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Dana Bakdach, Hamad General Hospital, Doha, Qatar (NOT PICTURED)
Farah Kablaoui Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
Nouran Salem, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
Rita Jebrin, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
Maha Elhamid, Hamad General Hospital, Doha, Qatar

Background

In the Middle East and North Africa (MENA), the scope of clinical pharmacy practice is relatively new and emerging. Several countries in the Middle East and the Gulf region (including Qatar, United Arab Emirates (UAE), Kingdom of Saudi Arabia, Jordan, Egypt and others) had established their practice in line with the American College of Clinical Pharmacy (ACCP) standards of practice that were developed in 2014.¹ These standards defined expectations for delivering comprehensive medication management in a team-based collaborative practice setting. For instance, clinical pharmacy services were first introduced in 2006 at Hamad General Hospital (HGH), and in 2015 at Cleveland Clinic Abu Dhabi (CCAD) when the hospital was inaugurated.

Pharmacists have since become integral members of the multidisciplinary teams in these regions across different health care settings and specialties including internal medicine, pediatrics, emergency, neurology, and critical care.

Critical care clinical pharmacy practice has been well-recognized, and pharmacists are described as an essential component for providing quality care to the critically ill population by multiple societies including the Society of Critical Care Medicine (SCCM)² and Neurocritical Care Society (NCS).³ The benefits of having pharmacists involved in the care of severely ill patients has been clearly documented, with a reduction in adverse drug events, morbidity and mortality being described.^4,5

Cleveland Clinic Abu Dhabi (CCAD) is a 364-bed tertiary referral center located in Abu Dhabi, United Arab Emirates, comprised of 6 Centers of Excellence in the following institutes: Heart & Vascular, Neurological, Digestive Disease, Eye, Respiratory, and Critical Care.⁶ The Critical Care Institute comprises 72 ICU beds divided into 3 specialized ICUs (Neurocritical Care Unit [NCCU], Medical/Surgical and Cardiothoracic Critical Care Unit). 

The CCAD NCCU is a dedicated 24-bed ICU that was established in 2016 and is currently staffed 24/7 by more than 4 U.S. neurocritical care board certified neurointensivists and advanced practice providers.  Hamad General Hospital (HGH), on the other side, is one of the tertiary hospitals under the umbrella of Hamad Medical Corporation (HMC); the principal public health care provider within the State of Qatar.⁷ Out of its 983 beds, 69 beds are devoted to intensive care services (including medical, surgical and trauma), with a 10-bed capacity dedicated for the NCCU, established in 2017.

Among both hospitals, NCCUs provide care to a wide spectrum of neurologic emergencies including but not limited to stroke (ischemic/hemorrhagic), cerebral venous thrombosis, status epilepticus, complex vascular malformations, brain tumors, and CNS infections. Although other neurologic emergencies including traumatic and spontaneous subarachnoid hemorrhages (SAH) and traumatic brain injury (TBI) are also covered by the NCCU at CCAD, those emergencies are still currently served by other intensive care services at HGH (e.g., TBI covered by the Trauma ICU, SAH covered by the Surgical ICU).

Recruitment

Before its establishment, our institutions had a plan to hire dedicated Neurocritical care specialists to best serve the NCCUs. To ensure optimal care, and in accordance with U.S. standards, recruited pharmacists were required to possess solid knowledge and skills in both neurology and critical care. Both institutions shared similar criteria for the minimal requirements in recruitment such as having a doctorate in pharmacy degree (PharmD) or equivalent Master’s in clinical pharmacy (in some institutions), along with a track record of subspecialty experience (a certain number of years of experience or post-graduate pharmacy residency, if available, in accordance with the local ministry of health requirements within each country). Additionally, holding other credentials was highly encouraged (e.g., basic/advanced cardiac life support, Board of Pharmaceutical Specialist certification in critical care [BCCCP], etc.), with a few differences specific to each country’s licensure. Similarly, recruited pharmacists were encouraged to complete the Emergency Neurological Life Support (ENLS) course while establishing their NCCUs.

Establishing Clinical Services

Neurocritical care pharmacists provide added benefit in specialized neurocritical care emergencies, including management of anticoagulation, status epilepticus, and “brain codes” with sustained intracranial hypertension or acute herniation. In a study conducted among NCCU patients, the inclusion of pharmacists in the NCCU translated into a reduction of pharmacy acquisition costs, ICU length of stay, and readmission rates.⁹

As one might expect, establishing an NCCU comes with baseline requirements that must be maintained in addition to continuous efforts to further advance care. At baseline, the availability and accessibility of crucial medications must be ensured. As part of this process, all urgent medications needed to be identified and made easily accessible within the units (through Pyxis machines) or as STAT (i.e., immediately available) medication orders to be delivered with a short turn-around time from pharmacy (within 30 minutes). For new or nonformulary medications, the process first requires a review of the literature by the clinical NCC team (including NCC pharmacists) to create a drug monograph, then an assessment of cost and obtainability. Our institutions have hardworking supply chains that have overcome the challenges of medication procurement. Almost every medication recommended by NCS guidelines is available in our NCCUs. Being pharmacotherapy experts, our experiences in our daily activities are similar.  Neurocritical Care (NCC) pharmacists in both institutions are heavily involved in daily multidisciplinary rounds, thorough profile reviews, medication reconciliation, medication therapy management, pharmacotherapy consults and more. 

