The need for pharmaceutical care in an intensive care unit at a teaching hospital in South Africa.
Clinical pharmacy practice was born in the 1960s and evolved to the responsible provision of medicine-related patient care in the 1980s.  The act of performing clinical pharmaceutical interventions by the pharmacist as part of a healthcare team is called pharmaceutical care.  Clinical pharmacy interventions and pharmaceutical care can be defined as the process of identifying a medicine-related problem and making a recommendation in an attempt to prevent or resolve it.
According to the Minnesota model, the first step for pharmaceutical care is to identify a patient's medicine-related needs.  Categories of medicine-related needs or potential pharmaceutical interventions included are as follows: 
* New medicine therapy needed
* Unnecessary or wrong medicine therapy
* Dosage too low/high
* Adverse medicine reaction
* Compliance problem.
The effects or benefits of the provision of pharmaceutical care are measured to see whether a positive difference is made to the patient's clinical, human rights and economic outcomes.  Benefits of pharmaceutical care can be derived by the patient, the healthcare team, the pharmacy profession and the health system. 
Currently in South Africa (SA), according to Schellack and Gous,  for a pharmacist to be effective in a healthcare team, he or she must move into the wards where drugs are prescribed and administered. They also noted that doctors' ward rounds were a good training ground for ward pharmacists and an effective way of building relationships with prescribers. Through pharmaceutical care, the clinical pharmacist can play a role in concurrent review of prescribing patterns, providing feedback to the prescriber and educating providers and the public. 
Many pharmacy managers see ward rounds as time consuming and taking the pharmacist away from the dispensing practice.  Combined with the low staff levels of pharmacists, suboptimal use of technical support staff and a lack of trained pharmacists, a low pharmacist presence in the wards has resulted. 
At the time of the current research, a clinical pharmacist was not part of routine care in medication monitoring to evaluate prescribing patterns or identify potential or actual medication errors in the surgical and trauma intensive care unit (ICU) at Steve Biko Academic Hospital. The study was initiated to address the need for pharmaceutical care and to evaluate the effect of the presence of a pharmacist in the ICU.
The study was conducted at Steve Biko Academic Hospital, an 832bed hospital with 53 ICU beds and 21 high-care beds, in Pretoria, Gauteng. The study site was the 12-bed surgical and trauma ICU. All the patients admitted to the unit during the 8-week study period, from Monday to Friday, were included in the study.
This was a cross-sectional, operational research study. Indicators of programme success, such as improving the quality of service by monitoring medication errors and adverse effects, and adding new service components such as antimicrobial stewardship and drafting and implementation of antimicrobial guidelines, was an important part of the study design. The data were collected prospectively for 8 weeks. Quantitative aspects included patient demographics, clinical data, the number of different types of interventions as portrayed in the pharmaceutical care problem list, time spent on activities at ward level, the cost implications of pharmaceutical care interventions, and prescribing patterns of antimicrobials.
Data collection instrument
The data collection instrument comprised a validated pharmaceutical care form, which has been used in multiple previous clinical studies in SA. [8-10] The form contained a patient database sheet to collect demographic data and a section to evaluate the patient's medication therapy, and to identify potential and actual drug problems.
Data collection process
Pharmaceutical care was rendered on a daily basis to all patients admitted to the ICU. Patient prescriptions and clinical data were evaluated by the pharmacist, whereafter necessary interventions were discussed with doctors during the daily ward rounds. The interventions and whether they were successful or not were recorded on the pharmaceutical care form. Interventions included discontinuation of antibiotics after completing a course, or reducing the antibiotic dose according to guidelines.
Medicine cost was calculated by determining the difference between the cost of medication used the day before and the day after an intervention. This amount was a direct calculation and only for the cost of one day after the intervention was performed. No calculations were made for indirect cost implications or length of ICU stay.
Validity and reliability
A pilot study was conducted prior to the main study to verify the appropriateness of the data collection instrument, in order to further enhance the reliability and validity of the data collection. Interventions towards patient therapy were based on the literature and discussed with medical practitioners to eliminate researcher bias.
Permission to conduct the study was obtained from the hospital management and institutional ethics review boards of the University of Limpopo (Medunsa campus) (MREC/H/15/2011) and the University of Pretoria (226/2010). Informed consent was obtained from patients, family members or legal guardians.
A total of 51 patients was included in the study.
Of the 51 study patients, 35 were male and 16 female. The age of the patients ranged from 12 to 86 years, with a mean of 44.9 years. The average length of stay (LOS) in the ICU was 8.7 days (range 1-46). Patients older than 60 years had a longer LOS (10-12 days) in the ICU compared with patients younger than 30 years (1-3 days). Only 13 (26%) of the 51 study patients' HIV status was known; 6 were HIV-positive, while 7 were HIV-negative. Of the 6 patients who were HIV-positive, 3 were previously receiving antiretroviral treatment, while 2 were prescribed antiretroviral treatment while admitted. One patient did not want her status disclosed and therefore could not be treated.
