Implementation, Evolution and Impact of ICU Telepharmacy Services Across a Health care System

Abstract

Purpose: A review of the implementation and development of telepharmacy services that ensure access to a critical care-trained pharmacist across a healthcare system. Summary: Teleintensive care unit (tele-ICU) services use audio, video, and electronic databases to assist bedside caregivers. Telepharmacy, as defined by the American Society of Health-System Pharmacists, is a method in which a pharmacist uses telecommunication technology to oversee aspects of pharmacy operations or provide patient care services. Telepharmacists can ensure accurate and timely order verification, recommend interventions to improve patient care, provide drug information to clinicians, assist in standardization of care, and promote medication safety. This tele-ICU pharmacy team is one of the only entirely clinical-based tele-ICU pharmacy models among the tele-ICU programs across the United States. The use of technology for customized alert generation and intervention proposal with medication orders and chart notation are unique. In a 34-month period from September 2015 to July 2018, more than 110 000 alerts were generated and 13 000 interventions were performed by telepharmacists. Conclusions: Tele-ICU pharmacists employ limited resources to provide critical care pharmacy expertise to multiple sites within a healthcare system during nontraditional hours with documented clinical and financial benefits. Further study is needed to determine the impact of tele-ICU pharmacists on ICU and hospital length of stay, morbidity, and mortality.

Introduction

Critical care pharmacists have demonstrated improved outcomes in traditional intensive care unit (ICU) settings including reductions in length of stay, adverse events, cost, and mortality.^1,2 As a result, American College of Critical Care Medicine guidelines state that pharmacy services provided by a qualified and competent pharmacist are essential in the ICU.³ Despite this recommendation, many centers have limited access to a critical care pharmacist.⁴ One way to narrow this gap is with the use of telepharmacists operating in a tele-ICU setting.

Tele-ICU services use audio, video, and electronic databases to assist bedside caregivers.⁵ Telepharmacy is defined by the American Society of Health-System Pharmacists as “a method used in pharmacy practice in which a pharmacist uses telecommunications technology to oversee aspects of pharmacy operations or provide patient-care services.”⁶ Telepharmacists can ensure accurate and timely order verification, recommend interventions to improve patient care, provide drug information to tele-ICU and bedside clinicians, assist in standardization of care across the healthcare system, and promote medication safety. Existing tele-ICU pharmacy models use the tele-ICU as a platform for clinical interventions, remote order entry and verification, or often a combination of both.^7-14 Medication reconciliations, allergy clarifications, and pharmacokinetic consults have also been performed.^8,13,14 Tele-ICU platforms, the electronic medical record, and pharmacy surveillance software may be used to generate alerts or algorithms to guide patient review. A recent systematic review of acute care services using telepharmacy noted enhanced patient outcomes, improved nursing satisfaction, and expanded services, with the goal of telepharmacy in the ICU setting primarily to expand services.¹⁵

There is a paucity of literature related to tele-ICU pharmacy services, but available data indicate the clinical benefit and cost savings associated with these programs.^7-14 The purpose of this article is to provide a description of the implementation and evolution of ICU telepharmacy across a health system.

Tele-ICU Services

The tele-ICU for Atrium Health (previously Carolinas HealthCare System), also known as Virtual Critical Care (VCC), was established in May 2013 with 24-hour nurse monitoring and 12 hours of intensivist coverage provided for 92 ICU beds. By the time of telepharmacy service implementation in September 2015, a total of 136 ICU beds at 8 facilities were covered. The service has continued to expand, with current coverage of 337 beds across 12 facilities in North Carolina and South Carolina. Nurse monitoring is 24/7, and 16 hours of intensivist coverage are provided daily. Five intensivists work 4- to 12-hour shifts from 3 pm to 7 am each day with review of new admissions during this time. Virtual respiratory therapists work from 6 am to 6 pm. Advanced Practice Providers are not currently incorporated into this model. The VCC provides an added layer of care and safety to bedside services, prompt patient evaluation, and reduced ICU and hospital length of stay, particularly at facilities without 24/7 on-site intensivist coverage.

