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Curtis E Haas, Travis B Dick, Productivity, workload, and clinical pharmacists: Definitions matter, American Journal of Health-System Pharmacy, Volume 79, Issue 10, 15 May 2022, Pages 728–729, https://doi.org/10.1093/ajhp/zxac003
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In a recent paper published in AJHP, the authors report weak correlations between both patient acuity (APACHE II score) and complexity of drug regimens, as measured using the medication regimen complexity–intensive care unit (MRC-ICU) score, and the number of pharmacist interventions (used as a surrogate for pharmacist workload) in a sample of critically ill patients.1 The optimal ratio of critical care pharmacists (CCPs) to patients that positively affects patient outcomes, healthcare costs, and CCP well-being is poorly defined, and the importance of work to help move the profession towards this goal has recently been well described.2 However, the research to characterize CCP workload and productivity, and correlating that productivity with meaningful outcomes like patient mortality, ICU length of stay, and total costs of care must conform to well-accepted business principles and definitions to be credible and embraced by those who control access to resources.3,4
In the simplest terms, workload is the amount of work to be done. Three factors contribute to the calculation of workload: tasks to be completed, intensity of effort to complete tasks (can be reflected by time and/or complexity), and frequency.5 Like others, Smith and colleagues1 used the number of interventions as a surrogate for the workload of a CCP; however, this metric does not meet the definition of workload. As used in their paper, it fails to incorporate a measure of intensity of effort, and there is no accurate way of knowing the total frequency with which a pharmacist should be intervening. The number of interventions is also a very incomplete measure of the totality of tasks to be completed, and its use unintentionally suggests that the remainder of the day (ie, time not spent intervening) is not spent working. It can also be argued that number of interventions is an unreliable, reactive measure of tasks (as a component of workload), since in a critical care environment where a CCP is a fully integrated member of the interdisciplinary patient care team that is collectively making most treatment plan decisions and in which the educational and other non–direct patient care activities of the CCP (development of guidelines, protocols, order sets, etc) have effectively changed the culture of drug use in the ICU, the number of reactive interventions should approach zero. In fact, near zero interventions could be a viable measure of the success of the CCP’s practice. Other limitations of using interventions are that (1) the typical voluntary reporting process can lead to incomplete data and (2) the complexity and nature of interventions reported are dependent on the level of education, training, and experience of the CCP.3,4,6,7
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