Clinical pharmacists with EM training slash medication errors, help to optimize therapies in the ED
Qualified, EM-trained pharmacists in short supply, but established programs get broad support
Despite continuing pressure to streamline operations, a small but growing number of EDs are adding clinical pharmacists with specialized training in emergency medicine to their ranks. Why? Daniel Hays, PharmD, BCPS, FASHP, a clinical pharmacist in the Departments of Pharmacy and Emergency Medicine at the University of Arizona (UAZ) Health Network in Tucson, AZ, suggests it's a matter of having checks and balances in place in an environment where some of the typical safeguards are not generally available.
"Everywhere else in the hospital, if a medication is ordered, it is cleared through pharmacy, then reviewed by nursing, and then given to the patient. But historically in the ED, it goes right from the prescriber to the nurse to the patient, and in many cases, from the prescriber to patient without a second check," says Hays. "By us being here physically in the ED, we can be there to provide input before the order is even written to insure minimization of drug errors and optimization of drug therapy."
Hays, who is a pioneer in the use of clinical pharmacists in the ED, having set up a program at the University of Rochester Medical Center in Rochester, NY, before moving on to UAZ, estimates that roughly 10% of EDs now have clinical pharmacist programs. It's not a huge number, but a considerable improvement from 10 years ago when the practice was practically unheard of, he says.
Further, many of the EDs that have implemented clinical pharmacy programs are highly protective of the approach, even when revenue pressures force cuts to be made. For example, despite several rounds of budget cuts at Grady Memorial Hospital in Atlanta, GA, clinical pharmacists continue to provide coverage in the ED seven days a week, explains John Patka, PharmD, BCPS, a clinical pharmacy specialist in emergency medicine at Grady.
While physician leadership at the hospital was largely responsible for bringing the pharmacy program to the ED 10 years ago, Patka credits strong support from nurses in the ED for saving the program from the budget-cutting knife. "There was some talk about getting rid of pharmacy services in the ED, and several of the nurses wrote letters of support to the hospital CEO and the high-level executive leadership at Grady," he explains. "Initially, we had to show the nurses what we could do, but ever since we did that, they've been strong supporters."
Deploy pharmacists to meet needs, improve care
Precisely how clinical pharmacists are deployed in the ED can vary depending on a department's needs and culture. However, pharmacists often serve on trauma teams, they get called in to consult on complex cases, and they may review a sizable portion of the medication orders written in the ED. At UAZ, for example, the clinical pharmacist does not do any medicine dispensing, but rather insures than an order is correct as it is being formulated, explains Hays. "We are physically present in the ED and, based on acuity, we will see the patients as they come in," he says. "We are part of the team." (Also, see study noting that older patients in the ED are less likely to receive pain medication than younger patients, below.)
Similarly, at Grady, clinical pharmacists review 50% to 60% of the medication orders that originate in the ED, and they are highly involved with the care of critical patients. "We go to any trauma patients who come in to the ED," explains Patka. "We don't just do critical care, but because we are a level 1 trauma center, we focus more on critical response-type situations."
Another issue the Grady pharmacists deal with frequently is helping providers select the optimal antibiotic therapy for a particular clinical situation. Physicians generally select agents that will work, but they may not always be the best choice for a specific patient, says Patka. For example, he recalls one recent case in which a patient who was HIV positive came in to the ED with pneumonia and the physician was going to prescribe typical coverage for community-acquired pneumonia. "This person had a lot of risk factors, so we really wanted to broaden the coverage to include more atypical or unusual organisms that the physician wouldn't ordinarily think of using," explains Patka.
The Grady pharmacists also frequently assist physicians and nurses in titrating medications. Typically, this involves guidance on what parameters to shoot for in a particular set of circumstances. For instance, one recent case involved a patient who came into the ED with an aortic dissection — a condition that needs to be treated differently than the norm, explains Patka. "It is one of the exceptions where you really want to drop the patient's blood pressure aggressively and quickly, and the physician didn't realize that," he says. "The physician was only going to drop it by 25%, but you really need to drop it to a much lower level. So in that patient we recommended a combination therapy."
