|Year : 2020 | Volume
| Issue : 2 | Page : 66-72
Critical care pharmacy services in the Western Region of Saudi Arabia
Ohoud A Aljuhani
Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
|Date of Submission||14-Jan-2020|
|Date of Decision||03-May-2020|
|Date of Acceptance||09-May-2020|
|Date of Web Publication||1-Jul-2020|
Ohoud A Aljuhani
Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, P. O. Box: 80260, Jeddah 21589
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
Background: The value of critical care pharmacists (CCPs) in intensive care units (ICUs) has been well documented, and various studies have demonstrated the positive impacts of CCPs. Despite growing evidence supporting the contributions of clinical pharmacists in general and CCPs in particular in improving patient outcomes, many hospitals in the Kingdom of Saudi Arabia (KSA) still lack clinical pharmacy services. Most studies that have measured the impacts of CCPs in ICU settings have been conducted outside Saudi Arabia, with a significant gap in the literature related to CCP-related impacts, needs and obstacles in Saudi Arabia. Objective: To evaluate the current status of CCP services and the CCP services that are needed in Saudi Arabia as well as the barriers to establishing these services. Setting: Governmental and non-governmental hospitals in the western region of the KSA. Method: This was a cross-sectional survey-based study conducted in the western region of the KSA. The questionnaire included questions investigating current CCP services, which include clinical, educational, administrative and research services. Additional questions assessed the obstacles, needs and limitations related to the development of CCP services. Main Outcome Measures: The primary outcome is to describe the current status of ICU pharmacists in the KSA. Secondary outcomes of interest are the evaluation of the need for CCP services and the identification of the main barriers to establishing these services. Results: Of the 130 hospitals with ICUs to which surveys were emailed, 94 (72%) responded. Forty-three percent of responding hospitals had an ICU multidisciplinary team structure that included a pharmacist who visited the unit during medical rounds. Up to 54% of the hospitals with CCP services had one dedicated pharmacist present at bedside and during medical rounds. Approximately 78% of the ICU pharmacists performed one or more clinical activities. Training pharmacy interns was one of the major educational activities provided by ICU pharmacists. Clinical services (42%) were the most needed services, followed by educational (14%) activities. Limited job availability was the main barriers to having CCP services among hospitals. Conclusion: Critical care pharmacists in the western region of the KSA mainly provide fundamental clinical services, with limited engagement in desirable and optimal services such as research activities. The limited CCP services in the KSA are due to several barriers that warrant national efforts from the Ministry of Health (MOH) and the Saudi Commission for Health Specialists (SCFHS).
Keywords: Clinical pharmacist, critical care, intensive care units, Saudi Arabia
|How to cite this article:|
Aljuhani OA. Critical care pharmacy services in the Western Region of Saudi Arabia. Saudi Crit Care J 2020;4:66-72
| Introduction|| |
Clinical pharmacy is relatively well developed in the Kingdom of Saudi Arabia (KSA), especially in tertiary care hospitals and to a lesser extent, in the Ministry of Health (MOH) hospitals. The clinical pharmacy has recently been expanded, with an increasing number of pharmacy schools and residency training programs. However, most MOH hospitals still utilize the satellite pharmacy concept, in which the intensive care units (ICU) pharmacy is located outside the ICU. Satellite pharmacies enable the immediate delivery of pharmaceutical care to medical and critical patient care areas with a limited presence of pharmacists at the bedside. In contrast, in some specialty tertiary centers in KSA, clinical pharmacists have established their presence and impact in areas such as adult and pediatric oncology, solid organ transplant, ambulatory care, adult surgical and medical intensive care, neonatal intensive care, nephrology, internal medicine, anticoagulation, cardiology, pain management, drug information, and infectious diseases.
