The Canadian Journal of Hospital Pharmacy (CJHP) / Le Journal canadien de la pharmacie hospitalière (JCPH)

Authors, Various

CSHP Publications & Services

Mailman, Jonathan F

Semchuk, William

215CJHP – Vol. 71, No. 3 – May–June 2018 JCPH – Vol. 71, no 3 – mai–juin 2018
RESEARCH LETTER
Pharmacists’ Roles in Critical Care: 
Environmental Scan of Current Practices 
in Canadian Intensive Care Units
Clinical pharmacists’ practice in critical care has grown and 
developed independently in different parts of Canada, guided largely
by international research and position papers.1-3 The association of
positive patient outcomes with the involvement of clinical pharma-
cists is well known.4 An environmental scan of current Canadian
practices is not available in the published literature. A non-
anonymous survey, consisting of 14 groups of open-form questions,
was distributed by e-mail to all members of the Canadian Society of
Hospital Pharmacists’ Critical Care Practice Speciality Network in
March 2017 (see Appendix 1, available from https://www.cjhp-
online.ca/index.php/cjhp/issue/view/155/showToc). A follow-up 
reminder to potential participants working in critical care was 
conducted by telephone. 
Respondents from 31 centres (Table 1), representing 54 of a
possible 180 intensive care units (ICUs), provided input. 
Institution size, setting, region, and pharmacist training levels 
did not significantly affect any of the survey responses. Most 
respondents (22 [71%]) practised in a tertiary care centre, 28
(90%) in mixed medical–surgical units, and 27 (87%) in closed
intensivist-managed units. The mean ICU size was 21 beds 
(median 20, range 6–44, interquartile range [IQR] 12–27), 
and the mean equivalent patient load per full-time equivalent 
pharmacist5 was 13 (median 12, range 6–23, IQR 10–17). 
A group of pharmacists shared ICU coverage in 24 (77%) of the
centres, and a tiered team combining advanced-training and
entry-to-practice pharmacists was reported for 14 (45%) of the
centres. Overall, 9 (29%) of the centres reported that their critical
care pharmacy practitioners had received advanced training with
either a postbaccalaureate Doctor of Pharmacy (PharmD) or 
a Master’s degree, and 12 (39%) of the centres required an entry-
to-practice degree as the minimum educational level to practise
in the ICU. Pharmacists had higher credentials in locations where
a postbaccalaureate PharmD program had been in existence for
longer than 10 years. Clinical pharmacists provided coverage for
8 h/day in 28 (90%) of the centres and for 5 days a week in 26
(84%) of the centres, with a mean of 4 h (range 3–8 h) devoted 
specifically to rounds. The remaining pharmacist time was 
devoted to either drug distribution or clinical coverage in non–
critical care areas.
Consistent-format patient care rounds were reported by 
17 (55%) of the centres, with another 11 (35%) reporting that
the specific format of rounds was determined by the attending
physician. In 16 (52%) of the units, time was allocated during
rounds for the pharmacist to present; in the remainder of the
units, pharmacists were expected to support and comment on pre-
sentations by other members of the team. Respondents indicated
that pharmacists’ most common contributions during rounds
were reviewing current medications, reviewing antimicrobial 
therapy, adjusting medication dosing for organ dysfunction, 
providing therapeutic drug monitoring, and ensuring appropriate
prophylaxis (Figure 1). These reported pharmacist activities during
rounds aligned with the “fundamental” and “optimal” activities
for clinical pharmacists outlined by the Society of Critical Care
Medicine and the American College of Clinical Pharmacy.1,2
Clinical pharmacists transcribed orders from rounds consistently
in 3 (10%) of the units (specifically those in the Lower Mainland
of British Columbia) and on a dependent basis in another 
5 (16%) of the units.
Respondents reported that pharmacists prepared for rounds
using checklists in 10 (32%) of the centres, with FASTHUG6
being the most common checklist. The majority of pharmacist
documentation occurred as shadow charting, with 25 (81%) of
respondents reporting that this documentation was not included
in the medical record; for example, 17 (55%) of the centres 
reported use of a standardized patient monitoring form. In 
27 (87%) of the units, pharmacists relied on the progress notes
of other team members to record their contribution during rounds
in the medical record, and 57% (17/30) of respondents reported
that they would supplement those notes if they were discordant
with the care decision made or if the pharmacist determined 
that further detail was necessary. Pharmacists spent much effort 
creating shadow charting, which is shared solely among pharma-
Table 1. Locations of Centres Responding to Survey
Province                                                          No. of Respondents
Newfoundland                                                         1
Nova Scotia                                                              1
