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Pharmacists Enhancing the Time to Cardiac Catheterization Laboratory and Patient Safety during Acute Myocardial Infarction Presentation to the Emergency Department

Nicole M. Acquisto, Pharm.D., Daniel P. Hays, Pharm.D., BCPS, Rollin J (Terry) Fairbanks, M.D., Manish N. Shah, M.D., M.P.H., Joseph Delehanty, M.D., Flavia Nobay, M.D., Curtis E. Haas, Pharm.D., BCPS

 

University of Rochester Medical Center, Strong Health, Rochester, New York

Our institution implemented an Emergency Pharmacist (EPh) position in 2000 to enhance patient safety in the emergency department (ED).  One duty of the EPh is to respond to acute myocardial infarction (AMI) presentation to the ED.  This study evaluates the impact of that service on patient outcomes.

The addition of clinical pharmacy services has many benefits including overseeing proper medication use, providing medication information and education, and designing efficient and safe drug delivery systems. When pharmacists are members of multi-disciplinary patient care teams the number of adverse drug events is reduced. EPh duties include clinical consultation, resuscitation response, medication order screening, medication preparation and dispensing, and education programs for health care providers. Our ED AMI response team is a multi-disciplinary team including cardiologists, emergency physicians, emergency nurses, patient care technicians, and, when available, an EPh. 

Goals of the EPh during ED AMI alerts are to:

  1. Facilitate medication preparation and administration
  2. Reduce medication errors through prospective screening and intervention
  3. Assure safe and appropriate medication therapy for patients

Specific duties during AMI include gathering patient specific information (weight, past medication history, and allergies), evaluating appropriate medications and medication doses, facilitating medication administration (obtaining medication from automated dispensing cabinets and the central pharmacy and programming medication infusion pumps), and preventing adverse drug events and potential adverse drug events (ADE/PADEs).

Chart review and analysis of an existing database of patients who presented to the ED with AMI that required urgent cardiac catheterization from August 15, 2005 to August 15, 2006 were conducted.  Data collection included baseline demographics, detailed medication administration history (medication, dose, and time), timing of arrival to the ED, diagnostic electrocardiogram (ECG), arrival to the cardiac catheterization laboratory (CCL), and balloon angioplasty.  Patients were separated into two groups following the blinded data collection, EPh present and EPh not present.  The groups were compared utilizing univariate and multivariate analyses to detect differences in the door-to-balloon, adjusted door/ECG-to-balloon, and adjusted door/ECG-to-CCL times. Chi-square analysis was used to detect differences in secondary outcomes.

CCL staff presence versus on-call staff and arrival to the ED by Emergency Medical Services versus self were identified as potential confounders.  Multivariate analysis determined that the EPh is independently associated with a mean 14 minute decrease in door-to-balloon time (p = 0.03) and a mean 11 minute decrease in both adjusted door/ECG-to-balloon and adjusted door/ECG-to-CCL times, p = 0.03 and 0.006, respectively.  When the EPh was present, patients were 3.8 times more likely to meet an adjusted door/ECG-to-balloon time ≤ 90 minutes (p = 0.02) and approximately 3 times more likely to meet both an adjusted door/ECG-to-CCL time ≤ 30 minutes and ≤ 45 minutes, p = 0.01 and 0.05, respectively.  Secondary analysis determined that EPh presence was associated with a decrease in all medication related events (ADE/PADEs, medication errors, and problem drug orders), p=0.002.           

Conclusion

EPh presence during AMI presentation to the ED is associated with a decrease in door-to-balloon, adjusted door/ECG-to-balloon, adjusted door/ECG-to-CCL times, and all medication related events.  

References

  1. Leape LL, Cullen DJ, Clapp MD et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999; 281:237-70.
  2. Antman EM, Anbe DT, Armstrong PW et al. ACC/AHA Guidelines for the management of patients with ST-elevation myocardial infarction. Circulation. 2004; 110:e82 – e293.
  3. Brennan TA, Leape LL, Laird NM et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. New Eng J Med. 1991; 324:370-6.  
  4. Fairbanks RJ, Hildebrand JM, Kolstee et al. Medical and nursing staff highly value clinical pharmacists in the emergency department. Emerg Med J. 2007; 24:716-9.
  5. 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.
  6. Kelly S, Hays D, Metz M et al. Pharmacist participation in trauma resuscitation.  Paper presented at the 24th Eastern States Conference. Baltimore, MD; 2005 Apr 26 and the 40th ASHP Midyear Clinical Meeting. Las Vegas, NV; 2005 Dec 4.

 View a pdf of the poster from the Midyear Meeting (440 KB).