imageHaving pharmacists in the emergency department (ED) and intensive care units (ICUs) can reduce drug costs and improve patient care and safety, according to a trio of studies.

Patient education, rounding with physicians and a dedicated error detection program were among the strategies used by ED pharmacists to achieve these improved outcomes and enhance the care of critically ill patients. However, another of the documented initiatives—medication reconciliation—may not be the best use of an ED pharmacist’s time, according to one early adopter of this growing clinical pharmacy subspecialty.

These studies point to the benefits of having pharmacists in the ED and the ICU, which has become more common in recent years and has been endorsed and encouraged by organizations such as the American Society of Health-System Pharmacists (ASHP), the Society of Critical Care Medicine and the American College of Clinical Pharmacists.

In the first study, Victor Manuel Monrreal Jr., PharmD, from Sharp Healthcare, in San Diego, and his colleagues retrospectively analyzed all interventions performed by the ED pharmacist between Dec. 23, 2010 and March 1, 2011, to measure the impact that a pharmacist could have in reducing potential medication errors in the ED. They found that of the 1,000 interventions that were documented, 513 related to medication reconciliation. Other frequent interventions included providing drug information (n=115), facilitating drug therapy (n=61) and making recommendations for drug dosing (n=58).

They also reported that the pharmacist’s interventions intercepted 50% of potential errors from prescription order communications, 25% from prescribing, 8% from administration, 7% from dispensing, 5% from education and 4% from other sources. “Because the documentation process was voluntary, not all intervention types may have been recorded,” Dr. Monrreal noted.

Pointing to the importance of pharmacist medication reconciliation, he said, “Had the medication reconciliation component not been done by the pharmacist, this could have resulted in prescription communication errors.”

However, not everyone considers this much emphasis on medication reconciliation to be appropriate for pharmacists. According to Daniel P. Hays, PharmD, BCPS, a clinical pharmacist at the University Medical Center, University of Arizona, in Tucson, medication reconciliation takes up too much of a pharmacist’s time and is something that can be done by other ED staff. “If we are in a room taking a drug history, we then miss a medical resuscitation,” Dr. Hays told Pharmacy Practice News. “The way we look at it, there are 50 nurses, 25 docs, and there’s one pharmacist. So, we may help with the more complicated [cases], but we don’t do them routinely. It seems from this study that more than half of their interventions were medication histories, and it seems that they could be focusing their time on other things.”

In response to these comments, Dr. Monrreal countered that, despite the major role that the ED pharmacist played in medication reconciliation, they did perform other responsibilities in the ED and collecting medication histories never took priority over responding to codes, requests from physicians for drug information or pharmacotherapy and pharmacokinetic consults.

“One of the reasons why medication reconciliation was completed so often was because a new computer system had just been launched at the time of the study,” he explained. “Amidst the new charting tasks that were now required by the nursing staff, medication histories were not often completed accurately. A team quickly began working on developing a process to ensure appropriate medication reconciliation, but in the meantime, the ED pharmacist was used extensively to assist with this process.”

Additionally, assisting with medication reconciliation afforded other opportunities, Dr. Monrreal said. “It gave an opportunity to develop positive relationships with nursing staff, and to further establish a presence in the ED. One of the lessons learned from the study was that if pharmacists are to expand their role in the ED, they will need additional support from auxiliary staff to effectively operate.”

In Omaha Study, Education Key

In the second study, Jayme M. Anderson, PharmD, of Creighton University, in Omaha, Neb., and her colleagues described their experience with a pilot study incorporating a pharmacist into the ED at Alegent Health-Bergan Mercy Medical Center, a community-based hospital in Omaha.

During the 33-day pilot study, pharmacists performed and documented 327 interventions for 210 patients. The most common intervention was patient education (68%), followed by drug information, order clarification and dosing consults.

The estimated cost savings was $36,954 using the Action-OI database. In general, interventions were assigned a category (such as dosing consult, patient education, adverse event prevention, etc.) at the time of documentation. At the end of the study, the recorded interventions were matched up with the categories in the system’s model. (The model has categories based on common interventions that pharmacists complete on a daily basis.) Then the number of interventions in each category was multiplied by the assigned “cost avoidance” value for that category and the totals from each category were added together to give a total potential cost savings.

Dr. Anderson noted that the information from the study will be used to justify a full-time pharmacist position at her institution.

Commenting on the Omaha study, Dr. Hays said that such an approach with patient education and consultation with physicians “is where pharmacists can really enhance patient care in the emergency department.”

Pharmacists Join Multidisciplinary ICU Teams

Pharmacists also can make an important difference in ICUs, according to Drew Kessell, PharmD, of Moore Regional Hospital, in Pinehurst, N.C.

