Table 1.
Key Knowledge Gaps to Critical Care Pharmacist Staffing Model Optimization and Strategies to Overcome Them
| Rationale | Potential Resolution Strategies |
|---|---|
| Mechanism(s) of how CCP activities improve patient outcomes are not clear | |
| • Unknown relationship of CCP activities to incremental improvements in patient outcomes (eg, renal dose adjustment in the ICU is counted via intervention tracking, but the effect on patient outcome is unknown) | • Increased research focus on measurement of ICU patient outcomes and evaluation of CCP impact in 2 distinct areas: direct patient care and indirect quality improvement activities37,41 |
| No standard/efficient method to characterize day-to-day CCP productivity | |
| • Cannot reliably predict the amount of CCP time spent per intervention, how many interventions a particular ICU patient will require, or whether an intervention with a potential clinical benefit (eg, preventing drug-drug interaction) will actually contribute to beneficial outcomes • Productivity tracking is dependent on the CCP’s efforts to individually record and appropriately classify each intervention.42-44 |
• Internal and external benchmarking across institutions • Investigating the relationship of CCP responsibilities to quality of interventions to predict what type of responsibilities are reasonable within a shift |
| Current methods to track CCP value are limited | |
| • Intervention tracking captures direct patient care activities but does not capture other indirect activities (eg, protocols, education) that likely prevent the need for direct “interventions.” • Value tracking supports the value of pharmacist services, but substantial limitations are present, notably the difference between cost avoidance and cost savings and low-quality data.45-48 The metric of “cost avoidance to pharmacist salary” may have more quickly diminishing ROI than using patient-centered outcomes (eg, length of stay). |
• Real-time documentation of CCP interventions that occurs concurrently with patient care and includes both direct and indirect interventions • While tracking the value of CCPs is essential for staffing justification, more robust foundational data and not “widget counting” are needed to lay the groundwork for more comprehensive and reliable evaluations of the holistic nature of clinical pharmacy services. |
| The potential for CCP workload to result in pharmacist burnout not considered | |
| • Practice models do not account for the high practice standards set by guidelines and may contribute to CCP BOS, which has higher prevalence across the whole critical care discipline and contributes to worse patient safety outcomes.29,49-52 | • Investigation of factors associated with CCP BOS (eg, lack of off-service time, vacation coverage, patient volume)50,53 • The link between CCP practice models, CCP-to–ICU patient ratios, ICU patient outcomes, and BOS requires exploration. |
| Limited ability to compare CCP practice models among institutions | |
| • No universal ICU pharmacy practice model can exist given the unique nature of each ICU and each institution (ie, there is no “one size fits all”) • Although scores like APACHE III and case-mix indices can provide general comparisons, the nature of the ICU patient population, specialty or focus area of the institution, geographic region, institution size, and other factors can lead to comparisons “between apples and oranges” when discussing the correct CCP-to–ICU patient ratio.54,55 |
• Development of pharmacy-specific metrics to “match” ICUs for more direct comparisons • Development of general standards regarding pharmacist-to–ICU patient ratio and staffing models (eg, evenings, weekends)4,56,57 |
| Lack of validated predictive metrics to define CCP resources | |
| • Tools have been derived to help predict workload for central pharmacy staffing but do not address the complexities of ICU patients and have significant limitations for objective measurement of pharmacy personnel allocation (Table 2).58-61 | • Development of a universally accepted and validated metric for productivity |
Abbreviations: APACHE, Acute Physiology and Chronic Health Evaluation; BOS, burnout syndrome; CCP, critical care pharmacist; ICU, intensive care unit; ROI, return on investment.