The Ultimate Consult Service: Emergency Pharmacists

Imagine a consult service located IN the ED. The consultants are some of the friendliest people you’ve met and are there to help you. They tirelessly go out of their way to guide you through hospital protocols, help you with treatments, keep a close eye on your work, and ensure that you and your patients stay out of trouble. Not only are these consultants helpful to you, but also your residents, mid-levels, nurses, and the admitting teams. Everything they know, they teach you – and some are very active in FOAMed and emergency medicine research.

ED Clinical Pharmacists, or Emergency Pharmacist (EPh)

Pharmacy practice is as diverse as medicine including retail (corner drug stores such as Walgreens in the U.S.), nuclear pharmacy (diagnostic radioisotopes), compounding, primary care, and clinical pharmacy – including subspecialties in pediatrics, hematology/oncology, critical care, psychiatry, infectious diseases, and recently emergency medicine – to name a few.

Now before I write anything else and in full disclosure, I am an EPh, and by default as biased as can be. But I do want to share with you some objective data:

• The EPh is relatively new, but have been in the EDs since the 1970s[1]
• They are present throughout the U.S., Canada, and Australia, and the numbers are rising
• Clinical pharmacists’ education (in the U.S.) parallels medical school – undergraduate, entrance examinations, 4 years of pharmacy school, residency, board certification, and (for some) fellowship
• In the last decade, the benefit of EPh’s bedside presence in the ED has begun to emerge:
  • Financial impact: Cost reduction in the millions of dollars [2-4]
  • Improved medication safety and prevention of drug errors [5-8]
  • The ED physicians, nurses, and staff like us. [1] They really do. [9]

Medication Safety in the ED

ED patients are deprived from the drug-safety mechanisms that exist for most patients in a hospital:

1. A medication order is written by a provider
2. It is verified by a pharmacist for safety and appropriateness
3. The medication is released to a nurse and often labeled specifically to a patient
4. The medication is yet verified again by a nurse
5. Finally the medication is administered to the patient

Multiple steps are added to the medication process for a good reason – it minimizes the chances of an error reaching the patient.

In the ED, drugs are often ordered by a provider and immediately administered (sometimes from verbal orders) in the high-stress environment. It is not surprising that medication errors in the ED are common. [5-8]

The EPh as a drug-safety intervention has been an area of interest for healthcare societies such as the American Society of Health-System Pharmacists and the Agency for Healthcare Research and Quality (AHRQ)[10] – who are investing in further research of EPh programs. Unfortunately, the societies from which we need the loudest support  – the American College of Emergency Physicians (ACEP) and Emergency Nurses Association (ENA) – remain silent.

Having an EPh physically in the ED has the potential to reduce errors without delaying care and may help with other outcomes – such as reduction of door-to-balloon time in acute myocardial infarction [11], or reduction in return visits to the ED through appropriate culture follow-up. [12] These areas and many more have shown potential benefit, setting the stage for future rigorous multicenter studies.

Disadvantages of having an EPh

There may be minor disadvantages of having an EPh:

• We’re expensive. But the financial data from above may justify the cost.
• There is a chance we might make residents/nurses too reliant on us for medication decision-making and preparation. Once the residents/nurses practice at another institution without an EPh, they might be at a disadvantage. However, most EPh take a big part in nursing and resident education.
• In most EDs we do not yet have 24/7 shift coverage.

“How do I get an EPh into my ED, and how much will this cost?”

Most of the EPh programs are supported through the Departments of Pharmacy. Expressing interest to the Department of Pharmacy would be the first step. An ED physician group’s request does not guarantee funding for a clinical pharmacist, but it does speak loudly to the hospital administration about the ED’s willingness to improve patient safety. As far as the cost – we’re expensive. Most pharmacists’ salaries are > $100,000/year in the U.S. Each EPh must justify their cost when working in the ED, and most do – but the hardest part is usually getting the initial funding and stepping into an ED. Online justification tool-kits exist in the ASHP Emergency Care Resource Center

Final Thought

The EPh position is new and has shown benefit to both patients and ED staff. It was not long ago that ED docs wanted to do something different in the hospital, and tried to prove themselves in a relatively hostile environment. I believe that the ED pharmacist are paralleling early ED physicians – being innovative and persistent, finding benefit where no one thought there was any, and willing to work at the front lines. Fortunately for us, the environment has been welcoming.

If you are or work with an EPh, we would love to hear your perspective. Please leave a comment!

 

References

1. Elenbaas RM, Waeckerle JF, McNabney WK. The clinical pharmacist in emergency medicine. Am J Hosp Pharm 1977;34(8):843–6.
2. Ling JM, Mike LA, Rubin J, et al. Documentation of pharmacist interventions in the emergency department. Am J HealthSyst Pharm. 2005; 62:1793-7.
3. Lada P, Delgado G. Documentation of pharmacists’ interventions in an emergency department and associated cost avoidance. Am J Health-Syst Pharm. 2007; 64:63-8.
4. Aldridge VE, Park HK, Bounthavong M, Morreale A. Implementing a comprehensive, 24-hour emergency department pharmacy program. Am J Health Syst Pharm. 2009;66:1943-7.

Medication Safety

5. Ernst AA, Weiss SJ, Sullivan A IV, et al. On-site pharmacists in the ED improve medical errors. Am J Emerg Med. 2012;30:717-725.
6. Patanwala AE, Hays DP, Sanders AB, Erstad BL. Severity and probability of harm of medication errors intercepted by an emergency department pharmacist. Int J Pharm Pract. 2011;19:358-62.
7. Rothschild JM, Churchill MS, Erickson A et al. Medication errors recovered by emergency department pharmacists. Ann Emerg Med. 2010;55:513-521.
8. Patanwala AE, Sanders AB, Thomas MC, et al. A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department. Ann Emerg Med. 2012;59:369-73.
9. Fairbanks RJ, Hildebrand JM, Kolstee KE, Schneider SM, Shah MN. Medical and nursing staff highly value clinical pharmacists in the emergency department. Emer Med J 2007;24(10):716–8.
10. Clinical pharmacists in emergency medicine. Agency for Healthcare Research and Quality 2008. (Accessed September 25, 2013, at http://www.ahrq.gov/downloads/pub/advances2/vol4/advances-fairbanks_20.pdf)
11. Acquisto NM, Hays DP, Fairbanks RJT, et al. The Outcomes of Emergency Pharmacist Participation during Acute Myocardial Infarction. The Journal of Emergency Medicine 2012;42(4):371–8.
12. Randolph TC, Parker A, Meyer L, Zeina R. Effect of a pharmacist-managed culture review process on antimicrobial therapy in an emergency department. Am J Health Syst Pharm. 2011;68:916-9.

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