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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 1  |  Issue : 4  |  Page : 134-140

Clinical pharmacist interventions in intensive care units during Hajj: A multicenter retrospective study


1 Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia; College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard – Health Affairs, Riyadh, Saudi Arabia; Saudi Critical Care Pharmacy Research (SCAPE) Platform, Riyadh, Saudi Arabia
2 Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
3 Pharmaceutical Care Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
4 Pharmaceutical Services Department, King Saud Medical City, Riyadh, Saudi Arabia
5 Pharmaceutical Care Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
6 Pharmaceutical Care Department, King Abdulaziz Medical City, Dammam, Saudi Arabia
7 General Administration of Pharmaceutical Care, Ministry of Health, Riyadh, Saudi Arabia
8 Therapeutic Affairs Deputyship, Ministry of Health, Riyadh, Saudi Arabia; Colleges of Medicine and Pharmacy, Al-Faisal University, Riyadh, Saudi Arabia
9 Therapeutic Affairs Deputyship, Ministry of Health, Riyadh, Saudi Arabia

Date of Submission07-Oct-2022
Date of Acceptance17-Nov-2022
Date of Web Publication31-Dec-2022

Correspondence Address:
Dr. Khalid Al Sulaiman
King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs (MNGHA), King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, 11426 Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjcp.sjcp_18_22

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  Abstract 

Background: Hajj pilgrimage is the largest mass gathering worldwide. The Saudi Ministry of Health (MOH) provides free medical services for all pilgrimages. In 2022, MOH incorporated clinical pharmacy services in intensive care units (ICUs) of the sacred rituals hospitals. In addition to their role in ICUs settings, they were involved in other activities related to emergency department admissions as well as conducting several educational services at the hospital level. This study aimed to describe the impact of clinical pharmacy services implementation during the Hajj season and to explore the clinical interventions delivered to ICU patients. Materials and Methods: A multicenter-retrospective, chart-review study including adult critically ill patients (>14 years old) admitted to ICUs of seven sacred rituals hospitals between June 30 and July 14, 2022. Patients were excluded if they were not admitted to the ICU or admitted to an area with no assigned clinical pharmacist. Clinical interventions were categorized based on a modified version of the American Society of Health-System Pharmacists (ASHP) categorization. The study was approved by MOH Central Institutional Review Board (IRB) on September 18, 2022 (Ref. 22-41 E). Results: Clinical pharmacists performed 269 interventions for 82 patients admitted to the ICUs of participating hospitals. Each patient had a median of three interventions (interquartile range 2–5). The most common intervention was the untreated indication (n = 93; 34.5%), followed by dose adjustment (n = 60; 22.3%) and improper drug selection (n = 42; 15.6%). The ICU teams ultimately accepted all interventions. Conclusion: Incorporating clinical pharmacy services into ICU settings during Hajj season optimized patient care. The variety of provided clinical interventions shows the impact of clinical pharmacists’ presence among multidisciplinary teams. Further studies are needed to explore the economic implication of clinical pharmacist services during Hajj.

Keywords: Clinical pharmacist, Hajj, pilgrimage, ICUs, intervention, pilgrim, Makkah


How to cite this article:
Al Sulaiman K, Aljuhani O, Al Harbi M, Thabit AK, F Alharthi A, Aldardeer N, Alenazi AO, Alghamdi B, Alissa D, Almudaiheem H, Alluwaymi W, Almushaikah S, Almustaneer R, Alshennawi M, Al-jedai A. Clinical pharmacist interventions in intensive care units during Hajj: A multicenter retrospective study. Saudi J Clin Pharm 2022;1:134-40

How to cite this URL:
Al Sulaiman K, Aljuhani O, Al Harbi M, Thabit AK, F Alharthi A, Aldardeer N, Alenazi AO, Alghamdi B, Alissa D, Almudaiheem H, Alluwaymi W, Almushaikah S, Almustaneer R, Alshennawi M, Al-jedai A. Clinical pharmacist interventions in intensive care units during Hajj: A multicenter retrospective study. Saudi J Clin Pharm [serial online] 2022 [cited 2023 Feb 2];1:134-40. Available from: http://www.sjcp.org/text.asp?2022/1/4/134/366502


