and pharmacist interventions at ICU-RCs remains unexplored, however, holds relevance given the well-reported challenges surrounding clinical pharmacy workforce and model optimization.^47-49 The purpose of this study was to, in patients with PICS, describe the effect of an inpatient, pharmacist-led medication reconciliation on the number of clinical pharmacist interventions at the first ICU-RC visit.

Study Design and Methods

A detailed description of the original study has been published. ⁴⁶ Briefly, an international, multicenter cohort study was conducted in 12 ICU-RCs between September 2019 and July 2021. Eligible patients were adults (≥18 years old) admitted to an ICU who met referral criteria to the institution’s ICU-RC and had a comprehensive medication review completed by a clinical pharmacist during their ICU-RC visit. The purpose of the original study was to describe the role of critical care pharmacists in the identification and treatment of medication-related problems in critical illness survivors who attended ICU-RCs after discharge. Most patients included in the original analysis were attending their first ICU-RC visit (70%). The completion (or lack thereof) of an inpatient, pharmacist-led medication reconciliation prior to hospital discharge was collected as part of the study’s methodology. This served as the basis for the presented post-hoc, subgroup analysis of the original multicenter study. The study was approved by the Institutional Review Board (IRB) at all participating centers with a waiver of informed consent. Procedures were followed in accordance with the ethical standards of the committee responsible for human experimentation (institutional or regional) and with the Helsinki Declaration of 1975.

In this subgroup analysis, only patients’ first ICU-RC visit was eligible for inclusion. Patients were excluded if they were not seen by a pharmacist at their ICU-RC visit or if their data were incomplete. Patients eligible for analysis were split into two groups: a medication reconciliation group and no medication reconciliation group. Patients in the medication reconciliation group had a pharmacist-led, inpatient medication reconciliation prior to hospital discharge, while patients in the no medication reconciliation group did not. Medication reconciliations done as part of the hospital and/or ICU admission process were not included. The precise location and timing (e.g., at ICU discharge, on medical ward, day of hospital discharge) of the medication reconciliation was not standardized across institutions; however, all were conducted by clinical pharmacists. Similarly, the time from hospital discharge to first ICU-RC visit was not standardized across institutions due to variable clinic and patient availability.

Data included in this post-hoc, subgroup analysis included relevant demographics, comorbidities, diagnoses and medication exposures, discharge disposition, and ICU and hospital lengths of stay collected from the original study. Additionally, data pertaining to the first ICU-RC visit including visit type (in-person or virtual), time from hospital discharge, and active medications at the time of the visit were also included. Data related to the ICU-RC comprehensive medication review were included. These included totals and types of identified interventions or barriers to medication access, as identified by the ICU-RC clinical pharmacist during the visit.

The primary outcome was the number of total medication interventions made at patients’ first ICU-RC visit. A medication intervention included any of the following: identification of ADEs, implementation of ADE preventative measures, identification of medication interactions, medication dose adjustments, medication discontinuation, or medication initiation. Secondary outcomes included each component of the medication intervention definition and the number of each intervention type made. We also assessed if patients had barriers to obtaining medications including lack of insurance, insufficient funds, lack of transportation, need for prior authorizations, or other reasons.

Statistical Analysis

Categorical data were reported as n (%) and continuous data as medians with associated interquartile ranges (IQR). Chi Squared or Fisher’s Exact tests for categorical variables and Mann-Whitney U or student’s t-test for continuous variables were used to make comparisons between groups as appropriate. A p-value of less than .05 was regarded as statistically significant. A multivariable logistic regression was performed to identify factors associated with a medication intervention at the first ICU-RC visit. Included covariates were selected based on the univariable analysis. Specifically, variables were considered for the multivariable logistic regression if univariate comparisons between groups revealed a p-value < .15. The exception to this was group assignment (medication reconciliation vs no medication reconciliation), which was forced into the model provided the study question. It was pre-determined that the number of events per variable (EPV) target was >10. If the EPV was below 10, group discussion and consensus would be employed to identify the variables with the strongest plausibility to maintain the EPV target. Further, assessments of multicollinearity were assessed by variance of inflation factors (threshold > 10) and Pearson correlation (threshold r² > 0.8). The association between each covariate and the need for medication intervention during the ICU-RC visit were reported as adjusted odds ratios with 95% confidence intervals. Statistical analyses were conducted using IBM SPSS Statistics 25 for Windows.

