Critical Care Pharmacy Practice in Saudi Arabia

By  Nadia H.Ismail,MSc, BPharm,FCCM

Why this review

Saudi critical care pharmacy has evolved from a handful of US and UK, trained pioneers in the 1980s–2000s to a recognized specialty with board-certified practitioners, a national network of critical care pharmacists, residency programs, and a burgeoning research enterprise. This post aims to provide an integrated summary of this literature for Pharmacy directors, pharmacy residents, and hospital managers to build , enhance and improve critical care pharmacy services in their institution.

Scope

Peer-reviewed manuscripts with a Saudi setting and authorship that focus on critical care pharmacy practice, training and their impact on patient care, or on ICU therapy research led by Saudi critical care pharmacists. The papers are grouped by theme, not chronologically.

A word on scope

Any review aiming to be comprehensive is necessarily limited by the availability of published literature. The ICU pharmacy specialty in Saudi Arabia has seen more than a hundred manuscripts published by local authors since 2020, including large multinational cohort studies. This post provides an overview of landmark and representative studies in each theme, all of which have been evaluated according to their abstracts. Your suggestions of additional relevant manuscripts are welcome for future updates.

i. Workforce, Services, and Training

The practice-related literature reveals an uneven development of ICU pharmacy services across the country: while most regional hospitals still lack critical care pharmacists, they are present in most large tertiary medical centers. Out of the 130 hospitals with ICUs to which surveys were sent, 94 (72%) responded. Forty-three percent of responding hospitals had an ICU multidisciplinary team structure that included a pharmacist who visited the unit during medical rounds. Up to 54% of the hospitals with CCP services had one dedicated pharmacist present at bedside and during medical rounds. Approximately 78% of the ICU pharmacists performed one or more clinical activities. Training pharmacy interns was one of the major educational activities provided by ICU pharmacists. Clinical services (42%) were the most needed services, followed by educational (14%) activities. Limited job availability was the main barriers to having CCP services among hospitals (April 2020).

Critical care pharmacy practice in Saudi Arabia: a review by SSCP Critical Care and Emergency Medicine PSN) board members of 2020. A narrative literature review combined with qualitative interviews with local pioneers’ sheds light on the specialty’s early development and emerging challenges.  The review describes critical care pharmacy services in Saudi Arabia by analyzing their historical development across patient care See Fig.1, education, scholarly research, and professional leadership, while outlining current challenges and strategic opportunities for professional advancement (Aug 2021)

Fig.1

Key Findings

• Historical Growth & Scholarship Impact: Clinical services began in the late 1970s and 1980s through centralized satellite pharmacies and Drug-Poison Information Centers. Strategic government scholarship initiatives—notably the King Abdullah Scholarship Program—enabled approximately 500 Saudi pharmacists to earn Pharm.D. degrees, with over 350 completing postgraduate residency or fellowship training in North America.

• Regional Credentialing Leadership: Board Certified Critical Care Pharmacist (BCCCP) holders in Saudi Arabia grew from 18 in 2018 to 48 in 2021, making it the leading country in the Middle East for credentialed critical care specialists.

• Workforce Deficit & Patient Ratios: Although total intensive care unit (ICU) capacity expanded to 10,950 beds by 2020, a severe workforce shortage persists: there are roughly 49 board-certified critical care pharmacists serving 10,950 ICU beds (an average ratio of 1 pharmacist per 224 beds). In major tertiary hospitals, individual practitioners frequently care for 15 to 30 patients.

• Geographic & Operational Constraints: Specialized pharmacists and PGY-2 critical care residency training programs are heavily concentrated in major urban centers such as Riyadh. Furthermore, clinical coverage is largely restricted to 8-hour day shifts on weekdays, with minimal off-hour or weekend service.

• Research Contributions & Institutional Leadership: Saudi critical care pharmacists actively participate in major randomized clinical trials (such as MIRACLE and ATTAINMENT) through initiatives like the Saudi Critical Care Trials Group (SCCTG). In 2020, the Saudi Society of Clinical Pharmacy (SSCP) launched the Critical Care and Emergency Medicine Specialty Network to formalize national standards. However, research output remains limited by sparse funding, a lack of senior research mentors, and language barriers.

ii. Closing the Gap in Intensive Care: The Purpose and Main Results of Saudi Arabia's National Critical Care Pharmacy Survey 2023

Critical care pharmacists are integral parts of multidisciplinary intensive care teams, making significant contributions to drug therapy, prevention of adverse drug events, shortening of length of stay, and improved outcome for patients. This nationwide cross-sectional study provides an in-depth survey of critical care pharmacy services delivery in hospitals from across the Kingdom.

Background Context

While critical care pharmacy services in Saudi Arabia have been established in the early 2000s, there has not been a comprehensive data collection about their scope and practice at the national level. The aims of this study were to describe pharmacy services offered by critical care pharmacists (CCPs) across the country, with a focus on clinical, educational, scholarly, and administrative aspects, to create the foundation for future improvement and policy setting.

 The study provides information on practice site, qualifications, and services offered by CCPs (classified as basic, desirable, and optimal services).

