Incorporating pharmacists into the ICU team

Similar to many hospitals in the country, Robert Wood Johnson University Hospital Hamilton in Hamilton Township, N.J., had just one critical-care pharmacist working in its intensive-care unit. That changed about two years ago.

Liza Andrews rounded on the 20-bed unit a few times a week and the remaining hours were filled by general pharmacists working remotely who did their best to solve routine prescription problems happening on the floor. Andrews would often receive calls from nurses who needed advice on her days off.

“The pharmacist in the satellite didn’t feel comfortable making specific recommendations,” Andrews said.

The result was disjointed care. ICU patients would experience changes to their drug regimen when Andrews came in after the weekend because she saw unaddressed problems after reviewing their charts and rounding on the floor. That’s because Andrews has expertise that general pharmacists don’t have. Critical-care pharmacists receive training on how to treat critically ill or injured patients who need specific pharmaceutical interventions to manage both their main condition and underlying health concerns like high blood pressure or poor nutrition.

ICU patients “are some of the most complex patients in the hospital and they have a lot of chronic disease and chronic medications they are on so there is a lot of consideration that has to be taken when it comes to medications,” Andrews said.

Interested in changing the approach, Andrews asked leadership in late 2016 if the hospital could hire another critical-care pharmacist. Her proposal was rejected for budgetary reasons. So she instead asked if she could train the hospital’s general pharmacists during their usual shifts. Leadership agreed. Andrews called the resolution “a compromise.”

Critical-care pharmacy as a specialty is relatively new and until recently wasn’t board-certified. Rather, most pharmacists received on-the-job training in critical care. Tight budgets at hospitals is another reason why hospitals don’t employ the specialists. Pharmacists with critical-care expertise are typically paid more than a general pharmacist. Furthermore, hospitals aren’t required by regulators to have pharmacists specialized in critical care working in the ICU.

Three experienced general pharmacists who already worked on the ICU took up Andrews’ offer. “I enjoyed working in the ICU and I liked being part of the team,” said Penny Wasylyk, a pharmacist for more than 30 years who took the training at RWJ University Hospital Hamilton.

Over the course of six months, Andrews taught the pharmacists skills needed to be adept in critical medicine. The pharmacists learned at the bedside and through one-on-one meetings. The lessons highlighted common diagnoses in the ICU and how those conditions as well as devices might interact with pharmaceuticals. The students would follow Andrews on rounds so they could see specific cases and how they should be addressed.

Wasylyk said the hardest part of the training was learning how to physically evaluate a patient. Her general pharmacy training didn’t include those skills in-depth. After her training, Wasylyk received her board certification in pharmacotherapy. Her shifts now include rounding on the ICU floor with the clinical team. “You just feel more connected to the team and to the patient and able to make better decisions,” she said.

Andrews made sure the ICU team incorporated the newly trained pharmacists into the team. If a nurse asked to speak with Andrews when she wasn’t on call, she directed her to a newly trained pharmacist who was working.

A survey of 29 ICU team members at the hospital found all agreed that the critical-care pharmacist enhanced care. Most team members also said continuity of pharmaceutical care had improved. Andrews no longer scrambles on Monday mornings to change drug regimens.

“A lot of the gaps or problems we see would get nipped in the bud,” she added.

RWJBarnabas Health wants to expand the program to its 10 other hospitals.