imageLas Vegas—The fluid environment of the emergency department (ED) creates persistent medication safety challenges: Medication reconciliation often is incomplete and inaccurate; verbal orders and interruptions during patient care are the norm; and patients are unfamiliar and their records incomplete. All of these factors are associated with heightened risks for drug errors and adverse events. The following article describes presentations during the American Society of Health-System Pharmacists Midyear Clinical Meeting about four approaches to expanding ED pharmacist services that successfully address some ED medication safety challenges.

Starting With Med Rec Can Open the Door for ED Pharms

Although the fast-paced environment of the ED presents heightened medication safety challenges and risks, fewer than 4% of EDs have consistent pharmacist involvement in patient care, according to a study from pharmacists in Ohio.

Sara Triglia, PharmD, an ambulatory clinical pharmacy specialist in the Family Medicine Center at St. Elizabeth Health Center, in Youngstown, Ohio, and her colleagues designed, implemented and evaluated a pilot program employing a clinical pharmacist in the ED to determine its effect on medication safety and efficacy, as well as costs.

Dr. Triglia spent one month in the ED and logged all interventions and associated patient care benefits and cost savings. Her primary outcome measure was the number of discrepancies avoided in the medication reconciliation process when it was performed by a pharmacist in the ED. Secondary end points included pharmacist interventions, recommendation acceptance rate, number of adverse drug events reported and prevented, cost avoidance and the perception of an ED clinical pharmacist by ED staff, as determined by a survey of physicians and nursing staff before and after the pilot period.

Dr. Triglia completed medication reconciliation for 71 patients, avoiding 802 discrepancies. Avoided discrepancies included 95 omitted medications, eight extra medications, 213 omitted doses, 221 omitted frequencies, 243 omitted routes, four wrong medications, six wrong dosage forms, three wrong doses and nine omitted allergies. Pharmacist intervention recommendations were accepted 96% of the time. The most frequent interventions were related to drug information, initial antibiotic choice, initial dose calculation and medication reconciliation. Total cost savings for the study period was calculated to be $21,494.

According to the survey results, the perceived value of pharmacy services in the ED improved during the one-month pilot. For example, the score for the survey item “pharmacy services improve quality of care in the ED” rose from 3.68 before the pilot to 4.5 (on a five-point scale), according to Dr. Triglia.

“When I took the results to hospital administration, they said, ‘this looks pretty good, why don’t we test it on a larger scale for six months,’ ” said Dr. Triglia. During that trial period, two full-time pharmacists were assigned to the ED. “They were able to provide enough documentation showing that they recouped their salaries in just three months, and now those ED pharmacist positions are permanent.”

Notwithstanding the reported economic and staffing gains that ensued from the initiative, Daniel Hays, PharmD, BCPS, FASHP, the clinical coordinator of emergency pharmacy services in the Departments of Pharmacy and Emergency Medicine, at the University of Arizona Health Network, in Tucson, said he still does not believe that medication reconciliation—which was central to the study’s primary outcome—is a good use of an ED pharmacist’s time. “It doesn’t require the expertise of a pharmacist,” he said. “A well-trained pharmacy technician can do it,” he said, adding that the majority of the other tasks conducted by pharmacists also could be done by a technician or performed remotely.

Dr. Triglia acknowledged the critique but explained that at the time of the study, the ED was still using paper charts and the medication reconciliation process was dysfunctional. “We knew that administration would be dumbfounded by us showing them the amount of errors in our medication reconciliations, so we went this route to show a great tangible effect from the project,” she explained. Pharmacists currently assigned to the ED no longer perform medication reconciliation, and the department is planning on having pharmacy technicians take on the task. Pointing to the clinical services the ED pharmacists now provide, she added, “The physicians ask us to go see the patients physically in the ED, and we respond to all traumas and codes in person.”