Results

A total of 474 patients attended the ICU-RC and were screened for study eligibility, of which 330 met eligibility criteria (Figure 1). The majority of patients ineligible for inclusion in this subgroup analysis were on clinic visit number two or three upon inclusion in the original study (N = 144). ⁴⁶ The exclusion of an additional 7 patients left 323 patients eligible for analysis. Of the 323 patients included, 83 were included in the inpatient medication reconciliation group and 240 in the no medication reconciliation group.

Figure 1.

Patient Consort Diagram.

Patient characteristics were largely similar between the cohorts and are described in Table 1. Patients in the medication reconciliation group had a higher incidence of COVID-19 (60.2% vs 42.5%, p < .01) and lower incidence of a past medical history of atrial fibrillation (1.2% vs 11.3%, p < .01) and illicit drug use (10.8% vs 22.5%, p < .01). The most common ICU diagnosis in both groups was respiratory failure. The medication reconciliation group had longer, non-statistically significant, median ICU and hospital lengths of stay compared to the no medication reconciliation group (14 vs 11 days, p = .27 and 23 vs 20 days, p = .74). Characteristics of the ICU-RC visit and patients at the time of ICU-RC visit are described in Table 2. The majority of ICU-RC visits were conducted in-person. The median time from hospital discharge to ICU-RC visit was 35 days (IQR 22-69) in the medication reconciliation group and 39 days (IQR 20-84) in the no medication reconciliation group. Patients in both groups had a median of 10 (IQR 5-15) active medications at the ICU-RC visit.

Table 1.

Patient Admission Characteristics. ^a

Characteristic	Medication reconciliation (n = 83)	No medication reconciliation (n = 240)	p-Value
Age b , years	53 (38-64)	57 (44-66)	.15
Female Gender	35 (42)	96 (40)	.73
Race			.58
White	55 (66.3)	152 (63.3)
Black	17 (20.5)	41 (17.1)
Hispanic	6 (7.2)	29 (34.9)
Other/not reported	4 (4.8)	10 (4.2)
Asian	1 (1.2)	8 (3.3)
Height b , cm	170 (163-180)	170 (163-178)	.45
Weight b , kg	94.5 (80.3-113.9)	88.0 (71.8-102.8)	.01
Body mass index b , kg/m2	32.3 (27.4-38.7)	30.7 (24.6-36.1)	.05
Comorbidities
Gastroesophageal reflux disorder	21 (25.3)	78 (32.5)	.22
Diabetes mellitus	30 (36)	63 (26.3)	.09
Tobacco/nicotine dependence	16 (19.3)	48 (20.0)	.30
Illicit drug(s) use	9 (10.8)	54 (22.5)	.02
Thyroid disorder	13 (15.7)	27 (11.3)	.29
Asthma	10 (12.0)	30 (12.5)	.91
Coronary artery disease	9 (10.8)	30 (12.5)	.69
Chronic obstructive pulmonary disease	5 (6.0)	27 (11.3)	.17
Atrial fibrillation	1 (1.2)	27 (11.3)	<.01
Chronic kidney disease	5 (6.0)	14 (5.8)	1.0
Congestive heart failure	4 (4.8)	16 (6.7)	.55
SOFA score at ICU admission b	7 (3-9)	5 (2-8)	.10
ICU admission source			.24
Emergency department	38 (45.7)	107 (44.6)
Outside hospital	21 (25.3)	58 (24.2)
Medical floor	19 (22.9)	38 (15.8)
Other	3 (3.6)	27 (11.3)
Other ICU	2 (2.4)	7 (2.9)
Rapid response team	0 (0.0)	3 (1.3)
ICU diagnosis			.03
Respiratory failure	56 (67.5)	115 (47.9)
Other	15 (18.1)	81 (33.8)
Sepsis/septic shock	6 (7.2)	20 (8.3)
Pneumonia	5 (6.0)	17 (7.1)
Altered mental status/coma	1 (1.2)	7 (2.9)
COVID-19 diagnosis	50 (60.2)	102 (42.5)	<.01
PICS-related medication receipt
Opiates	74 (89.2)	215 (89.6)	.91
Benzodiazepines	58 (69.9)	162 (67.5)	.69
Vasopressors	51 (61.4)	163 (67.9)	.28
Corticosteroids	55 (66.3)	150 (62.5)	.54
Anticholinergics	39 (47.0)	123 (51.3)	.50
Neuromuscular blockers	34 (41.0)	84 (35.0)	.33
ICU length of stay b , days	14 (9-20)	11 (6-23)	.27
Hospital length of stay b , days	23 (13-32)	20 (12-35)	.74
Discharge disposition			.33
Home with self-care	32 (38.6)	76 (31.7)
Inpatient rehabilitation	15 (18.1)	61 (25.4)
Home with home health	18 (21.7)	49 (20.4)
LTAC facility	11 (13.3)	25 (10.4)
Skilled nursing facility	5 (6.0)	27 (11.3)
Other	2 (2.4)	2 (0.8)