“The case for a pharmacist as part of a multidisciplinary team is well documented, especially in academic or teaching hospitals,” Dr. Kessell told Pharmacy Practice News. “Our study showed this concept can be extrapolated to community hospitals.”

In his study, a pharmacist took part in rounds together with a nurse and a physician every day for a year. During this time, the team accepted 1,665 pharmacist recommendations. The most common recommendations were for renal dose adjustments; correction of antimicrobial regimen; and appropriate anticoagulation therapy, including dose, route of administration, duration and bridging therapy.

The recommendations saved the hospital $36,779 during the study period, or $64.71 per hour of pharmacist time. They also prevented drug–drug interactions, improved venous thromboembolism prophylaxis and prevented potentially serious adverse drug events.

“What is novel about this study is that it takes place in a non-teaching community hospital,” said Samantha P. Jellinek-Cohen, PharmD, BCPS, CGP, an assistant clinical professor at St. John’s University College of Pharmacy and Allied Health Professions and an emergency medicine clinical pharmacy specialist at Beth Israel Medical Center, both in New York City. Pharmacists have a unique opportunity to help in non-teaching hospitals, she said. “Practitioners who are not involved in teaching can become complacent and may not always keep up with the literature and updated guidelines,” she said. “In these situations, the pharmacist has a tremendous role to play. But even when practitioners do keep up with the guidelines and the literature, pharmacists can help by preventing drug interactions or improving compliance with core measures, such as venous thromboembolism prophylaxis, as these authors showed in their study.”

The fact that this study demonstrated cost savings also was a strength, she added. “This is important when you go to your administration to show the need for a pharmacist.”

These studies were first reported at the American Society of Health-System Pharmacists 2011 Midyear Clinical Meeting in New Orleans.

Emergency Department Pharmacy Pearls

Pulling Bedside Tricks! Assisting With Patient Care in the ED

Joanne C. Witsil, PharmD, RN, BCPS, clinical pharmacist, emergency medicine/toxicology, Cook County Hospital (Stroger), Chicago.

To take critters (bugs) out of the otic canal: First, make sure it’s dead. To kill the bug, place mineral oil or viscous oral 2% lidocaine in the otic canal. Take care not to perforate the tympanic membrane or get too close to it because this can cause dizziness. Allow approximately one to two minutes for the mineral oil or lidocaine to kill the bug. Next, apply a tissue adhesive to the wooden end of cotton swab and insert it into the otic canal, allowing it to adhere to the bug. Then, the bug can be removed intact. Voila! The bug is gone, and the patient is much happier.

To optimize aerosolization of rescue medications for patients experiencing asthma exacerbations: To make a “homemade” spacer, use an already used or opened T-piece nebulizer unit, which comes with a five- to seven-inch piece of corrugated plastic tubing. Attach the tubing to the metered-dose inhaler. This works beautifully, and is especially useful for patients who are unable to afford a spacer.

To treat a methadone or heroine overdose: If you cannot give naloxone by injection, give it by nebulization. Place 2 mL (2 mg) naloxone in the medication reservoir and add 3 mL of saline. Place a facemask on the patient and administer naloxone with up to 8 L per minute of oxygen, encouraging the patient to breathe deeply.

To facilitate nasogastric tube insertion: To ease the pain of insertion, use lidocaine urologic jelly 2% to lubricate the first three inches of the tube instead of plain water-soluble gel or give a dose of metoclopramide 10 mg IV push over two minutes, 10 minutes prior to insertion.

What To Do When You Get It in Your Eye: Tips for Ocular Decontamination

Brittany R. Traylor, PGY2 emergency medicine pharmacy resident, The University of Arizona Medical Center, Tucson

For noncorrosive materials (hydrocarbons, neutral pH): Treatment includes 15 minutes of irrigation with lukewarm water, saline or Lactated Ringer’s solution. If symptoms persist, contact an ophthalmologist.

For corrosive materials (anything water-based): Treatment includes rinsing for more than 20 minutes as soon as possible after the contamination. Irritation and the need for irrigation may last for hours, and more than 2 L of fluid may be required for each eye.

For pediatrics: The irrigation solution of choice is normal saline (pH, 4.5-6.0); alternatives include Lactated Ringer’s and water.

Several other factors to consider:

  • The pH plays a significant role in irrigation solutions. Too high or too low a pH may cause edema and discomfort to the conjunctiva.
  • Consider a Morgan Lens (MorTan Inc.) for irrigation. The package insert for the Morgan Lens lists irrigation solutions that can be used with it, as well as rates of infusion and frequency. Use topical analgesics because the Morgan Lens is hard and can cause discomfort.
  • Check the conjunctival pH 10 minutes after irrigation.
  • Use fluorescein stain to check for burn, depth of damage.