Welcome. My name is Brian Erstad and the title of this talk is More Bang for Your Buck, the Service Justification and Return on Investment for ICU Pharmacists. I have nothing to disclose. Here are the learning objectives for this program. I'll let you read through those rather than read through each of those individually. The key points that I have at the beginning and end of this talk is that the role of the critical care pharmacist has been defined and redefined by both intra and intraprofessional consensus recommendations, and these can be used as a starting point to justify positions. Also, that demonstrating the value, and by value I mean health outcomes achieved per dollar spent of any of the healthcare professions is difficult, but there is evidence recognizing the value of clinical pharmacists. And finally, most of the economic justification for critical care pharmacists, including telecritical care pharmacists, is based on cost minimization and cost avoidance investigations. And I'll talk about some of the limitations and some of the the newer ways of calculating cost avoidance. Well, I like these two quotes by Carl Sagan and Mahatma Gandhi because they seem to go pretty well together. You have to know the past to understand the present, and the future depends on what we do in the present. And so let's start off with some of the past here. And this is just to show you sort of where critical care pharmacists fit in terms of hospitals having ICUs and the Society of Critical Care Medicine, etc. So you'll see by the 1960s, most hospitals have formal ICUs. Colleges and pharmacies are beginning to develop clinical programs. There's, in the 70s, initiation of critical care pharmacy practice in several hospitals, the formation of SCCM with the first president, of course, publications of intensive care medicine, critical care medicine. Critical care pharmacy practice gets more widespread in the 1980s. And this includes having board certification in critical care, although in this case, I'm referring to board certification of the medical specialties. And later, you'll see that we end up having board certification for pharmacists. 1989 is the SCCM clinical pharmacy and pharmacology section that's created. 2000, more than 5000 ICUs. ICUs are frequently monitored by hospital pharmacies. And then in 2013, critical care pharmacy is recognized as a specialty in the pharmacy profession by the Board of Pharmacy Specialties. Well, this is a study that I thought is very critical to the evolution of pharmacists. And this is true for a couple of reasons. So first, if you look at the title, it's referring to pharmacists participation on physician rounds and adverse drug events in the ICU intensive care unit. And the reason I think that this this study is just so important for this talk is that one, it was the primary author was Lucian Leib, who was, again, a key physician with respect to patient safety type of studies. Similarly, David Bates, the senior author, final author in this study, same thing, both recognized experts in the field of patient safety. And as you'll, as you probably already know, they have a number of publications related to adverse drug events in the field. And so one, we have highly recognized physicians who are involved in a study that's published in a major journal that is JAMA. And so this really got the attention, not only of pharmacists, but outside of the pharmacy world, the fact that it was published in JAMA with these authors. And again, you see the other authors involved, but I think it's important to note that having these big name physician authors on this paper really helped to disseminate the findings, even into the lay press. And so again, this study ends up being cited so often when you look at reviews of justifications of pharmacy services, systematic reviews, et cetera, because it's just such a key trial. Well, that was in 1999. And then you'll see by the year 2000, there was this position paper on critical care pharmacy services. And this was a joint effort by the Society of Critical Care Medicine and the American College of Clinical Pharmacy. It was the task force that came out with this position paper. And this was followed by a number of papers of a similar form and again, related that included having justifications for pharmacists. So for example, there was this paper in 2001 on critical care delivery and intensive care unit that defined clinical roles, best practice models, including those of pharmacists. There were these guidelines that were created in 2003 that again, talked about critical care services and personnel. Again, this included having pharmacists involvement. And this continued up into 2011, where here we had a number of pharmacists who had this opinion paper that was outlining recommendations for training, credentialing, documenting, justifying critical care pharmacy services. In this case, you'll see this was basically by all pharmacists in contrast to some of the interprofessional publications that I noted previously. And then this in 2020 was revised again, this position paper on critical care pharmacy services, again, with a number of pharmacist authors. So collaboration is critical. This is actually a photo of me when I was part of a disaster medical assistance team that went off to help out some folks during one of the major hurricanes in the US. And again, this just is something that it hit home to me that this collaboration is critical in various settings. And in this case, as part of a disaster medical assistance team, I think pharmacists can play a key role when you're dealing with the number of medications that maybe physicians aren't used to prescribing because they're on some type of a list that is again, different from what they may be using in their usual workplace. Well, I myself have written about clinical pharmacists involved in interprofessional practice and service. And this is an example