A landmark study published in JAMA found that including a pharmacist in patient care rounds with subsequent availability throughout the day led to a 66% reduction in preventable adverse drug events (ADEs) by prescribing physicians. The value of critical care pharmacists (CCPs) in ICUs has been well documented, and various studies have demonstrated the positive impacts of CCPs., Most studies have shown that CCPs play a significant role in reducing medication errors, improving patient outcomes, reducing medication costs, and decreasing mortality rates among patients with various diseases or infections. One study examined whether the absence or presence of clinical pharmacists in ICUs resulted in differences in mortality rates, the length of ICU stays, and ICU charges for Medicare patients with infections. The study found that the involvement of clinical pharmacists in the care of critically ill Medicare patients with infections was associated with improved clinical and economic outcomes. The study recommended that hospitals should consider employing clinical ICU pharmacists.
A review investigated the literature about pharmacists' contributions within a multidisciplinary ICU team. The review concluded that pharmacists have positive impacts on fluid management and contribute to substantial reductions in the rates of ADEs, medication administration errors, and ventilator-associated pneumonia. The CCPs' activities have been well defined based on the recommendations from the Society of Critical Care Medicine and the American College of Clinical Pharmacy (SCCM/ACCP). These organizations define critical care pharmacy services as fundamental, desirable, and optimal services. Fundamental activities are defined as having ICU pharmacists dedicated to critical care patients, with few commitments outside the ICU area. Desirable activities require an ICU pharmacist to regularly make rounds as a member of the multidisciplinary critical care team (if available) to provide pharmacotherapeutic management for all ICU patients. Optimal activities are considered when the ICU pharmacist assists physicians in discussions with patients and family members to help make informed decisions regarding treatment options. Per SCCM recommendations, these activities include but are not limited to “the pharmacist prospectively evaluating all drug therapy for appropriate indications, dosage, drug interactions, and drug allergies and the pharmacist regularly making rounds as a member of the multidisciplinary critical care team to provide pharmacotherapeutic management for all ICU patients.
Landmark trials on ADEs that were conducted in ICUs found high rates of ADEs, with approximately 6.5 ADEs for every 100 ICU admissions. Most of these errors occurred during the prescribing phase, and the estimated cost for each ADE ranged from 6000 to 9000 dollars., These errors could be prevented by having an ICU pharmacist who reviews medication prescribing in rapid-paced environments. A study conducted in a cardiac ICU in King Faisal Specialist Hospital and Research Center in Riyadh evaluated pharmacists' interventions. It concluded that the participation of clinical pharmacists in daily multidisciplinary team rounds in an ICU setting significantly reduces unfavorable morbidities and enhances therapeutic outcomes. Another study conducted to evaluate the clinical outcomes of pharmacist interventions at critical care services of a private hospital in Riyadh City, Saudi Arabia. This study concluded that the clinical pharmacist prevents the occurrence of drug-related problems in addition to saving additional economic burden on the health-care system.
Despite the growing evidence supporting the contributions of clinical pharmacists in general and CCPs in particular in improving patient outcomes, many hospitals in the KSA still lack critical care pharmacy services. Most studies that have measured the impacts of CCPs in ICU settings have been conducted outside of Saudi Arabia, showing a significant gap in the literature on CCP-related impacts, needs, and obstacles in Saudi Arabia.
Aim of the study
The main objectives for this study were as follows: (1) To evaluate the current status of CCP services and (2) To determine the CCP services that are needed in Saudi Arabia as well as the barriers to establishing these services.
| Methods|| |
Study design and setting
This was a cross-sectional survey-based study conducted in the Western region of Saudi Arabia. Hospitals that had ICUs were extracted from MOH records and verified by site visits to the regional office of the MOH in Jeddah, Saudi Arabia.
The survey questions were constructed based on the recommendations of the position paper on critical care pharmacy services that were prepared by SCCM and ACCP. Other survey questions were based on the recommendations for training, credential, and critical care pharmacy services justifications in the opinion paper.
All survey questions were closed-ended and required the respondent to check a response box. The survey draft was reviewed by an expert ICU pharmacist with >10 years of experience who has conducted multiple survey-based studies. The survey was pretested on a small set of hospitals. The questions were modified according to the suggestions and comments. The final survey format of general and service-specific questions was sent to the hospitals verified by MOH records. An electronic version of the survey was developed utilizing Google forms, and the survey link was sent to the ICU directors of the hospitals with a script highlighting the importance of the survey, confidentiality, and agreement to participate in the survey. The distribution of the survey occurred in October 2018, and the last survey response was received in January 2019.
