Methods
Setting
Robert Wood Johnson University Hospital Hamilton is a 248-bed suburban community hospital in New Jersey with a 20-bed ICU that provides level II6 critical care services as part of an 11-hospital system. Critical care pharmacy services spanned from fundamental (eg, order review) to optimal (eg, independent pharmacotherapy evaluation) activities, with tremendous variability associated with who was engaged in care. In this original model, weekday ICU pharmacy services were provided by satellite-based general practice staff pharmacists (satellite pharmacy located in the ICU provides services for ICU, telemetry, and the emergency department) across 2 shifts (0700-2300; 9 pharmacists during the day shift and 2 on the evening shift). Satellite pharmacists largely focused on traditional/fundamental pharmacy practice, including order review, drug therapy evaluation, and adverse drug event identification. Additionally, a hospital-based, residency-trained clinical pharmacist rounded 3 days per week. General practice staff pharmacists provided weekend and overnight services. Very limited, prospective, independent clinical evaluation or individualized pharmacotherapy optimization occurred routinely. No established clinical assessment priorities or strategies existed, and thus expectations of pharmacy services were associated with the individual pharmacist present.
Team Structure and Recruitment
The staff pharmacists were well-established, with each having 25 to 41 years of practice experience. All 11 full-time staff pharmacists graduated with Bachelor of Science degrees in pharmacy, and 5 of them had returned to acquire Doctor of Pharmacy degrees prior to the initiative. None had completed post-doctoral training residencies, as residencies were not the standard when these pharmacists entered practice. The staffing model necessitated that pharmacists maintain Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) competency as members of inpatient emergency response teams.
Three volunteers were recruited to the initial transformational process. These volunteer pharmacists were preferentially assigned to the ICU, with a clinically focused weekend rotation, to provide 7-day/week rounding continuity, but maintained general competencies and cross-functionality. Weekend responsibilities included critical care assessments and multidisciplinary rounding, inpatient emergency response, patient education/medication histories, and inpatient warfarin management consultations.
Team Training and Development
Longitudinal education of the CCPT included classroom, bedside, and practice-modeling training strategies to complement routine exposure and integration into the pharmacist’s practice in providing direct patient care. Concentrated learning occurred over a 3-month period, with extended bedside and patient-case-based learning continuing for another 3 months. Expectations of the critical care pharmacist as an independent consultant to the interdisciplinary team targeting holistic pharmacotherapy optimization were established, instilling independence and accountability within the role. Next, lecture and bedside training targeted the development of crucial assessment skills, including an understanding of device and equipment implications on pharmacotherapy decisions, pharmacokinetic and pharmacodynamic variations in critically ill patients, and supportive care. A minimum of 5 hours of group lectures were included for all members of the CCPT, with additional instruction provided based on individual needs. Lectures explored the evidence and practice associated with common diagnoses, including review of related literature, core guidelines, and institutional order sets. Fundamental topics included pain, agitation, and delirium (PAD) during mechanical ventilation, infectious diseases, and hemodynamic management.
To reinforce knowledge, build bedside assessment skills, and increase confidence, pharmacists routinely partnered with the specialist during independent morning bedside evaluations and rounds. Over time, the specialist role became increasingly supportive as the critical care pharmacist grew into the primary role. On weekends the specialist was not present but remained on call to discuss cases with the rounding critical care pharmacist. This served to reinforce clinical decision-making and expand knowledge; these patient-specific lessons were communicated with the team to support continued development and standardization.
In addition to these internal efforts, the specialist simultaneously recalibrated expectations among key ICU stakeholders, establishing uniform quality and scope of service from the CCPT. Historically, physicians and nurses sought input from specific pharmacists, and thus a cultural change regarding the perceived value of the team was required. To reinforce this, those demanding a specific pharmacist were referred to the CCPT member present.
The initial training process involved a significant proportion of the specialist’s time. Initially focused on classroom lecture and core skills development, time increasingly focused on individual learner’s needs and learning styles. Mentoring and partnering were key during this period. In the first 6 months, weekend calls were routine, but these quickly tapered as the team gained experience and confidence in their knowledge and skills.