A total of 71 diagnoses were recorded, with a mean of 1.4 (standard deviation 0.6) diagnoses per patient. It was noted that more than one diagnosis may apply to a single patient.
Trauma was the diagnosis most commonly encountered (n = 21), including motor vehicle accidents and gunshot wounds. The injuries ranged from fractures to soft-tissue lacerations and abdominal wounds obtained from gunshot wounds or blunt-force trauma. Most trauma patients admitted also had skeletal or gastrointestinal involvement. Another common diagnosis was gastrointestinal sepsis (n = 11) after general surgery.
The diagnosis of infection was made secondary to the admission diagnosis in 14 of the 15 (93%) cases. This included ventilator-associated pneumonia as well as surgical wound infections.
The medication used was classified according to the Anatomical Therapeutic Chemical (ATC) classification system. A total of 529 medicines were prescribed (Table 1). An average of 12 medicines was prescribed per patient. Medicines most frequently used were for the alimentary tract (174 items (according to the ATC system); 30%), the anti-infective system (124 items; 21%) and cardiovascular system (31 items; 54%). Medicine from the blood and blood-forming organ system, namely enoxaparin, was prescribed for 49 (8.5%) patients.
A total of 181 interventions was suggested for the 51 study patients (median 4; range 1-28 interventions per patient). A total of 127 interventions was accepted and implemented by medical and nursing staff in the unit (Table 2). 'Untreated medical conditions' were addressed most frequently (28 interventions, of which 9 were accepted; 15.5%). Reminding doctors to prescribe patients' chronic medications, e.g. antihypertensives, and suggesting antidepressants for long-term patients were included in this category.
This was followed by 'length of course or therapy appropriate' (25 interventions, of which 20 were accepted; 13.8%). This category included discontinuing antibiotics after completing the course, stopping antibiotic prophylaxis after 24 h and stopping pantoprasole continuous infusion for gastric bleeding after 72 h, as per hospital protocol.
'Investigations outstanding' made up 22 (12.2%) interventions. Only seven of the interventions were successful, because some culture results were never received from the laboratory. Some patients were discharged from the unit before results for serum concentrations of phenytoin were received.
Interventions made to address system errors or non-compliance and factors hindering therapeutic effect totalled 10 (5.5%) and 5 (2.125%), respectively. These included medicine not received from the pharmacy because of out-of-stock situations, and incorrect doses or medicine not administered to the patient by the nursing staff. Interventions were made during ward rounds with the treating doctors. The pharmacist did a pharmaceutical care round before the ward round, to familiarise herself with the clinical status of each patient. Interventions on drug therapy problems could then be discussed with the treating doctor during ward rounds. The interventions were either accepted or rejected immediately. Interventions made by the pharmacist concerning problems with the pharmacy or counselling of patients or nursing staff occurred after the ward round.
Time spent providing pharmaceutical care services
The total time spent providing pharmaceutical care services to the ICU was 250 h. Fig. 1 depicts the specific time spent on different activities in the ward. Pharmaceutical care rounds included reviewing the patient's prescription chart, vital signs and laboratory results. This took up the majority of time in the ward (71 h; 28.5%). Using information obtained during the pharmaceutical care rounds, interventions were suggested on the ward rounds. In some instances, more than one ward round was done per day because of different specialties doing rounds. Ward rounds took up 21.7% (54 h) of the pharmacist's time.
Medication reconciliation (45 h) was done by evaluating the patient's prescription chart, and monitoring the medication orders from the pharmacy and the dosing of the different medicines. The pharmacist checked that the correct medicine was received from the pharmacy, and that administration to the patient was correct.
A direct cost saving due to interventions made by the clinical pharmacist was calculated as R14 353. Having a pharmacist as a permanent member of the multidisciplinary team may be a cost-saving opportunity for the unit.
The male/female ratio in the ICU was 2.18:1, which was not a reflection of the general population. According to Statistics SA,  the male/ female ratio in 2011 was 0.94:1. The mean age of patients admitted to the surgical ICU was 44.92 years, which is lower than that in the USA or the UK. 
Trauma, including gunshot and motor vehicle accident injuries, comprised the most frequent diagnoses. This was expected, since it is a surgical and trauma ICU. Nosocomial pneumonia and surgical wound infections were also prevalent as secondary diagnoses. Nosocomial pneumonia has been confirmed in the literature as common in patients undergoing mechanical ventilation. 