Questions on general hospitals and ICU pharmacists' information used in this study included questions about hospital categories, ICU type, average ICU bed capacity, ICU team members, availability of ICU pharmacists, number of dedicated ICU pharmacists and their credentials, and average working hours for ICU pharmacists, as shown in section A of [Appendix 1]. The questionnaire included questions investigating current CCP services, such as clinical, educational, administrative, and research services, as shown in section B of Appendix 1. Additional questions identifying the obstacles and determining the needs and limitations related to the development of CCP services were included.
Each response was analyzed using descriptive statistical analysis with numbers and percentages by utilizing IBM SPSS Statistics for Macintosh, Version 25.0 (IBM Corp., Armonk, NY).
Ethical approval was not obtained based on no risk for participants in this survey. Furthermore, no confidential data were collected. STROBE checklist was followed in conducting this study.
| Results|| |
Of the 130 hospitals with ICUs that were E-mailed the surveys, 94 (72%) hospitals responded.
A total of 75 (80%) of these hospitals were MOH hospitals (governmental), and only 19 (20%) were non-MOH hospitals (non-governmental). The most common ICU types were medical and cardiac (57% each). More than half of these hospitals had more than one ICU (57%), with an ICU bed capacity ranging from 10 to 15 beds. A total of 28% of the hospitals had physicians, nurses, and respiratory therapists as the main ICU team members, and 28% of the hospitals had dietitians in addition to physicians, nurses, and respiratory therapists. Forty-three percent of responding hospitals had an ICU multidisciplinary team structure that included a pharmacist who visited the unit during medical rounds, as shown in [Table 1].
ICU pharmacist information
A total of 54 (57%) of the hospitals did not have CCP services, and only 40 (43%) of the hospitals had CCP services. Direct pharmacy services in ICUs were defined as one or more dedicated ICU pharmacists who devoted most of their time to the ICU. Furthermore, 21 (54%) of the hospitals with CCP services had one dedicated pharmacist present at bedside and during medical rounds. Of the hospitals surveyed, 13 (32.4%) had indirect pharmacy services, which engaged one pharmacist or more visiting the ICU during rounds. Indirect ICU pharmacists mainly performed medications review; then, they are involved in other inpatient pharmacy duties outside the ICUs. Only 5 (13.5%) of the hospitals had two dedicated pharmacists in the ICU providing direct patient care, which involved the availability of the pharmacist as an integral part of the ICU team during medical rounds. Direct patient activities were considered part of clinical services and included evaluation of drug therapy to all ICU patients for appropriate indications, dosage, drug interactions, drug allergies, and pharmacokinetic monitoring. The majority of pharmacists 18 (44.4%) working in these ICUs had Doctor of Pharmacy degrees (Pharm. D.), followed by 9 (22.2%) of pharmacists with a Bachelor of Science degree in pharmacy with >3 years of clinical experience. Only 9 (22.2%) of the pharmacists had residency training in clinical pharmacy, and 7 (16.7%) had fellowship training. Approximately 21 (52.6%) of ICU pharmacists spent >8 h working in the ICU per day involving in patient care, with only 1 (2.6%) spending <8 h in ICU pharmacy services, as presented in [Table 2].
Pharmacists in the ICUs provided a wide variety of clinical services. Approximately 31 (78%) of the ICU pharmacists performed one or more clinical activities, and 37 (92%) of the respondents performed most of the pharmacy clinical activities. Reviewing drug–drug interactions accounted for the highest percentage of activity type 10 (24%), as shown in [Table 3].
A total of 25 (61%) of ICU pharmacists participated in the training of pharmacy interns, and 23 (58%) were involved in educational seminars for ICU staff. Involvement in other educational activities was minimal and accounted only for 1 (2.6%).