of that. And again, there's been a number of papers along these lines written by other pharmacists and other health professionals basically talking about the impact of a pharmacist on interprofessionalism. This was a paper that I recently published, and it had to do with perceptions of pharmacists of interprofessionalism. And this was an article that was titled Raising the Interprofessional Bar in Your Specialty Interprofessional Healthcare Organization. And what I had done was I had created basically a list of items. And I used this categorization that had been used in the past for some of these position papers and guidelines from the Society of Critical Care Medicine, where these three categories of fundamental, desirable and optimal were used. And I thought these would be appropriate for assessing organizations and their level of interprofessional involvement. And so let me give you an example here. So this is again, just a list that I came up with that I thought, okay, if an organization is claiming to be interprofessional, these are examples of fundamental activities in my mind. One, it always has to be patient centered, that's sort of a given. And that they place no restrictions on attendance of educational or information sessions at meetings. And they provide accredited continuing education credit. So as an example, if an organization says we're interprofessional, but there may be restrictions on pharmacists attending certain sessions, or they don't provide pharmacist CE credit, well, again, then arguably, they don't really even have some of the fundamental activities that to me make them interprofessional. And so then you'll see a number of the items for fundamental are providing opportunities. So it doesn't necessarily mean it's being done, but at least it's providing the opportunity. Then I had a category called desirable activities. And here is an example where I again, I've highlighted some of certain of the items just to show the differences from the previous version, the fundamental level. And here for desirable, it's got actively promotes the interprofessional nature of the organization. In other words, the organization sort of brags about this, this is something we're proud of. And not now notice that instead of providing an opportunity for some of these items, I've got that they have a demonstrated record. So for instance, the organization has a demonstrated record of substantial organizational involvement of in this case, pharmacists demonstrate a record of submitted research by pharmacists at meetings, a demonstrated record of pharmacists as invited speakers. So you see my point, but then there's still some items at the very near the bottom of this slide, where it's providing opportunities still. And again, these are things that I think are going to be present in a more mature organization, and those would be under optimal activities. So my last category was optimal. And basically, you'll see the key here is that all of these organizations, all of these activities, the organization has demonstrated all of these activities to be the case. And so this was something that I had created, I just thought it was interesting. It was a way in my own mind of trying to assess whether an organization that claims to be interprofessional really is interprofessional. And then I ended up actually seeing what pharmacists thought of this and how they would rate some of the certain organizations that claim to be interprofessional. And so I emailed this to the leadership of these practice related specialty networks within the American College of Clinical Pharmacy. And I excluded some of the specialty networks that aren't really a specialty per se, like education and training. But then I got these responses back and basically evaluated the data. And so mostly from the United States and, excuse me. And so it turns out then in this survey, it turned out that SCCM, I should have pointed out, was one of the organizations that basically met all the categories of an optimal level of organizational involvement. Well, now continuing on to critical care pharmacy in 2023. Right now in academia, over 80% of the colleges or schools of pharmacy have at least one clinical faculty member specializing in critical care. It's a little tough to access this data, but again, I'm pretty confident that the number is over 80% by at this point. For postgraduate training, there are approximately 4,000 board certified critical care pharmacists. We still could use a lot more, but that's where we're at right now. And that has been growing exponentially. And then for PGY2 residencies, there's approximately 100 postgraduate year two critical care residencies that participate in this national matching program. What about the value of the pharmacist in the ICU setting? Well, first let's start with value. And earlier I mentioned that value is health outcomes achieved for dollars spent. And there's no simple cost reduction or volume of services delivered and efficiencies by definition are inherent to the definition. And the outcome must be defined from the context of the individual patient because these outcomes are multidimensional and costs really need to include all costs in the cycle of care. And the value needs to be considered over a long-term basis. Now you can see trying to meet all of these can be pretty difficult. Anyway, there was a report by the HRQ that attempted to get at least some aspects of value and the title of this report, and this was published in again, 2001. So a couple of decades ago, but it was making healthcare safer, a critical analysis of patient safety practices. And this was commissioned again by evidence-based practice center. And they had this list of evidence-based best safety practices for provider organizations. And they really tried to look at big picture patient safety practices, not targeted QI type things. And they ranked them by the most highly rated for impact and effectiveness and for cost and complexity. In other words, were they high cost and very complex to implement, in which case that would be high. And again, that would argue somewhat against whatever the item is. Well, this report is important because there was a list that with drug-related implications for critically ill patients. And if you'll look, one I have highlighted here was clinical pharmacist consultation services. And I bring this up because this is one of the very few evidence-based papers out there that actually helps to justify any healthcare provider. It is surprisingly difficult to justify the activities of individual healthcare providers, especially in an ICU where again, people are working as a team. But a key behind this recommendation, of course, was that study by LEAP that was published in 1999 about that pharmacist participation on rounds. And so you begin to see the impact of that study and the fact that it actually specifically includes having a pharmacist. Now, again, they called it clinical pharmacist consultation services. And I want to stress this is not necessarily specific to critically ill patients, but obviously that study again, that LEAP study was really a major basis for this recommendation. Excuse me, I skipped a slide there. This is a slide that's titled the impact of patient care outcomes on pharmacist participation in multi-disciplinary critical care teams. It was a systematic review and a lot of systematic reviews out there. This is at least one of those that's demonstrating a positive impact of a pharmacist on critical care teams. One thing that I think all of us as pharmacists are trying to do is we're trying to avoid being pharmacop. Pharmacists, we don't want to just be known as someone that's always talking about costs. We are really trying to make sure that drug medications use is optimized. We'd like to think that we're the medication optimization experts. And it's not just a question of keeping costs under control. But having said that, there are times when the efficacy of drugs is similar, the safety of drugs is similar. And in which case, then it's going to be very obvious that cost can and should be a consideration. And I'm a firm believer that we always basically need to be considering cost as health professionals, because we're under this constant pressure, both nationally and even at the level of the individual patient to keep costs low. Well, there are a couple of types of economic analysis when we begin to look at at issues related to cost. And two of the more common methods for evaluating for treatment comparisons, looking at costs is cost minimization. And that's one of the items and the other is cost effectiveness. And if you look, cost minimization, either presumes or proves two therapies to be equal. So let me give you an example of that. Let's say you have two H2 antagonists or two proton pump inhibitors. If you either assume there's no reason to believe the efficacy is going to be different between them, no reason to assume the adverse effects are going to be different. Well, then you could just directly compare the cost associated with obtaining, administering those products. And that could be your study. Or you could cite literature that shows that when these two drugs were given, they had similar efficacy and safety. In many cases, we often presume it based on, again, drugs in the same class, same mechanisms, et cetera, but it can either be assumed, presumed or proven. Cost effectiveness is different because suddenly now it's not just cost, but you're looking at consequences. And so now the units are in dollars, so your numerator is dollars, but there's some outcome of interest. And that is, for instance, could be avoidance of bleeding. Again, if you're talking about use of a H2 block or a proton pump inhibitor, avoidance of GI bleeding. And so in contrast to cost minimization, which is strictly in dollars, this cost effectiveness now suddenly you have costs and then the denominator is, again, a variety of different consequences. But in this case, you can look to see, is this particular drug cost-effective compared to this other drug, depending on which consequences, again, you're looking at. Cost utility, which some of you may have heard of, which is cost based on quality adjusted life years or QALYs, that's just another form of cost effectiveness analysis. But again, that presumes that you have these quality adjusted life year data available. And that is in many cases, that's not the case, especially in the critical care setting. Often these QALYs are available, but in certain types of lists, but often it's outside of the ICU setting. And cost avoidance is different from these above traditional forms of economic analysis. Cost avoidance is something where you're basically looking at some drug, for example, and saying, okay, by not using this drug, how much in terms of dollars did we cost did we avoid, for instance, by not using this drug? Or maybe we stopped an antibiotic early. Well, how much cost did we avoid by stopping an antibiotic early? And you can see that the key with this cost avoidance that can get tricky is because you're trying to say that something would have happened, but it didn't because of an intervention, for instance, by a pharmacist. And that can be a sort of a challenging or difficult to convince people to buy into that type of assumption. There's really no standardized consensus definition for cost avoidance. and however, there are some data, I know that I've been involved in trying to come up with some standardized metrics for evaluating cost avoidance. Anyway, here's a slide just giving you some of the different studies that have been conducted showing the economic benefits of ICU pharmacy services. These were all ones identified prior to 2010. So I just wanted to show you that we've had data related to impact of pharmacists in the ICU for some time, again, data for more than a decade old. Most of these studies were pretty much focused on cost minimization, which I talked about earlier, and cost avoidance, which I just talked about. And you see they go on, these are even more, again, all studies published prior to 2010 about the impact of pharmacists. So you can see a lot of data that's out there. All right, well, I mentioned earlier that cost avoidance, again, can be, these studies can be challenging and it can be difficult to convince people that this type of data is meaningful, because these are conceptually different from some of the traditional pharmacoeconomic analyses. And so this was a study or a publication that we came up with where we actually provided a step-by-step methodology for performing cost avoidance studies. And so this calculation that provides for evaluating a cost avoidance and it provides for sensitivity analysis. And I'd refer you to this publication if you're going to do a cost avoidance study in your particular intensive care unit, because again, it does give you a standardized methodology for doing so. Well, I wanted, one of my objectives was to talk about telecritical care pharmacy and more specifically, telecritical care pharmacists. And this was a study that was recently published. It was just a study published in 2023. And it was a multi-center observational study. And it was conducted to describe the implementation of a telecritical care pharmacist into an established telecritical care network and classify the interventions performed and quantify cost avoidance. Well, they had this centralized support center with option for remote work by caregivers. They had a simplified version of the cost avoidance equation that was recommended in literature, study that publication that I was involved with. And basically in this case, this was how they defined this cost avoided. The patients that in this publication were admitted to an ICU in one of eight community hospitals, 50 ICU beds, there was no control arm. Again, I commend the authors for conducting this type of study in community hospitals. Many of the studies we see are in academic medical centers. The project was implemented in eight hour shifts for five days a week and then expanded to seven days a week over two years. And what they found for greatest cost avoidance was prevention of major adverse drug events, 41.4% of the cost avoidance, initiation of VTE prophylaxis, 18.5%, and antimicrobial initiation streamlining 12.3%. And I must say the major, preventing major adverse events does not surprise me that that's again, patient safety, that is where pharmacists have a large impact. And so it's not surprising to me that there's gonna be a good deal of cost avoidance associated with interventions related to major adverse drug events. And you'll see that there were a total of almost 3000 interventions for a total cost avoidance of over a million and a half dollars and for a substantial return on investment. So this is one of the most recent and best studies we have demonstrating cost avoidance and a beneficial return on investment by having a telecritical care pharmacist. Well, what about prioritization of critical care pharmacist activities? This has been an interest, an area of mine for some time. And this was noted by a study, again, that I was involved with, where we were looking at the prioritization of pharmacist activities in the ICU. And the reason I bring this up is because you can have a pharmacist who's stationed in an ICU and all they do is enter orders and have very little interaction with the team. And frankly, in that case, if they're only entering orders, you could argue they even need to be in the ICU. Could they be in a central pharmacy? And so for most of my career, I've tried to focus on what are really the things that are most benefit related to pharmacist activities. And this was one study where we tried to look at that. And we were looking at, again, specifically pharmacists in an ICU. And we looked at different methods of identifying what in this case we call problems. So potential patient safety issues, et cetera. And you'll notice that between chart review and rounding, that comprised the vast majority of beneficial activities that were being performed by the pharmacist. Order entry verification was responsible for relatively few, less than 20% of the issues of problems were noted through order of entry verification. And a very small number, if you waited for medical staff to alert the pharmacist of a problem. In other words, this is an issue if you don't have a pharmacist stationed in the ICU is medical staff may not take the time to make that call and let a pharmacist know that there is a potential problem. And this study is, again, one that supports that. Again, there's many issues. I'm the first to criticize my own studies and talk about all the limitations of them. But I think what's unique about this and was unique at the time when we conducted it is just there were very few studies at the time and there still are very few studies talking about how pharmacist activity should be prioritized. And so, this is an area that we'll continue, we need to continue to work at. This is just basically putting, assigning cost avoidance to some of these activities. And by the way, this you'll notice was much older than this study we published in 2021 concerning this more uniform method of calculating cost avoidance. So this was, again, a much more basic and problematic way of calculating cost avoidance. But nevertheless, I don't think it would surprise anyone that these different interventions clearly led to some of the potential for cost avoidance. You could argue over the specific dollar figures, but again, even when there were two different evaluators looking at cost avoidance, we found similar savings. Okay, well these, so anyway, prioritization to me is a big key when looking at pharmacist activities and interventions by clinical pharmacists in an ICU can really result substantial cost avoidance, but it does depend on the specific activity. And the greatest impact appears to be from rounding chart review kind of activities back to that Lucien Leap study, again, of a pharmacist rounding the benefits which were shown in 1999. And obviously another recommendation is maximize use of automation and technician support. So, you know, so the pharmacist can concentrate on these high-level activities. And my opinion is that the best pharmacists thrive on these challenges and non-monetary rewards. I'm an example of one of those pharmacists. Like everyone else, sure, I like a raise, I like money, but again, that's not a primary driver for me. And, you know, I thrive on having a high practice level and again, I think it makes me a better pharmacist when I'm performing at this higher level. Well, what about justification of positions? Obviously this is extremely important and I've written on this. This was in response to a paper that had been written that basically said, do we even need to justify critical care pharmacists anymore? It was a paper that suggested we really don't. And I guess I have the attitude that it's still a work in progress that we have to continue to justify critical care pharmacists if nothing else, because there are many hospitals that still do not have critical care pharmacists, or if they do, they're maybe not using them at the proper level, the pharmacists aren't doing the things they should be doing. So it's, again, there's still work to do. So in my mind, it's ongoing. And every time that you have a pharmacist that is the first pharmacist in an ICU, well, even though that may be in year 2023, you know, that pharmacist has to do the same things I did at the beginning of my career, which was decades ago of demonstrating their value. And they're often serving as the model for other pharmacists who might end up in that unit. And so that first pharmacist in a critical care unit can be critical because if they make a really substantial impact and their team thinks they're great, well, that can lead to other pharmacists being placed in the unit. But obviously, if the pharmacist, you know, again, does not do all the things they should be doing and practice at a high level, that can have a negative impact and actually impede future progress. So I don't think the work is ever done at least we, but we get closer and closer to sort of where we should. Well, if you are starting critical care pharmacy services, like any other services, it's best to have a business plan. There are different kinds of business plans out there. This was one that I was involved with where it was more specific for justifying critical care pharmacy services. And this was sort of the general outline of this paper that we published with this executive summary, background proposal benefits. And this is something our intent was this could be used by pharmacy departments to help justify starting new critical care pharmacy services. This is something that could be presented to administrators. So we give a lot of this sort of as pre-packaged information and then you can add the specifics to your pharmacy group that provide the details, more details specific to your institution. Well, pharmacists that initiate these new critical care pharmacy services, as I mentioned earlier, the success is very dependent on the skills of this first clinician because this in essence is the pilot test of the new services. And this pilot test can identify barriers to implementation and future expansion. You really wanna have a step-by-step plan for this service implementation, but be willing to change it based on feedback. And you really have to try hard to have predictability and continuity of service. This can be a very difficult, very challenging. I know this from nine years of the beginning of my career when I was in a community hospital, where again, providing services 24 hours a day, seven days a week can be very difficult. So I won't pretend that there aren't challenges involved, but I think that's what we have to work towards. And you really need to have a plan for ongoing evaluation of costs and benefits. This is something that, you know, you can consider a cost benefit analysis where you're looking at the total dollars that it costs to implement something versus the benefits in terms of dollars that you're gonna gain. But bottom line, whether you perform a formal cost benefit analysis or not, it's always important to be focusing on medications that are high volume, high cost, prone to errors and adverse drug events. I mentioned the very last point in this slide that single cases of patient safety can be very useful for demonstrating the benefits to the service to administration. If you talked about how, boy, in this case, by this pharmacist intervening, this really bad event that could have occurred was prevented, again, that can be very, very important. You wanna tell a story to administrators. It's quality versus quantity. And so, you know, this is an example of, okay, there's an order for a drug that costs $100,000 and it was going to be used based on a single abstract. Well, you had the question, does that justify the use of this drug? Maybe it does, but in this particular case, I can tell you the abstract alone was not enough to justify the cost of this new drug. And then what about an adverse drug event, like a new NSAID that causes a problem? Like in this case, it was a new NSAID that had come out and we ended up having a patient to develop subcapsular liver hematoma. And this was something that was very unexpected for the type of surgery involved. And again, so these are the kinds of things that pharmacists can help avoid or when they do happen, stop the drug and try to ameliorate whatever problem did occur. What about the future? Well, there's a lot of changes going on, macro and micro changes and a lot of integration. This was an example of our particular health system when we merged with our academic medical center, we were merged with a large health system. And my point to this is this is going to be ongoing, likely more and more of you are going to see this happen, where you're becoming parts of much larger health systems. And this is my look at putting on the looking glass and trying to look at pharmacy practice for the next 10 years, something more specific to pharmacy practice. So that previous slide was talking about things some out of our control basically, healthcare at the system level, actually even to some extent at the national level, changes that are out of our control. Well, what about more specific to pharmacy? Well, I view that again, there's going to be this increased interprofessionalism with this emphasis on each team members, cognitive skills, and those are the pharmacists, that there'll be relatively stable numbers of general pharmacists, but a lot more specialized pharmacists, including critical care pharmacists, because they're going to parallel this advancement in technologies. Now, again, when I say stable numbers of general pharmacists I should say that, again, this depends a lot on what different pharmacists are doing because they clearly could, numbers could increase dramatically if pharmacists continue to get involved more in ambulatory care practices, et cetera. But I guess in this case, we're focusing on critical care pharmacists in particular, I think it's just worth pointing out that there are almost certain likely increase, again, various specialized pharmacists, they increase as the specialty matures and that no doubt will continue to happen to critical care pharmacy. There'll be increased responsibility, expectations, accountability. Again, this was true of, again, this patient care team, the critical care team, there's really going to be this need for patient-centered practice models that's already occurring. I came up with these things again some time ago, but so some of these things are now, they're moving along quite rapidly. And then increased credentialing with increasing demand for postgraduate training, I have no doubt that's going to continue. One of the limitations right now with respect to critical care pharmacists has been the lack of training programs for the number of pharmacists that are out there. And for pharmacists who would like to go back, who've been working maybe in a critical care setting but weren't able to do a residency, their ability to go back if desired and receive some training. Again, we still need some work in that area. So there are still things we need to do for pharmacy practice to move forward in the next 10 years. And that includes expanding some of the critical care pharmacy services in different types of hospitals. There's this thing by the Bureau of Labor Statistics that's often cited and I wanted to bring this up because it sometimes can be used to say, well, the pharmacists, number of pharmacists aren't going to increase a lot. And I use this when I'm talking to students because I have students in colleges of pharmacy because as often they hear some of these figures and they get depressed saying, oh gosh, the number of pharmacists is somewhat leveled off or not increased as much as we thought. But I always make the point of saying that, depending on what you're doing, those numbers are going to increase quite dramatically. And notice this healthcare diagnosing or treating practitioners, that includes pharmacists that are doing those activities. And that's expected to increase quite substantially. And along with that, I show this quote that's also on the Bureau of Labor Statistics when they specifically refer to clinical pharmacists who talk about these pharmacists that may go on rounds in a case of ICU pharmacists, they typically are going on rounds. Many are reviewing, they recommend medications, et cetera. So the point is that even this government agency here, they recommend, they acknowledge that the number of clinical pharmacists is likely to increase because they do provide a lot of these specialty kinds of services, specialty kinds of care that again are important for influencing positive patient outcomes. So back to the key points of this presentation, the role of the critical care pharmacist has been both defined and then refined by both intra and interprofessional consensus recommendations. And these can be used as a starting point if you're justifying new positions, new critical care pharmacy positions. In terms of demonstrating the value of any healthcare profession, it's difficult, but there actually is evidence demonstrating the value of pharmacists. And a lot of this comes from preventing adverse drug events, from recognizing, finding medication errors, preventing medication errors, and the associated adverse drug events. And again, a lot of that started with this important study in JAMA by Lucian Leap demonstrating the value of a critical care pharmacist rounding in an intensive care unit setting. And then most of the economic justification of critical care pharmacists, including telecritical care pharmacists is based on either cost minimization or cost avoidance investigations. Obviously we'd like to have a higher level like cost effectiveness studies, but those are very difficult to perform, but at least there's been some standardization with respect to how cost avoidance investigations can be performed. Well, that concludes my presentation. Thank you very much for your attention. I'll give you this one last quote by Harry Truman, and I hope you all have a great day and I hope everything goes well with the rest of your career.

ICU Pharmacists

Critical Care Pharmacists

Cost Minimization

Cost Avoidance Investigations

Multidisciplinary Teams

Specialization in Pharmacy Practice

Professional Development

Patient Care Outcomes