As there was a variety of medications used in the ICU, prescribed from short to more extensive periods, there were many opportunities for the clinical pharmacist to provide pharmaceutical care. The functions that the researcher performed correlated with the scope of a clinical pharmacist in a similar study by Bates et al.  Interventions were made regularly to address a variety of medicine-related problems, inappropriate dose or dosing frequency, relative safety of chosen medicine and other factors hindering achievement of therapeutic effect, such as non-compliance and system errors. Similar studies performed in SA also highlighted the abovementioned interventions as being made most frequently by the clinical pharmacist. [9, 10, 15]
The cost of antibiotics and other medicines used by patients the day before and the day after an intervention was calculated. Interventions made included discontinuation of antibiotics after completing a course, or reducing the dose of antibiotics according to guidelines. This amount was a direct calculation and only for the cost of one day after the intervention was performed. No calculations were made for indirect cost implications or length of ICU stay. The cost saving during the study period added up to R14 353, but potentially could be more. Begley  described the practice of pharmaceutical care as having benefits for the healthcare system, including cost saving. Having a pharmacist as a permanent member of the multidisciplinary team may be both a cost-saving and extra quality assurance opportunity for the unit. 
The study period was very short and considerable time was used to become familiar with the surroundings and routines in the unit. More time was also needed to establish good relationships with attending physicians and medical staff. Pharmaceutical services were rendered only from Monday to Friday, so patients admitted over weekends were not enrolled.
The study focused on the provision of pharmaceutical care in an ICU and the role of the pharmacist in assessing prescribing patterns, recognising and recording drug-related interventions and the time needed to provide pharmaceutical care.
Interventions were required across a broad spectrum of drug-related problems. Interventions suggested during ward rounds supplied a good platform for discussions regarding the use of antimicrobials and other medicines, or specific doses of medicine.
The number of medicines prescribed to the patients admitted to the unit during the study period provided an opportunity for the pharmacist to perform numerous interventions, and the conclusion can be made that the continued presence of a pharmacist in the ward would be beneficial to patient outcomes. The provision of pharmaceutical care has the potential to improve the quality of pharmacotherapy and save medicine costs.
After a 2-month period, it was established that there were enough tasks to warrant a full-time position for a clinical pharmacist in the ICU setting.
A permanent pharmacist should be appointed to the unit to be able to provide a consistent level of care to patients in the ward. A resident clinical pharmacist may also assist in the development and implementation of guidelines for the ward.
Acknowledgements. The authors would like to acknowledge Prof. Herman Schoeman for the statistical analysis of the data and the Department of Pharmacy, Medunsa campus, for financial and logistical support.
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E Bronkhorst, (1) BPharm, MSc (Med) Pharmacy; N Schellack, (1) BPharm, PhD Pharmacy; A G S Gous, (1) BPharm, Pharm D; J P Pretorius, (2) MB ChB, MMed (Surg), FCS (SA)
(1) Department of Pharmacy, University of Limpopo, Medunsa Campus, Ga-rankuwa, South Africa
(2) Department of Critical Care, Medical School, Faculty of Health Sciences, University of Pretoria; and Steve Biko Academic Hospital, Pretoria, South Africa
Corresponding author: E Bronkhorst (firstname.lastname@example.org)
Table 1. Medication used according to ATC classification Organ system ATC code International Frequency Rank proprietary name of medicine used Alimentary A11A Multivitamins 47 2 tract and A02BX02 Sucralfate 41 3 metabolism A02BA02 Pantoprasole 18 7 Blood and B01AB06 Enoxaparin sodium 49 1 blood-forming organs Cardiovascular C03CA01 Furosemide 10 12 system C09AA04 Perindopril 6 16 Dermatologicals H02AB09 Hydrocortisone 8 14 systemic Anti-infectives J01CR05 Piperacillin/ 22 8 for systemic tazobactam use Nervous system J01DA04 Cefazolin 13 10 J01CR02 Co-amoxyclav 11 11 J01DH02 Meropenem 11 11 J01DH51 Imipenem 11 11 J02AC01 Fluconazole 7 15 N02AG01 Morphine 38 4 N05CD08 Midazolam 32 5 N02BE01 Paracetamol oral 28 6 Respiratory R03BB01 Ipratropium 11 11 system bromide/fenoterol Various V06B Dipeptivan 5 17 ATC = Anatomical Therapeutic Chemical. Table 2. Most frequent types of interventions Most frequent Interventions Percentage Percentage type of (W=181), n accepted interventions Untreated 28 15.5 61 medical conditions Investigations 22 12.2 32 indicated/ outstanding Prescribed 20 11.0 80 doses and dosing frequency appropriate Length or 25 13.8 80 course of therapy Due to system 18 9.9 83 error or non-compliance Factors 10 5.5 70 hindering achievement of therapeutic effect Doses scheduled 9 4.9 66 to maximum effect Comparative 8 4.4 50 efficacy of chosen medication Therapy 5 2.8 100 tailored to individual patient Route/dosage 6 3.3 100 form or mode of administration Fig. 1. Percentage of time spent in the ward, total 250 h. Pharmaceutical care 28.50% Ward rounds 21.70% Ward functions 6.33% Meetings 7.83% Medication reconciliation 18.07% Note: Table made from pie chart.
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|Author:||Bronkhorst, E.; Schellack, N.; Gous, A.G.S.; Pretorius, J.P.|
|Publication:||Southern African Journal of Critical Care|
|Date:||Nov 1, 2014|
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