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Does having a pharmacist in the ED clinical care team impact the quality of medicine use?

A systematic review suggests that a pharmacist in the clinical care team within an emergency department improves the quality of medicine use

Having an emergency department (ED) pharmacist as a member of the clinical care team improves the quality of medicines use, according to the findings of a systematic review and meta-analysis by researchers from the School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Tasmania, Australia.

The term ‘quality use of medicines’ (QUM) covers the wise selection of management options and choosing suitable medicines where indicated, together with ensuring that patients and carers have the knowledge and skills to use medicines safely and effectively. Nevertheless, ensuring QUM within an emergency department is challenging because such departments are often very busy.

In fact, one analysis covering the period 2011 to 2020 revealed that the most common prescribed medications mentioned in reports were epinephrine, insulin, hydromorphone, sodium chloride, heparin, Propofol, diltiazem, ketamine, and morphine. Furthermore, serious medication error events occurred most often at the prescribing stage (42.0%) with the most common medication error type being an incorrect dose (42%).

It is possible that these errors could be reduced with access to an ED pharmacist in the clinical team and a 2019 systematic review concluded that pharmacy-led medication reconciliation within an ED, significantly decreased the number of medication discrepancies. Nevertheless, the authors of the systematic review called for further studies to investigate the direct clinical impact of decreased medication discrepancies.

Given that the impact and value of an ED pharmacist remains to be fully explored, for the present study, the Australian team undertook a systematic review and meta-analysis, specifically focusing on the effect of adult care, when departments had access to a pharmacist as part of the ED team.

A literature search was designed to uncover studies in which a pharmacist was a part of the ED team and where the impact was compared with usual care. The outcomes considered were changes in the rates or proportions of the medication-related outcomes such as medication errors, the appropriateness of prescribed medicines, length of hospital stay or re-admission.

Emergency department pharmacist and medication-related outcomes

The search identified a total of 31 eligible studies which included 13,242 participants and with individual study sample sizes ranging from 34 to 3,594. The types of included studies were pre-post interventions, cohort studies and randomised, controlled trials.

Not every study could be used to access all of the outcomes investigated. However, pooling results from 10 studies showed that an ED pharmacist intervention was associated with an average error rate decrease of 0.33/patient (95% CI -0.42 to -0.23, p < 0.001). Similarly, in a meta-analysis of 10 studies, use of emergency department pharmacists were associated with a 73% lower proportion of patients with at least one error (relative risk, RR = 0.27, 95% CI 0.19 – 0.40, p < 0.001).

Analysis of 7 studies indicated a 58% increased appropriateness of prescribing (RR = 1.58, 95% CI 1.21 – 2.06, p < 0.001) after input from pharmacists. Finally, there was a 30% reduced risk of re-presenting to ED (RR = 0.70, 95% CI 0.52 – 0.94, p = 0.02) and a 38% reduced risk of re-admission (RR = 0.62) after intervention by a pharmacist.

The authors concluded that their data showed how an ED pharmacist improved QUM and called for future studies to examine the cost-effectiveness of ED-based pharmacy interventions.

Atey TM et al. Impact of pharmacist interventions provided in the emergency department on quality use of medicines: a systematic review and meta-analysis Emerg Med J 2022

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