Optimization of Pharmacist Medication Management and Mortality in the Intensive Care Unit

Abstract Rationale Medication-related morbidity due to inappropriate prescribing, delays in appropriate treatment, and adverse drug events contributes to ICU patient mortality. Comprehensive medication management (CMM) is a care standard provided by pharmacists in collaboration with the interprofessional team. Optimizing ICU pharmacist workload via the pharmacist-to-patient ratio while ensuring daily CMM may reduce mortality. Research Question Is ICU pharmacist staffing, measured by the pharmacist-to-patient ratio and absence of comprehensive medication management (CMM), associated with in-hospital mortality among critically ill adults? Study Design and Methods Adults admitted to an ICU from 64 centers (in the United States, Jordan, and Saudi Arabia) were enrolled in a multicenter observational study that collected patient and team staffing data from August 2023-January 2025. The primary outcome was in-hospital mortality. The primary exposure was the patient-level pharmacist-to-patient ratio averaged over the ICU stay. A secondary exposure was the absence of CMM for at least 1 day. Multivariable generalized estimating equations (GEE) were used to estimate associations with in-hospital mortality, accounting for clustering by center and adjusting for patient-, ICU-, and hospital-level covariates. Results The 28,795 patients enrolled had a median (IQR) pharmacist-to-patient ratio of 1:17 (13-23). For every one patient increase in the pharmacist-to-patient ratio, the odds of mortality increased by 1% (Odds Ratio (OR) 1.01, 95% Confidence Interval (CI) 1.00-1.01, p=0.04). Patients without pharmacist CMM for 1 day had an increased risk of mortality of 20% (OR 1.20, 95% CI 1.03-1.40, p=0.02). The odds of hospital mortality were lower in a pharmacist-to-patient ratio of 1:7-15 compared to 1:16-46 (OR 1.10, 95% CI 1.00-1.22). Interpretation Increasing pharmacist-to-patient ratios and the absence of pharmacist CMM every day were both associated with an increased risk of in-hospital mortality.