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Table 2. Intervention Categories and Activities.
Glucose Management
** Initiate/increase/decrease/discontinue basal,
short-acting, or sliding scale insulin
** Initiate/discontinue/decrease dextrose
containing fluids
** Order lab test/point of care
** Initiate/transition from Insulin drip
** Discontinue oral glycemic agents
Code Sepsisa
** Timely initiation of antimicrobial regimen
** Recommend alternative antimicrobial regimen
** Add antimicrobial to regimen
** Antimicrobial dose adjustment
Electrolyte Management
** Hyponatremia/hypernatremia replacement
recommendation
** Replacement per protocolb
** Hyponatremia/hypernatremiab
recommendation outside of protocol
** Order lab test

Medication Management
** Adverse drug event avoided
** Drug allergy avoidance
** Recommend alternate dose or medication
** Serum drug level monitoring
** Drug information
** Change route/formulation
** Order/discontinue lab test
BCID
** Review antimicrobial regimen
** Add/escalate antimicrobial regimen
** Consult Infectious Disease MD on call
** Call results to Pediatric ICU Pharmacist/
Attending/ED or Telehealth RN
VTE/SUP Prophylaxis
** Initiate/discontinue therapy
** Change route
** Renal/weight-based dose adjustment
** Recommendation of alternate agent
** Discontinue duplicate therapy
** Order lab test

Note. BCID = blood culture identification; ICU = intensive care unit; RN = registered nurse; VTE/SUP = venous thromboembolism/stress ulcer
prophylaxis; SBP = systolic blood pressure; MAP = mean arterial pressure; IVF = intravenous fluid.
a
Code Sepsis is defined as a suspected infection AND hypotension (SBP < 90 mm Hg or MAP < 65 mm Hg) after 20 mL/kg IVF bolus OR Lactate greater
than 4 mmol/L.
b
Potassium, magnesium, and phosphorous replacement.

Figure 1. Second-shift tele-ICU pharmacist workflow.

Note. Tele-ICU = tele-intensive care unit; EMR = electronic medical record.

pharmacist's hours are Monday, Wednesday, and Friday
from 8 am to 12 pm. The VCC pharmacy team conducted
several site visits to introduce themselves to the on-site
teams, assess the pharmacy support and services offered at
these facilities, shadow on rounds, and determine points of
contact at the sites.
In contrast to the second-shift VCC pharmacist, the dayshift pharmacist uses TheraDoc® alerts in addition to reviewing all ICU patients at 6 facilities without a dedicated critical
care pharmacist, which include 76 beds. The dayshift telepharmacist makes recommendations via several routes: the

VCC nurse rounding with the team, the on-site pharmacists,
or on-site providers as the bedside teams are in-house during
daytime hours. The dayshift pharmacist even rounds virtually once a week at one facility, and 3 days a week at a second facility, allowing the pharmacist to directly interface
with the team via the use of audio and visual technology
through a workstation on wheels. First- and second-shift
tele-ICU pharmacists communicate patients needing followup via the electronic triage board and TheraDoc® to ensure
continuity of care. Although the dayshift model provides
remote patient monitoring and a responsive mode of care,

Hospital Pharmacy - July/August 2019

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