Three major emergency medicine organizations teamed up recently to persuade the Joint Commission to temper its policy on prospective pharmacy review of drugs administered in the emergency department, and by all accounts, it appears their efforts were successful, although a task force will reveal its final recommendations later this fall.
Representatives of the American College of Emergency Physicians, the American Academy of Emergency Medicine, and the Emergency Nurses Association will be part of that interdisciplinary task force, convened by the Joint Commission (formerly the Joint Commission for the Accreditation of Health Care Organizations), and will develop revisions to the standards. The commission also plans a field review to help with rewriting the rules.
The original standard — MM.4.10, EP 1 issued in January — required that a pharmacist review all medication orders before they were administered in the emergency department, creating a new barrier to treating patients quickly and efficiently in already stressed emergency departments and ignoring the fact that pharmacists are already in short supply.
After the three groups pressed their case, the Joint Commission suspended the measure and then reinstated it with the proviso that a retrospective review should be implemented when prospective review was not done. That also created problems, said Robert Wise, MD, the vice president for standards and survey methods with the Joint Commission. “There was general agreement that a pharmacist should be reviewing medications, but the emergency department represented a unique situation,” he said. “Pharmacists are not traditional in the emergency department. The [national] lack of pharmacists is a huge burden, and it is virtually impossible for every medication to be prospectively reviewed.
“We wanted to take some pressure off the emergency department, even though it was felt important that medicines be reviewed. Emergency departments are a place where errors can occur,” Dr. Wise said. “The retrospective review did not lessen the burden for the exact same reasons. It took a huge amount of pharmacists' time. Some people estimated it would take six hours a day, and there's already a shortage of pharmacists. We realized that this is a complicated problem, and a quick fix is not going to work here.”
“The lack of pharmacists is a huge burden, and it is virtually impossible for every medication to be prospectively reviewed.”
DR. ROBERT WISE JOINT COMMISSION
In the interim, his group allowed two important exceptions, and he said the organizations can interpret them broadly. One exception occurs when a licensed independent practitioner in the emergency department controls the ordering, preparation, and administration of the medication, and further loosens the regulations by allowing a registered nurse or other licensed staff with medication administration responsibilities such as a respiratory therapist to process and administer the medicine as long as a physician remains available to provide immediate treatment if the patient has problems.
The requirement is also suspended in urgent situations when a delay would harm the patient. It allows the doctor caring for the patient to define “urgent.”
“We still do not believe that this deals with all the issues,” said Dr. Wise. “What we did was allow this interpretation to go forward. We are in the process of putting together a task force to see how we can use pharmacists in the emergency department in a way that improves quality and safety without burdening the system or the physicians.”
Solution for Medication Safety
Tom Scaletta, MD, the president of AAEM, who was involved in negotiating the change, said emergency physicians expressed concern when the standard was first issued and questioned whether it was a reasonable approach. “It would slow things down and force hospitals to use resources for something that wasn't necessary,” he said. “That means something else wouldn't get the resources it needed.”
W. Richard Bukata, MD, who represented ACEP, said the college, AAEM, and ENA joined together to cite grave concerns that the JC rules would make care slower and potentially dangerous. Along with Dr. Scaletta and Denise King, RN, the president-elect of ENA, he was invited to sit on the JC task force, which held its first phone meeting in mid-July. “We are making excellent progress, and I am sure we will come up with a solution to medication safety in the ED that will be acceptable to all stakeholders,” Dr. Bukata said.
Dr. Scaletta said the Joint Commission's insistence on prospective pharmacist review of ED prescriptions was likely unnecessary, especially when a doctor-nurse team was capable of making a good decision about when to give a medication. “That doesn't mean I have anything against pharmacists, but they are busy enough. We do like their feedback on how we are prescribing. They could do a focused review. Are we giving the right drugs and the right dose? They can do all sorts of things to improve the process. But should they be approving every single Tylenol? That is kind of silly,” he said. “Emergency rooms are so busy that adding anything into the equation can put the system in gridlock.”
Understanding emergency medicine would help avoid having to rewrite the regulations, he said, adding that the Joint Commission would be well served to have an emergency physician or emergency nurse on its board. “Perhaps that would help guide them in developing these kinds of standards,” Dr. Scaletta said.
That might have helped avoid this problem, he added, noting that it's difficult for the Joint Commission to ignore the 60,000 members represented by the three organizations. “When we asked to meet with the Joint Commission, we had an in-person meeting in Oakbrook, IL [the commission's headquarters]. As a result of that meeting, what we are seeing looks more reasonable,” Dr. Scaletta said.
He said while it was positive that the groups were able to influence the Joint Commission, Dr. Scaletta said he thinks a more proactive stance would be better. The task force may open that dialogue. “The task force is focused on this particular area of management, but something else could pop up. If we could see the big picture of what the Joint Commission is planning and how they do their strategic planning, we could point out what works and what doesn't,” said Dr. Scaletta.
Dr. Wise said he hoped the task force could quickly create a standard that would go through the Joint Commission's normal process, hopefully completing its work by fall. “I hope this is not going to be a very complex process,” he said. “The important thing is that by creating a interpretation of the rule, it allows the organizations to meet the standard currently and form a task force to create a standard that improves overall quality and safety.”
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