Economic evaluations of adult critical care pharmacy services: a scoping review.

OBJECTIVES: To summarise the extent and type of evidence available regarding economic evaluations of adult critical care pharmacy services in the context of UK practice. METHODS: A literature search was conducted in eight electronic databases and hand searching of full-text reference lists. Of 2409 journal articles initially identified, 38 were included in the final review. Independent literature review was undertaken by two investigators in a two-step process against the inclusion and exclusion criteria; title and abstract screening were followed by full-text screening. Included studies were taken from high-income economy countries that contained economic data evaluating any key aspect of adult critical care pharmacy services. Grey literature and studies that could not be translated into the English language were excluded. RESULTS: The majority were before-and-after studies (18, 47%) or other observational studies (17, 45%), and conducted in North America (25, 66%). None of the included studies were undertaken in the UK. Seven studies (18%) included cost-benefit analysis; all demonstrated positive cost-benefit values for clinical pharmacist activities. CONCLUSIONS: Further high-quality primary research focussing on the economic evaluation of UK adult critical care pharmacy services is needed, before undertaking a future systematic review. There is an indication of a cost-benefit value for critical care pharmacist activities. The lack of UK-based economic evaluations is a limitation to further development and standardisation of critical care pharmacy services nationally.

Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechnical factor study.

OBJECTIVE: To understand the sociotechnical factors affecting medication safety when intensive care patients are transferred to a hospital ward. Consideration of these medication safety factors would provide a theoretical basis, on which future interventions can be developed and evaluated to improve patient care. DESIGN: Qualitative study using semistructured interviews of intensive care and hospital ward-based healthcare professionals. Transcripts were anonymised prior to thematic analysis using the London Protocol and Systems Engineering in Patient Safety V.3.0 model frameworks. SETTING: Four north of England National Health Service hospitals. All hospitals used electronic prescribing in intensive care and hospital ward settings. PARTICIPANTS: Intensive care and hospital ward healthcare professionals (intensive care medical staff, advanced practitioners, pharmacists and outreach team members; ward-based medical staff and clinical pharmacists). RESULTS: Twenty-two healthcare professionals were interviewed. We identified 13 factors within five broad themes, describing the interactions that most strongly influenced the performance of the intensive care to hospital ward system interface. The themes were: Complexity of process performance and interactions; Time pressures and considerations; Communication processes and challenges; Technology and systems and Beliefs about consequences for the patient and organisation. CONCLUSIONS: The complexity of the interactions on the system performance and time dependency was clear. We make several recommendations for policy change and further research based on improving: availability of hospital-wide integrated and functional electronic prescribing systems, patient flow systems, sufficient multiprofessional critical care staffing, knowledge and skills of staff, team performance, communication and collaboration and patient and family engagement.

Critical care pharmacist research activity, experience and interests: a 2021 United Kingdom survey.

BACKGROUND: Research and innovation are essential for effective healthcare service delivery, leading to improvements in patient health and wellbeing. National policy dictates that research delivery is embedded into daily practice of United Kingdom (UK) healthcare professionals, including pharmacists. There is a limited understanding of critical care pharmacist research activities, experiences and interests. It is, therefore, important to describe current practice including barriers and facilitators to enable increased engagement. OBJECTIVES: To describe UK critical care pharmacist research activity, experiences, interests and barriers to better engagement. METHOD: An electronic survey was developed, piloted and distributed (June to October 2021) to all critical care pharmacists via UK professional organisations. KEY FINDINGS: The survey was completed by 126 pharmacists, providing a 54% response rate. Few pharmacists reported research capability (postgraduate qualification with a research component, 31% (39/126)) and opportunity (dedicated research time, 28.6% (36/126)), only 12.7% (16/126) have both these influencers. Those that did, produced significantly more research outputs (median 4 (0,9) versus 0 (0,1), P = 0.023) and undertook grant funding applications (X2 (1, n = 126) = 25.8, P < 0.001), compared to those without. The most frequently reported barrier to research was the time (opportunity), (71.4%, 90/126). Few pharmacists reported having a research mentor (13.3%, 16/120). Most pharmacists reported an interest in collaborating on research projects across a broad range of areas. CONCLUSIONS: Critical care pharmacists are motivated to participate in the evaluation continuum including research, although most report capability and opportunity barriers to delivery. We suggest policy recommendations to address limitations and increase pharmacist research involvement.

A Delphi consensus study to identify priorities for improving and measuring medication safety for intensive care patients on transfer to a hospital ward.

