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doi: 10.1097/01.NURSE.0000388708.83307.b9
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Clinical pharmacists: Coming soon to an ED near you

Edwards, Christopher J. PharmD, BCPS; Jasiak, Karalea D. PharmD; Hays, Daniel P. PharmD, BCPS

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At University Medical Center in Tucson, Ariz., Christopher J. Edwards and Daniel P. Hayes are clinical staff pharmacists in the department of emergency medicine. Karalea D. Jasiak is a PGY2 pharmacy specialty resident in emergency medicine with the University of Arizona College of Pharmacy's department of pharmacy practice and science.

Adapted and updated from Edwards CJ, Jasiak KD, Hays DP. Clinical pharmacists: coming soon to an emergency department near you! Adv Emerg Nurs J. 2010;32(2):122–126.

The ED is an exciting, fast-paced work environment, but its hectic nature may increase the risk of medication errors. A recent study showed that 59.4% of patients had one or more medication errors while in the ED.1 Furthermore, the Institute of Medicine found that the ED had the highest rate of preventable adverse events in hospitals.2

Many factors contribute to the high medication error rate found in the ED. Written orders are the exception rather than the norm, and verbal orders have been associated with an excessive risk of dosing and therapeutic errors in hospitalized patients.3 In contrast to the practice in most healthcare settings, prescriptions in the ED may not be prospectively reviewed by pharmacy. When things run smoothly, very little time elapses between prescribing, dispensing, and the administration of medications. These challenges of the medication use process coupled with the fact that physicians and nurses are following multiple patients at one time with frequent interruptions may put patients at risk for medication errors.4

Clinical pharmacists are experts in the use of medications and bring a unique set of knowledge and skills to the medical team.5 Previous research has shown that a clinical pharmacist can significantly decrease the rate of medication errors by being an active member of the medical team in the ICUs.6,7 Although objective data are limited about the effect of adding a clinical pharmacist to the ED team, one retrospective review found that medication errors were reduced by 66.6% when a pharmacist was present in the ED.8 Therefore, improving pharmacy services in the ED may help reduce medication errors.

Institutions have used a number of different methods to improve pharmacy services in the ED.9 One of these methods involves opening an extension of the main pharmacy, known as a satellite pharmacy, in the ED, so that medications can be prepared and dispensed closer to the point of care. Satellite pharmacies have been shown to decrease turnaround time on prescriptions in other settings, such as the OR.10 Although a satellite pharmacy in the ED may be beneficial, it might not put a clinical pharmacist in the best position for point-of-care interventions. The potential benefits of having a clinical pharmacist working in the ED may be diminished if the emergency pharmacist (EPh) practices exclusively within a satellite pharmacy.

For EPhs to be used to their full potential, they must be highly visible and easily accessible. Many of the activities an EPh performs regularly involve working closely with the ED team (see What an emergency pharmacist does). The EPh should be present at the patient's bedside when key decisions are being made about medication therapy. Many emergency pharmacy practitioners frequently walk through the ED because this helps them identify the most critically ill patients while ensuring that staff members are aware of the pharmacist's presence.11 Carrying a pager or cell phone permits the EPh to be reached for consultation at any time. The EPh also should have access to a computer in a highly visible area of the ED, so that the EPh can be readily available to serve as a resource to everyone involved with patient care.

Nurses tend to be extremely satisfied when clinical pharmacy services are available in the ED.12 In fact, 98% of the nurses surveyed at an academic medical center felt that the presence of an EPh improved quality of patient care in the ED.12 This survey also found that 90% of the nurses had consulted the EPh at least once during their last five shifts—not surprising given all of the services that an EPh can offer to nursing staff.12 An EPh can assist with the acquisition and preparation of medications, adding another check to the system.13 An EPh can help with administration issues, such as checking medications for Y-site compatibility, calculating infusion rates, and programming medication pumps. In several states pharmacists are also permitted to administer medications.

Pharmacy services are particularly useful during emergent or code situations, when a multitude of tasks must be completed simultaneously. The American Society of Health-System Pharmacists granted a best practice award for a study showing that the presence of an EPh during trauma resuscitation was associated with a statistically significant increase in the number of patients receiving appropriate sedation following paralysis and subsequent intubation.14 In situations such as this, having someone focused on medications can help make things run smoother while improving patient care and potentially reducing medication errors.

