The role of the clinical pharmacist in the emergency department (ED) is an exciting and rapidly growing area of interest for hospitals. Within the last ten years, we’ve witnessed an increase in the number of pharmacists providing services in emergency departments across the United States, from virtually none to almost 20% of hospitals.1,2 As the number of patients seeking care in EDs continues to increase; care teams will increasingly look to pharmacists to provide essential services that improve the patient experience.
Historically, this is a field of clinical practice that we left to our nursing and physician colleagues with minimal order review and/or interaction regarding pharmacotherapy. In time, the medical community realized pharmacists could add value to the patient care experience in the ED. Today, pharmacists are called upon to provide specialized services in emergent situations where adverse drug events have a higher likelihood.
The most common roles of ED pharmacists include serving as part of the care team to assist with trauma and resuscitation, selection of proper medications in concert with appropriate dosing recommendations, providing drug information for patients and staff, management of critically ill patients, management of boarded patients, and assistance with antimicrobial stewardship.3
Optimizing pharmacists care of patients
As patient cases become more complex and healthcare costs continue to increase, we’re tasked with finding ways to help the healthcare system improve cost containment, patient safety and transitions of care. The use of a clinical decision support surveillance solution in the ED pharmacy can help us examine how we streamline processes and improve outcomes, thereby addressing some of the challenges that present to clinicians. The primary use of such software has its greatest impact when we’re boarding patients in the ED awaiting inpatient beds. For example, improvements in the provisioning of pharmaceutical care can be accomplished using of real-time alerts such as renal dosing adjustments and patient education for direct oral anticoagulants (DOACs). These are examples of interventions that can take place in the ED but may be overlooked due to historical medication management practices. Timely adjustments to medication therapy, along with a reduction in the delay of care, improves overall patient outcomes and patient satisfaction scores.
Matt Baldwin, PharmD, of Aultman Hospital (Canton, Ohio), describes their use of a clinical decision support surveillance solution across their healthcare system to facilitate ongoing initiatives:
"(It) gives us the ability to manage our larger target clinical initiatives like anticoagulation monitoring or AMS, as well as tailor our own rules as necessary, which gives us a lot of flexibility and control. We’ve seen a reduction of about $2 million in AMS spend alone since the inception of the program, as well as better patient outcomes. We’re looking to support our future initiatives in the areas of opioid management, oncology, and diabetes. We now know what’s possible in the solution and we’re asking ourselves, ‘what else can we do?"
Another example of how technology can be leveraged is the surveillance of high-cost medications and the management of medications on shortage. Pharmacists can use this type of technology to improve communications regarding medication shortages, thereby alleviating delays in patient care. Clinical alerts allow the clinician to initiate a dialogue with a prescriber in a timely fashion, avoiding interruptions in patient care, and improving the potential for the selection of a different, more readily available, or less costly medication. Ashleigh Mouser, a clinical pharmacy coordinator at Hardin Memorial Hospital (Elizabethtown, KY), describes how her facility is using clinical surveillance to aid with cost containment:
"We are effectively using this to manage drug shortages. Every hospital is going through this right now. When there is a shortage, we must react quickly to look for medication alternatives. We can pull the medication usage data from across our patient population through our EHR and then set up a rule that allows us to see in real-time which patients in the hospital are on that medication. Then, our pharmacists can identify alternatives and make the switch. This saves time when we have to act fast. This also allows us to have a huge impact on patient safety."
Over the last ten years, the role of the clinical pharmacist in the emergency department (ED) has evolved; care teams are increasingly looking to pharmacists to provide essential services that improve the patient experience. Advances in technology have made it possible to intervene early in the patient admission process to ultimately improve outcomes. We can and must leverage technology to manage both medically stable and critically ill patients seen in the ED. As the needs of our population expand and our Emergency Departments see more complex patients for longer lengths of stay, technology will prove instrumental in helping pharmacists efficiently manage their clinical interventions.References
1. Pederson CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2004. Am J Health Syst Pharm. 2005 Feb 15;62(4):378-90.
2. Pederson CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2013. Am J Health Syst Pharm. 2014 June 1; 71 (11): 924-942.
3. Roman C, Edwards G, Dooley M, Mitra B. Roles of the emergency medicine pharmacist: A systemic review. Am J Health Syst Pharm. 2018 June1; 75 (11):796-806.