BACKGROUND: Intensive care patients surviving to transfer to a lower-acuity hospital ward experience ongoing challenges to their recovery and lack a well-defined and developed care pathway. The transfer process to a hospital ward exposes intensive care patients to high rates of medication errors, which increase their risk of adverse drug events. OBJECTIVE: The aims of this study were to identify priorities for medication-related intervention components and outcome measures for improving medication safety for intensive care patients transferring to a hospital ward. METHODS: Three panels involving 129 participants covering (i) intensive care, (ii) hospital ward health-care professionals and (iii) public representatives completed an electronic Delphi survey conducted over three phases. The Delphi process comprised three sections (medication-related intervention components, medication outcomes and patient outcomes). Items were graded in their level of importance, with predefined important criteria. Item agreement required consensus across all three panels. Intervention barriers and facilitators identified in participant comments were categorized according to a socio-technical systems approach to the patient journey and patient safety (Systems Engineering Initiative for Patient Safety 3.0 model). RESULTS: Of the 129 (84.5%) participants, 109 completed all three Delphi phases. Consensus was achieved for 48 intervention components, 13 medication outcome measures and 11 patient outcome measures. Phase 1 provided 158 comments comprising >200 individual barriers and facilitators to intervention delivery. Frequently cited facilitators included clearly specified roles and responsibilities (10.7% (organizational conditions)), patient and family as agents (8.8% (care team)), medicines-related information easily accessible (7.8% (tools and technologies)) and clear medication plan and communication (7.3% (tasks)). CONCLUSIONS: Our findings provide identification of priorities for medication-related intervention components to improve medication safety for intensive care patients transferring to a hospital ward. Prioritization is complemented by the identification and socio-technical categorization of barriers and facilitators to intervention delivery. The identified important medication and patient outcomes to measure will inform the design of a future patient medication safety intervention study.

Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis.

BACKGROUND: Patients recovering from an episode in an intensive care unit (ICU) frequently experience medication errors on transition to the hospital ward. Structured handover recommendations often underestimate the challenges and complexity of ICU patient transitions. For adult ICU patients transitioning to a hospital ward, it is currently unclear what interventions reduce the risks of medication errors.The aims were to examine the impact of medication-related interventions on medication and patient outcomes on transition from adult ICU settings and identify barriers and facilitators to implementation. METHODS: The systematic review protocol was preregistered on PROSPERO. Six electronic databases were searched until October 2020 for controlled and uncontrolled study designs that reported medication-related (ie, de-prescribing; medication errors) or patient-related outcomes (ie, mortality; length of stay). Risk of bias (RoB) assessment used V.2.0 and ROBINS-I Cochrane tools. Where feasible, random-effects meta-analysis was used for pooling the OR across studies. The quality of evidence was assessed by Grading of Recommendations, Assessment, Development and Evaluations. RESULTS: Seventeen studies were eligible, 15 (88%) were uncontrolled before-after studies. The intervention components included education of staff (n=8 studies), medication review (n=7), guidelines (n=6), electronic transfer/handover tool or letter (n=4) and medicines reconciliation (n=4). Overall, pooled analysis of all interventions reduced risk of inappropriate medication continuation at ICU discharge (OR=0.45 (95% CI 0.31 to 0.63), I2=55%, n=9) and hospital discharge (OR=0.39 (95% CI 0.2 to 0.76), I2=75%, n=9). Multicomponent interventions, based on education of staff and guidelines, demonstrated no significant difference in inappropriate medication continuation at the ICU discharge point (OR 0.5 (95% CI 0.22 to 1.11), I2=62%, n=4), but were very effective in increasing de-prescribing outcomes on hospital discharge (OR 0.26 (95% CI 0.13 to 0.55), I2=67%, n=6)). Facilitators to intervention delivery included ICU clinical pharmacist availability and participation in multiprofessional ward rounds, while barriers included increased workload associated with the discharge intervention process. CONCLUSIONS: Multicomponent interventions based on education of staff and guidelines were effective at achieving almost four times more de-prescribing of inappropriate medication by the time of patient hospital discharge. Based on the findings, practice and policy recommendations are made and guidance is provided on the need for, and design of theory informed interventions in this area, including the requirement for process and economic evaluations.

Reducing medication errors in critical care patients: pharmacist key resources and relationship with medicines optimisation.

BACKGROUND: Medication errors are the most common type of medical errors critical care patients experience. Critical care units utilise a variety of resources to reduce medication errors; it is unknown which resources or combinations thereof are most effective in improving medication safety. OBJECTIVES: To obtain UK critical care pharmacist group consensus on the most important interventions/resources that reduce medication errors. To then classify units that participated in the PROTECTED UK study to investigate if there were significant differences in the reported pharmacist prescription intervention type, clinical impact and rates according to unit resource classification. METHODS: An e-Delphi process (three rounds) obtained pharmacist consensus on which interventions/resources were most important in the reduction of medication errors in critical care patients. The 21 units involved in the PROTECTED UK study (multicentre study of UK critical care pharmacist medicines interventions), were categorised as high-, medium- and low-resource units based on routine delivery of the final Top 5 interventions/ resources. High and low units were compared according to type, clinical impact and rate of medication interventions reported during the PROTECTED UK study. KEY FINDINGS: Consensus on the Top 5 combined medication error reduction resources was established: advanced-level clinical pharmacist embedded in critical care being ranked most important. Pharmacists working on units with high resources made significantly more clinically significant medicines optimisations compared to those on low-resourced units (OR 3.09; P = 0.035). CONCLUSIONS: Critical care pharmacist group consensus on the most important medication error reduction resources was established. Pharmacists working on high-resourced units made more clinically significant medicines optimisations.