New Brunswick                                                         2
Quebec                                                                     1
Ontario                                                                   10
Within Toronto                                                       4
Outside Toronto                                                      6
Manitoba                                                                  2
Saskatchewan                                                          2
Alberta                                                                     5
British Columbia                                                       7
Within Lower Mainland                                          3
Outside Lower Mainland                                        4
Total                                                                       31
CJHP – Vol. 71, No. 3 – May–June 2018 JCPH – Vol. 71, no 3 – mai–juin 2018216
cists. Shadow charting may be leftover from a time before 
computer information systems, when pharmacists rarely attended
the ward and conducted consultations over the telephone. 
Institutions should review the efforts expended on shadow 
charting, with a view to ensuring that pharmacists’ assessments
and actions are included in the formal medical record.
These results show that Canadian pharmacists’ self-
description of their practice in the ICU is variable and poorly 
defined, with clinicians often describing their practice as being
dependent on specific patient requirements. Clinical coverage
models, patient load, and pharmacist training levels also differ.
Documentation of drug therapy decisions largely relies on 
physicians’ progress notes, and the majority of pharmacist 
documentation occurs outside the legal record. However, clinical
pharmacists are commonly expected to document their interven-
tions, and doing so has been shown to have benefits in terms 
of cost avoidance.1,7,8 Work, research, and programming to 
decrease barriers to pharmacist documentation are ongoing.9,10
The sample in this survey study may have been too small to show
statistically significant practice differences in relation to centre
characteristics. This sample may also not be reflective of all 
centres in Canada, as there was likely selection bias among the 
participants; however, the findings may serve as a baseline for 
future environmental scans of ICU practice in Canada.
References
1. Society of Critical Care Medicine; American College of Clinical Pharmacy;
Rudis MI, Cohen R, Cooper BE, Gonzalez LS, Hassan E, Klem C, et al. 
Position paper on critical care pharmacy services. Pharmacotherapy. 2000;
20(11):1400-6. 
2. MacLaren R, Devlin JW, Martin SJ, Dasta JF, Rudis MI, Bond CA. Critical
care pharmacy services in United States hospitals. Ann Pharmacother. 2006;
40(4):612-8.
3. Preslaski CR, Lat I, MacLaren R, Poston J. Pharmacist contributions as 
members of the multidisciplinary ICU team. Chest. 2013;144(5):1687-95. 
4. Leguelinel-Blache G, Nguyen TL, Louart B, Poujol H, Lavigne JP, Roberts
JA, et al. Impact of quality bundle enforcement by a critical care pharmacist
on patient outcome and costs. Crit Care Med. 2018;46(2):199-207. 
5. SHPA Committee of Specialty Practice in Critical Care; Leung D, Kirsa S,
Egan A, Milne D, Lau R, Lum E, et al. SHPA standards of practice for critical
care pharmacy practice. J Pharm Pract Res. 2008;38(1):58-60.
6. Mabasa VH, Malyuk DL, Weatherby EM, Chan A. A standardized, 
structured approach to identifying drug-related problems in the intensive
care unit: FASTHUG-MAIDENS. Can J Hosp Pharm. 2011;64(5):366-9. 
7. Lada P, Delgado G Jr. Documentation of pharmacists’ interventions in an
emergency department and associated cost avoidance. Am J Health Syst
Pharm. 2007;64(1):63-8. 
8. ASHP Council on Pharmacy Practice. ASHP guidelines: minimum standard
for pharmacies in hospitals. Am J Health Syst Pharm. 2013;70(18):1619-30. 
9. Rector KB, Veverka A, Evans SK. Improving pharmacist documentation of
clinical interventions through focused education. Am J Health Syst Pharm.
2014;71(15):1303-10. 
10. Pullinger W, Franklin BD. Pharmacists’ documentation in patients’ hospital
health records: issues and educational implications. Int J Pharm Pract. 2010;
18(2):108-15. 
Jonathan F Mailman, BSc(Pharm), ACPR, PharmD, CD
Clinical Pharmacist Specialist
Saskatchewan Health Authority – Regina
Clinical Lecturer
College of Medicine, University of Saskatchewan
Regina, Saskatchewan
William Semchuk,MSc, PharmD, FCSHP
Manager, Clinical Pharmacy Services
Director, Hospital Pharmacy Residency Program
Saskatchewan Health Authority – Regina
Regina, Saskatchewan
Competing interests: None declared.
Funding: None received.
Acknowledgement: The authors wish to acknowledge Ali Bell for 
statistical analysis support.
Figure 1. Topics to which pharmacists contributed during rounds (n = 31 
centres responding to the survey). Med Adjt Organ Dysfxn = medication 
adjustment in context of organ dysfunction, SUP = stress ulcer prophylaxis, 
VAP = ventilator-associated pneumonia, VTE = venous thromboembolism.