Overnight ED Pharmacist Helps With Standards Compliance

The 127-bed Providence Health and Services, in Centralia, Wash., followed a different path to expanding pharmacy services into the ED. Motivated chiefly by a desire to comply with Joint Commission standards calling for prospective review of all medication orders, the facility’s pharmacy stopped outsourcing its after-hours order reviews and stationed an overnight pharmacist in the ED.

“We’re a small hospital, and about 85% of our admissions come through the ED, so it made sense to have the pharmacist work out of the emergency department,” said David Dietrick, PharmD, BCPS, an emergency department clinical specialist. The overnight pharmacist is responsible for hospital-wide services but also operates as a member of the ED’s clinical team.

Shortly after the staffing change, the ED staff requested a pharmacist’s presence in the department at all times, according to Dr. Dietrick. Their enthusiasm led to 20 hours of daily ED pharmacist coverage. “The ED has welcomed the presence of a pharmacist, and that’s very encouraging for us,” he said.

Dr. Dietrick and his colleagues also collected information on the clinical and financial effect of providing permanent pharmacy services in the ED. Over a 14-month period, ED pharmacists documented 10,875 interventions valued at more than $2.5 million (according to the monetary value assigned to various interventions by the hospital’s electronic medical record system).

Additionally, the volume of medication dispensed in the ED dropped significantly, resulting in an annual estimated savings of $11,300. Dr. Dietrick explained that ambulatory patients discharged from the ED often receive a day’s supply of prescribed drugs because there are no all-night retail pharmacies nearby. “Many patients would have to fill their prescriptions the next day, so ED physicians typically sent them off with enough to cover 24 hours. But the hospital has to absorb the costs of those drugs.” The pharmacy determined that the stop-gap medications were dispensed too freely and assigned more restrictive hours when they could be handed out.

A survey of non-pharmacy staff revealed that pharmacists had become an integral part of the ED medical team, Dr. Dietrick said. He pointed out that their expanded clinical role meant that they became more familiar with patients’ clinical findings and symptoms. “The presence of pharmacists has been greatly appreciated and has changed the dynamics of care and the interactions among the clinicians,” he said. Additionally, the pharmacists themselves reported greater job satisfaction as a result of their increased professional integration.

Dr. Hays complimented Providence Health for its innovative approach. “To cover 20 out of 24 hours a day is not only very impressive but very admirable,” he said. “It’s tough to pull off on a few levels: One is you never know when the ED is going to be busy, so how do you decide when to schedule those 20 hours? Also, it’s difficult finding pharmacists who are both interested in working those later hours and trained to fill the ED’s needs.”

image ED Pharms Enhances Antimicrobial Surveillance

An ED pharmacist-led antimicrobial surveillance program can optimize therapy and save physician time, according to a report from pharmacists at Northside Hospital, in Atlanta.

Because culture and susceptibility reports can take from 48 to 72 hours to complete, prescribers must rely on empiric antibiotic therapy decisions. In 2011, clinical pharmacists at the Northside Hospital ED established an antimicrobial surveillance program in which an ED pharmacist reviews all finalized culture and susceptibility reports daily and compares positive cultures with previously prescribed antibiotic therapy.

“For patients who received empiric therapy that matches the final culture reports, no further action is needed,” said Karen Biehle, PharmD, an ED clinical pharmacist at Northside. But if the prescribed antibiotic is not well matched to the bacterial infection, or if the pathogen turns out to be a drug-resistant strain, the pharmacist recommends a therapy change to the physician. If the recommendation is accepted, the pharmacist informs the patient by phone and calls the patient’s pharmacy to place the new order. “As soon as the labs come in, the calls go out,” said Dr. Biehle.

Dr. Biehle and her colleagues monitored the surveillance program for patients with urinary tract infections (UTIs), a common presenting complaint in the ED. Empiric antibiotic therapy for a suspected UTI often begins without the benefit of urine culture results. Over a one-year span, ED pharmacists reviewed 541 positive urine cultures; of these, 143 patients (26%) required pharmacist intervention, including 102 patients who required a change in antibiotic therapy.

