Clinical Pharmacy Services in the Emergency Department

History of Emergency Pharmacy Services

• 1970’s¹
• Billing
• Inventory control
• Clinical pharmacy services
• 1980’s led way for pharmaceutical care

1 Ellenbaas, et all
ED is a Unique Practice

• Many safety mechanisms not available in ED
• Pharmacy USUALLY not present
• NO DOUBLE CHECK
• JCAHO supports pharmacist double check on ALL medication orders

Unique Practice cont.

• High Patient Volume
• Verbal Orders
• HIGH STRESS situations

Contributing Factors to Hazards

• Patients are strangers
• Multiple patients being treated at same time
• Wide range of medications utilized
• Interruptions/distractions
• ED Dispensing
• Time Constraints
• Tight Coupling

Medication Errors in the ED

• ED has highest rate of preventable errors
• 110 MILLION ED patients yearly in US*
• 5% experience potential events
• 70% of these are PREVENTABLE**

*National Center for Health Statistics.
**Harvard Medical Study
Let’s Compare

• 77% of all ED medication errors between ordering phase and administration phase
• 23% of errors were discovered before patient received medication
• 39% in other area of hospital

USP Patient Safety CAPS Link
Challenges to Implementation

• Financial
• Staffing
• Acceptance by medical staff / turf issues
• Physicians, nursing, midlevel providers, etc
• Physical space within ED
• Training

Strong Memorial Hospital

• ED has > 120 beds
• Over 500 doses of medication dispensed per day
• Over 90,000 patient visits per year
• 60,000 adults
• 30,000 pediatrics
• Nationally ~ 3.5% of ED’s have Pharm presence

Pharmacist Duties in the Emergency Department

• Clinical
• Academic
• Research
• Administrative
• Distribution

Clinical Duties

• Clinical Consultation
• Attend rounds and present patient information
• Dose recommendations
• Therapeutic substitution
• Disease state specific pharmacotherapy
• Pharmacokinetics
• Being available – and visible!!

Clinical Duties

• Medication history
• Allergy screening
• Pregnancy medication consultation
• Weight based dosing
• Pediatric
• Obese
• Geriatric
• Disease specific (CF, FTT, etc)

Clinical Duties

• Patient Education
• Medication specific education
• Asthma
• Warfarin
• LMWH
• Diabetes
• Discharge counseling

Order Review

• Allergies
• Medication interactions
• Inappropriate
• Dose
• Route
• Indication

ED is only place within SMH that has handwritten orders

The Medication Process

• Prescribing
• Transcribing
• Dispensing
• Administering
• Monitoring
• Discharge Medications

Prescribing

• Incomplete knowledge of medication
• Incomplete knowledge of patient
• Less access to
• Patient medications prior to visit
• Patient history

Transcribing

• Verbal Orders
• Poor penmanship
• Team communication errors

Dispensing

• Dispensed by nursing
• Dispensed by physicians
• Thorough counseling not available/performed

Administration of Medications

• Multiplicity of medications
• Therapeutic duplications
• Potency of medications
• Multiple patients in the ED
• Parenteral administration
• Drug incompatibilities
• Physician administration

Monitoring

• Parenteral administration
• Esp cardiac medications, insulin, etc…
• Emergency procedures
• Inadequate personnel

Discharge Medications

• Complex procedures
• Medicated patients leaving the ED

Chart Review

• Review all patient charts for appropriate medication use
• Underutilization
• Overutilization
• Polypharmacy

Distribution

• Automated dispensing machines
• CPOE for admitted patients
• Pharmacy System
• PYXIS
• Pharmacist available for assistance

Public Awareness

• ASHP / ACCP involvement
• National EM/CC society involvement
• Publications
• AHRQ Grant