  Introduction Top


Pilgrimage (Hajj) is the fifth pillar of Islam and one of the largest mass gatherings worldwide. It occurs yearly between the 8th and 12th of Dhu al-Hijjah, the last month of the lunar calendar, at Makkah city in the Kingdom of Saudi Arabia. Millions of Muslims come at least once in their lifetime to perform Hajj.[1],[2]

Mass gatherings in Hajj pose challenges for many governmental sectors in Saudi Arabia in planning and preparing strategies to ensure a safe and smooth Hajj for all pilgrims. The constitution of the Kingdom requires the government to provide free health care to all pilgrims; on top of this, the Ministry of Health (MOH) is responsible for promoting health and preventing diseases.[3]

The MOH is the primary health sector that works hard to optimize a free healthcare service provided to pilgrims. The MOH prepares hospitals across Makkah city with the needed medical equipment, supplies, medications, and healthcare providers. Moreover, The MOH opens seasonal hospitals yearly in the sacred ritual areas of Mena and Arafat (four and three hospitals, respectively), in addition to 78 primary healthcare centers to ensure efficient and accessible medical services to all pilgrims.[4],[5] Those hospitals can handle the most common health conditions during Hajj, such as cardiovascular emergencies, respiratory and gastrointestinal diseases, and heat stroke.[6]

The Saudi Society of Clinical Pharmacy (SSCP), which was founded at the end of 2018, is leading efforts on the scientific and professional aspects of clinical pharmacy in Saudi Arabia in addition to MOH efforts. SSCP is governed by the Saudi Commission for Health Specialties (SCFHS), and to support in the establishment of a consensus regarding the field’s range of practice, the society standardized a number of aspects relating to definitions and descriptions of the clinical pharmacy profession in Saudi Arabia. They define clinical pharmacy as “The pharmacy professional’s division in which the licensed pharmacist obtains the required postgraduate training or education or to optimize patient outcomes via providing cost-effective, evidence-based, comprehensive medication management, promoting disease prevention, and assuring continuity of care at the individual and population levels.”[7]

The clinical pharmacist’s impact on patient care is well-described in the literature.[8],[9] The availability of a clinical pharmacist with the medical team during the round resulted in a positive multidisciplinary collaboration in several aspects.[10] For instance, clinical pharmacists’ interventions reduced medication errors, adverse drug reactions (ADRs), and drug costs and improved patients’ quality of life.[11],[12] Nationwide, Saudi Arabia has been considered one of the leading countries in clinical pharmacy with different specialties since the 1970s.[13],[14] Most clinical pharmacists in the Kingdom of Saudi Arabia are qualified with postgraduate education, either residency programs or a master’s degree in clinical pharmacy. In addition, most hold additional board certification from the American Board of Pharmacy Specialties in different specialties.[7] The criteria for selecting clinical pharmacists in Hajj duty were based on holding a specialized clinical pharmacy residency certificate and board certification or being an expert in critical care or other related specialties, for example, infectious diseases.

The status of clinical pharmacy services in Saudi Arabia is growing, especially in tertiary care hospitals. The returning clinical pharmacists after scholarship completion and the introduction of SCFHS-specialized residency training in the country helped to increase the number of clinical pharmacists.

Their traditional role is rounding with the health care multidisciplinary team; other roles include but are not limited to running several clinics (e.g., anticoagulation clinic, transplant clinic). Moreover, many hospitals have 24-h clinical coverage through on-call clinical pharmacists for critical issues that need to be addressed after working hours. Pharmacists are required to record and keep track of their interventions and recommendations to aid in assessing these indicators.[15]

Clinical pharmacy services are growing and consider a fundamental part of the multidisciplinary healthcare team. Moreover, pharmacists and clinical pharmacists are considered integral members through multiple tasks and responsibilities, including but not limited to developing guidelines, selecting the optimal regimen, monitoring and minimizing drug-drug interaction (DDI) and ADRs by using different approaches, and ensuring appropriate education and patient counseling.[16]

Many studies discussed healthcare-related issues in mass gatherings,[17],[18],[19],[20],[21],[22],[23] but only a few tackled medication-related problems during Hajj. In 2022, the primary health care centers established clinical pharmacy services with seven clinical pharmacists covering intensive care units (ICUs) in each seasonal sacred ritual hospital. However, no study has described the value of incorporating clinical pharmacy services at sacred ritual hospitals. Thus, our study aims to describe the impact of clinical pharmacy services implementation during the Hajj season and to explore the clinical interventions delivered to ICU patients.