Description of Technology

This tele-ICU is a hub (Clinical Operations Room [COR] in Mint Hill, NC, USA) and spoke (the 12 acute facilities managed) model using continuous monitoring and fully collaborative care for all 337 ICU beds. Although the model can be entirely centralized with the intensivists, nurses, respiratory therapists, and pharmacists all located in the COR, it is more often decentralized as the intensivists and pharmacists often work from remote locations. Telepharmacists commonly work from workstations called bunkers, which are located in 3 of the larger North Carolina facilities as well as 1 facility in South Carolina. Intensivists may be located across North Carolina and South Carolina, in several US states, or even in countries across the world, necessitating robust technology and collaboration to ensure coordination of care.

TheraDoc^® is used as clinical decision support system (CDSS) for telepharmacy to facilitate review via the electronic medical record (EMR), Cerner^®. Philips eCare Manager^® is used by the telepharmacist to determine patient census, but is relied on extensively by other VCC staff. eCare Manager^® is the clinical workflow application providing decision support, predictive analytics, risk-adjusted scoring, and surveillance for the tele-ICU population that also facilitates audiovisual calls. Face-to-face communication if the pharmacist is working alongside other VCC staff, video conferencing, telephone calls, EMR notes, and Skype^® communication are also used to relay messages with VCC and bedside staff.

The tele-ICU physicians and nurses engage in real-time telemedicine with synchronous communication using video conferencing software. Although the VCC has a continuous care model with 24/7 monitoring by nurses, there are also elements of the scheduled and reactive care models incorporated into care. Scheduled care occurs with VCC nursing rounds at least once per shift and during new patient admissions. Responsive (reactive) care occurs when the VCC physician is alerted by the bedside or VCC staff due to a phone call, alarm, alert, or bedside staff pushing the eLert^® button located within the patient’s room.

Initiating Telepharmacy

In preparation for VCC go-live, during a system-wide day-long continuing education program in 2012, the eCare Manager^® platform was exhibited. Shortly after this program, one of the system’s Critical Care Clinical Pharmacy Specialists routinely discussed with the tele-ICU Medical Director how pharmacy services could be incorporated into the current workflow. After VCC implementation and as additional facilities went live, additional physician coverage was needed daily for patient evaluation and management. The intensivists recognized that many medication-related interventions performed, particularly those related to glycemic control, could be delegated to a pharmacist with physician oversight. As a result, in 2014, a proposal for a pilot telepharmacy program was presented to and approved by pharmacy administration. Prior to telepharmacist implementation, the intensivist staffing model was one intensivist from 3 pm to 11 pm, a second physician from 11 pm to 7 am, and a swing shift physician from 6 pm to 12 am if ICU census exceeded 70 patients. The swing shift was used an estimated 329 days per year, or 90% of the time, per VCC physician leadership. It was proposed that the addition of a residency-trained critical care pharmacist to the VCC team could replace the need for the swing shift physician, providing anticipated cost savings of $140 000 to $167 000 in physician salary annually after accounting for pharmacist salary. It was also estimated that an additional $102 000 in savings of physician salary could be realized by the telepharmacist performing 30% of the activities with physician oversight that were previously performed by the intensivist alone. This was theorized to provide intensivists with more time to extend the depth of medical decision-making for existing patients and to expand care to an increased number of patients. Adding a critical care pharmacist resource to facilities without this coverage, decreasing the number of adverse drug events, and reducing targeted medication costs were also anticipated benefits of the telepharmacy service. The optimal time for the initial telepharmacist shift was determined to be 3 pm to 11 pm Monday through Friday. This mirrors the first intensivist shift, is during peak admission time, and provides access to a critical care-trained pharmacist on second shift for the entire system.

In July 2015, a residency-trained critical care pharmacist joined the current pharmacist to form the tele-ICU Clinical Pharmacy team and provided the system with its fifth adult critical care clinical specialist. Tele-ICU pharmacy services went live in September 2015, with the 2 telepharmacists alternating VCC coverage weekly, with one working in the tele-ICU and the other working as a rounding clinical specialist at a 35-bed medical-surgical ICU at the system’s second largest facility. Staffing limitations precluded dayshift, overnight, and weekend telepharmacist coverage. In July 2017, a dayshift pharmacist began to provide coverage for 4 hours a day, 3 days a week. Initially, telepharmacists worked from the COR location, but with continued expansion, additional nursing space was needed. This allowed the pharmacists to work from bunkers.

