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
Aurora, Colorado

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.

Program Description

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 of care.

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.

Conclusion

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 care.