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Clinical pharmacy services in the ED

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Daniel Hays
PharmD BCPS
Clinical Pharmacy Specialist
Pharmacy Emergency Medicine Department
Strong Memorial Hospital
Rochester, NY
USA
E:daniel_hays@urmc.rochester.edu

The Emergency Department (ED) is a unique environment in medicine, and many safety mechanisms used in the inpatient setting are not possible to apply to the ED setting. Clinical pharmacists have traditionally provided extra layers of protection to hospital in‑patients by cross-checking provider orders for appropriate dose, route, indication, allergies, etc. Because of the chaotic and complex environment of the ED, this safety mechanism is not manageable. By having central pharmacy provide services from off-site, the delay could be detrimental to patient care. As a result, EDs are without the layer of protection that pharmacy services offer to inpatient units. Indeed, it has been reported that studies based in New York, Colorado and Utah found that the ED had the highest rate of preventable adverse events among all
clinical environments studied.(1,2)

Pharmacy in the ED
According to the literature, pharmacy began servicing EDs in the USA in the 1960s and 1970s.(3–5) Although this service was primarily for dispensing and inventory control, it paved the way for pharmacy to become more clinically involved with direct patient care. The ED is a department that has not previously been associated with pharmaceutical care. As more and more patients are utilising the ED for their primary care, a pharmacist is able to work with them to optimise their care. From simple medication refill to inhaler discharge counselling, the pharmacist can interact with just about every patient type.

My practice is primarily patient care-based, as well as academic. Strong Memorial Hospital is a university-based educational facility. It is a level I trauma centre, as well as a regional burn centre. With over 90,000 visits per year and over 500 doses of medications dispensed daily, the opportunities for errors abound. When physicians are taking care of patients with traumatic injuries as well as common colds and nursing staff are continually busy, many aspects of pharmacy tend to be forgotten. There are 33 emergency physician residents, and they have the opportunity for a two-week rotation to optimise their knowledge of pharmaceuticals. This provides an excellent opportunity for training residents, to ensure that formulary is being followed, proper dosing is used and medications are selected appropriately.

The current role of the pharmacist in the ED is to provide their pharmaceutical expertise via:

  • Dose recommendations.
  • Therapeutic substitutions.
  • Disease state-specific pharmacotherapy.
  • Patient-specific pharmacokinetics.
  • Patient discharge counselling.
  • Medical/surgical resuscitation.

Additionally, the pharmacist is available for patient consultation/education, discharge counselling and assisting with medication-related ED visits. Many patients use the ED as primary care and may even arrive for the sole purpose of a medication refill. The pharmacist can assist to decrease length of stay. It is also possible to work with a patient’s primary care provider to optimise their therapy. Patients are often over- or undermedicated, and this is an opportunity to remedy this problem.

When implementing a practice as such, there are always obstacles. One of the primary issues is the shortage of pharmacists. If the medications cannot get to the patient, the clinical pharmacist’s role must be to assist with distribution. In addition to the ­shortage of pharmacists, training pharmacists for this area can also be a challenge. In the USA, there are only four recognised programmes for pharmacists in emergency medicine, with only two of these being accredited. With the annual number of ED visits virtually exploding, it is imperative to train pharmacists for this type of clinical practice. Our specialty residency in emergency medicine/critical care requires a year of pharmacy practice residency, before acceptance in this specialty residency, to ensure that the resident is comfortable with critical patients. Their training consists of rotations ranging from ambulatory to intensive care.

With chaos being the rule and not the exception in the ED, a pharmacist can feel out of place. Most pharmacists are very meticulous and prefer a standard outline of their duties. With emergency medicine, triage is the only way to manage a shift. There is never a standard order to the day. It becomes necessary to handle tasks, just like the patients themselves, in an order based on urgency and complications. Although a patient may require discharge counselling, a cardiac resuscitation is more crucial for immediate attention. Describing the chaos that occurs during a trauma is difficult in words. For this typically short, but extremely intense time, the care that the patient requires is critical. The hectic environment makes the occurrence of errors all too feasible. Through pilot data, we were able to demonstrate that having a pharmacist as a member of the trauma resuscitation team is of importance. Medication errors, both potential and actual, were reduced. Our goal was to reduce medication errors as well as provide safe, timely and appropriate medications for patients (see Table 1).(6)

[[HPE24_table1_17]]

Conclusion
Integrating the pharmacist into the healthcare team can be a challenge. Many emergency medicine practitioners question the need for a pharmacist until they have had the opportunity to work with one. The first time that you mention a pharmacist to the incoming residents, their usual response is, “Why do we need one of those?” These pioneers in ­pharmaceutical emergency medicine need only a few shifts with naysayers for their value to be made priceless. Soon, the rest of the ED staff will come to depend on the pharmacist as an integral, vital link in their team and in the outcome and welfare of their patients’ care.

References

  1. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. New Engl J Med 1991;324:377-84.
  2. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38:261-71.
  3. Elenbaas RM, Waeckerle JF, McNabney WK. The clinical pharmacist in emergency medicine. Am J Hosp Pharm 1977;34:843-6.
  4. Elenbaas RM. Role of the pharmacist in providing clinical pharmacy services in the emergency department. Can J Hosp Pharm 1978;31:123-5.
  5. Angelides AP, Manzelli TA. Control of emergency department medications. Hospitals 1966;40:98-102.
  6. Kelly SH, Fairbanks RJ, Gestring ML. Pharmacist participation in trauma response. Eastern States Residency Conference, 2005.


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