Orlando, Fla.—Emergency department (ED) pharmacists do more than simply review orders, as evidenced by a large body of data presented at the American Society of Health-System Pharmacists 2013 Midyear Clinical Meeting. Whether providing antibiotic stewardship recommendations, titrating drips during code and trauma responses or optimizing sedation levels in patients undergoing rapid-sequence intubation, the sophisticated scope of services provided by this growing pharmacy subspecialty was well on display at the meeting.
Collecting Data Helps Make the Case
It took a while for ED staff at WakeMed Health and Hospitals in Raleigh, N.C., to realize that a pharmacist can contribute to the department’s operations. “There was definitely difficulty involved with integrating new, unfamiliar pharmacy services into a department that had been traditionally run by physicians and nurses,” said Ryan Owenby, PharmD, who was an ED pharmacist at WakeMed and is now a clinical pharmacy specialist in emergency medicine at the Durham VA Medical Center in Durham, N.C.
The professional tension he felt with other WakeMed ED staff spurred Dr. Owenby and a colleague to develop an electronic worksheet so that he and the eight other pharmacists added to the ED in 2012 could document their clinical services (poster 5-068). The worksheet is structured as a series of drop-down menus, beginning with broad categories of interventions such as code responses, and narrowing down to more detailed interventions—differentiating code stroke responses from code trauma responses, for example.
Between January and June 2013, he and the other ED pharmacists documented 866 interventions. The information showed the most common steps taken were code responses (42.6%), followed by drug information interventions (14.9%), protocol or consult management during a patient’s ED stay (13%) and admission medication order interventions (10.4%). A wide range of subinterventions was nested within these categories (Figure 1).
Figure 1. Top three intervention categories.
- Code stroke
- Trauma alert
- Trauma one
- Code STEMI
- Code blue
- Resuscitated code
- Pediatric trauma code
- OB trauma code
- Vancomycin management
- Heparin protocol management
- Anticoagulant management
- Other protocol management
- Aminoglycoside management
- High-dose solumedrol protocol
- Integrilin protocol
- Fosphenytoin management
- Provide drug information – nurse
- Provide drug information – ED practitioner
- Provide drug information – admitting physician/practitioner
- Initiation of needed lab draws
- Provide drug information – patient/family member
Dr. Owenby said he used the data to assemble intervention-specific “job descriptions.” For example, the collected information revealed that during code trauma responses, two of the most common pharmacist interventions were managing rapid-sequence intubation kits and obtaining medications that were needed STAT from the automated dispensing machines located just outside the trauma bay.
Delineating pharmacists’ duties is one way the worksheet has helped Dr. Owenby and his team integrate into the ED, he said. “Trauma response teams in particular are very well-oiled machines,” he noted. “So, in those situations, being part of a very regimented structure and having everyone know what you are responsible for is critical.”
Saving Time and Money
Like Dr. Owenby, Patrick Ryan, PharmD, who is an ED pharmacist at the 234-bed Melrose-Wakefield Hospital, a Hallmark Health System hospital located in Melrose, Mass., also found he needed to clarify what skills he could offer in the ED (poster 5-071).
“Emergency room docs at my hospital didn’t seem to know what the value of a pharmacist in the ED could be,” said Dr. Ryan, who was hired for the position in July 2012.
Although he primarily meant to conduct medication reconciliations—and has been doing so for roughly one-third of the ED patients who present during his shifts—Dr. Ryan’s supervisors gave him free rein to intervene wherever he saw a need for his skills. Their green light allowed him to expand his services to include everything from providing antibiotic stewardship recommendations to titrating drips during code and trauma responses to verifying that supposed drug allergies were not, in fact, adverse drug reactions.
Taking on those duties has reduced some of the workload for ED nurses. “The chief nursing officer has received numerous emails and calls from staff and they’ve all been very positive,” he said.
Although Dr. Ryan has not studied the actual clinical effects of his interventions, he has used clinical surveillance software (Sentri7; Pharmacy OneSource) to estimate the financial effects of the 1,783 interventions he conducted between September 2012 and May 2013. By preventing adverse events and making sure medications were not used unnecessarily, he helped save or avoid an estimated $47,736 in treatment costs during that nine-month period, or $63,648 on annualized basis.
Suffice it to say, ED staff are now far clearer than they had been before about the usefulness of Dr. Ryan’s skills.
“Now they think my work is invaluable,” he said.
Safer N-Acetylcysteine Rx For Acetaminophen Toxicity
ED pharmacists are in a good position to address the high rate of IV N-acetylcysteine (IV N-AC) infusion errors in patients with acute acetaminophen toxicity, according to findings from a single-center retrospective study conducted by Nadia Awad, PharmD (poster 3-066), who is a clinical assistant professor of emergency medicine at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey in Piscataway.
In the study, Dr. Awad and several colleagues reviewed medical records from 93 patients who had received IV N-AC at Robert Wood Johnson University Hospital in New Brunswick, N.J., between 2006 and 2012. The patients were between ages 21 and 89 years at the time of treatment, and more than 90% (86 of 93) had presented with acetaminophen toxicity and 71% (66 of 93) had ingested the medication along with other substances.
According to Dr. Awad, physicians made 79 infusion errors in 52.7% (49 of 93) of the patients (Figure 2). The most common errors Dr. Awad found were infusion interruptions, which lasted a mean of 7.5 hours.
“The complexity of this protocol makes it prone to dosing- and infusion-related errors,” said Dr. Awad, noting that the protocol begins with an infusion of 150 mg/kg N-AC for one hour, followed by 50 mg/kg for four hours and 100 mg/kg for 16 hours.