During the months preceding go-live, the telepharmacists familiarized themselves with TheraDoc^® with the goal of using this secondary platform for custom alerts, stimulus for interventions, and report generation. This was necessary because of the difficulty of extracting pharmacist intervention data from the EMR. Data retrieval was streamlined with the TheraDoc^® system and assisted with ongoing progress reports for the tele-ICU physician leadership and both critical care and pharmacy administration. TheraDoc^® alerts were designed for abnormal glucose, electrolyte, and lactate levels (Table 1).

Table 1.

TheraDoc^® Alerts.

Alert category	Laboratory parameter
Blood glucose	<70 or >180 mg/dL
Magnesium	<1.7 or >3 mg/dL
Phosphorus	<2.6 or >4.6 mg/dL
Potassium	<2.8 or >6 mmoL/L
Sodium	<128 or >152 mmoL/L
Lactate	>2 mmoL/L

Custom intervention categories were also designed in TheraDoc^® to allow telepharmacists to tie interventions to alerts and included 6 overarching categories: glucose management, medication management, Code Sepsis evaluation, electrolyte management, stress ulcer prophylaxis, and venous thromboembolism prophylaxis. Individual intervention activities (eg, increase sliding scale insulin or add basal insulin) were added to each category to provide depth to intervention reporting. A seventh category, blood culture identification (BCID) calls, was added in 2017. Descriptions of the activities performed in each category are included in Table 2.

Table 2.

Intervention Categories and Activities.

Glucose Management • Initiate/increase/decrease/discontinue basal, short-acting, or sliding scale insulin • Initiate/discontinue/decrease dextrose containing fluids • Order lab test/point of care • Initiate/transition from Insulin drip • Discontinue oral glycemic agents	Medication Management • Adverse drug event avoided • Drug allergy avoidance • Recommend alternate dose or medication • Serum drug level monitoring • Drug information • Change route/formulation • Order/discontinue lab test
Code Sepsisa • Timely initiation of antimicrobial regimen • Recommend alternative antimicrobial regimen • Add antimicrobial to regimen • Antimicrobial dose adjustment	BCID • Review antimicrobial regimen • Add/escalate antimicrobial regimen • Consult Infectious Disease MD on call • Call results to Pediatric ICU Pharmacist/Attending/ED or Telehealth RN
Electrolyte Management • Hyponatremia/hypernatremia replacement recommendation • Replacement per protocolb • Hyponatremia/hypernatremiab recommendation outside of protocol • Order lab test	VTE/SUP Prophylaxis • Initiate/discontinue therapy • Change route • Renal/weight-based dose adjustment • Recommendation of alternate agent • Discontinue duplicate therapy • Order lab test

Note. BCID = blood culture identification; ICU = intensive care unit; RN = registered nurse; VTE/SUP = venous thromboembolism/stress ulcer prophylaxis; SBP = systolic blood pressure; MAP = mean arterial pressure; IVF = intravenous fluid.

^aCode Sepsis is defined as a suspected infection AND hypotension (SBP < 90 mm Hg or MAP < 65 mm Hg) after 20 mL/kg IVF bolus OR Lactate greater than 4 mmol/L.

^bPotassium, magnesium, and phosphorous replacement.

Second-Shift Workflow

A standard workflow was developed and refined by the telepharmacists. This model is remote patient monitoring with asynchronous communication and a responsive mode of care. Although real-time, synchronous video communication capabilities are available, the second-shift model does not incorporate this technology. TheraDoc^® alerts are the primary source for prompting patient review on second shift, with each alert generating a full chart review in addition to investigation of the alert. At the beginning of each shift, interventions are manually tallied by the pharmacist. This provides an initial snapshot of the anticipated workload throughout the day; however, it is an overestimation as patients without ICU-status orders and those at the quaternary referral center are not routinely reviewed. EMR reviews are also conducted for new admissions or when consulted by a VCC or bedside provider for assistance.

On second shift, interventions are proposed to intensivists via an electronic triage board. The tele-ICU pharmacist enters pertinent details and the requested medication or laboratory orders. This request is flagged directly to the tele-ICU intensivist who reviews and responds to the pharmacist within the intervention request in real-time. After the intensivist agrees with a recommendation or provides an alternate course of action, the pharmacist enters these orders as a verbal communication and writes a short progress note detailing the changes in the EMR. The orders and progress note are then cosigned by the intensivist, so they appear readily in the chart for the bedside nurses, physicians, or pharmacists to view. The medication changes are then communicated to the bedside nurses by the tele-ICU nurse or the pharmacist (Figure 1).