Note. ICU = intensive care unit; SOFA = Sequential Organ Failure Assessment; LTAC = long-term acute care; COVID = Coronavirus disease of 2019; PICS = Post-intensive Care Syndrome.

^aData reported as n (%), unless otherwise noted.

^bData reported as median (IQR).

Table 2.

Patient Characteristics at/of ICU-RC Visit. ^a

Characteristic	Medication reconciliation (n = 83)	No medication reconciliation (n = 240)	p-Value
Visit type			.99
In-person	57 (68.7)	165 (68.8)
Virtual	26 (31.3)	75 (31.2)
Time from hospital discharge to visit b , days
Number of active medications at visit start b	35 (22-69)	39 (20-84)	.87
Active medication classes at visit c	10 (5-15)	10 (5-15)	.97
Vitamins/Minerals	52 (62.7)	156 (65.0)	.70
Non-opiate pain medications	39 (47.0)	113 (47.1)	.99
Antidepressants	34 (41.0)	90 (37.5)	.58
Proton pump inhibitors	32 (38.6)	92 (38.3)	.97
Statins	37 (44.6)	80 (33.3)	.07
Beta blockers	28 (33.7)	85 (35.4)	.78
Anticoagulants	23 (27.7)	87 (36.3)	.16
Bronchodilators	28 (33.7)	72 (30)	.53
Antiplatelets	27 (32.5)	58 (24.2)	.14
Anti-constipation	20 (24.1)	60 (25.0)	.87
Opiates	19 (22.9)	58 (24.2)	.81
Calcium channel blockers	23 (27.7)	53 (22.1)	.30
Diuretics	17 (20.5)	54 (22.5)	.70
Neuropathic pain medications	13 (15.7)	57 (23.8)	.12
Topicals	16 (19.3)	43 (17.9)	.78
Corticosteroids	15 (18.1)	42 (17.5)	.91
Antihistamine	20 (24.1)	36 (15)	.06
ACE inhibitors	11 (13.3)	43 (17.9)	.33
Insulin	14 (16.9)	37 (15.4)	.76
Antihyperglycemic	13 (15.7)	35 (14.6)	.81
Antibiotics	8 (9.6)	34 (14.2)	.29
Antipsychotics	9 (10.8)	31 (12.9)	.62
Anxiolytics	4 (4.8)	35 (14.6)	.02
Thyroid medications	12 (14.5)	26 (10.8)	.38
Angiotensin receptor blockers	13 (15.7)	24 (10.0)	.16
Alpha blockers	9 (10.8)	26 (10.8)	.99

^aData reported as n (%), unless otherwise noted.

^bData reported as median (IQR).

^cClasses active in > 10% of population reported.

Table 3 describes primary and secondary outcomes. The same median number of total medication interventions were made at the first ICU-RC between the medication reconciliation group and no medication reconciliation group (2 vs 2, p = .06). Similarly, no significant difference in the incidence of any medication intervention between groups (86.3% vs 78.3%, p = .09) was observed. A higher incidence of medication dose adjustments was observed in the no medication reconciliation group (20.4% vs 9.6%, p = .03). No other differences between groups were observed pertaining to types and associated numbers of medication interventions made.

Table 3.