The reasons for antibiotic changes included 81 organisms resistant to the empiric antibiotic ordered, seven organisms with intermediate susceptibility and 14 organisms that were not routinely tested for the antibiotic prescribed. Prescribers accepted all of the pharmacists’ recommendations for a therapy change.

Review and documentation of a single positive culture required approximately 15 minutes; it was somewhat longer if a therapy change was required. The researchers estimated that the surveillance program saved at least 170 hours of physician time.

“We get everything ready for the physicians, and they review our recommendation,” Dr. Biehle said. “We’ve had a big impact on the physician’s choice of therapy, and the program has been a great way to increase pharmacists’ visibility in the ED.”

Antimicrobial stewardship in the ED not only saves time for physicians, it also “provides the best and most accurate treatment,” noted Dr. Hays, adding that too often, the follow-up actions such as those documented by Dr. Biehle and her colleagues are not done at other facilities.

ED Pharmacists in Chicago Enhance Pain Management

After a Chicago hospital initiated clinical ED pharmacy services in October 2010, the pharmacists there learned that intubated patients nationwide frequently don’t receive adequate pain control after their procedures.

“We found in the literature that less than half of patients in the ED who undergo rapid-sequence intubation receive analgesia, and dosing is adequate in only 25% of cases,” said Erin Robey-Gavin, PharmD, BCPS, an emergency medicine clinical pharmacist at Mercy Hospital and Medical Center. The analgesia administration rates at Mercy turned out to be even lower: In early 2010, only 20% of patients received an analgesic along with a sedative.

Dr. Robey-Gavin and a colleague conducted a series of interventions designed to increase the rate of post-intubation analgesia. The specific interventions included stocking premixed fentanyl infusions in the ED’s automated dispensing cabinet (which made the drug readily available and obviated the need for a nurse to travel to the central pharmacy to obtain it), and regularly reminding ED providers that the fentanyl was on hand. They also educated physicians and nurses about the importance of post-intubation analgesia, offered pharmacologic reviews of sedatives and analgesics commonly used for intubated patients, which covered fentanyl’s hemodynamic effects and safety profile and provided information about compatibility of analgesics and sedatives, as well as dosing and titration recommendations.

A retrospective review of adult intubated patients—41 in the preintervention group and 41 in the postintervention group—showed that the rate of analgesia more than doubled postintervention, rising to 49%. Dr. Robey-Gavin observed that 85% of analgesia administration occurred during cases when an ED pharmacist was on duty (10 a.m. to 8 p.m.). “That suggested it was our direct presence that served as a reminder to use fentanyl with the sedative regimen,” she said. An informal query of the ED clinical staff confirmed her impression: “They told us that when a pharmacist is here, they think more about pain control.”

Dr. Robey-Gavin also noted that assessing pain levels in intubated patients is difficult, which is why the study examined only whether or not analgesia was administered, not its adequacy. “It’s hard to evaluate patient pain when they’re under sedation, and particularly difficult if they’re oversedated,” she said. “We’ve done a lot of education about pulling back on the sedation a little bit to see how patients react. You can tell a lot by simply observing their body language during procedures.” Moving away from sometimes unreliable physiologic markers such as heart rate and blood pressure to evaluate pain, and increasing the use of nonverbal pain scales, is the next step, she added. “I still encounter many providers who don’t understand the difference between sedation and comfort. This is another area where a pharmacist can have a big impact.”

Dr. Hays agreed that this was an important area for pharmacists to play a role. “This is something that pharmacists need to be doing,” he said. “With the trend toward more frequent use of nondepolarizing paralytics, which last much longer than standard depolarizing paralytics, I think physicians often forget about analgesia, and they risk having a patient who is paralyzed but wide awake and completely aware of what’s going on.”

Drs. Triglia, Hays, Dietrick, Biehle, and Robey-Gavin reported no relevant financial conflicts of interest.