Order sets, guidelines, and protocols were created jointly between the clinical pharmacy team and other health care providers in line with relevant international guidelines (e.g. NCS, SCCM) to ensure optimal care and service. These protocols have been especially helpful for the treatment of neurological emergencies such as status epilepticus, raised intracranial pressure, or the reversal of oral anticoagulation. Titratable medications such as inotropes and pressors, analgesia and sedation were incorporated to reflect different dosing and concentrations for neurocritical care indications. It was essential for safety purposes that we separated these orders from those of other critical care units, and ensured that these NCCU-specific orders were smoothly integrated into the unit’s smart pumps. For example, a continuous infusion panel for midazolam in status epilepticus was created and highlighted in a way to differentiate it from midazolam orders and titration doses used for sedation. Similarly, we have also created orders for some novel evidence-based therapies, including the intra-ventricular administration of antibiotics and alteplase. 

Education/Training

In both institutions, precepting pharmacy residents and students through NCCU rotations is an integral part of our routine education and training.  Establishing this unique rotation was considered vital for learners to gain specialized experience in the management of neurologic emergencies and contrast it with the experience gained from other ICU rotations.

Moreover, given that both institutions have staff recruited from different countries with different background practices and NCCU experience, staff education was a high priority. Pharmacists played a central role in the education of not only basic neuropharmacology concepts but also newly implemented local protocols/guidelines and changes in medication processes, along with training new nurses and other staff. Nurse education was a central focus especially for those who were newly recruited, to ensure that nurses were familiar with the process of preparing bedside drugs during emergencies (given that pharmacists in both institutions are not yet required to have 24/7 attendance during codes or other acute critical situations).

Similarly, communications are announced whenever there is a change to drug suppliers that leads to changes in the formulation or preparation of different therapies.

Challenges

Ensuring continual service provision is vital and having continual access to critical care pharmacists has been recommended by multiple societies. Unfortunately, given the fact that clinical pharmacy services are still evolving in both institutions, 24/7 on-site pharmacist coverage is not always available. Similarly, although weekend clinical pharmacy coverage during daytime hours was recently implemented in Qatar, in-hospital clinical pharmacy services for after-hours coverage remains an area of improvement in both institutions. To tackle this challenge, 24/7 access to an on-duty central staff pharmacist was implemented to ensure coverage for emergencies or urgent inquiries, and to serve as a liaison to communicate with the NCC pharmacists when a critical situation arises during off-hours.

Future Considerations

The role of the pharmacist practicing in neurocritical care units throughout the Arab-Gulf region has evolved over the last few years. Although major steps have been made to improve care and expand the role of pharmacists in the NCCU, there are still areas of improvement that would benefit from further emphasis in the future. Expanding pharmacy services to include 24/7 coverage and code attendance are two areas of opportunity. The concept of the “brain code” has been implemented at CCAD and this could be an opportunity to reflect on the experience and translate it to other institutions in the MENA region. Similarly, staff education and certification (such as ENLS), along with active involvement in both national and international research, should also be prioritized in the future. Research collaboration with other NCC pharmacists within the MENA region, along with those from other international regions such as the U.S or Europe, is currently being discussed among both facilities, and steps to establish such connections are currently being considered.

References 

1. American College of Clinical Pharmacy. Standards of practice for clinical pharmacists. Pharmacotherapy. 2014 Aug;34(8):794-7.
2. Rudis MI, Brandl KM. Position paper on critical care pharmacy services. Society of Critical Care Medicine and American College of Clinical Pharmacy Task Force on Critical Care Pharmacy Services. Crit Care Med. 2000;28:3746–50.
3. Moheet, Asma M et al. “Standards for Neurologic Critical Care Units: A Statement for Healthcare Professionals from The Neurocritical Care Society.” Neurocritical care vol. 29,2 (2018): 145-160. 
4. Kane SL, Weber RJ, Dasta JF. The impact of critical care pharmacists on enhancing patient outcomes. Intensive Care Med. 2003;29(5):691-698. 
5. MacLaren R, Bond CA. Effects of pharmacist participation in intensive care units on clinical and economic outcomes of critically ill patients with thromboembolic or infarction-related events. Pharmacotherapy. 2009;29(7):761-768.
6. Cleveland Clinic’s Neurocritical Care Is in Abu Dhabi. Neurocritical Care Society Currents Newsletter. Jan 2019. Available at: https://currents.neurocriticalcare.org/currents/blogs/currents-editor/2019/01/17/cleveland-clinics-abu-dhabi
7. On the Frontline of COVID-19 in Qatar: Navigating Through Crisis, Embracing Change and Leading Innovation. Neurocritical Care Society Currents Newsletter. Sep 2020. Available at: https://currents.neurocriticalcare.org/blogs/currents-editor/2020/09/03/on-the-frontline-of-covid-19-in-qatar-navigating-t