A group of Spanish pharmacists and emergency medicine specialists have issued a joint declaration to streamline understanding of pharmacists’ roles in emergency departments and improve patient care. Here, Jesús Ruiz Ramos, clinical pharmacology services pharmacist at Hospital Santa Creu i Sant Pau, Barcelona, shares the consensus.
The number of clinical pharmacists involved in patient care in emergency departments (EDs) in Europe has increased significantly in recent years. There are an increasing number of studies demonstrating the clinical benefits of pharmacist involvement in EDs, and these, together with the rising number of elderly patients with polypharmacy, and the increasing complexities of pharmacotherapies, have created a growing need for pharmacists in these units.1
Given the wide range of activities performed in EDs, it is necessary to prioritise those that have the most significant impact on patients and healthcare professionals in the unit. These priorities are based on the available scientific evidence and the experiences of physicians and pharmacists working in the field.
In 2008, the American Society of Health-System Pharmacists published a document outlining the activities that pharmacy services in EDs should provide, which was subsequently updated in 2021.2 The guidelines are undeniably helpful, but the levels of participation and competencies of clinical pharmacists in the USA and European countries differ significantly. Therefore, there is a need to adapt the competencies and activities of pharmacists working in EDs in different countries.
To address this, a joint effort between hospital pharmacists coordinated by the REDFASTER group of the Spanish Society of Hospital Pharmacists (SEFH) and emergency medicine specialists from the Spanish Society of Emergency Medicine (SEMES) led to a consensus and publication of a recent paper, which is summarised here.3
The primary objective of this joint declaration was to establish the main activities and services to be carried out by pharmacists in an emergency department. The activities are categorised as basic, intermediate and advanced, depending on their priority and complexity.3
The recommendations
The document comprises 25 activities grouped into five main areas: logistics management, pharmaceutical care, risk management, education and research. Each activity has measurable indicators to monitor its progress.
- Logistics management
Emergency departments provide rapid medical care and deal with a wide variety of patients, making the availability of medicines in these units challenging. Pharmacists play a crucial role in ensuring medication availability throughout different areas of the ED.
They should be actively involved in preventing supply shortages, proposing alternatives during drug shortages, participating in decision-making processes regarding the availability of medications in the unit, and developing specific programmes to ensure immediate access to medications and antidotes.
Updating available medications should be based on changes in prescription practices, guideline or protocol updates and medication supply to the unit.4 An updated administration guide tailored to the specific ED is essential and should be one of the pharmacist’s core activities in these units.
Additionally, pharmacists possess the skills and knowledge to collaborate actively during emergencies, such as pandemics, natural disasters and mass casualties. Therefore, they should be included in the hospital’s emergency preparedness plans.
- Pharmaceutical care
The review and validation of medical prescriptions have been a standard practice of pharmacists within hospitals for years, proving essential in preventing medication errors and optimising patient pharmacotherapy based on their clinical condition.5,6
Medication reconciliation in EDs reduces medication errors, although it needs to adapt to their short-stay and dynamic natures. Participation in clinical rounds and working as part of the team on site in the ED is of great relevance in enhancing patient pharmacotherapy. It should be an objective for pharmacists working in these areas.
Furthermore, developing antibiotic stewardship programmes is another essential role, as first doses of antibiotics are often prescribed in the ED. Many antibiotics are also prescribed for patients discharged directly to their homes or other healthcare facilities without a subsequent follow-up until the consultation in primary care. However, implementing these programmes still needs to be improved in EDs. Hence, it is crucial to promote the development of such programmes, proposing empirical treatment protocols for managing prevalent infections and monitoring antibiotic usage in the unit.7
Enhancing pharmacokinetic monitoring of antibiotics, antiepileptics or digoxin should be a tool that pharmacists develop, both in the early stages of treatment for rapid optimisation and in cases of suspected intentional or unintentional poisoning.
Lastly, incorporating pharmacists into time-critical conditions has been classified as an advanced activity in EDs due to the need for continuous attention. Several studies have shown that including pharmacists as a standard part of the initial multidisciplinary response team for managing sepsis, coronary syndrome, stroke or polytrauma significantly reduces the time of drug administration and prevents drug errors.8,9 Including a pharmacist in these multidisciplinary rapid response teams represents a challenge in the future.