  Materials and Methods Top


Study design

A multicenter-retrospective study was conducted during the Hajj season between June 30, 2022 and July 14, 2022. All critically ill patients admitted to ICUs at sacred ritual hospitals (Makkah) and who met the eligibility criteria were included in the study. The rounding clinical pharmacists collected eligible patients’ data from the electronic record system. The clinical interventions were classified using a modified version of the American Society of Health-System Pharmacists (ASHP) categorization system for medication-related problems after customization based on the type of interventions implemented during Hajj. MOH Central Institutional Review Board (IRB) approved the study on September 18, 2022 (Ref. 22-41 E). The IRB committee waived informed consent from the study participants due to the retrospective observational nature of the study. The study was carried out following relevant guidelines and regulations.

Study participants

The study included hospitalized patients aged 14 years and older admitted to sacred ritual hospitals during the Hajj season in 2022 with documented interventions. Patients were excluded if they were not admitted to the ICU or admitted to an area with no assigned licensed clinical pharmacist, such as the outpatient clinics [Figure 1].
Figure 1: Flowchart showing patients’ inclusion and reasons for exclusion

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Study setting

This multicenter study was conducted in seven sacred ritual hospitals in Makkah Saudi Arabia. The total ICUs bed capacity of the included hospitals was 211 beds during the Hajj and was distributed as follows: East Arafat (52 beds), Alrahmah Mountain (44 beds), Mena Emergency Hospital (34 beds), Mena Bridge (28 beds), Mena Alwadi (25 beds), Mena New Street (16 beds), and Namerah Hospital (12 beds). The ICUs operate as closed units 24/7 with a multidisciplinary team. Clinical pharmacy coverage for the multidisciplinary team was 12 hours during the daytime.

Data collection

We retrieved all clinical pharmacists’ documented interventions from the system during the study period. Only interventions for patients admitted to ICU were considered for inclusion [Figure 1]. Each patient’s data was collected and controlled using an electronic sheet. The demographic data, comorbidities, type of interventions, and intervention acceptance status were collected for each included patient. The data were obtained from electronic health records (CareWare system and Doctor web). A total of seven clinical pharmacists collected the data, one assigned in each hospital. Daily, all assigned clinical pharmacists attended the rounds in the ICU, reviewed all patient’s treatment plans, adjusted doses, and recommended alternate therapy if needed with the ICU team. The clinical pharmacists’ interventions were initially categorized based on the ASHP categorization system for medication-related problems.[24] However, certain intervention types were not included in the system; therefore, additional categories were added and customized based on the types of interventions that are frequently encountered. The following were the clinical pharmacists’ interventions included in this study: untreated indication, dosing recommendation/adjustment (renal or hepatic), improper drug selection, medication use without indication, monitoring/laboratory order, Intravenous to oral route switch, recommendation of alternative therapy, therapeutic duplication, route of administration, ADR, medication reconciliation, patient counseling, and medication preparation.

Study endpoints

The primary endpoint is the number of clinical pharmacist interventions in ICUs during Hajj. The secondary endpoint is the type of clinical intervention provided by clinical pharmacists.

Statistical analysis

Data were analyzed using Statistical Package for the Social Sciences (SPSS) software program, version 24.0 (SPSS, Chicago, Illinois). Descriptive statistics using median and interquartile range (IQR) were used for continuous variables. Frequencies and percentages were used for categorical variables.


  Results Top


Seven hundred forty patients were admitted to the seven sacred ritual hospitals. The total number of patients who required ICU admission was 215, including 69 (32.11%) in Mena Alwadi Hospital, 48 (22.3%) in Mena Bridge, 30 in Mena New Street Hospital (14%), 28 (13%) in Mena Emergency Hospital, 15 (7%) in East Arafat Hospital, 14 (6.5%) in Alrhmah Mountain Hospital, and 11 (5.1%) in Namerah Hospital. Among these admissions, 99 patients had documented clinical interventions by clinical pharmacists. Therefore, only 82 patients were included in the study [Figure 1]. Most of the included patients were admitted to Mena Alwadi Hospital (n = 25; 30.5%), followed by Mena Emergency (n = 13; 15.9%) and Mena New Street hospital (n = 13; 15.9%).