The majority of responding hospitals 24 (60%) had ICU pharmacists who were engaged in administrative activities. Approximately 31 (76.3%) of the pharmacists were involved in updating and developing ICU treatment protocols, and only 14 (34%) have active involvement in the pharmacy and therapeutic committee.
More than half (58%) of the CCPs were involved in research activities, particularly evaluation of medication use. Forty-eight of pharmacists participated in the performance of ICU clinical trials, and only 13 (32%) of pharmacists had active involvement in case reports and case series.
Critical care pharmacist services needs
Ninety-six percent of the 54 hospitals without CCP services agreed that they had a high need for ICU pharmacists. Twenty-two (41%) of responding hospitals believed that they were in high need of ICU pharmacists all four categories of services (clinical, educational, administrative, and research services). Clinical services were the most needed services (42%), followed by educational (14%), administrative, and research services, which accounted for 8% each. Within each of the services categories, hospitals rated the highest needed type of activities, as shown in [Table 4].
Barriers to critical care pharmacist services
Almost half (49%) of the responding hospitals referred to limited job availability as one of the main barriers to having CCP services. Other reasons were also reported, such as lack of required experience and the proper credentials (20% and 14%, respectively).
| Discussion|| |
As of July 2019, this was the first survey to describe the current status of CCP services in the western region of the KSA. The major findings include several points. CCPs are mainly involved in clinical services and administrative activities followed by educational activities, but they are less frequently involved in the research conducted in ICUs. Referring to the position paper from 2000 that was published by SCCM/ACCP, most of the current CCPs working within the Western region's hospitals of KSA offer fundamental activities. ICU pharmacists provide optimal and desirable activities to a lesser extent.
In this study, we found that 92% of ICU pharmacists are involved in clinical activities and have limited engagement in ICU research activities compared to the other types of services. This finding is consistent with the results of MacLaren et al.,(2006) were they found that ICU clinical pharmacy activities were the most frequently performed services (62.2%). Furthermore, MacLaren et al. reported that less than half of the ICU pharmacists were involved with research (scholarly) activities.
Only 22.2% of pharmacists practicing in ICUs have specialized residency training. This shortage could be explained by the limited availability of the practice sites. There are only three sites in the KSA providing critical care pharmacy residency training as per the Saudi Commission of Health specialist (SCFHS) last reports. On the other hand, there are over 150 positions of specialized pharmacy residency in critical care in the United States as per the last American Society of Hospital Pharmacy (ASHP) reports.
There are several limitations to this study. The data were self-reported by the respondent hospitals with no means to verify them. Although the response rate was high, caution should be used when extrapolating the results to other hospitals in different geographical areas or non-ICU pharmacy services. Some questions had inconsistent responses due to respondents' differing interpretations of the questions, and these differences may be difficult to assess. Furthermore, we were unable to document more detailed information about the responding hospitals, such as the number of job vacancies for ICU pharmacists, whether the hospital had a practice site or any plan for it to become a practice site for ICU pharmacy residents, and the number of US-trained versus nationally trained clinical pharmacists in critical care settings. A comparison between governmental and nongovernmental hospitals in terms of CCP services would be of great interest. However, this comparison was limited by the unavailability of data for such a comparison. Additional studies are needed to compare the status of clinical pharmacy practice in Saudi Arabia, especially in the ICU setting, before and after the expansion of the clinical pharmacy concept in the KSA. In addition, studies are needed to assess the economic outcomes and the benefits of adding ICU pharmacists to the practice sites in KSA.
| Conclusion|| |
CCPs in the western region of the KSA mainly provide fundamental clinical services, with limited engagement in desirable and optimal services such as research activities. The limited CCP services in the KSA are due to several barriers that warrant national efforts from the MOH and SCFHS to increase the number of training sites and the availability of ICU pharmacists' jobs. Future efforts by expert ICU pharmacists and researchers in the region are needed to conduct more training programs and larger nationwide studies to overcome some of these barriers.
The authors would like to thank the Doctor of Pharmacy students L. Moumenah, M. Alaklouk, and M. Baghdadi for their help with the survey data acquisition.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]