Figure 1.

Second-shift tele-ICU pharmacist workflow.

Note. Tele-ICU = tele–intensive care unit; EMR = electronic medical record.

In January 2017, second-shift VCC pharmacy collaborated with the Antimicrobial Support Program (ASP) to receive calls from the microbiology laboratory regarding positive rapid BCID results. The VCC pharmacist receives these calls from 4:30 pm to 10:30 pm and is responsible for initiating or escalating antimicrobial regimens for inpatients as well as notifying emergency departments, pediatric pharmacists, and primary teams of patients requiring follow-up. Although the process for obtaining orders was the same for ICU-status patients, non-ICU-status patients required contacting the primary physician team (or infectious diseases, if consulted) via page, a secure text messaging platform, or via telephone. In this model, orders were ultimately entered by the provider or as a telephone order by the VCC pharmacist after a phone call had occurred. This further expanded the scope of the tele-ICU pharmacist.

Dayshift Expansion and Workflow

In early 2017, the second-shift tele-ICU pharmacists were approached regarding the addition of a critical care pharmacist to the VCC team to determine the feasibility of dayshift services. This pharmacist also serves as faculty at a nearby school of pharmacy and wished to establish an innovative practice site. After this pharmacist shadowed the second-shift tele-ICU pharmacists for several weeks, the pharmacist transitioned to daytime hours to determine workflow. This pharmacist’s hours are Monday, Wednesday, and Friday from 8 am to 12 pm. The VCC pharmacy team conducted several site visits to introduce themselves to the on-site teams, assess the pharmacy support and services offered at these facilities, shadow on rounds, and determine points of contact at the sites.

In contrast to the second-shift VCC pharmacist, the dayshift pharmacist uses TheraDoc^® alerts in addition to reviewing all ICU patients at 6 facilities without a dedicated critical care pharmacist, which include 76 beds. The dayshift telepharmacist makes recommendations via several routes: the VCC nurse rounding with the team, the on-site pharmacists, or on-site providers as the bedside teams are in-house during daytime hours. The dayshift pharmacist even rounds virtually once a week at one facility, and 3 days a week at a second facility, allowing the pharmacist to directly interface with the team via the use of audio and visual technology through a workstation on wheels. First- and second-shift tele-ICU pharmacists communicate patients needing follow-up via the electronic triage board and TheraDoc^® to ensure continuity of care. Although the dayshift model provides remote patient monitoring and a responsive mode of care, both synchronous and asynchronous communications are used. A timeline of the evolution of tele-ICU services and expansion of pharmacy services is displayed in Figure 2.

Figure 2.

Evolution of virtual critical care and telepharmacy services.

Note. ICU = intensive care unit.

Intervention Analysis

From September 2015 to July 2018 (34.5 months), more than 110 000 TheraDoc^® alerts were generated and 13 638 interventions were performed. More than 55 000 alerts were blood-glucose-related, 38 000 were electrolyte-related, and 21 000 were lactate-related. Although most of these interventions were completed for ICU patients across 12 facilities, several freestanding emergency departments, general medical floors, pediatric hospitals, and rehabilitation facilities were covered by BCID calls. Of the interventions routinely documented within the clinical surveillance system and reported quarterly on a routine basis (n = 13 527; excludes South Carolina interventions [n = 75] and BCIDs at facilities without routine coverage [n = 36]), the most common activity group was glucose management (36.1%), followed by medication management (20.3%), Code Sepsis evaluation (16.6%), BCID calls (11.6%), electrolyte management (9%), stress ulcer prophylaxis (5.1%), and venous thromboembolism prophylaxis (1.3%) (Figure 3).

Figure 3.

Alerts generated and interventions performed.

Note. Alerts received and interventions documented from September 15, 2015, to July 31, 2018. No alerts were generated for medication management, BCID calls, SUP, or VTE prophylaxis as interventions in these categories are stimulated by electronic medical record review or laboratory calls rather than alerts. BCID = blood culture identification; SUP = stress ulcer prophylaxis; VTE = venous thromboembolism.