As a public access hospital, Grady has a very restricted formulary, but it has been impacted by shortages of some very basic medicines, such as morphine. And in these instances, the expertise of the clinical pharmacists has been helpful when substitutions need to be made. "Most of the drug shortage issues have involved selecting alternative agents that we don't normally use, and then providers aren't sure how to dose them," says Patka.
Analyze your medication errors
At UAZ, there is no question that the clinical pharmacists are preventing medication errors, says Hays. For example, in the high-pressure ED environment, it is not uncommon for drug allergies to be overlooked by treating providers. "We will have someone come in with a penicillin allergy, and the physician will order Zosyn, which has penicillin in it," he explains. "That is something that we will catch and immediately prevent the medication error."
In a specific case that occurred recently, the clinical pharmacist was able to prevent an error involving a patient who presented to the ED with anaphylaxis and was subsequently prescribed epinephrine to be delivered intravenously. "The paramedic who was taking care of the patient pulled the wrong drug strength out of [the automatic dispensing machine], and had we not been there and caught that, it would have resulted in significant injury to the patient," recalls Hays.
It may also be instructive to look at errors that occur when clinical pharmacists are not present in the ED, says Hays.
While computerized-physician-order-entry (CPOE) systems can prevent many errors, medication orders in the ED are often verbal, so they escape this type of safeguard, explains Hays. Further, even when CPOE is used, it is easy for miss-clicks to occur, and such systems don't always contain complete information regarding such issues as patient drug allergies, he says.
Consider the evidence
With such a small number of clinical pharmacy programs in place in hospital EDs, the approach has not been studied to the degree that proponents might like, but an evidence base is being developed. A recent study by researchers at the University of New Mexico (UNM) in Albuquerque, NM, found that there were 13 times more errors reported at UNM's level 1 trauma center when pharmacists were not present when compared to times when pharmacists were on site.1 In this study, antibiotic medications were associated with the most errors. However, errors associated with pain medications, cardiac medications, gastrointestinal drugs, and antiemetics were also reported. When pharmacists were present, they typically made dosage corrections or suggested alternative therapies. Physicians accepted these suggestions more than 90% of the time, say researchers.
In another study, co-authored by Hays, researchers at the University of Rochester Medical Center in New York found that the presence of a pharmacist in the ED quickened the pace with which patients with ST-elevation myocardial infarctions moved from the ED to the cardiac catheterization laboratory.2
In a third study conducted at the University of Kentucky, researchers compared error reports in an ED setting before and after the addition of two emergency medicine (EM) pharmacists, and found that the EM pharmacists were able to capture significantly more errors (94.5%) than other health care personnel (5.7%). The authors concluded that the addition of the pharmacists resulted in 14.8 times as many medication-error reports as were made when no EM pharmacists were in the ED.3
Identify champions to build support
While such dividends are attractive, cost and availability remain as barriers to the proliferation of more clinical pharmacy programs in the ED. However, a far bigger issue, according to Hays, is the dearth of qualified clinical pharmacists who have been trained to work in the ED setting. "Right now, there are only 10 or 11 residency programs to train pharmacists to work in the ED, and there just aren't enough people trained yet," he says.
Another problem is that not all pharmacists are well-suited to the environment of emergency medicine, adds Hays. "I have worked with several people in the past who had ICU training but they didn't have an ED mentality, and these people then struggled to make the position work," he says. "It requires the ability to really tolerate unusual situations, the ability to let things roll off you, and the ability to roll with the punches."
Nevertheless, Hays suggests that ED leaders interested in implementing a pharmacy program should reach out to established programs to discuss how their programs work, and what policies and steps are needed to make this type of intervention successful.
Size is certainly a factor, as there needs to be enough volume to make having a pharmacist in the ED worthwhile, says Patka. However, he points out that smaller EDs might be able to work out an arrangement where they share a clinical pharmacist with another hospital department.
For a program to be successful, it must have the support of physicians and nurses, stresses Patka. He suggests that one good way to do that is to find the physicians and nurses in the organization who have previously worked with ED-based clinical pharmacists and enlist their support in gaining buy-in for the approach.