Figure 2. Types of administration errors associated with IV N-acetylcysteine infusion in the treatment of
- Interruption in the infusion for more than 30 minutes
- Deviation in rate of infusion of third dose by at least 10%
- Deviation in rate of infusion of second dose by at least 10%
- Deviation in loading dose by at least 10%
- Failure to order loading, second or third dose
- Deviation in rate of infusion of loading dose by at least 10%
- Deviation in rate of infusion of second dose by at least 10%
- Deviation in rate of infusion of third dose by at least 10%
- Continuation beyond 21 hours with no clinical evidence
Errors did not affect the efficacy of IV N-AC in reversing hepatoxicity or coagulopathy but in a subgroup of 32 patients whose hospital length of stay exceeded one week, 72% (23 of 32) had errors in administration of their IV N-AC infusions. “The effect was particularly strong in those patients who had the infusion beyond the recommended 21-hour period,” Dr. Awad said.
Ensuring physicians, toxicologists and others involved in the care of patients receiving IV N-AC understand the regimen protocol and the now-documented effect of interrupting it could help minimize errors, Dr. Awad noted, adding that Robert Wood Johnson University Hospital is also considering changes to how N-AC solution is prepared. “They currently prepare each dose in separate bags, but there are a number of studies that have found that preparing the entire dose in a single bag and programming the pump to deliver the correct dose at the correct rate can prevent these types of errors from occurring.”
Improved Rapid-Sequence Intubation
Patients undergoing rapid-sequence intubation (RSI) are more likely to receive sedation if a pharmacist is present during intubation, University of California, San Francisco (UCSF) researchers reported (poster 3-069).
Lead investigator Zlatan Coralic, PharmD, BCPS, an emergency medicine clinical pharmacist at UCSF, reviewed medical records from 499 patients who underwent RSI at the university’s ED between 2008 and 2012 and found many were not receiving appropriate sedation and analgesia. Specifically, 55.7% (278 of 499) did not receive post-RSI analgesia and 25.7% (128 of 499) were not given sedatives during their stay in the ED.
“Intubation hurts and analgesia and sedation need to be administered,” Dr. Coralic emphasized. “There are very few instances where these should not be administered.”
Further analyses revealed two interesting sets of findings: 60.8% and 28.3% of a subset of patients given rocuronium for RSI did not receive analgesia and sedation, respectively, compared with 48.6% and 15.6% of those administered succinylcholine (P≤0.004 for both).
“There may be a false sense that patients are sedated with rocuronium,” Dr. Coralic said. “It is a much longer- acting paralytic than succinylcholine but it is just that—a paralytic. It does not provide any analgesia or sedation.” In contrast, the effect of succinylcholine diminishes after five to 10 minutes, “unmasking a patient’s agitation and prompting providers to administer analgesia and sedation much sooner than with rocuronium.”
On average, succinylcholine recipients received analgesia and sedatives 20 minutes sooner than rocuronium patients, he found.
Further analyses showed that only 19% of rocuronium recipients were left unsedated when an ED pharmacist was present during RSI compared with 35% who were unsedated when a pharmacist was not present (P=0.01).
“I think that pharmacists are aware of rocuronium’s pharmacokinetics and its duration of action and they prompt providers to order analgesia and sedation,” Dr. Coralic said. He added that pharmacist attendance did not correlate with analgesia use in rocuronium recipients or with both analgesia and sedation in succinylcholine recipients.
Although his was a single-center study, the findings are not unique to UCSF, Dr. Coralic said. A retrospective analysis of data from more than 1 million patients included in the National Hospital Ambulatory Medical Care Survey found that fewer than half of ED patients who underwent RSI received appropriate sedation (Am J Emerg Med 2013;31:222-226).
“There is plenty of room for improvement in every emergency department,” he said.
Boosting Accuracy Of Medication Reconciliation
ED pharmacists at Little Company of Mary Hospital in Evergreen Park, Ill., improved the accuracy of admission-time medication lists so profoundly that the effects were felt all the way to the time of discharge (poster 5-024).
According to Richard Mioni, PharmD, BCPS, who is a clinical pharmacist at the hospital, as the number of accurate admission medication lists rose from 32.3% when gathered by nurses to 94.2% when pharmacists conducted reconciliations, the number of accurate discharge medication lists increased from 16.7% to 33.7%.
The findings are based on an analysis conducted by his pharmacy’s clinical coordinator, Dr. Mioni said. She compared medical records and nurse-collected medication lists for 31 ED admissions seen during a single day in August 2011, before the ED’s pharmacist-run medication reconciliation program was implemented in September 2012. The coordinator also looked at 40 patients’ medical records from a single day during that inaugural month. Twelve of those patients had both nurse-obtained medication histories and pharmacist medication reconciliations, and 28 only had nurses obtain their drug histories. Finally, she compared medical records from 104 ED admissions that took place over several days in August 2013 with the same patients’ pharmacist-conducted admission medication reconciliations.
“We used charts as the benchmark since they are the only legal documents we have showing whether physicians made any corrections to the medication histories and reconciliations,” Dr. Mioni said.
The findings showed the average number of errors per patient medication history, including incorrect, incomplete or omitted information, dropped from 2.94 in August 2011, when nurses were obtaining histories, to 0.07 in August 2013, when pharmacists were conducting reconciliations.
Errors in discharge medication lists also decreased over the same period, from 4.2 to 2.06 per patient.
“Our plan is to include a pharmacist on discharge to further improve the accuracy of those medication reconciliations,” Dr Mioni said.
The researcher did not study possible associations between medication list inaccuracies and adverse events, but said, “We know that the rate of errors prior to pharmacists coming into the ED impacted in-hospital quality measures, and we have survey results from physicians, nurses and pharmacists that indicate dissatisfaction with the medication history process at that time.”
None of the participants reported relevant financial conflicts of interest.