The nature of prescribing in the emergency department

In emergency departments in general, patient care is focused on the process that has led to the visit to the department at that particular moment. Guaranteeing patient safety and supporting the continuity care is the responsibility of healthcare staff.

An emergency department (ED) has certain intrinsic features that cause it to have a unique character within the hospital complex. Emergency departments are open to the entire population, and as such they are a means of entry for patients who in many cases subsequently require hospital admission. This means that the level of care for patients in this department is able to change on several occasions in a relatively short space of time. Furthermore, typically within the ED there is the turnover of staff as well as high level of pressure in terms of care.

These unique characteristics, among others, contribute to patients who attend emergency departments being vulnerable to adverse events caused by a lack of information and medication errors when changing between care levels. A further contributing factor to this is the type of care that the patient receives. This is focused on the emergency process that was the reason for the visit to the department, and as such concurrent pathologies and home treatments take a back seat.

The EVADUR study,¹ published in the journal Emergencias in 2010, investigated adverse events linked to care in emergency departments in Spanish hospitals. The causes, repercussions and whether or not these adverse events were avoidable, were assessed. The study was carried out in 21 Spanish emergency departments. It included 3854 patients, of whom 462 (12%) presented at least one adverse event.

Adverse events in emergency departments could have been avoided in around 70% of cases and demonstrated the shortage in drug therapy monitoring in those patients or the necessity of conciliation medication. It would be advisable to establish follow-up measures in order to prevent adverse events occurring, given that 43% of the adverse events were detected during follow-up more than seven days after discharge from the ED, in the search that was performed for the purpose of uncovering late-developing adverse events.

Effects arising from the process, medication and procedures were the most frequently occurring, whereas the most commonly involved reasons were those related to aspects of care, medication, diagnosis and communication, which were independent risk factors. There were 209 events (25.3%) related to managing patient care, followed by 190 events (23%) related to managing medication, of which 68 (8%) were adverse reactions to medication and 132 (14.7%) were medication errors.

Patients visiting the ED as a result of negative clinical outcomes of medication

An incomplete pharmacotherapy history can be a cause of negative clinical outcomes linked to medication in a patient, due to interruptions in treatments or to the inappropriate use of the medication required by the patient.

To discover the prevalence of negative clinical outcomes linked to medication that led to visits to the EDs of nine Spanish hospitals, Baena et al. designed a cross-sectional descriptive observational multicentre study² that was carried out over a three-month period. The Dáder methodology was used, based on studying the patients’ pharmacotherapy and health problems, making use of patient interviews in addition to medical records.

The prevalence of negative clinical outcomes resulting in ED visits was 35.7%. Based on Dáder methodology classification, the prevalence was as follows: necessity, 14.9%; effectiveness, 18.2%; and safety 2.4%. Around 80% of negative clinical outcomes linked to medication were avoidable. The medications most commonly associated with negative clinical outcomes linked to medication were in the following groups: N (nervous system), C (cardiovascular system), M (musculoskeletal system), J (anti-infectives for systemic use) and A (alimentary tract and metabolism) by frequency order.

Patients discharged following their visit to the ED

Treatment protocols and electronic prescriptions

Patients who attend EDs and who are discharged after they have seen a doctor, having been given a prescription for a pharmacological treatment, find themselves experiencing a deficit in the flow created by the healthcare system for patients.

A tendency has existed in Spanish EDs to not issue official prescriptions for the treatments prescribed in emergency processes. This trend has been justified by the professionals for the purpose of preventing these departments from becoming saturated, as they are visited on a daily basis by a high number of patients. It has worked in the belief that if patients can obtain everything they need for resolving their issue, they will tend to use the hospital ED more frequently than necessary and treat it as a primary care consultation.

This routine practice of not issuing official prescriptions leads to a shortfall in care for patients who pass through these units, who are unable to go to a pharmacy to collect their treatment as they do not have official prescriptions. This, by extension, necessitates a subsequent visit to their primary care physician, who is put in the position of having to issue official prescriptions for a treatment that they have not prescribed and with which they do not always agree.

The analysis about this reality by emergency pharmacists as well as their interest in ensuring continuity of care in such patients has led to programmes being devised and implemented in EDs that help to achieve this.

The Virgen de las Nieves University Hospital has pioneered setting one such initiative in motion, with the model subsequently being adopted in other hospitals across Spain. The initiative that made its first appearance in the Granada hospital³ was the creation of drugs protocols for the nine most frequent diagnoses in the emergency department.

These protocols contain medication for three days’ worth of treatment for the health problem, taking the hospital’s pharmacological guidelines into account. The diagnoses selected account for 19.5% of patients treated in the EDs.

In a subsequent step and in an attempt to cover 100% of the people treated, electronic prescriptions have been implemented in the hospital’s emergency department.⁴ The electronic prescription is a model for prescribing and dispensing medications and medical products that are included in public financing.

There is a Central Dispensing Module that can be accessed by the various professionals from different healthcare facilities by means of the patient’s medical card, which makes use of information and telecommunications technology. In this way a pharmaceutical credit is created with the full treatment prescribed by the primary care physician or by the hospital care physician who treats the medical incident.

As such, the patient attending the emergency department has access to the treatment prescribed for the emergency process from the moment they leave the hospital, using their medical card and at any pharmacy.

