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Breaking News: Do the Math Time for Pharmacists in the ED

SoRelle, Ruth MPH

doi: 10.1097/01.EEM.0000446049.04242.88

    Acting on a hunch that a pharmacist in the ED would yield positive results, Jesse Cannon, MD, proposed a pilot study for the emergency department at the Atlanta VA Medical Center. A pharmacist was installed there for two weeks, yielding a savings that even Dr. Cannon didn't expect: more than $40,000.

    “If the study was positive, we could make a case to the administration. But when we did the math, we realized the benefit we could have,” said Dr. Cannon, an assistant professor of emergency medicine at Emory Healthcare. Extrapolating the savings over a year would total more than $2.7 million.

    Dr. Cannon and his colleagues performed a prospective observational study in which residency-trained doctors of pharmacy provided clinical pharmacy services for just 30 hours over that two-week period. (Acad Emerg Med 2013:20[Suppl 1]:178.) The patients they saw needed anticoagulation consults, diabetic education, pharmacokinetic consults, medication reconciliation, formulary management, and screening for drug interactions. They also consulted on allergies and nonformulary and restricted medication requests, reviewed charts, clarified orders and IV compatibility, eliminated duplicate therapy, and screened for medication errors and adverse events. They then estimated the costs that were avoided through these interventions.

    Those 30 hours yielded that whopping $40,000. Forty-two patients received 71 interventions by the clinical pharmacists, and the researchers estimated that the pharmacists reduced costs by $1,486 by adjusting medication dose or frequency. They saved another $205 by avoiding duplication of therapy and $1,374 by preventing or managing adverse drug events. Preventing or managing allergies saved $1,721 and fulfilling educational or requests for information saved $512. Savings from formulary management totaled about $175 and the same amount for therapeutic interchange. The cost difference between having a physician order a prescription refill and a pharmacist order the refill was $12.50 each time.

    “When we did the math, we realized the benefit we could have. We made the case to the administration effectively, and got a pharmacist in the VA emergency department,” said Dr. Cannon. “I think pharmacists have a definite value in the emergency department. The benefit we saw in regards to patient safety and satisfaction and physician satisfaction were significant. I think pharmacists would have a benefit in any emergency department that sees more than a few people each day.”

    Victor Cohen, PharmD, the pharmacy residency program director at Maimonides Medical Center in Brooklyn, NY, needs no persuasion. He and colleagues demonstrated the value of a pharmacy-based influenza immunization program in an academic emergency department. (Ann Pharmacother 2013;47[11]:1440.) Pharmacists vaccinated 62 ED patients (41%) who consented. The median time to screen and vaccine was eight minutes. The majority of those who refused said they thought their personal risk was low.

    Dr. Cohen said the idea to immunize in the ED came from an American Pharmacists Association project designed to allow pharmacists to perform immunizations in the community. “We know that nurses don't have time to do vaccinations in the ED,” Dr. Cohen said. “Then the H1N1 outbreak [in 2009] created the buzz. Our institution was overwhelmed with possible patients. The potential of pandemics led to a consideration of using pharmacists in the emergency department.”

    They decided, he said, that providing immunizations in the emergency department was a public health service, but how could they do that and have an impact on the institution as well? After several meetings between the medical director and the chair of emergency medicine, the decision was, “Get it done,” said Dr. Cohen. “Again, it was another role. Pharmacists prevent medication errors, optimize treatments, and understand the nuances of therapy in a variety of situations. We need to generate revenue as well as value and justify our existence,” he said.

    Putting the study in place proved a challenge. Even some of the pharmacists were not interested in providing those services, but the physicians eventually created a standing protocol. The pharmacy intern could administer the vaccine during triage or the ED's lulls. “You can go back to the patient who needs the vaccine,” said Dr. Cohen.

    He said he anticipated pharmacists assuming more roles in emergency departments, increasing their value to the institution while improving patient and physician satisfaction.

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