EPhs regularly provide drug information to everyone involved in patient care.15 Clinical pharmacists frequently answer questions about medication interactions, appropriate dosing, and adverse drug reactions.16 An EPh helps optimize patient outcomes by assisting the physician with drug selection to ensure that a medication regimen is both appropriate and evidence-based.17 Clinical pharmacists in the ED can serve as a drug information resource for providers and students of all healthcare disciplines and also can educate patients about their medications.18 An EPh can inform healthcare providers who practice outside of the ED about medication needs that a patient may have following admission, which can improve the continuity of care.18

An EPh should act as a liaison between the ED and the pharmacy. Having someone who understands the inner workings of both departments can be instrumental in developing policies and procedures that consider the needs, capabilities, and limitations of each department. EPhs can help optimize the inventory stored in automated dispensing machines to ensure that the right medications are available when they're needed.13 An EPh will understand the urgency associated with a given situation and can help expedite the delivery of medications not available in the ED.19 For example, the presence of an EPh has been shown to decrease door-to-balloon time in patients presenting to the ED with an acute myocardial infarction.20 In this study, the EPh acquired medications from either an automated dispensing machine or the inpatient pharmacy when the medication wasn't available in the ED; the EPh then programmed the medication infusion pumps. This let the EPh expedite medication administration while evaluating the therapy for appropriateness, which ultimately improved patient outcomes.

The implementation of an EPh position can be a difficult process.21 Decision makers in pharmacy, emergency medicine, and emergency nursing tend to be receptive to the idea of adding an EPh to the team once they learn about the potential benefits; however, funding for the position may be difficult to obtain. Several studies have shown significant cost avoidance with the implementation of an emergency pharmacy program.15,22 A university-affiliated level 1 trauma center projected the annual cost avoidance associated with an emergency pharmacy program to be $3,089,328.15 The potential for cost avoidance and improved patient outcomes may help justify the creation of an EPh position.

Proper training and experience may contribute to the success of an EPh. In addition to work experience, pharmacists who earn a doctor of pharmacy degree can take advantage of optional pharmacy residency programs. Postgraduate year 1 of pharmacy residency training typically provides a broad experience by letting the pharmacist practice in a variety of clinical settings. If the pharmacist desires specialty training in a particular field, a postgraduate year 2 (PGY2) residency can be completed. However, few programs offer PGY2 residencies in emergency medicine. Graduates from PGY2 programs in emergency medicine tend to be well rounded and can not only function independently, but should also have the skills and abilities necessary to establish clinical pharmacy services in an ED. Other PGY2 specialty programs, such as critical care, ambulatory care, and internal medicine, may prepare a pharmacist to practice in the ED; however, the extent to which these programs are beneficial will depend on the individual's experience during the residency year and the practitioner's own level of interest in emergency medicine.

Above all, the facility must find a pharmacist who fits the needs of the ED: A level 1 trauma center in a tertiary care facility will be serving a different patient population than a lower acuity hospital, and each will require the pharmacist to have a different set of skills and knowledge to function well in that particular environment.

In addition to education and training, certain personalities may be better suited for success in the ED. Characterizing the personality type that's most likely to flourish in the ED is difficult because no objective information is available on this subject; however, a self-motivated practitioner who can think and make rational decisions quickly in a chaotic environment may be desirable for the position. The EPh should be able to handle some of the more emotionally difficult situations that can occur in the ED. A team-based practice approach also is important because working in the ED requires multidisciplinary cooperation. Above all, the clinical pharmacist must integrate well with the ED staff. Having representatives from pharmacy, emergency medicine, and emergency nursing involved in the candidate selection process can help ensure that everyone is comfortable with the final decision. Selecting the right pharmacist when implementing a program is crucial because that person will be responsible for determining the success of the program.

Clinical pharmacists have much to offer to an ED, from assisting with drug selection and policy development to medication acquisition and administration. Although it may be difficult to initially justify the costs associated with hiring an EPh, the cost avoidance from decreasing medication errors and the potential for improving patient outcomes can easily justify a position. Everyone will benefit in some way from the presence of clinical pharmacy services in the ED when the right pharmacist is selected for the position.

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What an emergency pharmacist does8,12,16,19

These are some of the services that an EPh can provide.

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Medication acquisition and administration

* Optimize inventory of automated dispensing machines

* Acquire medications from automated dispensing machines or inpatient pharmacy

* Compound or prepare medications

* Check Y-site compatibilities

* Calculate infusion rates

* Program medication pumps

* Administer vaccinations

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Drug information

* Assist with medication selection to ensure that regimens are appropriate and evidence-based

* Recommend patient-specific medication dosages

* Recommend alternate routes of administration

* Assess for adverse drug reactions

* Provide information about drug interactions

* Identify medications

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Educational

* Serve as a preceptor to residents and students

* Provide medication counseling to patients

* Provide staff development sessions for healthcare providers and students

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Quality improvement

* Guide the development of policies and protocols

* Maintain compliance with standards of national accrediting bodies

* Represent pharmacy and/or the ED on hospital committees

* Participate in emergency preparedness planning

* Conduct research

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REFERENCES

1. Patanwala AT, Warholak TL, Sanders AB, Erstad BL. A prospective observational study of medication errors in a tertiary care emergency department. Ann Emerg Med. 2010;55(6):522–526.

2. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

3. Fijn R, Van den Bemt PM, Chow M, De Blaey CJ, De Jong-Van den Berg LT, Brouwers JR. Hospital prescribing errors: epidemiological assessment of predictors. Br J Clin Pharmacol. 2002;53(3):326–331.

4. Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency department workplace interruptions: are emergency physicians “interrupt-driven” and “multitasking”? Acad Emerg Med. 2000;7(11):1239–1243.

5. American College of Clinical Pharmacy. The definition of clinical pharmacy Pharmacotherapy. 2008;28(6):816–817.

6. Kopp BJ, Mrsan M, Erstad BL, Duby JJ. Cost implications of and potential adverse events prevented by interventions of a critical care pharmacist. Am J Health Syst Pharm. 2007;64(23):2483–2487.

7. Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;282(3):267–270.

8. Brown JN, Barnes CL, Beasley B, Cisneros R, Pound M, Herring C. Effect of pharmacists on medication errors in an emergency department. Am J Health Syst Pharm. 2008;65(4):330–333.

9. Szczesiul JM, Fairbanks RJ, Hildebrand JM, Hays DP, Shah MN. Survey of physicians regarding clinical pharmacy services in academic emergency departments. Am J Health Syst Pharm. 2009;66(6):576–579.

10. Thomas JA, Martin V, Frank S. Improving pharmacy supply-chain management in the operating room. Healthc Financ Manage. 2000;54(12):58–61.

11. Witsil JC, Aazami R, Murtaza UI, Hays DP, Fairbanks RJ. Strategies for implementing emergency department pharmacy services: results from the 2007 ASHP Patient Care Impact Program. Am J Health Syst Pharm. 2010;67(5):375–379.

12. Fairbanks RJ, Hildebrand JM, Kolstee KE, Schneider SM, Shah MN. Medical and nursing staff highly value clinical pharmacists in the emergency department. Emerg Med J. 2007;24(10):716–718.

13. Case LL, Paparella S. Safety benefits of a clinical pharmacist in the emergency department. J Emerg Nurs. 2007;33(6):564–566.

14. Kelly-Pisciotti SJ, Hays DP, O'Brien T, Gestring M, Fairbanks RJ, Metz M. Pharmacists enhancing patient safety during trauma resuscitation. Poster session presented at the American Society of Health System Pharmacists Mid-Year Clinical Meeting, Las Vegas, NV, 2005.

15. Lada P, Delgado G Jr. Documentation of pharmacists' interventions in an emergency department and associated cost avoidance. Am J Health Syst Pharm. 2007;64(1):63–68.

16. Cohen V, Jellinek SP, Hatch A, Motov S. Effect of clinical pharmacists on care in the emergency department: a systematic review. Am J Health Syst Pharm. 2009;66(15):1353–1361.

17. American Society of Health System Pharmacists Council on Pharmacy Practice. ASHP statement on pharmacy services to the emergency department. Am J Health Syst Pharm. 2008;65:2380–2383.

18. Fairbanks RJ, Hays DP, Webster DF, Spillane LL. Clinical pharmacy services in an emergency department. Am J Health Syst Pharm. 2004;61(9):934–937.

19. Wymore ES, Casanova TJ, Broekemeier RL, Martin JK Jr. Clinical pharmacist's daily role in the emergency department of a community hospital. Am J Health Syst Pharm. 2008;65(5):395–396, 398–399.

20. Acquisto NM, Hays DP, Fairbanks RJ, et al. Pharmacists enhancing the time to cardiac catheterization laboratory and patient safety during acute myocardial infarction presentation to the emergency department. Poster session presented at the American Society of Health System Pharmacists Mid-Year Clinical Meeting, Orlando, FL, 2008.

21. Aldridge VE, Park HK, Bounthavong M, Morreale AP. Implementing a comprehensive, 24-hour emergency department pharmacy program. Am J Health Syst Pharm. 2009;66(21):1943–1947.

22. Levy DB. Documentation of clinical and cost-saving pharmacy interventions in the emergency room. Hosp Pharm. 1993;28(7):624–627, 630–634, 653.

© 2010 Lippincott Williams & Wilkins, Inc.

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