Also, focus on specific drug-related goals that the organization is trying to achieve and show how a clinical pharmacist can help the ED achieve that goal, advises Patka. For example, one of the most common problems that Patka hears from colleagues in other ED settings is that they have difficulty communicating with the inpatient pharmacy. "Turnaround time and speedy throughput are important factors in the ED, and sometimes it is hard for the people in the pharmacy to see that or to understand that," he says. "That's a gap that the clinical pharmacist can help to bridge because [he or she] can help both of those groups see both sides," explains Patka.
While there are challenges involved with implementing an EM clinical pharmacy program, Hays points out that such programs are getting high marks where they have been established. "I would say do it without reservation," he says. "Every place I know that has started a program has gone from one to two pharmacists, if not 24/7 coverage. The benefit of it well outweighs the cost."
References
- Ernst A, Weiss S, Sullivan A, et al. On-site pharmacists in the ED improve medical errors. Am J Emeg Med. 2011 June 10. [Epub ahead of print]
- Acquisto N, Hays D, Fairbanks R, et al. The outcomes of emergency pharmacist participation during acute myocardial infarction. J Emerg Med. 2010 August 31. [Epub ahead of print].
- Weant K, Humphries R, Hite K, et al. Effect of emergency medicine pharmacists on medication-error reporting in an emergency department. American Journal of Health-System Pharmacy 2010;67:1851-1855.
Sources
- Daniel Hays, PharmD, BCPS, FASHP, Clinical Pharmacist, Departments of Pharmacy/Emergency Medicine, University of Arizona Health Network, Tucson, AZ.
Phone: 520-694-9815. E-mail: [email protected]. - John Patka, PharmD, BCPS, Clinical Pharmacy Specialist in Emergency Medicine, Grady Health System, Atlanta, GA. E-mail: [email protected].
- The Emergency Pharmacist Research Center. Web: www.emergencypharmacist.org.
Study: Older patients in the ED less likely to receive pain medication than middle-aged adults A new study suggests that older patients who present to the ED with pain are less likely to receive treatment for that pain than younger adults. The study, which appeared in the Annals of Emergency Medicine,1 involved an analysis of data collected from the National Hospital Ambulatory Medical Care Survey for 2003 through 2009. The researchers found that 49% of patients aged 75 years and older received an analgesic medication, as compared with 68.3% of middle-aged patients. Further, while 34.8% of the elderly patients received an opioid for their pain, 49.3% of middle-aged patients, aged 35 to 54, received an opioid. Other emergency providers have noted that pharmacists often refuse pain medications, fearing they will not like the effects of the medication. Even after analysts adjusted the findings for sex, race/ethnicity, pain severity, and other factors, the differences remained between the two age groups. Researchers report that the elderly patients were 19.6% less likely to receive an analgesic medication and 14.6% less likely to receive an opioid medication than middle-aged patients. The researchers did not investigate the reasons behind the treatment differences, but Timothy Platts-Mills, MD, the lead author of the study and an assistant professor of emergency medicine at the University of North Carolina at Chapel Hill School of Medicine, indicates that this may be because physicians are concerned about potential side-effects in older adults. "Older patients are at higher risk for adverse reactions, so physicians may under-treat them or not even treat them at all," agrees John Patka, PharmD, BCPS, a clinical pharmacy specialist in emergency medicine in the Grady Health System in Atlanta, GA. "What I see is that [physicians in the ED] may provide a dose of medication and then not reevaluate later to continue to titrate the medicine up." Another contributing factor, says Patka, is that elderly patients often under-report their pain. Sometimes it's because they don't want to bother a busy clinician with their problems. "You really have to consider that they may not tell you about their pain, and use your clinical judgment," he explains. "Try to ask patients about it again, or ask them in a different way." The issue comes up in the ED because physicians don't typically have that extra 15 minutes to spend with patients, says Patka, noting that it is one area where clinical pharmacists who are stationed in the ED can step in. "Most EDs are really getting pushed to see patients faster," he says. Platts-Mills says further research on how to most effectively manage pain in older patients is needed, and that for most older adults, effective treatment for acute pain is likely to provide substantial benefits. Reference
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Despite continuing pressure to streamline operations, a small but growing number of EDs are adding clinical pharmacists with specialized training in emergency medicine to their ranks.
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