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Kosmisky et al
with 82 intensivists across the healthcare system and around
the globe, which provides a variety of different perceptions
and practices. A final challenge is prioritization of workflow
during periods of high census or high acuity.
Dayshift has its own set of challenges. The biggest challenge is determining optimal avenues for intervention delivery and integration with the bedside multidisciplinary teams.
As many sites the dayshift pharmacist follows do not have a
dedicated critical care trained pharmacist that rounds daily,
integrating the tele-ICU pharmacist into this model remains
an ongoing endeavor. Another challenge includes intervention documentation as the intervention recommended may
not be implemented immediately. Thus, follow-up may be
needed by the second-shift pharmacist.

Implementation Considerations
There are several ways in which pharmacists may become
involved when facilities are considering implementing
telepharmacy services. Review your current physician processes and determine how much time is spent on tasks that
could be delegated to a pharmacist. Pharmaceutical expenditures and processes should be examined to determine whether
there are any high-cost medications that may benefit from
additional pharmacy oversight or processes that may improve
patient outcomes, including ABCDEF bundle adherence,19
and identify opportunities for improvement of core measure
compliance. If ASP is not available, this may be a suitable
first step. Once target activities are developed, evaluate the
workflow of current pharmacy staff to determine whether
cross-coverage of other facilities is feasible. If additional
staff is not able to be hired initially, data collection and support for the program can begin as a resident project or be
conducted by specialized overnight staff. Communication
capabilities should be assessed and the best avenues for
delivering and documenting interventions should be determined. Tele-ICU pharmacy metrics should be identified and
a schedule for reporting to leadership should be outlined.
Ongoing assessment and refinement of the program should
be performed.
In addition, regulatory issues should be considered when
implementing a telepharmacy practice. Compliance at a federal level with the Health Insurance Portability and
Accountability Act (HIPAA), subtitle D of the Health
Information Technology for Economic and Clinical Health
(HITECH) Act, and Food and Drug Administration Standards
for medical software, equipment, and mobile applications is
necessary.6 Many states also have telepharmacy regulations;
however, there is significant variation in scope, definitions,
and requirements. The National Associations of Boards of
Pharmacy's Pharmacy Practice Model Act (Model Act)
includes definitions of the practice of telepharmacy and pharmacist care. The Model Act provides states with framework
for developing laws or board of pharmacy rules, although it
primarily focuses on requirements for remote dispensing
sites.20 At a minimum, the telepharmacist must be licensed in

each state in which the patient they are caring for is located.
They should be credentialed by institutions, if applicable. The
states in which these telepharmacists practice do not yet have
specific telepharmacy regulations, however, it is anticipated
that these will be implemented in the future as telepharmacy
continues to expand.

Future Directions
When this telepharmacy program was implemented, Clinical
Pharmacist Practitioners (CPPs), licensed pharmacists able
to provide drug therapy management under the supervision
of a licensed physician in North Carolina, were not ardently
promoted in the inpatient setting.21 The lack of standardized
protocols and preferred formulary agents across these sites,
the number of VCC and bedside physicians that would need
to sign these agreements, and the certification and practice
requirements for pharmacists did not make the CPP route
feasible at implementation. Since the inception of VCC services, all pharmacists practicing at ambulatory clinics within
the health care system have become CPPs. An exploratory
committee has been created to explore the role of CPPs in the
inpatient setting, with members currently obtaining buy-in
from key stakeholders across the health care system.
Reciprocal interest has been expressed in using the emergency department and tele-ICU pharmacists as part of the
initial roll-out of CCPs in the inpatient space.
This telepharmacy program hopes to expand the number
of pharmacists on the team and shifts covered, with the ultimate goal of 24/7 coverage. An expanded virtual rounding
presence to all facilities without daytime critical care-trained
pharmacists is also desired. The telepharmacists also hope to
conduct additional research and quality improvement projects, particularly in the areas of pain, agitation, and delirium,
fluid balance, and acute kidney injury.

Conclusions
This tele-ICU program is innovative for several reasons. To
our knowledge, it is one of the only entirely clinical-based
tele-ICU pharmacy models among the few tele-ICUs across
the United States with pharmacy integration. The addition of
dayshift tele-ICU coverage is also a distinctive feature.
Although many of tele-ICUs focus on a single facility, this
model serves a large and diverse patient population across
critical access, community, and tertiary facilities and 1 quaternary medical center across 2 states. The use of technology
for customized alert generation and intervention proposal
and management is unique. In addition, the tele-ICU pharmacist is responsible for medication orders and chart notation, which are not routinely performed by pharmacists
outside of ambulatory settings under collaborative practice
agreements. This program was initiated with several anticipated benefits to the healthcare system: an increased amount
of tele-ICU intensivist time available for new admissions,
cost savings, and provision of critical care pharmacy services

Hospital Pharmacy - July/August 2019

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