THE SPEED AND COMPLEXITY OF CARE for patients in emergency departments (EDs) is a well-known contributor to medication errors and adverse drug events (ADEs). Studies show that twice as many medication errors occur in EDs than in the inpatient setting.
And of the approximately 110 million patients who receive ED care each year in the U.S., 35 percent experience ADEs. Seventy percent of those are thought to be preventable. 
In 2007, the Agency for Healthcare Research and Quality corroborated ASHP’s view that hospital emergency rooms around the country could benefit greatly from pharmacists’ medication knowledge and oversight. It provided funding for the ASHP Patient Care Impact Program (PCIP), a small but crucial six-month traineeship to help practitioners implement an emergency pharmacist role within their own institutions.
“Pharmacists in the ED have been shown to reduce preventable adverse drug events, improve medication reconciliation, and help reduce drug costs,” said Barbara Nussbaum, B.S. Pharm., MEd, Ph.D., ASHP’s director of adult learning and education programs. “It’s a total win-win for the hospitals who implement a pharmacist position in the ED.”
A Challenging Environment
Up to 10 trainees are picked for the program each year. Nationally recognized expert emergency practitioner Daniel P. Hays, Pharm.D., BCPS, FASHP, specialist in poison information, Arizona Poison & Drug Information Center, Tucson, serves as the program mentor, advising PCIP participants on the clinical projects they have chosen.
The pharmacists then engage in brainstorming sessions and monthly teleconferences for status updates, group mentoring, and problem solving, all while earning 25 hours of CE credit.
“My role is to act as a sounding board for trainees and to provide guidance in moving ED services forward within their institutions,” said Hays. “Implementing this kind of program is not easy, and I help the participants deal with unique challenges they face in the emergency-care environment.”
The high stakes and elevated tensions of an ED can be challenging for a pharmacist who is used to working in a centralized pharmacy, according to Hays. In a place where orders are processed stat, it’s not always clear how and where medication experts fit in.
“Unfortunately, a pharmacist who is not trained in the unique environment of the ED will not last long,” he said. “There may be personality conflicts, and it’s a uniquely chaotic environment. The ED pharmacist needs to be able to function within and to integrate with the team while helping with all aspects of patient care.”
Trainees feel they have gleaned myriad benefits from the program. Rachana Patel, Pharm.D., pharmacy clinical manager, St. John Medical Center, Westlake, Ohio, and her PGY1 resident Steve Margevicius, have used what they learned to help embed a full-time pharmacist in St. John’s emergency department (ED).
“We are excited to have hired a pharmacist with several years of critical care experience, and I’ll be using my PCIP experience to help him bridge the pharmacy’s clinical activities throughout a patient’s entire stay in the hospital,” Patel said, adding that she was also able to add three full-time medication reconciliation technicians to the ED.
Tiffany Mitchem, Pharm.D., an emergency room (ER) pharmacist with Mobile Infirmary Health, Mobile, Ala., used the program to get the emergency care skills she needed in lieu of an intensive residency. Mitchem recently led an initiative to expand ER pharmacist’s services in her hospital to seven days a week.
“At Infirmary Health, unless pharmacists are physically in the ER, there is no pharmacist supervision of medication orders there. So, it’s really critical to get these services into the emergency care environment,” Mitchem said, adding that the PCIP program made her much more confident in her clinical abilities.
Given the fact that 70 pharmacists have completed the program to date, it’s not a stretch to say that the PCIP saves lives.
During his PCIP traineeship, Cody Maldonado, Pharm.D., clinical emergency department pharmacist, Saint Vincent Healthcare, Billings, Mt., undertook a project to decrease mortality and improve outcomes in patients with septic shock.
“We found that the key to improving outcomes was faster detection and administration of antibiotics and fluids,” Maldonado said. “So, we implemented a ‘sepsis swarm’ that would alert the physician, pharmacist, charge nurse, and bedside nurse to the life-threatening situation. By having a pharmacist deliver the antibiotic directly to the patient’s bedside, we decreased average time from sepsis recognition to administration of antibiotics from over three hours to less than one hour.
“This multi-disciplinary alert has greatly improved awareness about sepsis, and I believe that it is part of the reason why our sepsis mortality has decreased by over 50 percent.”
The six-month traineeship concludes with a poster presentation given by each participant at ASHP’s Midyear Clinical Meeting. The information that trainees share with the thousands of pharmacists who attend ASHP’s Midyear serves to sensitize many more practitioners to the special aspects of emergency care.
Nussbaum noted the success of a specific 2013 poster on antibiotic stewardship in the ED.
“Understanding the resistance patterns of patients who are coming in from outpatient settings is a hot issue because of the upswing in more dangerous bacterial strains,” she noted, adding that trainees are developing processes to use the most-effective medications in the ED setting.
Other participants appreciate the opportunity the PCIP provides them to present on a profession-wide “stage.”
“The PCIP advanced several career goals of mine, including my desire to publish more within my specialty and to present the results of our project at Midyear,” said Nicole Abolins, Pharm.D., emergency medicine clinical pharmacist with Novant Health Forsyth Medical Center, Winston Salem, N.C.
Abolins presented a poster at the 2013 Midyear on “Expanding emergency department pharmacy services by decentralizing existing pharmacy staff resources.”
Despite the challenges of practicing in an emergency environment, the payoffs can be big, according to Hays. Working directly with critically ill patients requires special skills but can be a real gift.
“When a pharmacist works in the ER, not only is he or she providing safe medication use, but he or she is a key part of the care team’s front line,” Hays said. “I tell my mentees, ‘Don’t be afraid to get a warm blanket for someone.’ And I’ve never heard an ER pharmacist say, ‘That’s not my job.’ ”
–By Evan Mulvihill
 Santell JP, Hicks RW, Cousins DD. Medication errors in emergency department settings—5 year review. Presented at American Society of Health-System Pharmacists Summer Meeting; June 2004; Las Vegas, NV. Abstract.
 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. N Eng J Med. 1991;324(6):370-376.