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JT is a 47-year-old man who was admitted into the neuroscience intensive care unit (ICU) after sustaining traumatic brain injury in a motorcycle accident. His Glasgow coma score was five, and he required intubation and an intraventricular catheter to monitor and manage intracranial hypertension. After three days of hospitalization, he became agitated and pulled out the intraventricular catheter. At the time the catheter was removed, JT was receiving a continuous intravenous (IV) infusion of propofol at 10 mcg/kg/min and fentanyl citrate at 25 mcg via IV boluses as needed. No fentanyl citrate boluses had been administered within 12 hours of the event. Looking in retrospect at the patient's chart, it was noted that his level of sedation was not documented consistently on the nursing flowsheet. The prescriber's orders for sedation read propofol 5 mcg/kg/min, titrate to sedation.
Circumstances like JT’s were not uncommon in the neuroscience ICU. During the next two weeks, two other incidents occurred in which patients were over-sedated or under-sedated, resulting in situations of similar magnitude. These events prompted further investigation, which identified several inconsistencies with the sedation practices in all the hospital's ICUs. The critical care pharmacist's prompt identification of these management breakdowns coupled with the coordination of a multiprofessional team intervention facilitated quality improvement in the ICU.
Critical care clinical pharmacists can be referred to as walking personal digital assistants (PDAs) because of the unique and extensive pharmacologic and pharmacokinetic backgrounds required of them when serving as part of the healthcare team in the ICU. Clinical pharmacists, however, are more than that. They provide pharmacologic expertise, important clinical perspective and therapeutic judgment beyond the capabilities of any medical software program.
Over the last several decades, the role of the critical care pharmacist has been defined more clearly; however, some members of the ICU team still may ask questions.¹ Where exactly does a pharmacist fit in on the multiprofessional critical care team? How does the pharmacist integrate individual patient care and clinical responsibilities with the more traditional role of drug dispenser?
The investigative process in the above example began with a thorough review of published literature focusing on evidence-based strategies for the provision of sedation and analgesia. Deviations from the standard of care were recognized by evaluating practice guidelines published by the Society of Critical Care Medicine (SCCM).² Breakdowns can be identified when:
- No guidance is provided to the prescriber related to the selection of sedative or analgesic therapy. - An inadequate level of sedation is administered.
- Documentation regarding the level of sedation is omitted.
- The sedation scale used on nursing flowsheets is invalid.
- The sedation endpoint in the prescriber’s order is absent.
- A pharmacist’s direct involvement in bedside rounds is lacking.
As part of the team, the critical care pharmacist was instrumental in coordinating the activities to rectify these issues. A sedation and analgesia protocol was developed to provide guidance regarding sedative and analgesic choices based on patient-specific characteristics and length of sedation. The ICU pharmacists were in a position to educate nursing and medical staffs regarding the intent and utilization of these guidelines. Nursing education was initiated to address the appropriate assessment of sedation. The importance of documenting the level of sedation was re-emphasized to nurses, and the sedation scale was changed from the Ramsay scale to the ICU-validated motor activity assessment scale (MAAS). Pharmacists participated in bedside rounds with the ICU team, providing the perfect opportunity for them to integrate these new principles into the plan of care for patients. Physician education further stressed the need to address analgesia in conjunction with sedation and to specify the desired level of sedation based on the MAAS scale. Standard prescription orders also were developed, streamlining the process and minimizing deviations from protocol.
Follow-up evaluation of sedation management in this particular ICU has resulted in a drastic improvement in patient outcomes. To maintain this level of consistency, the entire team must reinforce appropriate patient care practices.
By partnering with other members of the ICU team, pharmacists are able to expand on the traditional role of dispensing drug information support. In 2002, SCCM published a position paper by M. Rudis and K. Brandi in Critical Care Medicine which provided a detailed description of the scope of critical care pharmacy practice and service.³ Pharmacists can assist the critical care team in effective and safe drug utilization by coordinating the development and implementation of drug therapy protocols or guidelines. Implementing guidelines is one of the many opportunities a clinical pharmacist has to give input on drug therapy, provide pharmaceutical care, manage resources, optimize medication-related outcomes and improve the safety and quality of care in critically ill patients.
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