Clinical pharmacy professionals (including pharmacists, pharmacy technicians and assistants) are essential members of the multi-disciplinary team (MDT) in critical care units (CCUs) in the United Kingdom (UK). The addition of clinical pharmacists to critical care teams has been repeatedly shown to lower critical care (CC) mortality, lower CC length of stay, lower healthcare costs, and lower adverse drug events [1–3]. CC patients have a high severity of illness, with dynamic organ dysfunctions and complex medication regimens [4]. Clinical pharmacists provide patient-centred care through patient consults, prescribing and participating at MDT ward rounds [5, 6]. Pharmacist presence in CCUs optimise patient outcomes by personalising drug dosing adjustments, adapting to pharmacokinetics and pharmacodynamics (PK-PD) changes in critical illness, addressing drug interactions, deprescribing, mitigating adverse drug events and therapeutic drug monitoring [4, 7]. In addition, pharmacists undertake directorate responsibilities, including financial analysis, clinical governance activities (including preparation of evidence-based guidelines), research and clinical audit, and leading medication safety.
Pharmacy technicians and assistants provide an essential role in medicines reconciliation, patient counselling, stock inventory, and the supply of time-critical medicines [8]. In one study, investigators reported the utilisation of pharmacy technicians and assistants to support the supply of time critical medicines led to a reduction of omitted doses of antimicrobial and antiseizure medication [9]. The utilisation of pharmacy assistants led to a significant reduction in time to complete nurse medication rounds in a second study [10].
Extracorporeal membrane oxygenation (ECMO) provides advanced respiratory and/or cardiac support, delivered to patients with severe respiratory and/or cardiac failure in CCUs, when conventional therapies have failed. Two ECMO modalities exist, veno-venous (V-V) ECMO: a funded service by the NHS in specific specialist centres in the UK [11], and veno-arterial (V-A) ECMO which although not nationally commissioned, it is still widely provided in the UK [12]. Patients receiving ECMO have a high severity of illness and receive multiple modalities of organ support. As a result, polypharmacy, adverse drug events and drug interactions are a daily challenge in these patients. Added to this, the ECMO circuit itself may sequester drugs that are lipophilic and highly protein bound, potential impacting the apparent volume of distribution and thus clearance of these drugs [13, 14]. Examples include sedatives, opioids and some anti-infectives [13]. Higher dosing may be required to prevent therapeutic failure, and this is balanced against excessive dosing that can lead to toxicity, although the overall impact of the ECMO circuit on drug PK-PD remains uncertain [13–15]. Medicines optimisation is a delicate balance between efficacy and toxicity and requires daily CC pharmacist review to maximise patient outcome [16]. ECMO services also require additional pharmacy input because of increased drug utilisation necessitating frequent drug supply, as well as ECMO specific professional support including evidence-based guideline development, participation at ECMO MDT meetings, clinical governance, and education.
Professional standards for clinical pharmacy staff in the UK in CCU are reported in the Guidelines for the Provision of Intensive Care Services (GPICS v2.1) [6]. GPICS v2.1 guidelines state that every CCU must have a clinical pharmacist and a clinical pharmacy service 7 days a week [6]. There should be a 0.1 whole time equivalent (WTE) pharmacist for every Level 3 CCU bed and 0.1 WTE pharmacist for every two Level 2 CCU beds for a 5-day a week service [6]. Furthermore, the NHS England critical care service specification states that commissioned CCUs must align to GPICS guidelines [17]. In the UK, there is a good evidence base describing the CC pharmacy workforce and activities, especially clinical pharmacists, although there remains great variation in the delivery of the clinical pharmacy service, MDT ward round participation and 7-day clinical pharmacy services, despite evidence of benefit [18–20].
This is not the case for commissioned ECMO services, where no data exists for the clinical pharmacy workforce. In 2019, NHS England published a national service specification describing provision of care to adult ECMO patients, although, disappointingly, there was no mention of clinical pharmacy [11].
Aim
To describe workforce characteristics, pharmacy service provision, and pharmaceutical care activities in critical care units providing an adult ECMO service in the United Kingdom (UK), and compare to national staffing standards for critical care units.
Ethics approval
Institutional approval was gained from the quality improvement and safety committee at Guy’s and St Thomas’ NHS Foundation Trust, the lead coordinating site (reference number: 14610), and at all participating sites. The need for review by a research ethics committee and informed consent was waived as the study met the criteria of a service evaluation and involved healthcare professionals in their NHS role. All respondents consented to participation via the national ECMO pharmacy network. Patient level data was not collected.