Patients requiring observation or admission following their visit to the ED

Reconciliation of treatments and record of home medication

Patients who visit EDs usually experience several changes to their care level in a short period of time, making these patients targets for the reconciliation of treatments. To achieve the reconciliation of a patient’s treatment, it is necessary to have a certain amount of time to enable a full and reliable pharmacotherapy history to be written up. This condition is met when the patient spends several hours under observation or when they are admitted to hospital.

The reconciliation⁵ of treatment is defined as a formal process that consists of obtaining a complete and precise list of the patient’s prior medication and comparing it with the medical prescription after the care transition (hospital admission, reassignment, hospital discharge, etc.). If discrepancies are found they must be considered and, if necessary, the medical prescription should be modified.

The reconciliation of treatments is the generally accepted proposal within different medical establishments around the world for dealing with the problem of medication errors that arise when a new medical professional becomes responsible for a patient when they move between the different levels of care, in order to ensure the patient’s safety.

Carrying out a full pharmacotherapy history is an important part of the medical anamnesis when a patient is admitted and is also the central step within the reconciliation process. Baena et al. designed a multicentre, nationwide study⁶ in 11 EDs in Spanish hospitals in order to assess the record of the home treatments of patients attending the department.

Overall, 387 patients were included; in 79.3% of these patients, discrepancies were found between the list in the pharmacotherapy history of the patient recorded in the ED and the home treatment recorded by the pharmacist during the study. There were 1,476 discrepancies recorded, the type most frequently found was incomplete information in 44.2% of cases, very closely followed by omission of medication in 41.8% of cases. The discrepancies found were associated with age, number of medications and the Charlson comorbidity variables.

EDs have certain unique characteristics, which we have described above. With the intention of adapting to the typical needs of these departments and of achieving the reconciliation of the maximum number of patients by establishing priorities based on needs in terms of treatments, a set of guidelines for the reconciliation of medications in emergency departments⁷ has been drawn up.

A reconciliation time of four hours for high-risk medications or those with a short plasma half-life and of 24 hours for all other medications has been set.

Medications with a reconciliation time of less than four hours are: oral anti-diabetics, if multiple daily doses; alpha-adrenergic agonists (clonidine, methyldopa and moxonidine); beta-adrenergic agonists (ipratropium bromide and inhaled corticosteroids); anti-arrhythmics (amiodarone, quinidine, disopyramide and dronedarone); anti-epileptics and anticonvulsants (phenytoin, carbamazepine, valproic acid, oxcarbazepine, phenobarbital, pregabalin and topiramate); antiretrovirals; azathioprine; beta-blockers; calcium antagonists; cyclophosphamide; angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists, if multiple daily doses; leukotriene inhibitors (montelukast, zafirlukast); insulin; methotrexate; nitrates and ocular therapy.

The risk associated with the contraindicated administration or the omission of medication increases in the case of: antibiotics, insulin, oral lipid-lowering drugs, anti-hypertensives, immunosuppressants, inhalers, anti-epileptics, anti-anginal drugs and analgesics.^8,9

The role of the pharmacist in the ED

From a systematic review¹⁰ published in 2009 on the effect of a clinical pharmacist in an ED, it was possible to conclude from the literature that pharmacists have been involved in the ED for decades. Services provided by pharmacists in the ED included traditional clinical pharmacy services, responding to medical emergencies, providing consultations on medication issues, identifying and reducing medication errors, and conducting medication histories at the time of hospital admission. Some services were shown to be cost saving or cost avoiding.

To analyse the role of the pharmacist from a different point of view, a study was recently carried out on ED staff perception with respect to the value of the pharmacist.¹¹ Among those surveyed, 93% agreed that the presence of a pharmacist in the emergency department improved the quality of care for the patients and 71% were of the opinion that the pharmacist should become a member of the medical care team.

The ED personnel considered the pharmacist to be particularly useful in consultations on drug interactions, adverse reactions, the use of medications during pregnancy and patients’ habitual medications.

Conclusions

A hospital is comprised of different specialties or departments, which are normally independent from one another. However, the pharmacy department has a somewhat different and special dimension, as in dealing with the medications that are part of the patients’ treatment: it interacts with all of the departments. For that reason, the inclusion of a pharmacist in the multidisciplinary teams of each specialist unit is becoming a regular practice and increasingly popular, so they can look after the unique and specific needs of the patients who are cared for in each department.

Key points

The organisation, the patient’s nature and the health problems that are addressed at emergency departments (EDs), makes these departments a perfect target for the occurrence of adverse events.
The provision of treatment for three days with drugs protocols tackling the most frequent diagnoses in the ED encompasses around 20% of patients and ensures the continuity of their care.
The reconciliation of treatments is an optimum resource for ensuring the safety of patients when they are transferred from one care level to another and when they are assigned to a new medical professional.
A pharmacist in the ED detects and resolves medication-related errors, improving the quality of care for patients and resulting in their presence within the care team being valued positively by the professionals in the emergency department. Some services provided by pharmacist in the ED were shown to be cost avoiding.

Authors

María Isabel Chinchilla Fernández PhD
Emergency Pharmacist, Granada, Spain
Email: [email protected]

María Isabel Baena Parejo PhD
Regional Office for Health and Social Welfare, Autonomous Government of Andalusia, Córdoba, Spain

Juan Roca Guiseris MD
Emergency Department Coordinator, Granada, Spain

Miguel Ángel Calleja Hernández PhD
Head of Pharmacy, Cross-center Cross-level Pharmacy Clinical Management Unit, Granada, Spain

References

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