English

Pharmacists’ Roles in Critical Care: Environmental Scan of Current Practices in Canadian Intensive Care Units

CSHP Meritorious Service Award Recipients

Tribute to 1991 /92 Award Appraisers

(CPAC), CSHP, Clinical Pharmacy Advisory Committee

164 The Canadian Journal of Hospital Pharmacy - Volume 45, No. 4, August, 1992 
SPECIAL REPORT ~ 
Going Clinical: 
The White Paper - Two Years Later 
A review of the Canadian Society 
of Hospital Pharmacists' "White 
Paper on the Establishment and 
Elaboration of Clinical Pharmacy 
Services" two years after its initial 
publication. 
INTRODUCTION 
In 1987, CSHP Council created the 
Clinical Pharmacy Advisory Com-
mittee (CPAC) to develop guidelines 
and direction for the membership in 
the development of clinical services. 
Although clinical pharmacy services 
have existed for nearly twenty years 
in individual Canadian hospitals and 
most have met with some success, 
it was felt that progress was very 
slow and that members had diffi-
culty, for a variety of reasons, in 
developing clinical services. Implicit 
in this statement is that there was 
no clear direction across the pro-
fession on what should be our prior-
ities. It was felt that some solid 
direction was needed. CSHP Council 
wished to assist members in devel-
oping a framework for constructing 
clinical pharmacy services within 
their institutions. CPAC responded 
with a "White Paper on the Estab-
lishment and Elaboration of Clinical 
Pharmacy Services in Canada" 
which was distributed in both official 
languages to all Canadian hospitals 
employing a pharmacist. This doc-
ument outlined the need, obstacles 
and the modifying factors involved 
in establishing clinical services. 
Although the initial objective was 
the document called the "White 
Paper", CPAC also developed other 
mechanisms intended to stimulate 
hospital pharmacists to adapt to the 
clinical movement. A series of audio 
cassettes on "How To" approaches 
for developing clinical services was 
included with the "White Paper" and 
distributed in a binder entitled "Clin-
ical Pharmacy and You" through an 
educational grant from Glaxo Can-
ada. In addition, regional seminars, 
involving established clinical prac-
titioners, were held in Ottawa, Van-
couver, Banff, London, Montreal, 
Quebec City and Halifax. These se-
minars provided further "How To" 
information to attendees, particu-
larly on aspects of Patient Pharma-
cotherapy Monitoring (PPM). Based 
on initial highly positive reaction to 
these seminars, a second series has 
been planned for 1992 with empha-
sis on the "How To" of PPM. CP AC 
prepared formal written Guidelines 
and Standards on Clinical Services 
for review by CSHP Council. Most 
recently, CPAC was successful in a 
related venture, namely obtaining a 
research grant from the Ontario Hos-
pital Incentive Fund to measure the 
impact on patient care of the various 
levels of PPM defined in the White 
Paper. 
The purpose of this article is to 
review the feedback received by 
CP AC and, in particular, the results 
of surveys held at several of the 
regional seminars with a view to 
helping CP AC and CSHP determine 
the future needs of members. 
SURVEY RESULTS 
Each of the regional seminars was 
well attended with a total of approx-
imately 750 members attending the 
eight seminars. The presentations at 
the seminars were rated "very high" 
in terms of practicality and the most 
common recommendation was for 
more such seminars on the topic of 
PPM. Many also recommended se-
minars on the administrative promo-
tion of clinical services. 
Three surveys dealt specifically 
with the White Paper and were dis-
tributed at seminars in Banff, London 
and Toronto. A total of 115 of the 
two-page surveys were returned for 
a response rate of 35%. The follow-
ing data are some of the more per-
tinent results: 
Replying to a question, "Do you 
believe clinical pharmacy is the way 
of the future?", 100% of respondents 
declared yes. 
Asked whether certain groups had 
given sufficient priority to clinical 
