Transcending Traditional Practice Boundaries:
Providing Pharmaceutical Care in the Emergency Department
Diane E. Barker, Pharm.D., Amanda L. Holley, Pharm.D.,
Leslie L. Kerst, Pharm.D., Geoffrey C. Lawton, R.Ph., MBA.
The Medical Center of Aurora
In the late 1990’s, pharmacy services at our metro-suburban
hospital could be characterized as generally distributive
in nature and focused largely on the inpatient population.
However, in response to increasing patient volumes as well
as socioeconomic and demographic evolutions within the community,
the pharmacy department developed several clinically-focused
pharmaceutical care models within non-traditional settings.
As a part of this ongoing patient care improvement effort,
decentralized clinical pharmacy services were implemented
within our Emergency Department (ED) in 2001.
Rationale & Objective
Escalating patient volumes and increasingly complex medication
utilization—together with projected future growth—all
contributed to the need for reallocation of pharmacy services
to provide care continuity in the ED setting. The need for
improved pharmacy services within our ED was first recognized
in mid-2000 following the observance by pharmacists of several
near-miss medication errors. Subsequently, pharmacy staff
endeavored to provide additional support services to the ED
with the goal of enhancing patient care by improving the safety
and quality of medication utilization.
The ED of our 346-bed tertiary care hospital provides services
to more than 80,000 patients each year. With 54 beds and a
level II trauma designation, the ED usually operates at maximum
capacity, treating a variety of patients with varying degrees
of morbidity. On average, 220,000 doses of medication are
administered to ED patients in our facility each year.
Currently, a unit-based clinical pharmacist is stationed in
the ED ten hours per day, six days per week. Pharmacy shifts
cover the hours of projected peak patient volume—between
2:00 PM and midnight. ED pharmacists facilitate the maintenance
of and improvements to proper selection, distribution, administration,
and monitoring of medications. The decentralized pharmacist
is responsible for monitoring all activities related to medication
use within the ED.
The pharmacist must attend and assist with all cardiopulmonary
arrest and trauma situations, review orders and acquire patient
medications, obtain and document medication and allergy histories,
provide discharge patient education, provide pharmacotherapy
consults, complete and monitor drug information requests,
and document adverse reactions. Secondary to the completion
of these tasks, the ED pharmacist also performs educational
inservices, drug cost analyses, trains current and future
practitioners, and participates in ongoing quality improvement
and research efforts.
Summary of Outcomes
Perhaps the most global improvements afforded by decentralized
pharmacy services pertain to medication safety; the majority
of pharmacist activities in the ED aim to improve patient
outcomes by enhancing the appropriateness of medications ordered.
Indeed, improvements to any aspect of medication safety can
justify ED pharmacy services. Since the inception of decentralized
pharmacy services in the ED in August of 2001, 73 major medication
errors have been averted. Nineteen (26%) of the errors would
have been life-threatening had they occurred. Twenty-five
(34%) errors were dosing related. ED pharmacists have documented
approximately $147,000 in avoided direct care costs. Continual
oversight of the causative factors leading to medication errors
has created a proactive atmosphere of error prevention through
rapid implementation of education and on-site process improvements.
Point-of-care presence in the ED has also allowed our pharmacy
staff to identify aspects of care provision that were in need
of improvement. Soon after pharmacists began working in the
ED, outdated drug information handbooks and posters were noticed
and updated. Another initial improvement was that the ED formulary
was streamlined. Both of these actions served to reduce the
potential for medication administration errors.
More recently, pharmacist involvement in the ED has grown
to include an integrated multidisciplinary program to facilitate
the management of acute myocardial infarction (AMI) and acute
coronary syndrome (ACS) patients. This program was designed
to improve and expedite the care of patients requiring emergent
percutaneous interventions. A kit containing commonly ordered
cardiac medications was designed by the pharmacy department
to be used for AMI and ACS patients. Pharmacists now assist
directly in caring for these patients by drawing up medications,
calculating dosages, and documenting medications administered
in the ED. Pharmacy involvement has served to make the treatment
of these patients more systematic and organized.
Pharmacy has also worked actively to improve the care of patients
requiring rapid sequence intubation (RSI) while in the ED.
The development of an optimized RSI kit containing appropriate
medications, as well as dosing guidelines, has been supplemented
by education and pharmacist participation at the bedside.
These efforts have successfully increased the number of patients
who receive appropriate sedation and analgesia prior to paralysis
and subsequent intubation.
An algorithm for recognizing and appropriately treating community-acquired
pneumonia has also been successfully implemented at our facility.
The algorithm was developed with the goal of increasing appropriateness
of therapy and reducing the time to first dose of antibiotic
for patients presenting to the ED. The form is used throughout
the facility and increases the consistency and appropriateness
The clinical services afforded by an on-site pharmacist have
become an essential part of ED operations. A survey of ED
clinical staff was conducted to determine the level of satisfaction
or dissatisfaction with ED pharmacy services. Results revealed
an overwhelming positive response to the presence of an ED
based pharmacist, citing their services as useful in reducing
errors, increasing education, optimizing resources, and improving
timeliness of patient care.
Pharmacy has an opportunity to touch more patients in the
emergency department than any other unit in the hospital setting.
In this environment, a pharmacist will be called upon to provide
both critical care and ambulatory care services. The very
structure and atmosphere of the emergency department setting
creates a place where pharmacy services are both necessary
and welcome. The ED pharmacist practice model has grown well
beyond the confines of a merely process-centered distributional
service—it is an emerging area of comprehensive patient