Audit Overview

Period : Conducted between September 2022 and January 2023, using an electronic survey platform and distributed through the Critical Care and Emergency Medicine Pharmacy Specialty network of the Saudi Society of Clinical Pharmacy (Nov 2023) 

Sample Size: Of the 44 eligible critical care pharmacists 23 participated (response rate: 52.3%)

Regional Representation: Central region (47.8%), Eastern region (30.4%), and the Western region (21.7%). Of the 23 respondents, 34.7% worked in Ministry of Health hospitals, 30.4% in academic hospitals, and 26.1% in military hospitals. The majority of the hospitals had mixed medical-surgical ICU with a bed capacity between 10 and 100.

 Some of  Key Findings:

1. High-Level Education and Competency

Among the four largest categories of respondents, the most numerous ones were pharmacists with 4–10 years of experience in critical care (47.8%). Moreover, 60% of respondents had completed an advanced postgraduate pharmacy residency (PGY-1 and PGY-2) compared to 13% who graduated from a critical care fellowship. Moreover, a considerable number of the respondents held advanced clinical degrees, including Master of Clinical Pharmacy (43%) and Doctor of Pharmacy (39%). 

2. Active Participation in Multidisciplinary Care as Part of the Core Responsibilities

• Focus on Intensive Care Unit (ICU) Patients: 86.9% of respondents dedicated their time to ICU patients with limited responsibilities in other settings
• Multidisciplinary Rounds: 86.9% (95.6% in some cases) of respondents took part in multidisciplinary ICU clinical rounds five days a week
• Interprofessional Communication: 91.3% of respondents served as liaisons between pharmacy, nursing, and medical staff in terms of drug information and guidelines

3. Active Engagement in Scholarly Activities

• Research: 82.6% of respondents participated in retrospective research studies
• Mentoring: 82.6% of respondents provided informal teaching/mentoring for pharmacy residents, students, and staff
• Committees: 78.2% of respondents participated in Pharmacy and Therapeutics (P&T) committees, 56.5% – in critical care committees while 56.5% – contributed to pharmacy department policy development.

4. Predominance of Core Services and Opportunities for Technology Introduction

CCPs are primarily focused on delivering fundamental clinical pharmacy services, while desirable and optimal services require additional workforce and resources. Only 43.4% of respondents had access to computerized direct provider order entry systems in their ICUs, signifying a key technology gap, which, when addressed, can free up valuable time for clinical pharmacy services.

The following recommendations have been proposed:

• Standardizing the number of pharmacists per patient in order to prioritize patient safety and staff productivity
• Developing national performance indicators to ensure balanced time management between clinical, administrative, and scholarly responsibilities
• Creating greater access to advanced health technology, including computerized direct provider order entry and bedside systems, in all ICU settings
• Enhancing critical care pharmacy residency programs to allow for a broader scope of services, including the adoption of desirable and optimal services.

iii. Revisions to Critical Care Pharmacy Training & Accreditation Standards in Saudi Arabia

Objective of The opinion paper by the Critical Care and Emergency Medicine Pharmacy Specialty Network (CC & EM PSN) Published in 2022,  aims to propose broad ranging amendments to accreditation standards and competency blueprints for specialized critical care pharmacy residency programs in the Saudi Arabia.(June 2022)

By drawing on feedback from residency directors and trainees currently in practice, the paper seeks to catalyze program expansion across the country while maintaining high quality, standardized clinical training.

Main Findings While the growth in clinical pharmacy training programs has seen an impressive 14-fold increase overall between 2001 and 2021, capacity for critical care residencies is limited due to a lack of suitable facilities. As of 2022, there were only 5 residency seats available at 4 accredited centers, of which 3 were located within Riyadh and one in Jeddah.

The accreditation standards currently in place, established by the Saudi Commission for Health Specialties (SCFHS) in 2020, have restrictive criteria such as bed-number requirements for each rotation that limits program expansion to large tertiary hospitals in major cities.

The current frameworks for clinical pharmacy residency programs in Saudi Arabia rely on the physician centered CanMEDS competency framework and do not provide standardized Program Learning Outcomes (PLOs) or assessment blueprints required to enable trainees to enter independent practice.

 Authors' Recommendations

1. Updating accreditation and resource requirements to enable expansion beyond large tertiary hospitals

Elimination of bed-count mandates for individual rotations to align with adult critical care medical fellowship standards

More relaxed preceptor criteria to enable senior clinical pharmacists to fulfill the role of preceptors in areas where consultant critical care pharmacists are in short supply

2. Reorganization of curriculum and core rotations to develop standardized core rotations and longitudinal experiences

The core rotations should be grouped into 6 main areas (Medical ICU, Cardiac ICU, Infectious Diseases, Emergency Medicine, Nutrition Support and other specialized ICUs) with mandatory longitudinal experiences (Code Blue response, rapid response team, research)

Mandatory certification courses such as Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) should be included as core requirements for the program.

3. Adoption of pharmacy specific learning outcomes and assessment blueprints as opposed to physician centered frameworks such as CanMEDS

The competencies and learning outcomes should be defined in terms of Knowledge, Skills and Attitude (KSA) and follow ASHP competency domains.

A three tier content structure for the end-of-year summative examination should be introduced, with Scientific Competency (75%), Clinical/Research Skills (15%) and Educational/Administrative Skills (10%).

Enhanced examination and OSCE quality through annual question review, peer consultation (consultants not involved in item writing), clinical scenario based questions with pharmacy focus and OSCE assessment by practicing critical care consultants.

4. Development of emergency medicine clinical pharmacy residency programs in Saudi healthcare institutions in the future, building on existing critical care expertise.