Demographic data

[Table 1] shows patients’ demographics and clinical characteristics. Most were males accounting for 47 patients (56.6%), with a median age of 56.5 years (50–61.8). Diabetes was the most prevalent comorbidity in 34 patients (35.8%), followed by hypertension in 24 patients (25.3%). Nonetheless, seven patients (7.4%) reported unknown comorbidities. The most common documented admission diagnoses in the included patients were hyperglycemic emergencies (n = 14), ischemic heart disease (n = 11), septic shock (n = 10), heat stroke/dehydration (n = 8), and pulmonary edema (n = 8). Other less frequent diagnoses included hypertensive emergency/urgency, upper gastrointestinal bleeding, pneumonia, status epilepticus, status asthmaticus, acute decompensated heart failure, and meningitis.
Table 1: Patients’ demographics and clinical characteristics (n = 82)

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Clinical interventions

Clinical pharmacists documented a total of 269 interventions for 82 ICU patients. The median number of interventions per patient was 3 (IQR 2-5), with most interventions being reported from Mena Alwadi Hospital (n = 83; 30.8%), where most of the included patients were admitted (n = 25; 30.5%). [Figure 2] shows the distribution of interventions per hospital. About one-third, 93 (34.5%), of the interventions were therapeutic recommendations for untreated indications. Dosing recommendations or adjustments due to organ failure were the second most common type of clinical intervention accounting for 60 interventions (22.3%), and improper drug selection ranked third, 42 (15.6%) [Table 2]. The ICU teams’ acceptance rate of clinical interventions was 100% as a documentation in the patient’s file, a physician staff or clinical pharmacist order entry, or verbal recommendation during the rounds in the ICU.
Figure 2: Distribution of clinical pharmacists’ interventions in each of the sacred rituals hospital

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Table 2: Types of clinical pharmacist interventions (n = 269)

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  Discussion Top


This multicenter retrospective study represents the first to describe the impact of clinical pharmacy services implementation during the Hajj season. This study aimed to investigate the clinical interventions made by clinical pharmacists to patients admitted to ICUs. Notably, the highest number of interventions occurred at Mena Alwadi Hospital, with therapeutic recommendations for untreated conditions considered the primary interventions by clinical pharmacists in the ICU. The Mena area is the area that pilgrims reside in during their Hajj. Therefore, the patient volume in different hospitals might be linked to the pilgrims’ flow in the sacred rituals. This should help the future distribution of clinical pharmacists in Hajj based on hospital capacity and patient flow.

The types of interventions in our study are consistent with other published studies. A prospective observational study by Rech et al.[25] showed that the most frequent interventions were discontinuation of clinically unwarranted therapy (15.8%), renal dosage adjustments (15.3%), initiation of non-antimicrobial therapy (13.9%), and antimicrobial therapy initiation and streamlining (9%). Another observational study in adult ICUs found that the top five intervention classifications were inappropriate drug frequency or dosing (55.8%), discontinuation of drug therapy (16.6%), changes in drug therapy (11.8%), an indicated drug not prescribed (8.7%) and therapeutic drug monitoring (4.3%).[26] The present results appear comparable to earlier studies on clinical pharmacists’ intervention types. Some differences in intervention distribution exist. Several factors could explain these differences, such as variations in healthcare provider practices, clinical pharmacist training, clinical pharmacist-to-patient ratios, the training level and years of experience and the duration of the study.[27],[28],[29]

Notably, the acceptance rate of the interventions carried out by the clinical pharmacists in this study was 100%. These findings are similar to previous studies (99.2%, 99.4%, and 99.8%, respectively).[25],[26],[28] In another local study conducted by Nurgat et al.[30] The average acceptance rate was 93.37%. This high acceptance rate of clinical pharmacist interventions showed the significance of the clinical pharmacist’s role and impact on the multidisciplinary team during ICU medical rounds. Other factors associated with a high acceptance rate included but were not limited to the quality of intervention, pharmacist-physician relationship, and the high level of clinical pharmacists’ competency. However, we must consider the selection bias in which pharmacists may opt to document interventions that are accepted and disregard the unaccepted interventions. A meta-analysis by Lee et al.[10] showed that including critical care pharmacists in the multidisciplinary ICU team improved patient outcomes (i.e., mortality, length of stay in the ICU, and adverse drug events).[31]