- Risk management
The environment and activities within EDs pose a high risk of medication-related safety failures. Pharmacists must encourage and help maintain a safe environment for medication use by continually reviewing the entire medication use process to identify these potential risks and areas for improvement. Standardising medications classified as high risk, requiring double verification and directly participating in the double-checking process in staff shortages should be part of the pharmacist’s activity in these areas.
Ensuring care coordination is crucial in avoiding adverse events related to medication use, especially in fragile patients who are frequently transferred between different levels of healthcare, with EDs acting as intermediate referral points. Pharmacists in these units should be involved in identifying and correcting any errors in medications while providing education to the patient. Involving pharmacists in care coordination reduces adverse events and eliminates unnecessary medical costs.
Lastly, pharmacists should be involved in various committees on medication use, quality and safety within EDs, ensuring compliance with recommendations and prescription criteria.
- Education
Pharmacists should educate all healthcare professionals in the unit, including assistant pharmacists, residents, physicians, nursing staff and other support personnel. This education should cover appropriate medication use, quality and clinical outcome improvements, identifying adverse events and elements to enhance patient safety.
Regarding patient education, the influx of patients to EDs necessitates prioritisation systems that identify those patients who could benefit most from such interventions, either due to their high-risk medications or because they have visited the ED due to drug-related problems.10
- Research
Research related to pharmacotherapy, including pharmacovigilance, safety and treatment responses, represents one of the main pillars of exploration in the ED. The ability of pharmacists to collaborate and lead research projects in this field has been demonstrated extensively.
Conclusion
Hospital pharmacists can perform a wide range of activities in the ED, thereby contributing to improved patient care. Given the increasing evidence that integrating pharmacists into these units enhances patient safety, clinical outcomes and healthcare system efficiency, the positioning document is a starting point for developing pharmacy care activities in EDs.
The implementation of these activities should be progressive and adapted to the needs and resources of each unit or service. The REDFASTER-SEFH group believes it is necessary to create European working groups in the near future that help enrich and promote pharmacists’ activity in emergency care.
Study authors
Jesús Ruiz Ramos PhD, Hospital Santa Creu i Sant Pau, Barcelona, Spain
Beatriz Caldéron Hernanz, Hospital Universitari Son Llàtzer, Spain
José Manuel Real Campaña, Hospital Universitario Miguel Servet, Zaragoza, Spain
Manuel Bonete Sánchez, Hospital Universitario San Juan, Alicante, Spain
References
- Morgan SR et al. Clinical pharmacy services in the emergency department. Am J Emerg Med 2018;36:1727–32.
- Ortmann MJ et al. ASHP guidelines on emergency medicine pharmacist services. Am J Health-Syst Pharm 2021;78:261–75.
- Ruiz Ramos J et al. Pharmacist care in hospital emergency departments: a consensus paper from the Spanish hospital pharmacy and emergency medicine associations. Emergencias 2023;35(3):205–17.
- Uba RO, Priftanji D, Hill JD. Redistribution of short-dated emergency medications as a cost avoidance and drug shortage management strategy. Am J Health-Syst Pharm 2020;77:1504–9.
- Pérez-Moreno MA et al. Clinical relevance of pharmacist intervention in an emergency department. Emerg Med J 2017;34:495–501.
- Proper JS et al. Impact of clinical pharmacists in the emergency department of an Australian public hospital: A before and after study. Emerg Med Australas 2015;27:232–8.
- Losier M et al. A systematic review of antimicrobial stewardship interventions in the emergency department. Ann Pharmacother 2017;51:774–90.
- Draper HM, Eppert JA. Association of pharmacist presence on compliance with advanced cardiac life support guidelines during in-hospital cardiac arrest. Ann Pharmacother 2008;42:469–74.
- 9. Rech MA et al. Pharmacist participation in acute ischemic stroke decreases door-to-needle time to recombinant tissue plasminogen activator. Ann Pharmacother 2017;51:1084–9.
- Crannage AJ et al. Implementation of a discharge education program to improve transitions of care for patients at high risk of medication error. Ann Pharmacother 2020;54:561–6.