Approximately 20% of interventions were performed at a single facility (Table 3). Of note, Facilities K and L are in South Carolina and do not have alerts supported by TheraDoc^®. Second shift only addresses issues at these facilities as requested by the VCC nurses or intensivists. Although TheraDoc^® alerts fire for Facility I, a quaternary care facility with 131 ICU beds, telepharmacy services are only provided when requested by VCC nurses or intensivists. This model was developed due to prioritization of care by telepharmacists to smaller facilities without robust critical care pharmacist support.

Table 3.

Pharmacist Coverage Model and Interventions by Facility.

Facility	Number of ICU beds	Routine TheraDoc® alert review	On-site dayshift critical care-trained pharmacist	VCC dayshift pharmacist coverage	Interventions n (%)
Facility A	18	Yes	No	Yes	2726 (20)
Facility B	30	Yes	Yes	No	1821 (13.4)
Facility C	14	Yes	No	Yes	1746 (12.8)
Facility D	10	Yes	No	Yes	1362 (10)
Facility E	16	Yes	No	Yes	1313 (9.7)
Facility F	49	Yes	Yes	No	1041 (7.7)
Facility G	8	Yes	No	Yes	981 (7.2)
Facility H	30	Yes	No	No	934 (6.9)
Facility I	131	No	Yes	No	829 (6.1)
Facility J	10	Yes	No	Yes	774 (5.7)
Facility K	11	No	Yes	No	58 (0.4)
Facility L	10	No	Yes	No	17 (0.1)

Note. Numbers displayed are total intervention numbers, resulting from both clinical surveillance alert review and electronic medical record review. Percentages are out of the total number of interventions. Interventions were performed between September 15, 2015, and July 31, 2018. ICU = intensive care unit; VCC = virtual critical care.

First shift performed 991 (7.3%) interventions and second shift performed 12 647 interventions (92.7%). First shift provided approximately 12 hours of coverage weekly for a 13-month period, whereas second shift provided 40 hours of coverage weekly for a 34.5-month period, resulting in a mean of 76.2 interventions per month on first shift and 367.6 interventions per month on second shift. Although most of second-shift activities are within the categories of glucose management and medication management, most of first shift activities are medication management and stress ulcer prophylaxis (Figure 4). As second shift began taking BCID calls, these became the second most common activity after glucose management interventions.

Figure 4.

Intervention activities per shift from July 2017 to July 2018 with both first and second shifts operating concurrently.

Differences by shift are speculated to be related to the difference in workflow and number of patients covered. Although second-shift chart reviews are guided by alerts, nursing or physician requests, and new patient admissions, first shift reviews all ICU-status patients at the selected facilities, providing more opportunity to generate medication management interventions at these facilities. In addition, as the dayshift pharmacist is often interfacing directly with the bedside provider or a pharmacy representative, more in-depth conversations may occur to determine the appropriateness of therapies such as stress ulcer or venous thromboembolism prophylaxis.

Overall, 71.5% of interventions (9755) were linked to TheraDoc^® alerts. Most of the dayshift pharmacist’s interventions (63.5%, 629 of 991) have not been linked to alerts, likely because of reviewing all ICU-status patients at select facilities rather than review being alert-driven. On second shift, excluding BCID interventions, 73.6% of interventions (4468 of 5949) were tied to alerts within that same timeframe.

Tele-ICU pharmacists at Atrium Health have demonstrated a reduction in average patient days with blood glucose greater than or equal to 180 mg/dL from 18.8% to 16.1% (P < .001), cost savings associated with prevention of adverse events, and increased identification and time-sensitive management of serum sodium correction in hyponatremia.^9-11

Medication Safety

Due to the variability in critical care pharmacist and physician coverage, progress toward system standardization, and the continually changing nature of critically ill patients, the tele-ICU pharmacist quickly established a role in medication safety. From September 2015 to July 2018, 594 adverse drug reactions (ADRs) were avoided based on pharmacist documentation. ADRs were defined as any undesirable response associated with the use of a drug that either compromises therapeutic efficacy, enhances toxicity, or both.¹⁶ As these ADRs were associated with medication errors (MEs), defined as any preventable event that may cause or lead to inappropriate medication use or patient harm, they are referred to as preventable ADRs.¹⁷ These should not routinely fall into other documentation categories, but the choice to document an ADR avoided is often a judgment call on the part of the pharmacist. In theory, reducing ADRs reduces patient harm and length of stay, resulting in improvement in patient quality of care and cost savings to the healthcare system.¹⁸ Many of these medication changes that resulted in the avoidance of an ADR included stopping, adjusting doses, or recommending alternate medications due to a change in patient condition (eg, stopping nephrotoxic drugs in the setting of acute kidney injury or withholding basal insulin in the setting of hypoglycemia).

