Impact of pharmacists to improve patient care in the critically ill: A large multicenter analysis using meaningful metrics with the medication regimen complexity-ICU (MRC-ICU)


Andrea Sikora, Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA.
Deepak Ayyala, Department of Population Health Science: Biostats & Data Science, Medical College of Georgia, Augusta, GA.
Megan A. Rech, Department of Pharmacy, Loyola University Medical Center, Maywood, IL.
Sarah B. Blackwell, Department of Pharmacy Services, Princeton Baptist Medical Center, Birmingham, AL.
Joshua Campbell, Department of Pharmacy, Guthrie Robert Packer Hospital, Sayre, PA.
Meghan M. Caylor, Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA.
Melanie Smith Condeni, Department of Pharmacy, Medical University of South Carolina, Charleston, SC.
Ashley DePriest, Department of Pharmacy, Wellstar Kennestone Regional Medical Center, Marietta, GA.
Amy L. Dzierba, Department of Pharmacy, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, NY.
Alexander H. Flannery, Department of Pharmacy, University of Kentucky College of Pharmacy, Lexington, KY.
Leslie A. Hamilton, Department of Pharmacy, The University of Tennessee Health Science Center College of Pharmacy, Knoxville, TN.
Mojdeh S. Heavner, Department of Pharmacy, University of Maryland School of Pharmacy, Baltimore, MD.
Michelle Horng, Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX.
Joseph Lam, Department of Pharmacy, Highland Hospital, Alameda Health System, Oakland, CA.
Edith Liang, Department of Pharmacy, Critical Care/Emergency Medicine Clinical Pharmacy Specialist, AMITA Health Saints Mary and Elizabeth Medical Center, Chicago, IL.
Jennifer Montero, Department of Pharmacy, Lakeland Regional Health, Lakeland, FL.
David Murphy, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, GA.
Angela M. Plewa-Rusiecki, Department of Pharmacy, John H. Stroger, Jr Hospital of Cook County, Chicago, IL.
Alicia J. Sacco, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Phoenix, AZ.
Gretchen L. Sacha, Department of Pharmacy, Cleveland Clinic, Cleveland, OH.
Poorvi Shah, Advocate Aurora HealthFollow
Michael P. Smith, Department of Pharmacy, LRGHealthcare, Laconia, NH.
Zachary Smith, Department of Pharmacy, Henry Ford Hospital, Detroit, MI.
John J. Radosevich, Department of Pharmacy, St. Joseph's Hospital and Medical Center, Phoenix, AZ.
Antonia L. Vilella, Sarasota Memorial Hospital, Sarasota, FL.


Advocate Christ Medical Center


Objectives: Despite the established role of the critical care pharmacist on the ICU multiprofessional team, critical care pharmacist workloads are likely not optimized in the ICU. Medication regimen complexity (as measured by the Medication Regimen Complexity-ICU [MRC-ICU] scoring tool) has been proposed as a potential metric to optimize critical care pharmacist workload but has lacked robust external validation. The purpose of this study was to test the hypothesis that MRC-ICU is related to both patient outcomes and pharmacist interventions in a diverse ICU population.

Design: This was a multicenter, observational cohort study.

Setting: Twenty-eight ICUs in the United States.

Patients: Adult ICU patients.

Interventions: Critical care pharmacist interventions (quantity and type) on the medication regimens of critically ill patients over a 4-week period were prospectively captured. MRC-ICU and patient outcomes (i.e., mortality and length of stay [LOS]) were recorded retrospectively.

Measurements and main results: A total of 3,908 patients at 28 centers were included. Following analysis of variance, MRC-ICU was significantly associated with mortality (odds ratio, 1.09; 95% CI, 1.08-1.11; p < 0.01), ICU LOS (β coefficient, 0.41; 95% CI, 00.37-0.45; p < 0.01), total pharmacist interventions (β coefficient, 0.07; 95% CI, 0.04-0.09; p < 0.01), and a composite intensity score of pharmacist interventions (β coefficient, 0.19; 95% CI, 0.11-0.28; p < 0.01). In multivariable regression analysis, increased patient: pharmacist ratio (indicating more patients per clinician) was significantly associated with increased ICU LOS (β coefficient, 0.02; 0.00-0.04; p = 0.02) and reduced quantity (β coefficient, -0.03; 95% CI, -0.04 to -0.02; p < 0.01) and intensity of interventions (β coefficient, -0.05; 95% CI, -0.09 to -0.01).

Conclusions: Increased medication regimen complexity, defined by the MRC-ICU, is associated with increased mortality, LOS, intervention quantity, and intervention intensity. Further, these results suggest that increased pharmacist workload is associated with decreased care provided and worsened patient outcomes, which warrants further exploration into staffing models and patient outcomes.

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