Primary and Secondary Outcomes. ^a

Outcome	Medication reconciliation (n = 83)	No medication reconciliation (n = 240)	p-Value
Primary outcome
Number of medication interventions	2 (1-3)	2 (1-4)	.06
Secondary outcomes
Any medication intervention, n (%)	65 (78.3)	207 (86.3)	.09
Any ADE identified, n (%)	18 (21.7)	34 (14.2)	.11
Number of ADEs identified (n = 52)	1 (1-1)	1 (1-1)	.31
Any ADE prevention measure implemented, n (%)	26 (31.3)	53 (22.1)	.09
Number of ADE prevention measures implemented (n = 79)	1 (1-1)	1 (1-2)	.70
Any medication interaction identified, n (%)	4 (4.8)	17 (7.1)	.47
Number of medication interactions identified (n = 21)	1 (0-2)	1 (1-1)	.83
Any medication dose adjustment recommended, n (%)	8 (9.6)	49 (20.4)	.03
Number of dose adjustments recommended (n = 57)	1 (1-2)	1 (1-2)	.54
Any medication discontinued, n (%)	22 (26.5)	73 (30.4)	.50
Number of medications discontinued (n = 95)	1 (1-2)	1 (1-2)	.89
Any new medication recommended/initiated, n (%)	15 (18.1)	47 (19.6)	.76
Number of new medications recommended/initiated (n = 62)	1 (1-2)	1 (1-2)	.66
Lack of means to obtain medications identified, n (%)
Lack of insurance	1 (1.2)	6 (2.5)	.49
Insufficient funds	1 (1.2)	7 (2.9)	.39
Lack of transportation	0 (0.0)	2 (0.8)	.40
Prior authorization needed	0 (0.0)	3 (1.2)	.31
Other, n (%)

Note. ADE = Adverse drug event.

^aData reported as median (IQR), unless otherwise noted

The multivariable logistic regression model included eight covariates (Table 4). Initially considered covariates based on univariate analysis included age, weight, body mass index (BMI), atrial fibrillation, diabetes mellitus, illicit drug use, ICU Sequential Organ Failure Assessment (SOFA) score at ICU admission, ICU diagnosis, and COVID-19 diagnosis. Due to identified multicollinearity, weight and ICU diagnosis were removed from inclusion in the model. Only ICU SOFA score was observed to be associated with an increased odds of any medication intervention being made at the first ICU-RC visit (aOR 1.15, 95% CI 1.05-1.25, p < .01). Notably, the completion of an inpatient medication reconciliation did not significantly predict any medication intervention at ICU-RC visit (aOR: 0.52, 95% CI 0.26-1.04, p = 0.06).

Table 4.

Independent Factors Associated with Medication Intervention at First ICU-RC Visit.

Covariate	Adjusted odds Ratio	95% confidence Interval	p-Value
Age, years	1.01	0.98-1.03	.61
BMI, kg/m2	1.00	0.96-1.04	.87
Diabetes mellitus	1.08	0.53-2.23	.83
Atrial fibrillation	1.22	0.32-4.59	.77
Illicit substance use	1.87	0.72-4.88	.20
ICU SOFA score	1.15	1.05-1.25	<.01
COVID-19 diagnosis	1.27	0.63-2.56	.51
Inpatient medication Reconciliation	0.52	0.26-1.04	.06

Discussion

In this post-hoc, subgroup analysis of a large, international, multi-center cohort study, we did not observe a significant difference in the number of medication-related interventions at the first ICU-RC visit in patients with PICS who received an inpatient, pharmacist-led medication reconciliation compared to those who did not. The paucity of data surrounding this transition of care highlights the novelty and importance of our observations. While the primary outcome was not statistically significant between groups, other observations may have important clinical implications for optimizing the care of ICU survivors and critical care clinical pharmacists.

The findings of this study were consistent with prior literature describing the high incidence of medication-related interventions made by clinical pharmacists in ICU-RCs. For example, the original study observed an identical incidence (84%) of patients with one or more medication-related intervention made during their ICU-RC visit. ⁴⁶ Observational studies by Stollings et al. and MacTavish et al. reported over 80% of patients required a medication-related intervention.^32,50 While not statistically significant, the observed 8% absolute difference in incidence of any medication intervention may represent a clinically meaningful difference for patients and healthcare systems. While the median number of interventions did not differ between groups, this post-hoc analysis is hypothesis generating and reiterates the importance of pharmacist involvement during transitions of care.^17-26

Patients that received an inpatient, pharmacist-led medication reconciliation prior to hospital discharge were observed to have a lower incidence of medication interactions, discontinuations, and initiations identified at the ICU-RC visit. These observations were not statistically significant but may, again, highlight the contributions and importance of pharmacist involvement in medication reconciliation prior to hospital discharge. Moreover, receiving a medication reconciliation was associated with a significantly lower incidence of medication dose adjustment at ICU-RC visit. Patients in the medication reconciliation group also had a higher incidence of having an ADE identified and ADE prevention measure implemented during their ICU-RC visit. It is possible that these ADE prevention measures were identified in the context of having an accurate and updated medication list at the ICU-RC visit; however, this finding may also represent an area of opportunity for pharmacists to provide further education or interventions during an inpatient discharge medication reconciliation.

