title: Pharmacist proactive medication recommendations using electronic documentation in a UK general critical care unit.
abstract: BACKGROUND
  Specific data on the actual clinical practice of United Kingdom pharmacists in Critical Care are limited. Within the general critical care units of Sheffield Teaching Hospitals, clinical pharmacists have the facility to electronically document, communicate and follow-up proactive recommendations using a Pharmacy Review Form via the Clinical Information System, MetaVision(®).
  
  
  OBJECTIVE
  The objective of the service evaluation was to describe the acceptance rate by medical staff of pharmacist proactive medication recommendations; including data on the types of recommendations and reasons thereof, for general intensive care patients of a UK teaching hospital trust.
  
  
  METHODS
  Sheffield Teaching Hospitals National Health Service Foundation Trust with 20 intensive care beds located on two hospital sites admitting Level 3 and 2 mixed general medical, surgical, trauma, burns and haematology/ oncology patients.
  
  
  METHODS
  Retrospective analysis of pharmacist proactive recommendations recorded electronically from January 2009 to July 2011 in general intensive care unit patients. Main outcome 5,623 electronic medication recommendations were documented, providing an average of 2.2 proactive recommendations per patient admitted to intensive care from January 2009 to July 2011. 5,101 (90.7%) of the recommendations were accepted and acted upon by medical staff.
  
  
  RESULTS
  The most common recommendations were Add Drug 1,862 (28.2%); Dose Review 1,707 (25.8%); Discontinue Drug 1,185 (17.9%); Alternative Drug 903 (13.7%); Alternative Route 770 (11.7%). The most common reasons for the proactive medication recommendations were related to changes in gastrointestinal absorption 951 (15.6%); compliance with medication guidelines 857 (14.1%); sedation/delirium/agitation management 764 (12.6%); dose adjustment for renal dysfunction or continuous renal replacement therapies 756 (12.4%); and medication reconciliation 612 (10.1%). The majority of medication recommendations involved drugs in Gastrointestinal, Central Nervous System, Cardiovascular, Infection, Nutrition and Blood classes (British National Formulary).
  
  
  CONCLUSIONS
  There was a high acceptance rate for proactive medication-related recommendations made by critical care pharmacists via the electronic review form. The majority of pharmacist recommendations were related to adding or refining currently prescribed medication. Ten percent of recommendations related to medication reconciliation of patients' pre-admission medication.
authors.affiliation: Department of Pharmacy, Sheffield Teaching Hospitals, Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK. richard.bourne@sth.nhs.uk
authors.forename: Richard S
authors.initials: RS
authors.lastname: Bourne
authors.forename: Chui Lynn
authors.initials: CL
authors.lastname: Choo
mesh_terms: D002983:Clinical Competence / Q000592:standards*; D003299:Cooperative Behavior; D003422:Critical Care / Q000592:standards*; D004347:Drug Interactions; D064420:Drug-Related Side Effects and Adverse Reactions; D057286:Electronic Health Records / Q000592:standards*; D004739:England; D019983:Guideline Adherence; D006742:Hospital Bed Capacity; D006751:Hospital Information Systems / Q000592:standards*; D006757:Hospital Units / Q000592:standards*; D006784:Hospitals, Teaching / Q000592:standards*; D006801:Humans; D033183:Interdisciplinary Communication; D059065:Medication Reconciliation; D010348:Patient Care Team / Q000592:standards; D010595:Pharmacists / Q000592:standards*; D010607:Pharmacy Service, Hospital / Q000592:standards*; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies