Standard of practice in intensive care for pharmacy services · 47 management and patient care; (4) leadership and management; and (5) education and research. 48 The purpose of this

DRAFT prepared 25/11/19. Property of The Society of Hospital Pharmacists Australia 1

Standard of practice in intensive care for pharmacy services 1

Karlee Johnston BPharm, MClinPharm, AdvPracPharm, FSHP1,2, Melissa Ankravs BPharm, 2

GradCertPharmPrac, MClinPharm, MSHP3, Belinda Badman BPharm, GradDipClinPharm, AdvPP(II) 3

MSHP4, Lynn Choo BPharm (Hons), MSc (PharmPrac), AdvPracPharm, FSHP, MRPharm 5, Michele Cree 4

BSci, BPharm, DipClinPharm, AdvPracPharm MSHP6, Jason A. Roberts BPharm (Hons), BAppSc, PhD, 5

FSHP7,8, and Courtney Munro, BPharm, GradCertPharmPrac, MPharmPrac, MSHP, AACPA, PhD9 6

7

1 Australian National University Medical School, Australian Capital Territory 8

2 Canberra Hospital, Australian Capital Territory 9

3 Melbourne Health, Parkville, Victoria 10

4 Princess Alexandra Hospital, Metro South Health Service, Queensland 11

5 Pharmacy and ICU, John Hunter Hospital, New South Wales 12

6 Queensland Children’s Hospital and Children’s Health, Queensland 13

7 The University of Queensland Centre for Clinical Research, Faculty of Medicine & Centre for 14

Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, 15

Brisbane, Queensland 16

8 Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women’s Hospital, 17

Brisbane, Queensland 18

9 The Society of Hospital Pharmacists of Australia, Collingwood, Victoria 19

20

Address for correspondence: 21

Karlee Johnston,1 Chair, Leadership Committee, The Society of Hospital Pharmacists of Australia, 22

Collingwood, Victoria, Australia. Email: [email protected] 23

24

Preface 25

This Standard references and relies upon SHPA Standards of Practice for Clinical Services1 as the 26

foremost Standard. This Standard supersedes the previous SHPA Standards of Practice for Critical Care 27

Pharmacy Practice.2 28

This Standard may overlap with others and given the case-mix of patients admitted to an intensive 29

care unit, it may be advisable to refer to additional Standards of Practice. 30

The use of the word ‘specialisation’ in this standard is in line with the National Competency Standards 31

Framework for Pharmacists in Australia,3 where ‘specialisation’ refers to the scope of practice rather 32

than the level of performance. ‘Specialisation’ itself does not confer additional expertise. 33

This Standard is for professional practice and is not prepared or endorsed by Standards Australia. It is 34

not legally binding. 35

36

mailto:[email protected]


Introduction 37

In Australia, everyone shares a fundamental right to safe and high-quality healthcare. This is defined 38

in the Australian Charter of Healthcare Rights,4 which all healthcare systems must strive to uphold. 39

The Charter summarises the basic rights of patients and consumers when accessing healthcare 40

services including; access, safety, respect, partnership, information, privacy and the ability to give 41

feedback. The provision of pharmacy services must encompass the Charter, in order to deliver 42

effective, efficient, timely, and equitable patient-centred care. 43

The National Competency Standards Framework for Pharmacists in Australia3 complements the 44

underpinnings of the Charter across five domains of competency for the pharmacy profession, 45

namely: (1) professionalism and ethics; (2) communication and collaboration; (3) medicines 46

management and patient care; (4) leadership and management; and (5) education and research. 47

The purpose of this Standard is to describe current best care for the provision of pharmacy services to 48

intensive care units (ICU) and paediatric intensive care units (PICU). 49

Intensive Care Units 50

An intensive care unit (ICU) is typically for the most acutely ill, unstable patient, who is in a critical 51

condition and needs very intensive healthcare interventions and monitoring. 52

An ICU is able to provide critically ill patients with a higher level of medical care and observation than 53

other areas in the hospital can provide. 54

ICUs are staffed by large and varied teams which include highly trained, specialised doctors, nurses, 55

and pharmacists, as well as other allied health professionals. 56

Pharmacists play a key role in managing medicines within the complexity of various routes of 57

administration, severe and rapidly shifting pharmacokinetic and dynamic parameters, and extremes 58

of physiology in critical illness.5 59

60

Box 1 An overview of an intensive care unit and the role of a pharmacist 61

This Standard refers to both the role of the pharmacy service and the pharmacists’ practice in intensive 62

care units (ICU) and paediatric intensive care units (PICU). The Standard predominantly refers to ICU 63

and PICU pharmacists but does not intend to exclude suitably qualified pharmacy technicians where 64

appropriate.1 The Society of Hospital Pharmacists of Australia (SHPA) supports both pharmacists and 65

pharmacy technicians to operate at their full scope of practice in order to achieve optimal patient and 66

pharmacy outcomes. 67

This Standard is intended to be used across hospital pharmacy services in Australia, irrespective of the 68

service type (public or private) or location (metropolitan, regional or rural). It is acknowledged there 69

are significant variations in pharmacy services that are dependent on organisational capacity, patient 70

population, ICU models of service delivery and pharmacy department priorities, as well as the 71

availability of ICU pharmacists; all of which may influence the scope of services. 72

In this Standard, essential services relate to services that demonstrate the full scope of pharmacy 73

practice. Emerging services relate to services that are innovative and future-focused and are 74

provided in addition to essential services. SHPA encourages all pharmacy services to strive to provide 75

emerging services wherever possible, in addition to essential services. 76


Purpose and definitions 77

This Standard focusses on the practice of intensive care medicine, which is a branch of critical care. 78

Critical care practice and services also encompass emergency medicine and anaesthesia specialties. 79

Adult and paediatric intensive care are within the scope of this document. Neonatal intensive care is 80

excluded and will be covered elsewhere. 81

An Intensive Care Unit (ICU) 82

‘is a specially staffed and equipped, separate and self-contained area of a hospital dedicated to the 83

management of patients with life-threatening illnesses, injuries and complications, and monitoring of 84

potentially life-threatening conditions’6 85

Box 2 Definition of an Intensive Care Unit 86

An ICU is capable of providing specialist expertise and facilities, which supports vital life functions, and 87

utilises the skills of medical, nursing and other personnel experienced in the management of these 88

problems. The scope of adult and paediatric intensive care services includes the sub-specialties listed 89

in Table 1. Paediatric Intensive care units (PICU) have specialised paediatric multidisciplinary teams, 90

including paediatric allied health, who specialise in intensive care for the critically ill child.0F

i 91

92

Types of Intensive Care Units (ICUs)

General – includes medical and trauma

Surgical

High dependency

Neuro-surgical

Medical

Cardiac – includes post cardiac surgery care

Transplant-includes bone marrow transplants and/or solid organ

transplants

Table 1 Types of intensive care sub-specialties 93

In New South Wales, Queensland, Western Australia7 and South Australia, ICUs are streamlined into 94

the three standardized State Health service levels (Levels 4, 5 and 6). Victoria,8 Tasmania, Australian 95

Capital Territory and the Northern Territory, on the other hand, use the College of Intensive Care 96

Medicine (CICM) classification system levels 1,2 and 3.1F

ii CICM advises that the State Health 97

i A child is defined from birth to under 18 years of age ii Victoria are currently reviewing classification of ICU levels and propose to move from CICM to standardised levels as for NSW, QLD


classification levels 4, 5 and 6 are largely equivalent to the College’s levels 1, 2 and 3 (see Table 2). 98

Side by side descriptions of these levels are provided in Table 3. 99

100

State Health Departments’ health service level The College of Intensive Care Medicine’s ICU

service level

4 1

5 2

6 3

Table 2 Equivalent ICU service level classifications for State Health Departments health service level and CICI ICU service 101 level. 2F

iii 102

iii Reference provided by personal correspondence with CICM via email, on 6th November 2019, from Angela Dalit (CICM, Policy)


Table 3 Side by side descriptions of equivalent State Health Department’s health service levels and CICM ICU service levels 103

State Health Departments’ health service level The College of Intensive Care Medicine’s ICU service level 3F

iv

Level 4 • Separate and self-contained facilities

within the hospital (i.e. closed unit)

• Have limited ability to provide basic

multi-system life support (i.e.

mechanical ventilation) usually for

<24-hours and can provide simple

invasive cardiovascular monitoring9

Level 1 • Capable of providing immediate resuscitation and short-term cardio-respiratory support for critically ill patients

• Must be capable of providing mechanical ventilation and simple invasive cardiovascular monitoring for a period of at least several hours

• It will also have a major role in

monitoring and prevention of

complications in ‘at risk’ medical and

surgical patients10

Level 5 • Capable of providing complex multi-

system general intensive care, life-

support including ventilation, renal

replacement therapy and invasive

cardiovascular monitoring for an

indefinite period

• Transfer of patients to a level 6 ICU will

primarily be due to unavailability of

Level 2 • Capable of providing a high standard of

general intensive care, including complex

multi-system life support

• Capable of providing mechanical

ventilation, renal replacement therapy

and invasive cardiovascular monitoring

for an indefinite period, providing that

appropriate specialty support is available

within the hospital.

iv CICM service level descriptions are available https://www.cicm.org.au/CICM_Media/CICMSite/CICM-Website/Resources/Professional%20Documents/IC-1-Minimum-Standards-for-Intensive-Care-Units.pdf

https://www.cicm.org.au/CICM_Media/CICMSite/CICM-Website/Resources/Professional%20Documents/IC-1-Minimum-Standards-for-Intensive-Care-Units.pdf

https://www.cicm.org.au/CICM_Media/CICMSite/CICM-Website/Resources/Professional%20Documents/IC-1-Minimum-Standards-for-Intensive-Care-Units.pdf


State Health Departments’ health service level The College of Intensive Care Medicine’s ICU service level 3F

iv

sub-specialty services at home facility

e.g. neurosurgery or cardiac surgery11

• Where appropriate specialty support (e.g.

neurosurgery, cardiothoracic surgery) is

not available within the hospital, there

should be an arrangement with a

designated tertiary hospital so that

patients referred can be accepted for

specialty management (including ICU

management)10

Level 6 • The highest-level referral unit for

intensive care patients

• Capable of providing tertiary, complex,

and multi-system life support for

indefinite periods to a general, and

sub-specialty critical care patient case-

mix11

Level 3 • A tertiary referral unit for intensive care

patients

• Capable of providing comprehensive

critical care including complex multi-

system life support for an indefinite

period10

104


ICU staff are often required to provide services outside of the ICU.6 For example: 105

• pharmacist involvement in advanced life support (ALS) and deteriorating patient calls, which 106

include medical emergency team [MET] calls and rapid response team [RRT] calls 107

• pharmacist outreach, for example, post ICU follow up. 108

109

Evidence of pharmacist impact in ICU and PICU services 110

Managing medicines in ICU and PICU is complex due to several factors. These include, but are not 111

limited to, fluctuating pharmacokinetics, rapid physiological changes, high volume use of intravenous 112

medicines and a high rate of medicine related errors.12,13 ICU and PICU pharmacists have been shown 113

to contribute significantly to patient care with high numbers of interventions and 114

medicines optimisation.14,15 Furthermore, overwhelming evidence supports the role of the ICU and 115

PICU pharmacist in providing improvements in both economic16,17 and clinical parameters, for 116

example, reductions in adverse medication reactions,18 medicine errors,18,19 length of stay and 117

morbidity and mortality rates.20,21 Due to these extensive benefits, a dedicated and specialist ICU 118

pharmacy service is advocated for and supported internationally by key ICU organisations.5,22-26 119

The scope of activities undertaken by the ICU or PICU pharmacist may include: 120

• participation in ward rounds 121

• provision of drug and dosing information 122

• medication order clarity and optimization 123

• management of drug interactions 124

• management of line compatibility 125

• recognition and reporting of adverse drug reactions (ADRs) 126

• contributing to therapeutic recommendations and the implementation of evidence-based 127

care.20,21,25-27 128

The specialised role of ICU and PICU pharmacists will often involve making judgements about 129

medication management, where evidence is scarce or non-existent. These judgements involve 130

considerations of pharmacological, pharmacokinetic, pharmacodynamic, pharmacogenomic 131

and pharmaco-economic factors, in the context of pathophysiological changes of critical illness.5,14 132

Due to the dynamic and changing status of the ICU patient, this process will often require constant 133

review and adjustment. It is essential, therefore, that ICU and PICU pharmacists have a strong clinical 134

knowledge base and a diverse skillset. This should include effective communication, advanced 135

problem solving and critical thinking, judgement, leadership and management skills.5,26,28 136

The consistent exposure to patient morbidity and mortality, traumatic and ethical issues and the 137

challenging work duties have led to ICU healthcare professionals experiencing a high rate of 138

burnout.29-31 This may, in turn, have a negative impact on the quality of patient care.32 It is for this 139

reason, that self-care and burnout minimisation measures are becoming a significant focus for ICU 140

healthcare workers.30 Pharmacists are certainly not immune to this risk,33,34 and care should be taken 141

to recognise, acknowledge and minimise burnout in ICU pharmacists. 142


143

Objectives of the Pharmacy Service 144

The objective of this Standard is to define the scope of ICU pharmacy services, identify the scope of 145

practice for the ICU pharmacist and recommend service and staffing levels, in order to provide optimal 146

care to ICU patients. 147

An ICU pharmacy service should ensure: 148

149

Box 3 Overview of an ICU pharmacy service 150

The ICU pharmacist should be a point of contact for other pharmacists and health professionals, and 151

for the hospital or health service for medicines inquiries related to ICU. 152

153

Scope 154

This Standard applies to all pharmacists working in ICU and PICU services. The service provided by the 155

ICU and PICU pharmacists may be delivered across several settings including both public and private 156

hospitals, but is typically in an inpatient setting. Broadly, the scope of service considers activities that 157

have a direct impact on patient care (e.g. governance, policies and procedures as well as direct patient 158

care activities) and in-direct activities such as teaching and research. These are summarised in Table 159

4. 160

In addition to providing clinical pharmacy services, as outlined in the SHPA Standards of Practice for 161

Clinical Pharmacy Services,1 ICU and PICU pharmacists are expected to provide services relevant to 162

• delivery of high-level specialised clinical pharmacy services by suitably trained and qualified 1

pharmacists with sound clinical knowledge appropriate to the case-mix of patients seen 2

• participation on ward rounds, at multi-disciplinary team meetings and at individual patient 3

case conferences 4

• provision of medicines advice to health professionals and patients (or carers) based on the 5

best available published evidence 6

• prevention of adverse drug events and associated costs through optimisation of medication 7

use and prevention, detection and correction of medication errors 8

• development of and input into policies, procedures, guidelines, and resources 9

• leadership over ICU formulary applications and decisions 10

• involvement with equipment used for medication provision and administration (robotics, 11

smart-pumps, etc.) 12

• provision of education and training for healthcare professionals and students 13

• quality improvement activities 14

• research related to intensive care; and 15

• involvement in the medication module for digital health records. 16


their clinical area and scope of practice. The scope of services provided by ICU pharmacists will be 163

dependent on a variety of factors including: 164

• the setting 165

• the patient case-mix 166

• the services the hospital or health service provides 167

• funding models 168

• governance structures for ICU services 169

• ICU and pharmacy department priorities 170

• organisational priorities and 171

• the scope of practice of the individual pharmacist. 172

Whilst the range of services provided in ICU is primarily delivered by pharmacists, it is increasingly 173

supported by pharmacy technicians in clinical and non-clinical roles. 174

175

ALS = Advanced Life Support; BPMH = Best Possible Medication History; CMI = Consumer Medicines Information; CRRT = Continuous Renal Replacement Therapies; CVC = Central Venous Catheter; ECMO = Extracorporeal membrane oxygenation; FASTHUG = Feeding/fluids, Analgesia/antimicrobials, Sedation, Thromboprophylaxis, Head-up position, Ulcer prophylaxis, Glycemic control; IV = intravenous; MARS = Molecular Absorbent Recirculating System; MET = Medical Emergency Team; SAS = Special Access Scheme; and TBI = traumatic brain injury.


Scope of pharmacy services in intensive care and the role of the pharmacist

Direct impact on patient care

Policies, Procedures, and Governance Direct Patient Care

Prescribing

Contribute to:

• development, review, and maintenance of intensive care medicine guidelines, including: o sedation, pain and delirium

management o illnesses requiring intensive care e.g.

sepsis, shock, multi-organ failure, post-op, TBI, trauma

o Routine care bundle: FASTHUG o extracorporeal therapies (CRRT,

ECMO, plasmapheresis, MARS)

• development and maintenance of electronic medication management systems for prescribing in intensive care

• development and maintenance of dose error reduction software database in smart IV pumps

• local, state +/- national governance committees with regards to intensive care medication management

• Ensure timely, safe, optimal and cost-effective medicine prescribing in critically ill patients

• Demonstrates skills to critically appraise available information in a timely manner to make recommendation/clinical decision

• Use pharmaceutical expertise to make clinical judgements and recommendations about medicine therapies where evidence may be scarce, emerging or contradictory

• Making expert clinical judgements in a high-paced clinical environment, where evidence may be scarce or contradictory

• Ensure use of referenced and locally approved guidelines where appropriate and if not, able to justify reasons for diverting from a guideline

• Active participation in ICU clinical rounds to contribute to therapeutic decision making as part of a multi-disciplinary team

• Acknowledge patient vulnerabilities, high-risk environment, patients and medicines

Medication reconciliation

and clinical review

Lead on the development of clinical verification procedures for intensive care medicine therapies e.g. for digital health systems

• BPMH amidst challenges of eliciting timely information from critically ill patients who may not be able to provide it e.g. unconscious

• Medication reconciliation in the context of critical illness where acute emergencies are weighed up against continuing chronic therapies

• Regular and ongoing review of medicines in critically ill patients






• Development of tailored medication action plans in the context of: o severe and fluctuating physiology, pharmacokinetics, multi-

organ failure o high volume use of high-risk medicines o multiple medicine administration routes o challenges of limited IV access o medicine incompatibilities o vulnerable patients at high risk of adverse medication

reactions and interactions o consideration for medicine-related causes of admission o medicine choice and dosing in extracorporeal therapies

(CRRT, ECMO, plasmapheresis, MARS)

• Therapeutic drug monitoring in the context of deranged physiology, pharmacokinetics and off-license use of medicines.

• Transfer of care handover (discharge from ICU to ward)- ward transfer reconciliation, including the transfer of records between electronic systems given high-risk of medicine related errors.






Compounding and Dispensing

Contribute to:

• Development of intensive care therapy

manufacturing guidelines in collaboration

with compounding pharmacists - often off-

license use of medicines

• Development of dispensing guidelines for intensive care medicines with dispensary pharmacists

• Development and maintenance of ICU medicine stock list including MET packs and Retrieval Packs

• Safe work environment

• Facilitate the safe provision of compounded intensive care therapies in collaboration with compounding services (either internal, external or both)

• Suitability of the appropriate product for patient e.g. paediatrics

• Ensure timely medicine delivery processes are in place to avoid and minimise delay in accessing medicine for critically ill patients

Materials Management

• Management of medicine shortages

• Procurement and provide alternative medicines

• Ensure appropriate storage of medicines and fluids.

• Involvement in the management of: o ICU inventory/imprest stock o MET and Retrieval Packs as required o Medicine shortages o Medicines access programs o SAS medicines

• Liaise with clinical trials pharmacists and research team regarding investigational products

• Formulary and individual patient use applications

• Storage of high-risk drugs






Resuscitation – Advanced Life Support (ALS) and Medical Emergency Team (MET) (emerging roles)

• Development of guidelines for pharmacist-led medication management during resuscitation (ALS)

• Development of guidelines for review of medicines during MET e.g. medicine-related cause of MET call

• Provision of education to MET team members

• During ALS at arrests: o Accurate and timely selection of appropriate medicine o Conduct dose calculations o Prepare dose of medicine for administration

• MET calls: o Conduct pharmaceutical review for the medicine-related

cause of MET

• Provide recommendation for immediate and ongoing medication action plan and follow-up as part of a multidisciplinary team approach

Patient Education

• Lead and contribute to the development of

written information and educational

resources on ICU medicine therapies

• Educate patients and/or carers on ICU medicines where necessary

and appropriate35

• Provide written information e.g. CMIs and medication lists






Administration of therapy

• Contribute to the development of medicine

administration and dosing guidelines

(including in the digital health record)

• Educate and support nursing and medical staff on the administration

of medicines including off-license use e.g. dilutions for CVC use;

compatibilities, nasogastric versus transpyloric tube, etc.

• Provide advice to health professionals on the safe handling of high-

risk and potentially hazardous medicines

• Advise patients and/or carers on the administration of medicines as

appropriate

Monitoring of therapy • Contribute to the development of policies and procedures regarding:

o Monitoring of patient’s therapy

o Use of digital health record tools to

facilitate monitoring

• Monitor:

o Response and toxicities to medicines

o Organ function

o Pathology – biochemistry, haematology, microbiology

o Drug concentrations

o Medicine compatibilities and interactions

o Use of extracorporeal therapies and impact on medicines

o Fluid balance and contribution of medicines

o Ensures medicine choice, doses, and routes are adjusted

appropriately to the needs of the individual patient

• Liaise with clinical trials pharmacists and research team regarding

monitoring of investigational products






Indirect impact on patient care

Teaching and training • Provide structured training and competency assessment for ICU pharmacists which may include local credentialing practices

• Education of pharmacy students, interns, and pharmacists providing care in ICU settings

• The teaching of medical, nursing and allied health professionals

Research • Retrieve and critically appraise literature

• Identify evidence gaps in the treatment and pharmaceutical care of critically ill patients

• Initiate, conduct and supervise research in ICU

• Participate in interdisciplinary and multidisciplinary research

Quality Assurance and Improvement

• Conduct audits to demonstrate compliance with guidelines for medicine use in intensive care services

• Report and investigate incidents and adverse effects. Participate in root cause analyses and potentially in open disclosure36

• Monitor compliance with and variations from approved treatment protocols

• Lead and contribute to quality improvement initiatives

• Lead and contribute to health economic evaluations of medicines and prescribing practices

Clinical Trials • Liaise with the clinical trials pharmacists and/or personnel

• Ensure that the prescribing, preparation, dispensing and administration of clinical trial medicines adheres to the trial protocol

• Order investigational agents and ensure inventory accountability

• Refer to the Standard of Practice for Pharmacy Investigational Drugs Services37

Table 4 The scope of pharmacy services in ICU and the role of the pharmacist in direct and indirect patient care activities 176


Operation (of the service) 177

The ICU pharmacy service must be provided by pharmacists whose main area of specialisation is, and 178

who demonstrates competence in intensive care medicine (refer to Training and Education). 179

Components of the service may be delegated to non-specialised pharmacists after undergoing training 180

and demonstrating an appropriate level of competence to perform their tasks. 181

Direct Patient Care 182

Clinical Services 183

A clinical pharmacy service must be available to all ICU and PICU patients, which aligns with the 184

clinical activity of the health service. For example, if an inpatient service is provided and where 185

resources allow, a seven-day clinical pharmacy service should be facilitated. 186

ICU and PICU pharmacists must participate as a member of the multidisciplinary team. The 187

establishment of an effective working relationship with other health professionals, patients and/or 188

carers, as well as other stakeholders form the basis of successful clinical practice. The ICU and PICU 189

pharmacist should regularly contribute to relevant clinical activities such as ward rounds, ward 190

meetings, case presentations, journal clubs, and lectures. 191

192

Policies, Procedures, and Governance 193

Pharmacists must have knowledge of the following documents, which provide a framework in which 194

they must practice: 195

• Australian Charter of Healthcare Rights4 196

• National Safety and Quality Health Service Standards,38 including the National Model Clinical 197

Governance Framework39 198

• Pharmacy Board of Australia Code of Conduct40 199

• SHPA Code of Ethics41 200

• National Competency Standards Framework for Pharmacists in Australia3 201

• Professional Practice Standards for pharmacy practice42 202

• Clinical Governance Principles for Pharmacy Services43 203

• Relevant State and Territory legislation. 204

Policies for the practice of clinical pharmacy provide a basis upon which ICU specific policies may be 205

developed and applied. 206

Local, institutional and state-based policies guiding practice may include consultation and/or 207

ownership by other professions or by the pharmacy department and should cover: 208

• medicines management, including digital and paper-based systems 209

• clinical management, for example: 210

• complex supportive care requirements e.g. inotropes management in sepsis 211

• manipulation of dose forms, when a suitable dosage form is not available, and the 212

alternative route of administration is required e.g. nasogastric, transpyloric 213

• training and competencies for ICU and PICU pharmacists and technicians 214


• quality and auditing in PICU and ICU, for example, prescribing variation and individualising 215

therapies. 216

217

Recommended Staffing 218

As per the Clinical Pharmacy Standard,1 there are three major factors driving staffing levels for clinical 219

pharmacy services including; the range of clinical pharmacy services, the complexity of care required 220

and hospital throughput. Recommended ICU and PICU pharmacist staffing levels are presented in 221

Table 5. They should be interpreted with consideration of the health service, activities performed by 222

the ICU pharmacist, and those that are undertaken by other pharmacists and pharmacy technicians. 223

The time taken per patient varies depending often on the level of ICU, with higher acuity and more 224

complex patients taking more time and requiring more frequent reviews and follow up. 225

The United Kingdom Faculty of Intensive Care Medicine and Intensive Care Society (ICS)22 provide 226

recommended standards for pharmacist staffing and clinical services. These should be interpreted 227

with care, given differences between classification and practice differences between countries.228

The traditional model for staffing of ICUs has changed. Large tertiary ICUs are being restructured into 229

pods. For example, surgical, medical and cardiac pods. Each pod has its own ICU and PICU pharmacist, 230

medical and allied health team. 231

For larger level 6 ICUs, equivalent to CICM level 3, and for hospital networks with multiple ICU sites, 232

there should be a lead pharmacist(s) responsible for the coordination of the ICU service. Staffing ratios 233

should allow for dedicated time for the lead pharmacist(s) to perform indirect patient care duties. This 234

will also include training, succession planning and supporting multi-site ICUS within a health service 235

or district. 236

237

Type of care Level 4 ICU5F

v Level 5 ICU Level 6 ICU

Optimal pharmacist: patient ratio Adults 1:20

Paediatrics 1:15

Adults 1:10

Paediatrics 1:10

Adults 1:10

Paediatrics 1:10

Table 5 Recommended pharmacist:patient ratios for ICU services 238

Clinical pharmacy service Level 4 ICU6F

vi Level 5 and 6 ICU

Medication history and reconciliation on admission

v The categories of level 4,5 and 6 ICU are in use in NSW, QLD, WA and SA. CICM level – add to table. vi The categories of level 4,5 and 6 ICU are in use in NSW, QLD, WA and SA.


Coordination of supply for medicines including special access scheme, off-label use, or highly specialised medicines

Clinical review of medication chart, monitoring of therapies including therapeutic drug monitoring

Provision of medicine administration advice e.g. IV compatibilities, NG administration, drug interactions.

Optimisation of medicines when on supportive therapies e.g. RRT, ECMO, etc.

Frequency of patient review (patient complexity / case-mix)

Once-daily Twice daily

Extended hours service

5- or 7-day specialist pharmacist service

5 day 7-day

Multidisciplinary ward rounds

Multidisciplinary team meeting

Executive and management meetings

Input into the budget and financial management for resource management

Discharge reconciliation to a ward and on interhospital transfer

Development and review of protocols, procedures, and guidelines relating to ICU


Participation in governance committee and Quality Use of Medicines activities such as audits

General education for staff (e.g. pharmacists, nursing, medical)

Specialist education for staff (e.g. pharmacists, nursing, medical)

Precepting students and SHPA Residents

Participation in research projects

Provide specialist expertise for the organisation, local health district, state, National e.g. policies and procedures, smart pumps

Provide specialist advice to

committees such as medication or

patient safety, adverse drug reaction

review

Table 6 Recommended clinical pharmacy services for ICU services239

240

Training and Education 241

It is essential to develop the pharmacy workforce through the training and education of pharmacists 242

and technicians, to enable the delivery of advanced pharmacy care in ICU. ICU and PICU pharmacists 243

should have a scope of practice competency profile with a Continuing Professional Development plan 244

that covers the five domains of professional performance as per the National Competency Standards 245

Framework for Pharmacists in Australia 2016.3 Whilst the framework itself is not tied to any area of 246

specialisation, for ICU and PICU pharmacists there are qualifications, educational activities, 247

knowledge, and skills that are recommended in addition to those of a clinical pharmacist. These have 248

been informed by the SHPA Critical Care Leadership Committee. 249

In addition, pharmacists and pharmacy technicians commencing practice in ICU services must 250

undertake a relevant orientation and training program as determined by the health service. This 251

should include credentialing relative to their role as implemented by local or state-based health 252

services. 253


Credentialing and Qualifications 7F

vii 254

It is desirable for ICU and PICU pharmacists to undertake credentialing and higher education. Available 255

qualifications and programs include: 256

• a postgraduate qualification, for example, 257

o Graduate Diploma or Master of Clinical Pharmacy 258

o Research higher degree (e.g. MPhil, Ph.D.) 259

• SHPA Foundation Residency or Advanced Training Residency Program (critical care) 260

• credentialing as an Advancing or Advanced Practice Pharmacist, as provided by Pharmacy 261

Development Australia27 262

• formalised certification in Critical Care Pharmacy such as that offered by the US Board of 263

Pharmaceutical Specialties 264

• other relevant postgraduate degrees which may be available nationally or internationally. 265

Examples include: 266

o MSc (Critical Care) Cardiff University 267

Educational Activities 268

Further to the Pharmacy Board of Australia Guidelines on Continuing Professional Development,44 it 269

is recommended that ICU and PICU pharmacists have a significant proportion of their continuing 270

professional development per year tailored towards intensive care medicine. Recommended 271

continuing education for ICU and PICU pharmacists includes the following: 272

Attendance at local or national courses: 273

• SHPA Critical Care Seminars and related CPD activities 274

• the Basic Assessment and Support in Intensive Care course (BASIC) 275

• paediatric BASIC 276

Joining professional organisations: 277

• Australian and New Zealand Intensive Care Society (ANZICS) 278

• European Society of Intensive Care Medicine (ESCIM) 279

• Neurocritical Care Society see Pharmacist Resources 280

• Neonatal and Paediatric Pharmacists Group (UK) - includes PICU 281

• Society of Critical Care Medicine (SCCM) 282

• United Kingdom Clinical Pharmacy Association (UKCPA) Critical Care Group 283

Educational material and resources are additionally provided on the SHPA Specialty Practice Critical 284

Care stream page via the SHPA eCPD website. For pharmacists working in intensive care, joining and 285

actively participating in the SHPA Specialty Practice Critical Care stream at the Practice Group level is 286

strongly recommended. 287

vii This is a limited list offered for general information and does not represent endorsement of any provider; new providers may emerge, and this list is current as of September 2019.

https://www.bpsweb.org/bps-specialties/critical-care-pharmacy/

https://www.bpsweb.org/bps-specialties/critical-care-pharmacy/

https://www.cardiff.ac.uk/study/postgraduate/taught/courses/course/critical-care

https://www.anzics.com.au/

https://www.esicm.org/

https://www.neurocriticalcare.org/home

http://nppg.org.uk/

https://www.sccm.org/Home

http://ukclinicalpharmacy.org/


The Critical Care Leadership Committee considers the ability to undertake preceptorships and/or site 288

visits to health services in either geographically diverse areas or areas of diverse practice to be a useful 289

way of expanding knowledge and skills, particularly for those ICU and PICU pharmacists practicing 290

alone or at smaller sites. 291

Attendance at specialist conferences and educational meetings should be supported to maintain and 292

update specialist knowledge in intensive care. Relevant domestic conferences include those organised 293

by: 294

• SHPA, 295

• Australian and New Zealand Intensive Care Society (ANZICS)/Australian College of Critical Care 296

Nurses (ACCCN) 297

• Annual Scientific Meeting 298

• Australian and New Zealand Intensive Care Society (ANZICS) Safety and Quality Conference. 299

International conferences include: 300

• the Critical Care Congress hosted by the Society of Critical Care Medicine (SCCM) 301

• European Society of Intensive Care Medicine (ESCIM) LIVES Annual Congress 302

• European Society of Paediatric and Neonatal Intensive Care (ESPNIC) 303

• World Federation of Paediatric Intensive & Critical care Societies Congress (WFPICC). 304

305

Knowledge, Skills, Activities and Experiential Learning 306

Peer collaboration and peer-to-peer supported learning and review should be encouraged in the 307

workplace. The focus of peer engagement should be on the knowledge and skills which result in clinical 308

practices that improve patient outcomes. Informal and formal frameworks including the SHPA Clinical 309

Competency Assessment Tool (ClinCAT) and MiniCEX could be used ideally with assessment by a 310

senior ICU or PICU pharmacist. Recommendations for essential and desirable knowledge, skills, 311

activities and experiential learning are listed in Table 7.312

https://www.shpa.org.au/


https://www.acccn.com.au/

https://www.acccn.com.au/


https://www.sccm.org/Home

https://www.esicm.org/

https://espnic-online.org/

https://www.wfpiccs.org/


Essential (Adv I & II UKCPA) Desirable (Mastery UKCPA)

Knowledge • Pharmacology (including PK and PD) of medicines used in critically ill patients e.g. antibiotics, analgesia, sedation, inotropes, and vasopressors.

• Medicine dosing in special situations e.g. dialysis, ECMO, augmented renal clearance

• Medicine administration in ICU i.e. different routes of administration, IV (CVC), NG, IO

• The aetiology, presentation, diagnosis, monitoring, and management of common critical care presentations

• Prevention and management of critical illness-related morbidities e.g. prevention of delirium, GI ulcers, ventilator-associated pneumonia, bowel care, electrolyte derangements, fluid balance, VTE

• Management of shock

• Post-surgical care in critically ill patients

• Antimicrobial stewardship and infection control

• Therapeutic drug monitoring (TDM)

• End of life care

• Research and clinical trial methodology Knowledge required according to the role of the pharmacist and range of services:

• Paediatrics

• Organ and bone marrow transplantation

• Cardiothoracic surgery & General surgery

• Burns

• Neurosurgery

• Ventricular Assist Device (VADs)

• ECMO

• RRT

• Basic ventilation principles

• Acid-base balance

• Managing deteriorating patients and advanced life support (ALS)

• ICU survivorship (impact on long term outcomes)

• Pharmacoeconomics Knowledge required according to the role of the pharmacist and range of services:

• Management of patients for organ donation

• Paediatrics o Congenital heart disease

o Metabolic conditions



• Plasma exchange

• Spinal & other trauma

• Neurology

• Toxicology

Skills • Being able to exercise independent, responsible clinical judgment in relation to individual scope of practice and knowledge limitations

• Competence to participate in multidisciplinary ward rounds and meetings

• Ability to provide clinical input in the multidisciplinary setting contributing to decision-making at the point of care

• Capability to critically appraise evidence-based literature

• Well-developed communication and negotiation skills

• Demonstrates the ability to communicate where the content of the discussion is based on professional opinion

• Demonstrates ability to use skills to make decisions in complex situations where there are several factors that require analysis, interpretation and comparison and an ability to see situations holistically

• Demonstrates confidence, competency and cultural sensitivity, in addition to empathy, when dealing with patients and carers in the ICU and at the end of life care stage

• Ability to practice self-care principles and maintain professional boundaries for ICU pharmacists

• Demonstrates the ability to make decisions in the absence of evidence or data or when there is conflicting evidence or data

• Demonstrates the ability to present complex, sensitive or contentious information in a hostile, antagonistic or highly emotive atmosphere

• Ability to promote and support the skills development of early-career ICU pharmacists and those newly working in critical care

• Demonstrating leadership to support and promote advanced pharmacy care in ICU

• Teaching skills to increase advanced capability e.g. training and education of healthcare professionals regarding ICU pharmacy

• Research in critical care, with a focus on decreasing healthcare burden and improving quality of life

Activities and experiential learning

• Completion of an evaluation of clinical skills using the ClinCAT (version 2) which can be found in Chapter 15 of the SHPA Standards of Practice for Clinical Pharmacy Services1

• Effectively impart up to date ICU medicine-related information to health professionals and patients

• Provide expert advice to drug committees on formulary applications relating to medicine use in ICU



• Mentorship of early career pharmacists and those newly working in ICU

• Teaching, training, and education of healthcare professionals regarding ICU medicine therapy

• Effective contribution to medicine safety and clinical governance committees

• SHPA Advanced Training Residency (Critical Care)

• Engagement and advocacy in National health and community policy

Table 7 Knowledge, Skills, Activities and Experiential Learning313


314

Training and education will predominantly be work-based education and should follow adult learning 315

principles. Further information can be found in Chapter 10 of the SHPA Standards of Practice for 316

Clinical Pharmacy Services.1 317

318

Quality Improvement 319

Quality improvement activities should demonstrate advanced pharmacy care in the ICU and PICU, by 320

delivering improvements in patient care. Activities should target and achieve the best outcomes for 321

all patient groups, including those at greatest risk for medicine misadventure. Collaborative quality 322

improvement activities between sites and within states and territories (e.g. Safer Care Victoria) are 323

also advocated. Examples of quality improvement activities that may be considered within a plan, do, 324

study, act (PDSA) cycle for quality improvement activities are listed in 8. 325

Quality improvement activities for intensive care pharmacy services

Essential • Auditing and reporting on ICU and PICU practices with the aim to improve

patient safety, quality of care and cost optimisation

• Incident analysis relating to intensive care medicines

• Optimising sedation and analgesia for patients in ICU and PICU

• Minimising delirium and proposal of strategies to decrease the risk of hyperactive delirium

• Optimising and reviewing patients with enteral administration of medicines, providing recommendations regarding absorption, tolerability

• Adherence to local antimicrobial guidelines and involvement in sepsis initiatives

• Adherence to thromboprophylaxis guidelines

• Maintaining drug libraries for smart pumps and for digital health record

• Development and review of practice guidelines and treatment protocols considering current evidence

Desirable • Medicines Usage Evaluations or Quality Use of Medicines audits for specific agents or protocols e.g.:

o the utilisation of new agents o supportive care medicines e.g. mouthwash cares, eye care, etc.

• Report on medicines usage and medicines expenditure within intensive care

• New practice introduction and assessment

• Evaluating clinical and patient-reported outcomes

• Review of pharmacist interventions resulting in a change to the treatment

Table 8 Quality improvement activities for intensive care pharmacy services 326

As part of quality improvement, the key performance indicators listed in Table 9 should be considered, 327

in addition to indicators set in accordance with local policies. 328


Key performance indicators for intensive care pharmacy services

Governance Policies and Procedures Protocol Governance

• The proportion of ICU guidelines that have been reviewed and are up to date and within use dates

Prescribing • The proportion of patients with enteral administration of medicines if feeding is tolerated where there is an enteral formulation available

• The proportion of patients with appropriate oral medicine dosing in terms of feed intolerance

• The proportion of patients on oral medicines that are known to have absorption issues with feeds with no separation of medicine-feed

• The proportion of patients with a clinically relevant food-drug interaction

• The proportion of patients with appropriate prokinetic medicine use

Medication reconciliation and Clinical verification

• The proportion of patients for whom a medication reconciliation is completed prior to ward transfer

• The proportion of intensive care therapy orders clinically verified by an intensive care pharmacist.

• The proportion of patients meeting target pain scores

• The proportion of patients experiencing analgesia withdrawal

• The proportion of patients with an analgesia plan on discharge from ICU

• The proportion of patients results checked including blood gases, full blood counts, creatinine clearance, liver function tests and any other parameter required for medicine administration

Patient Education • The proportion of patients and/or carers educated and provided written information about their care by a pharmacist according to local practice

Teaching and training Pharmacist training and authorisation

• The proportion of pharmacists skilled in managing the ICU case mix

Table 9 Key performance indicators for intensive care pharmacy services 329

Further information on quality improvement can be found in Chapter 14 of the SHPA Standards of 330

Practice for Clinical Pharmacy Services.1 331

332

Research 333

Research is vital for advancing the provision of pharmacy service in ICU and PICU, and for optimising 334

patient care. Pharmacist-led research should contribute to the body of knowledge providing evidence 335

of impact for safe use of medicines and advanced pharmacy care in critical care. This may include 336

identifying evidence gaps and implementing evidence-based practice in critical care. The research 337


question and study design should be of interest to the critical care team and of benefit to patients. 338

The research should focus on improving the quality of life for patients post ICU admission, in addition 339

to addressing the ongoing healthcare burden and minimising deficits. 340

Examples of pharmacist-led research include: 341

• sepsis initiatives – early identification and improving outcomes 342

• optimised dosing of medicines in critically ill patients 343

• impact of extracorporeal therapies e.g. ECMO, RRT and plasmapheresis 344

• multidisciplinary research e.g. delirium and antimicrobials 345

• management of staff burnout and wellbeing initiatives 346

• improvement of quality of life outcomes post ICU e.g. minimizing long term neurological 347

deficits 348

• improving patient outcomes with a life-threatening illness 349

• interventions to reduce post ICU stress syndrome 350

• expanding roles of pharmacists e.g. medical emergency team (MET) calls 351

• study of medicine safety e.g. electronic prescribing, digital health records, smart pump 352

interventions, transitions of care 353

• cost-effectiveness studies. 354

Cross-sector, inter-sectoral and interdisciplinary research is advocated to ensure the input of key 355

stakeholders and that research is relevant to the Australian community. 356

External funding enables larger and possibly multi-centre studies to be conducted. The SHPA funds 357

research grants, practitioner grants, and educational grants. Grants may also be available from other 358

organisation’s local research foundations and charitable trusts such as the Intensive Care Foundation, 359

Australian and New Zealand Intensive Care Society (ANZICS), Australian and New Zealand College of 360

Anaesthetists (ANZCA), Australian Society of Antimicrobials (ASA), National Health and Medical 361

Research Council (NHMRC) and pharmaceutical industry investigator-initiated studies. Presentation 362

and publication of studies by Australian ICU and PICU pharmacists are imperative, to aid others in the 363

implementation of critical care services and illustrate how pharmacists are contributing to 364

improvements in patient care. 365

The choice of a journal to publish in depends on the consideration of the best audience for the study 366

results. The Journal of Pharmacy Practice and Research (JPPR) presents findings to primarily an 367

Australian pharmacy audience. Journals specific to critical care that may be appropriate are listed in 368

Appendix 2. Resources. 369

Further information on research can be found in Chapter 11 of the SHPA Standards of Practice for 370

Clinical Pharmacy Services.1 371

372

https://www.intensivecarefoundation.org.au/

https://www.asainc.net.au/research-grants


Acknowledgements 373

The authors additionally wish to acknowledge the work of the former SHPA Committee of Specialty 374

Practice in Critical Care on previous versions of this Standard Dennis Leung, Sue Kirsa, Annie Egan, 375

Dianne Milne, Ren Lau, Elaine Lum and Luke Mannix. 376

References 377

378

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7. Department of Heath GoWA. WA Health Clinical Services Framework 2014-2024: Health 392 System Improvement Unit, Department of Health, 2015. 393

8. Victorian Government Health and Human Services. Critical and Intensive Care Core 394 Capability Framework. In: State of Victoria DoHaHS, editor. Melbourne; 2019. 395

9. NSW Government DEPARTMENT OF HEALTH. NSW Health Guide to the Role Delineation of 396 Clinical Services. North Sydney: NSW Ministry of Health, 2018. 397

10. Zealand CoICMoAaN. Minimum-Standards-for-Intensive-Care-Units. College of Intensive 398 Care Medicine of Austalia and New Zealand; 2011. 399

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Appendices 482

Appendix 1. ICU Glossary 483

Term Description

ALS / ACLS Advanced Life Support/ Advanced Cardiac Life Support

CAPD Cornell Assessment of Paediatric Delirium

CICM College of Intensive Care Medicine

CRRT Continuous Renal Replacement Therapies – includes continuous venous hemodiafiltration and continuous venous haemodialysis

CVC Central Venous Catheter Sometimes referred to as a CVL - Central Venous Line

ECMO Extracorporeal membrane oxygenation includes VA= veno-arterial supports the heart and lungs and VV= veno-venous supports lungs only

EMM Electronic Medicines Management

FASTHUGS • Feeding/fluids

• Analgesia and Antimicrobials

• Sedation

• Thromboprophylaxis

• Head-up position

• Ulcer prophylaxis

• Glycaemic control

• Stools

HF Haemofiltration

ICU Intensive Care unit

MARS Molecular Absorbent Recirculating System

MET Medical emergency team Sometimes referred to as an RRT – Rapid Response Team

PD Peritoneal Dialysis

PICU Paediatric intensive care unit


SAS / RASS Sedation Agitation Score Richmond Agitation Sedation Scale

SCUF Slow Continuous Ultrafiltration

WAT Withdrawal Assessment Tool

484

Appendix 2. Resources 485

Recommended texts for ICU

• Bersten AD, Handy J. Oh's Intensive Care Manual, 8th Edition: Elsevier; 2018.

• Handbook of Drugs in Intensive Care: An A to Z Guide, 6th Edition, 2019, Cambridge University

Press, Cambridge

• Pharmacokinetics Made Easy, 2nd Edition, 2010, McGraw Hill

• Pharmacology & Pharmacokinetics: A Basic Reader (Competency-Based Critical Care), 2010,

Springer

• The renal drug handbook. The ultimate prescribing guide for renal practitioners, 5th Edition,

2018

• Rogers textbook of Pediatric of Intensive care 5th edition 2015

• UK Clinical Pharmacy for Paediatric Critical Care 2011

• Erstad BL. Critical Care Pharmacotherapy, 2016, American College of Clinical Pharmacy

Key Journals for ICU practice and research

• American Journal of Respiratory and Critical Care Medicine (US) - publishes high-quality

original papers, reviews, and clinical trials in respiratory, critical care, and sleep medicine to

foster advances in translational research and clinical practice.

• Australian Critical Care – publishes research, reviews and commentaries in intensive care

• Critical Care (UK) - publishes commentaries, reviews, and research in all areas of intensive care

and emergency medicine. It provides a comprehensive overview of the intensive care field.

• Critical Care Clinics (UK) - updates you on the latest trends in patient management and

provides a sound basis for choosing treatment options. Each issue focuses on a single topic in

critical care.

• Critical Care Medicine (SCCM – US) - covers all aspects of acute and emergency care for

critically ill patients. Clinical breakthroughs, promising research, and advances in equipment

and techniques.

• Critical Care and Resuscitation (CICM – Aust) - original articles of scientific and clinical interest

in the specialties of Critical Care, Intensive Care, Anaesthesia, Emergency Medicine and related

disciplines.

• Current Opinion in Critical Care (US) - reader-friendly reviews on key subjects such as the

respiratory system; neuroscience; cardiopulmonary resuscitation; the surgical patient; trauma;

and infectious diseases

http://nppg.org.uk/wp-content/uploads/2017/11/Clinical-pharmacy-for-critical-care.pdf


• Intensive Care Medicine (ESICM - Europe) - pre-clinical subjects and medical sciences basic to

critical care medicine

• Journal of Critical Care (UK) - leading international, peer-reviewed journal providing original

research, review articles, tutorials, and invited articles for physicians and allied health

professionals involved in treating the critically ill. The Journal aims to improve patient care by

furthering understanding of health systems research and its integration into clinical practice.

• NEJM – Critical Care articles and reviews

• Paediatric Critical Care Medicine (US) covers all aspects of acute and emergency care for

paediatric critically ill patients. Clinical breakthroughs, promising research, and advances in

equipment and techniques.

• UKCPA Critical Care Journal Club is published on www.ukclinicalpharmacy.org monthly. Covers

a variety of anaesthetic and critical care journals, as well as the BMJ and NEJM

Useful Guidelines

• Uzark KC, Costello JM, DeSena HC, Thiagajaran R, Smith-Parrish M, Gist KM. Useful References

in Pediatric Cardiac Intensive Care: The 2017 Update. Pediatric critical care medicine: a journal

of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and

Critical Care Societies. 2018;19(6):553-63. doi: 10.1097/PCC.0000000000001523.

• Faculty of Intensive Care Medicine, Intensive Care Society (ICS). Guidelines for the Provision of Intensive Care Services 2nd Edition. 2019.

Useful websites

• Critical Care Reviews The hub of critical care literature including journal watch, newsletter, podcast, meeting presentations, studies, review articles, guidelines, journal lists, and meeting lists.

https://criticalcarereviews.com/

• Life in the Fast Lane – critical care compendium A comprehensive collection concisely covering core topics and controversies in critical care. Use the search bar – type in “Pharmacology” or medication name. Blogs, podcasts, and videos of intensive care clinical topics and cases are also available.

https://litfl.com/ccc-critical-care-compendium/

• The Bottom Line A compendium of all landmark papers which are shaping the way we manage our critically ill patients. Each paper is summarised, critiqued and ends with a 'bottom line' paragraph of key points.

https://www.thebottomline.org.uk/

https://criticalcarereviews.com/

https://litfl.com/ccc-critical-care-compendium/

https://www.thebottomline.org.uk/


• Deranged Physiology Unofficial CICM Fellowship Exam preparation resource. It contains useful basic principles behind intensive care medicine, specifically the quintessential ICU topics like mechanical ventilation, dialysis, inotropes, hemodynamic monitoring, arterial blood gasses, etc.

https://derangedphysiology.com/main/home

• Australian and New Zealand Intensive Care Society

www.anzics.com.au

• Australian Resuscitation Council www.resus.org.au

• Society of Critical Care Medicine (SCCM) https://www.sccm.org

• World Federation Paediatric & Intensive Critical care Societies

www.wfpiccs.kenes.com

• Pediatric cardiac intensive care society (PCICS)

www.pcics.org

Podcasts

• Neurocritical Care (NCS) Podcast Series https://www.pathlms.com/ncs-ondemand/courses/1549

• Paediatric Intensive Care podcasts https://intensivecarenetwork.com/media/podcasts/paeds-podcasts/ https://www.podbean.com/podcast-detail/3kcfw-3590f/iCritical-Care-Pediatric-Critical-Care-Medicine-Podcast

486

https://derangedphysiology.com/main/home

http://www.anzics.com.au/

http://www.resus.org.au/

https://www.sccm.org/

https://wfpiccs.kenes.com/

http://www.pcics.org/

https://www.pathlms.com/ncs-ondemand/courses/1549

https://www.pathlms.com/ncs-ondemand/courses/1549

https://intensivecarenetwork.com/media/podcasts/paeds-podcasts/

https://intensivecarenetwork.com/media/podcasts/paeds-podcasts/

https://www.podbean.com/podcast-detail/3kcfw-3590f/iCritical-Care-Pediatric-Critical-Care-Medicine-Podcast