Another high-risk condition where the tele-ICU pharmacist was found to have an impact was on hyponatremia management. Due to the high-risk nature of this condition and need for careful serum sodium correction, it was found that tele-ICU pharmacists could recommend close monitoring of serum sodium, interpret levels, and notify the tele-intensivists of overcorrection. Substantial variation was found in treatment and monitoring.¹⁰ This information was used to support the approval of system-wide 3% sodium chloride order sets that use weight-based dosing and frequent sodium monitoring to provide conservative sodium corrections. A total of 98 hyponatremia interventions have been performed from September 2015 to July 2018.

Value on Investment

To date, a formal return on investment analysis has not been conducted on telepharmacy services within this healthcare system. With an extended number of beds covered with VCC growth, telepharmacists were not able to replace the need for a swing shift physician. Expansion into first shift was the result of a faculty member changing practice sites and of no financial consequence to the healthcare system. Internal estimates of $1150 per ADR avoided alone would be realized as a cost-avoidance of $237 600 annually.

On second shift, an analysis was conducted to determine pharmacist impact on physician workload optimization. In 2017 and 2018, a total of 4786 requests were placed on the electronic triage board. Each request could contain multiple interventions. Over a total of 505 worked days, this resulted in an average of 9.48 requests per shift. Each request was valued at 10 minutes of physician time to complete (average of 5-15 minutes). This represents 95 minutes of physician time reallocated during peak admission hours, which contributed to efficiency of physician workflow and minimized or eliminated the need for physician EMR review. In addition, although difficult to quantify, benefits exist to telepharmacists identifying clinical concerns outside of bedside requests, providing drug information and performing medication safety interventions. The impact of these telepharmacy services on satisfaction of bedside physicians, nurses, and pharmacists and VCC nurses and intensivists has also not been evaluated.

Barriers to Implementation and Challenges Encountered

Barriers identified to the implementation and expansion of telepharmacy services included justifying the cost of additional pharmacist staff, obtaining buy-in from leadership, tele-ICU, and bedside providers, and the cost of CDSS software and other technology resources. Expanding the type and complexity of interventions provided by the telepharmacist has been limited by the patient census to telepharmacist ratio. There is an ongoing effort by VCC intensivist leadership and telepharmacy to provide feedback to the facilities covered on the types of interventions provided with the goal of increasing facility accountability, especially in the areas of glycemic control and electrolyte management. Reducing the number of these interventions provided by telepharmacists would provide time for expanded patient review and additional interventions, such as an increased focus on pain, agitation, and delirium management.

Challenges that arose after go-live included optimizing alerts and determining which situations warranted bedside pharmacist or physician contact. Another challenge to implementation was adapting to various intensivist and facility preferences. The ICU telepharmacists currently collaborate with 82 intensivists across the healthcare system and around the globe, which provides a variety of different perceptions and practices. A final challenge is prioritization of workflow during periods of high census or high acuity.

Dayshift has its own set of challenges. The biggest challenge is determining optimal avenues for intervention delivery and integration with the bedside multidisciplinary teams. As many sites the dayshift pharmacist follows do not have a dedicated critical care trained pharmacist that rounds daily, integrating the tele-ICU pharmacist into this model remains an ongoing endeavor. Another challenge includes intervention documentation as the intervention recommended may not be implemented immediately. Thus, follow-up may be needed by the second-shift pharmacist.

