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By the time emergency medical services arrived at University of Texas Southwestern Medical Center in Dallas with a 2-year-old boy who had ingested his mother’s ramipril and labetalol, the ED’s pharmacist already had prepared detailed information sheets for the nurse and physician. Those sheets listed the care pathway for each agent involved, appropriate evidence-based management, potential side effects, necessary lab tests, and complications that might occur. This type of scenario now occurs in the ED on a daily basis, due to the use of a dedicated on-site pharmacist in the ED, says Paula J. Mialon, PharmD, the facility’s clinical pharmacist for emergency medicine.
This individual responds to codes, reviews medications before administration, and educates staff on important issues related to risks and alternatives, says Robert A. Wiebe, MD, FAAP, FACEP, professor and director of the division of emergency medicine and department of pediatrics at the facility. Although the program started only a year ago, there have been dramatic results, Wiebe says. "This program is still maturing, but we have some preliminary data that show a 50% reduction in medication errors since the pharmacist has been on site," he reports. This alone has been enough justification for hospital administrators to allocate this resource for the ED with 24-hour coverage, he says. He reports that four clinical staff pharmacists soon will be providing coverage for more than 95% of the patients seen through the ED.
Here are some benefits of having a dedicated pharmacist in the ED:
• Staff are assisted with complex medication issues. Mialon serves as the link between the central pharmacy and the ED for drug delivery and administration and acts as a resource for the medical and nursing staff. She gives inservices on drug calculations, toxicology, and rapid sequence induction pharmacology to ED nurses. As a result, clinicians are freed from having to worry about dosages, drug interactions, complications, and routes of administration, Wiebe says. "It isn’t just a convenience," he says. "This allows us the luxury of devoting our time and energy to other critical patient care issues."
Wiebe notes that new drugs are appearing daily, and each new drug has pharmacokinetic issues that create problems for the clinician. "The pharmacist is the expert in drug delivery, interactions, and complications," he says.
Mialon explains that she reviews the patient’s entire list of medications, including herbal products or teas, over-the-counter drugs, and vitamins. She notes that any of these may cause clinical symptoms that may imitate or mask another disease. She also points to patients on complicated drug regimens at home, such as a patient who comes to the ED with active seizures. "He takes Tegretol at home, and we run a level, and it is critically low. The next question is — how much do we give him to get him controlled again?" she asks. In this case, Mialon would calculate his pharmacokinetic parameters, make clinical recommendations based on the results, and review the patient’s history to rule out potential adverse drug interactions.
Next, Mialon provides nurses with information about preparation and delivery of the medication and potential side effects. "Should a side or adverse effect occur, the pharmacist is there to help with management," she says.
• Medical errors are reduced. Orders are reviewed for appropriateness, dose, route, and frequency, and determining if the agent is the best, most cost-effective, and safest agent available, Mialon says. "Common errors such as incorrect decimal points are intercepted," she adds.
Curbside’ educational opportunities
Mialon says there is plenty of "curbside" education that takes place. "Any question we are asked, we find the answer for," she says. She uses other hospital pharmacists as a resource. "If a patient presents to the ED with a complex cardiac issue, I can call my cardiology pharmacist, who specializes in this area, for consultation." The other pharmacist may be familiar with a specific patient’s history, Mialon adds. "She may know details such as the best vancomycin dose the patient tolerates, which saves someone else from starting over completely," she says.
She adds that the ED pharmacists attend all traumas and codes in the ED to assist with dosing and drawing up of medications, preparing drips such as epinephrine or dopamine, and assisting with administration. "This frees up the nurse to do other things, such as procedures and charting," Mialon says. She stresses that every drug provided by the pharmacist is labeled. "Not one syringe leaves the hands of the pharmacist to be given to the patient without a label and at least one second check by another member of the team," Mialon says.
• Costs are reduced. In a one-month pilot test with just one pharmacist on eight-hour days, $61,000 was saved in direct costs, she reports, by switching to less expensive but equally effective agents and recommending "judicious use" of laboratory draws, particularly for drug levels. "And that’s not including potential’ reductions based on errors such as legal fees," Mialon adds. (See Emergency Department Pharmacist Activities.)
Sources
For more information on the benefits of a dedicated emergency department pharmacist, contact:
• Paula Mialon, PharmD, Children’s Medical Center, Department of Pharmacy Services, 1935 Motor St., Dallas, TX 75235. Telephone: (214) 456-2279. Fax: (214) 456-6014. E-mail: [email protected].
• Robert A. Wiebe, MD, FAAP, FACEP, Director, Division of Emergency Medicine and Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, 1935 Motor St., Dallas, TX 75235. Telephone: (214) 456-6116. Fax: (214) 456-7736. E-mail: [email protected].
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