While not assessed as a covariate in the multivariable logistic regression model, we also hypothesize discharge disposition may impact ICU-RC medication interventions given the variable degree of patient involvement in medication prescribing, administration, and monitoring. Over one-third (37.4%) of patients included in this analysis were discharged to a skilled nursing facility (SNF), long-term acute care facility, or inpatient rehab facility where medication adjustments may be made on a more frequent basis than in patients discharged home with routine follow-up care. Moreover, discharges to these facilities present an additional opportunity for medication discrepancies, and therefore ADEs, at transitions of care.^51,52 Such discrepancies have been reported to occur in over 70% of SNF admissions in a previous study. ⁵³ Further data are warranted to describe the impact pharmacist contributions prior to and after hospital discharge in ICU survivors discharged to long-term care facilities.

Increasing ICU survival rates combined with the proximity and familiarity of critical care pharmacists with ICU patients and their medication regimens has them uniquely positioned to contribute at transitions of care like never before. Unfortunately, challenges surrounding pharmacist burnout, workload, and models must be considered alongside departmental priorities and resources.^47-54 Recently, a medication regimen complexity scoring tool, the Medication Regimen Complexity-ICU (MRC-ICU), observed a significant association between MRC-ICU and several clinical outcomes. ⁵⁴ Tools such as MRC-ICU provide opportunity to guide pharmacist triage at the bedside or may contribute to a larger framework for pharmacist workforce utilization. The reported multivariable logistic regression model was developed to identify factors associated with the need for any medication intervention at ICU-RC visit. When controlling for other confounding factors, the model associated ICU SOFA score significantly with the need for a medication intervention at ICU-RC visit. Identification of such predictors may aid critical care pharmacists in prioritizing medication reconciliation amidst other responsibilities. We offer cautious interpretation of this finding as a sole means of prioritizing medication reconciliation efforts. We also suggest future studies should aim to expand on these findings and may consider incorporating pre-existing scoring tools, such as MRC-ICU, as predictors in future analyses.

Strengths of this study are rooted in its novelty as the only study to have described and assessed the effect of an inpatient, pharmacist-led medication reconciliation on pharmacist interventions at the first ICU-RC visit in PICS patients. In addition, data collection was performed across many institutions and internationally, improving generalizability. Still, these data must be interpreted in the context of several limitations. First, this observational, post-hoc analysis must be interpreted only as hypothesis-generating and non-causal in nature. Provided the focus of the original study was not inpatient medication reconciliation, differences in practices including timing and expectations/protocols (or lack thereof) were neither standardized nor granularly collected. As such, they could not be controlled for in the current study and represent a source of potential bias. It is possible medication reconciliations were completed by other healthcare professionals (e.g., nurses, physicians, advanced practice providers) in the no medication reconciliation group. Next, the observed imbalance in the number of patients in the medication reconciliation group compared to the no medication reconciliation group, as well as differences patient characteristics, may represent selection bias. While multivariable modeling included treatment group assignment and other characteristics, it was unlikely to fully account for these potential biases. The primary outcome of this post-hoc study was objective and readily available but was a surrogate of pharmacist value and patient outcome. Future studies of ICU-RC pharmacist involvement should more clearly describe these relationships and explore what type(s) of intervention(s) during inpatient medication reconciliation most prominently effect ICU-RC interventions. Finally, included patients may have been discharged to facilities that provided various transitions of care services, including medication reconciliation, and should be considered in future work.

Conclusions and Relevance

No difference in the total number of medication interventions made by ICU-RC clinical pharmacists was observed in patients who received an inpatient, pharmacist-led medication reconciliation before hospital discharge compared to those who did not. Still, clinical observations within this study highlight the continued importance and study of clinical pharmacist involvement during transitions of care, including ICU-RC visits.