Implementation Considerations

There are several ways in which pharmacists may become involved when facilities are considering implementing telepharmacy services. Review your current physician processes and determine how much time is spent on tasks that could be delegated to a pharmacist. Pharmaceutical expenditures and processes should be examined to determine whether there are any high-cost medications that may benefit from additional pharmacy oversight or processes that may improve patient outcomes, including ABCDEF bundle adherence,¹⁹ and identify opportunities for improvement of core measure compliance. If ASP is not available, this may be a suitable first step. Once target activities are developed, evaluate the workflow of current pharmacy staff to determine whether cross-coverage of other facilities is feasible. If additional staff is not able to be hired initially, data collection and support for the program can begin as a resident project or be conducted by specialized overnight staff. Communication capabilities should be assessed and the best avenues for delivering and documenting interventions should be determined. Tele-ICU pharmacy metrics should be identified and a schedule for reporting to leadership should be outlined. Ongoing assessment and refinement of the program should be performed.

In addition, regulatory issues should be considered when implementing a telepharmacy practice. Compliance at a federal level with the Health Insurance Portability and Accountability Act (HIPAA), subtitle D of the Health Information Technology for Economic and Clinical Health (HITECH) Act, and Food and Drug Administration Standards for medical software, equipment, and mobile applications is necessary.⁶ Many states also have telepharmacy regulations; however, there is significant variation in scope, definitions, and requirements. The National Associations of Boards of Pharmacy’s Pharmacy Practice Model Act (Model Act) includes definitions of the practice of telepharmacy and pharmacist care. The Model Act provides states with framework for developing laws or board of pharmacy rules, although it primarily focuses on requirements for remote dispensing sites.²⁰ At a minimum, the telepharmacist must be licensed in each state in which the patient they are caring for is located. They should be credentialed by institutions, if applicable. The states in which these telepharmacists practice do not yet have specific telepharmacy regulations, however, it is anticipated that these will be implemented in the future as telepharmacy continues to expand.

Future Directions

When this telepharmacy program was implemented, Clinical Pharmacist Practitioners (CPPs), licensed pharmacists able to provide drug therapy management under the supervision of a licensed physician in North Carolina, were not ardently promoted in the inpatient setting.²¹ The lack of standardized protocols and preferred formulary agents across these sites, the number of VCC and bedside physicians that would need to sign these agreements, and the certification and practice requirements for pharmacists did not make the CPP route feasible at implementation. Since the inception of VCC services, all pharmacists practicing at ambulatory clinics within the health care system have become CPPs. An exploratory committee has been created to explore the role of CPPs in the inpatient setting, with members currently obtaining buy-in from key stakeholders across the health care system. Reciprocal interest has been expressed in using the emergency department and tele-ICU pharmacists as part of the initial roll-out of CCPs in the inpatient space.

This telepharmacy program hopes to expand the number of pharmacists on the team and shifts covered, with the ultimate goal of 24/7 coverage. An expanded virtual rounding presence to all facilities without daytime critical care-trained pharmacists is also desired. The telepharmacists also hope to conduct additional research and quality improvement projects, particularly in the areas of pain, agitation, and delirium, fluid balance, and acute kidney injury.

Conclusions

This tele-ICU program is innovative for several reasons. To our knowledge, it is one of the only entirely clinical-based tele-ICU pharmacy models among the few tele-ICUs across the United States with pharmacy integration. The addition of dayshift tele-ICU coverage is also a distinctive feature. Although many of tele-ICUs focus on a single facility, this model serves a large and diverse patient population across critical access, community, and tertiary facilities and 1 quaternary medical center across 2 states. The use of technology for customized alert generation and intervention proposal and management is unique. In addition, the tele-ICU pharmacist is responsible for medication orders and chart notation, which are not routinely performed by pharmacists outside of ambulatory settings under collaborative practice agreements. This program was initiated with several anticipated benefits to the healthcare system: an increased amount of tele-ICU intensivist time available for new admissions, cost savings, and provision of critical care pharmacy services to improve patient care, promote medication safety, and achieve benchmarking goals.

Tele-ICU pharmacists employ limited resources to provide critical care pharmacy expertise to multiple sites within a health care system, often during non-traditional hours, with documented clinical and financial benefits. Communication with tele-ICU and bedside providers, including pharmacists, is necessary to implement recommendations and improve continuity of care. Further study is needed to determine the impact of tele-ICU pharmacists on morbidity and mortality. Individual institution and health-system needs should be addressed to optimize the role of the telepharmacist.