On the surface, the answer to the question of the title of this editorial seemed to be a rhetorical and obvious yes. This is not because two pharmacists are involved in authoring this editorial, but because there is a substantial amount of literature—arguably more than which exists for any other clinical team member in the ICU and likely more than some of the standard-of-care interventions (such as mechanical ventilation)—which linked the presence of a pharmacist in an ICU to improved patient outcomes.

Since the beginning of ICU clinical pharmacy services in the 1960s [1], the practice has matured along with the subspecialty of critical care medicine into one that has been considered by the Society of Critical Care Medicine (SCCM) as essential [2]. In fact, within the SCCM guidelines for best practice model and ICU staffing [2], pharmacist presence was considered as best practice supported by grade C evidence, the highest level of all recommendations in that document. A summary of the studies evaluating the impact of having a dedicated pharmacist in the ICU is shown in Table 1 [3–15]. In general, these studies show reductions in drug prescribing errors, adverse drug events, and costs, with no worsening and typically improvement in clinical outcomes such as ICU length of stay and mortality. A large survey of US hospitals conducted in 2004 compared costs and clinical outcomes in ICUs with at least a part-time dedicated pharmacist to those without this resource. It showed improved costs and clinical outcomes (shorter ICU lengths of stay and lower hospital mortality) particularly in patients with infections [5] and thromboembolic diseases [6]. In a landmark paper, Leape and colleagues [3] clearly demonstrated that presence of pharmacists in a medical ICU reduced medication errors and cost. These benefits appear generalizable since the studies have been conducted in a variety of ICUs (e.g., medical, surgical, neurosurgical, cardiac, and pediatric) using different physician staffing models (e.g., open vs closed ICU), and date back to the early 1990s [13]. The majority of the studies have been conducted in North America, but similar beneficial results have been published from studies conducted in Asia [4, 8, 9], the Middle East [10], and Europe [11]. Provision of drug information, clarifying and correcting medication orders, identifying drug interactions as well as actual or potential adverse drug events, and recommending alternative therapies account for greater than 90 % of ICU pharmacists’ activities [3, 4, 8, 13, 14]. The studies indicate that a large majority, and in most studies almost all, of pharmacists’ recommendations are accepted by the physicians [3, 4, 13–15]. These significant improvements in patient care afforded by the presence of dedicated pharmacists are clearly viewed as important by medical colleagues, as shown by a recent survey [16].

Table 1 Evidence summarizing the clinical and economic outcomes of pharmacists’ impact in the ICU
Full size table

In addition to the clear benefits for the patients, ICU pharmacists can play a multitude of other roles [17] such as education of other team members, leadership or administrative roles in critical care committees, and in scholarly work and research. The extent to which these are seen in individual ICUs is variable, as outlined by a recent survey [18]. As an example, in one of the studies listed in Table 1 [12], the development and implementation of sedation guidelines were initiated and led by the ICU pharmacist. However, the bulk of the activities still involve provision of pharmaceutical care where a patient’s drug-related issues (e.g., wrong dose, wrong drug, interactions, and adverse reactions) are identified, prevented, and resolved with pharmacists making recommendations that are accepted by the physicians a majority of the times.

Upon closer examination of the published data, it appears that while pharmacists in the ICU are clearly essential and beneficial for the patients and the team, not all ICUs have a pharmacist, and even in ICUs that do have such a dedicated person, he or she is only present for part of the day. In a recent survey conducted in the USA, only 62.2 % of 382 ICU respondents had clinical pharmacy services [18]. Similarly, Leblanc and colleagues [19] reported that only 74.4 % of 168 international ICU pharmacists who responded were routinely attending rounds, one of the key activities demonstrated to be of benefit to the patient. This contradiction (clear evidence of need but yet not universally available) is likely due to several reasons. First and foremost are likely financial barriers. Despite the fact that ICU pharmacists have been demonstrated to provide cost-effective care and cost savings in many facets of care, some hospital administrators may still not (however erroneously) see the clear return on investment. Studies estimate that costs saved in terms of direct drug costs and avoidance of preventable adverse drug events compared to the pharmacist cost is a multiple of at least 4 [11, 13]. Second, critical care training is not common in pharmacy training curricula, and thus the specialized training required to be a competent ICU pharmacist must be obtained either “on the job” or in a formal manner through a limited number of residency/fellowship-type training programs. In a recent survey, this type of residency/fellowship was only available in 16.2 % of the US hospitals with ICU pharmacy services [18]. Finally, much like the care gaps that exist for many well established evidence-based therapies, it may be that the uptake process to move towards this best practice requires time.

While the spread of this knowledge needed to close the gap is happening, as evidenced by the international nature of the publications supporting the role of a pharmacist, further efforts are still needed [18]. Perhaps the next time an editorial of this topic is authored for the journal, the title will not be “Do we need a pharmacist in the ICU?” but rather “Do we have enough pharmacists in the ICU?”