We observed that patients with comorbid conditions, including diabetes mellitus, cardiovascular disease, and hypertension, were more likely to receive clinical interventions. A previous study conducted by Chiang et al.[26] indicates that the interventions were executed mainly in patients with organ dysfunction, such as renal dysfunction (30.9%), liver dysfunction (2.7%), and patients with combined liver-kidney dysfunction (5.3%) 24. These results are consistent with our finding that most patients had chronic diseases; however, the type of these diseases differed from ours. This year’s Hajj age restrictions of a maximum of 65 years old for pilgrims may be a factor that led to the lower percentage of organ dysfunction we observed. On the contrary, other reported studies do not have an age limit in their inclusion criteria. The presence of several chronic and organ failure diseases in ICU patients necessitates treatment with multiple drug combinations, making them more sensitive to complications, DDIs, and ADRs. In these situations, clinical pharmacists’ interventions will reduce the potential risk of iatrogenicity, DDI, ADRs, and other complications. This could explain the higher rate of clinical pharmacist interventions in patients with such comorbidities to ensure an ideal treatment plan that will optimize patient care.[28],[31] These interventions potentially prevented harm to patients that could have prolonged their hospital length of stay or caused permanent disability or injury.

Numerous pharmacoeconomic studies have shown that pharmacy interventions can lead to cost savings.[26] Our study did not determine the cost savings of ICU pharmacist interventions because there are no supply chain modules that interface with our electronic health records. A previous study found that ICU pharmacists generated $7,435 in cost avoidance per shift when all interventions were considered and $2,529 per shift when only the most validated intervention categories were used. A significant portion of cost avoidance resulted from interventions that individualized patient care, used resources more effectively, and prevented ADRs.[25]

In our study, clinical pharmacists participated and contributed to other clinical services, such as protocol development and in-service training for the medical team. These contributions were similar to what was reported in a local study evaluating the status of ICU pharmacist services; it showed that 76.3% of the pharmacists were involved in updating and developing ICU treatment protocols.[32] The establishment of particular therapeutic protocols is required since Hajj is unique in that it brings together clinical pharmacists, doctors, and nurses from all over the Kingdom of Saudi Arabia for a brief period of time with diverse practice perspectives. These protocols would help standardize management plans among all healthcare practitioners practicing during Hajj, thus potentially preventing or minimizing medication-related problems. A possible area for future research would be to investigate other clinical services provided by clinical pharmacists during Hajj to standardize patient care. Future studies on clinical and economic outcomes are warranted.

This study examined the impact of clinical pharmacists in ICU during the Hajj season, including multicenter with diversity in healthcare practitioners and experiences. In addition, there are enormous varieties of patients since they come from around the world with minimal medical history documentation. However, several limitations must be addressed, such as the small sample size, retrospective, and non-comparative design. In addition to the high turnover of patients and the loss of follow-up due to the short period of the Hajj season and patient transfer to other medical facilities after the conclusion of the Hajj, respectively. Moreover, Clinical and economic outcomes could not be evaluated due to data unavailability, and the lack of patients’ records of past medical histories, as most of the patients were short-term visitors for Hajj only and may have had a language barrier. In addition, selection bias in the acceptance rate could be added to the limitations of this study.


  Conclusion Top


Incorporating clinical pharmacy services into ICU during Hajj season optimized patient care. The variety of provided clinical interventions shows the impact of clinical pharmacists’ presence in multidisciplinary teams. Further studies are needed to explore the economic implication of clinical pharmacist services during Hajj.

Ethical policy and Institutional Review Board statement

MOH Central IRB approved the study on September 18, 2022 (Ref. 22-41 E). Participants’ confidentiality was strictly observed throughout the study by using anonymous unique serial numbers for each subject and restricting data only to the investigators. Informed consent was not required due to the research’s method as per the policy of the governmental and local research center.

Data availability statement

The datasets used and/or analyzed during this study are available from the corresponding author (Dr. Khalid Al Sulaiman, email: [email protected]) on reasonable request.

Acknowledgement

The authors thank the Saudi Critical Care Pharmacy Research (SCAPE) Platform for their support.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

Patients and public involvement

Patients or the public were not involved in the design, conduct, reporting, or plans of our research.

Consent for publication

Not applicable.



 
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