From dispensary to bedside and beyond: the evolving role of the intensive care unit pharmacist

The Society of Hospital Pharmacists Australia (SHPA) Standard of Practice in Intensive Care for Pharmacy Services published in this issue1 builds on and expands the SHPA’s previous practice standard published in 2008.2 This Standard of Practice also represents the evolution of the hospital pharmacist’s role, from drug dispensing to being a key member of the multidisciplinary clinical team committed to the improvement of healthcare outcomes. This role is of particular importance in the intensive care setting where critical illness – with multiorgan dysfunction and metabolic derangements together with pre-existing comorbidities and intrusive therapeutic strategies – has a complex and dynamic effect on drug pharmacokinetics and pharmacodynamics. The Standard of Practice sets out to define the scope of services provided and the role of the pharmacist in both the intensive care unit (ICU) and the paediatric ICU (PICU), including recommendations for staffing levels, competencies, credentialling and professional development, with the aim of describing current best practice. The ever-increasing number of new drugs prescribed in the community and the time-critical nature of intensive care practice add to the risk of dangerous drug interactions, as well as prescribing and administration errors. The role of the ICU pharmacist has been repeatedly shown to reduce the adverse effects arising from poor practice in relation to drug prescription and administration, to improve patient outcomes and to reduce healthcare costs.3 The ICU pharmacist is an important resource for medical and nursing staff, giving guidance and oversight on drug management, including contexts where robust evidence and guidelines for dose adjustment are, at best, rudimentary. These include renal replacement therapy and other extracorporeal strategies, as well as extreme obesity. The ICU pharmacist is also invaluable for providing advice on medications unfamiliar to the average intensive care clinician, such as those prescribed for oncological and immunological conditions. The scope of practice of the ICU pharmacist is not just limited to drug management. It often includes an active role in ward rounds, the parenteral nutrition team, antibiotic stewardship, staff and patient education, audits and research, and unit governance with protocol, policy and evidence-based guideline development. Additional services suggested by the Standard of Practice include participation in rapid response team calls, advanced life support and post-ICU follow-up and outreach. Inclusion of pharmacists as participants in courses such as ALS and BASIC is a logical extension. The Standard of Practice makes wide-ranging recommendations addressing the role of both the pharmacy service in ICU and PICU and that of the ICU pharmacist as a healthcare professional. The recommendations for the latter relate to domains of practice including clinical competency, professional and ethical behaviour, and communication and collaboration. The Standard also addresses the important issue of wellbeing and the need for the awareness and prevention of workplace stress and burnout. It is noteworthy that the current College of Intensive Care Medicine document on minimum standards for intensive care units (IC-1)4 stipulates access to a 24 h pharmacy service but does not specifically mention the pharmacist as part of the multidisciplinary ICU team, an obvious omission. The publication of this Standard of Practice is timely, as a working party with representation from all intensive care craft groups has recently been established to determine minimum standards for staffing in intensive care. This Standard of Practice in Intensive Care for Pharmacy Services may not currently be met by all units, and may not even be achievable in the foreseeable future; certainly, however, they are aspirational and to be given consideration in ICU workforce planning. Achieving excellence in patient outcomes in ICU and PICU is dependent on a high-functioning multi-disciplinary team, and this includes recognition and acknowledgement of the diversity of the role of the intensive care pharmacist, utilisation of the expertise this role brings to the team, and inclusion in interdisciplinary educational, cultural and wellbeing initiatives. The authors declare that they have no conflicts of interest.