practice, the "yes" replies were as 
follows: 
- hospital administration 17% 
- directors of pharmacy 64 
- clinical coordinators 89 
- supervisory pharmacists 60 
- staff pharmacists 5 7 
- schools of pharmacy 30 
- other groups 14 
Asked if respondents agreed that 
patient pharmacotherapy monitoring 
l The Canadinn Journal of Hospital Phannacy - Volume 45, No. 4, August, 1992 
should be the highest priority, 88% 
replied to the affirmative. 
As to which of the barriers to 
clinical pharmacy identified at the 
Hilton Head Conference had been 
encountered, the most frequently 
cited were (in order of frequency): 
1. Inadequate financial resources to 
hire sufficient pharmacy staff 
(Hilton Head #22) 
2. The limited expectations that 
other health professionals have of 
pharmacists (H.H. # 14) 
3. Responsibility for drug distribu-
tion (H.H. #3 7) 
4. Lack of appropriate technical 
support in pharmacy (H.H. # 19) 
5. Lack of a consumer demand for 
clinical pharmacy services based 
on a poor understanding by the 
public of the services pharmacists 
can offer (H.H. #4) 
6. Poor motivation among pharma-
cists (H.H. # 12) 
7. Failure of the educational process 
to adequately "professionalize" 
pharmacy students (H.H. # 18) 
8. Pharmacists' self-image (H.H. 
#6) 
9. Ill-defined priorities in the pro-
vision of clinical pharmacy ser-
vices (H.H. #7) 
Asked whether they agreed with 
priorities established in the White 
Paper, 96% of respondents replied 
'Yes'. 
When asked if they participated 
in decentralized level II PPM (se-
lective patient pharmacotherapy 
monitoring in patient care areas), the 
answers were distributed as follows: 
daily 5% 
most days/week 51 
weekly 15 
not at all 30 
When questioned as to what 
CSHP should be doing to promote 
the establishment and elaboration of 
clinical pharmacy services, a wide 
variety of responses were elicited. 
Most frequently cited were com-
ments recommending more contin-
uing education programs on PPM, 
more seminars on implementing the 
CP AC recommendations, corres-
pondence courses and training man-
uals. Second most commonly cited 
were comments on the need to pro-
mote reasonable standards, guide-
lines, and methods to monitor pro-
gress. There were also a significant 
number of comments suggesting 
CSHP's responsibility in promoting 
our clinical role to outside organi-
zations to educate others about its 
importance. Finally, a number of 
respondents recommended that 
CSHP promote the White Paper as 
widely as possible through publica-
tions and other promotional means. 
The survey also asked whether the 
educational grant from a pharma-
ceutical firm was a good investment 
or should it be used for other ven-
tures. The reply to this question was 
almost universally that this was mo-
ney well spent. Comments included 
a number of "thank you's" to indus-
try for supporting this need in prac-
tice. Some noted that this investment 
really benefitted patient care, since 
it allowed practitioners to imme-
diately use the material in the White 
Paper and the seminars in their own 
institution. Others commented that 
such investment was imperative if 
the profession was to advance into 
this critical new role. 
DISCUSSION 
Although the "White Paper on the 
Establishment and Elaboration of 
Clinical Pharmacy Services" was 
developed over many months by 
members of CP AC who collectively 
had considerable experience in de-
veloping clinical services, it could not 
necessarily be expected that the doc-
ument would receive wide support. 
With virtually 100% of the respon-
dents supporting clinical pharmacy, 
88% agreeing that PPM should be 
our highest priority and 96% agree-
ing with the priorities of the White 
Paper, the support is very solid. How-
165 
ever, there may be a bias in that those 
opposed to these efforts would not 
presumably be at the seminars; the 
extent of any such opposition is un-
known. Nevertheless, in view of the 
expressed strong support for the 
White Paper and the likelihood that 
this will direct CP AC and CSHP for 
the years to come, it behooves those 
opposed to make their arguments to 
the Society. 
CP AC will be urging the Society 
to continue to invest time and re-
sources in the task of redirecting our 
profession to a clinical one. As cited, 
the second series of regional Semin-
ars has already begun, with emphasis 
on the practice of PPM; these will 
be held in the same centres as the 
first series. To meet the particular 
needs of managers regarding the 
administrative promotion of clinical 
services, a series of three to four 
Clinical Pharmacy Management 
Seminars has been planned ( one in 
Toronto at the PPC, one in the West, 
one in Quebec and perhaps one in 
the Maritimes). 
The originally distributed binder 
"Clinical Pharmacy and You" which 
contains both the White Paper and 
audio cassettes on related talks will 
be updated with additional cassettes 
from time to time. The most recent 
addition includes material on the 
administrative promotion of clinical 
services, PPM in a small community 
hospital and the concept of "Phar-
maceutical Care". Regarding the lat-
ter, CP AC is exploring with the 
authors of this concept the similar-
ities and/or differences between this 
new concept and the White Paper's 
approach. An official position will 
be developed by the Society. 
CP AC members, with the support 
of the CSHP Council, have devel-
oped official links with the Associ-
ation of Faculties of Pharmacy of 
Canada (AFPC), at the level of their 
Education Committee. Views on 
curricular emphasis, the need for 
post-graduate programs, and the 
166 
mission of the profession will all be 
considered at this level. 
Finally, a research effort, long 
cherished by the CP AC, has been 
funded. The Ontario Hospital Incen-
tive Fund has supported CP AC 
efforts to identify the impact on 
patient care of the various levels of 
PPM identified in the White Paper. 
An initial two-year study will pro-
vide some interesting data on this 
issue. 
SUMMARY 
Overall, there is agreement from 
attendees at the Regional Seminars 
that the White Paper on the Estab-
lishment and Elaboration of Clinical 
Pharmacy Services is a document of 
major importance to the profession, 
that the principles and the skills 
stressed in the White Paper should 
The Canadian Journal of Hospital Pharmacy - Volume 45, No. 4, August, 1992 
be promoted continually through se-
minars and standards, and that it is 
appropriate in terms of meeting the 
needs of practitioners for the ad-
vancement of clinical pharmacy 
practice. There is a general sense that 
these "How To" efforts are the best 
mechanism for practitioners to in-
creasingly adapt to the needs of 
becoming clinical practitioners. In 
addition, the idea is often expressed 
that this type of seminar needs to 
be offered repeatedly for different 
practice populations. 
There are implications expressed 
for political action by CSHP and for 
changes in our schools of pharmacy. 
Overall, the first efforts of CPAC 
have been met with broad satisfac-
tion and a demand for further pub-
lications, educational seminars and 
research projects. 
By the Clinical Pharmacy Advisory 
Committee (CP AC), CSHP 
Outgoing Chairperson: William 
McLean, Ottawa; 
National Committee: Glen Brown, 
(Incoming Chairperson), Van-
couver; Erwin Friesen, Edmon-
ton; Richard Eppel, Owen Sound; 
Charles Bayliff, London; Nancy 
Winslade, Toronto; Marc LeBel, 
Quebec; Ingrid Sketris, Halifax; 
Local Committee: Samantha Fong, 
Ottawa; Myrella Roy, Ottawa; 
Michael Tierney, Ottawa; 
Consultants: Reta Johnson, Calgary; 
Jane Richardson, Saskatoon; 
Research Consultants: Jeffrey 
Poston, Ottawa; Marianne Greer, 
Saskatoon; James L. Mann, 
Toronto; Timothy Stratton, Van-
couver. 


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Pharmacists’ Roles in Critical Care: Environmental Scan of Current Practices in Canadian Intensive Care Units

CSHP Meritorious Service Award Recipients

Tribute to 1991 /92 Award Appraisers

Going Clinical: The White Paper — Two Years Later

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