ASHP InterSections ASHP InterSections

Pharmacists in the ER bring much-needed medication expertise to often-chaotic and complex medical situations. Above, Katelyn Dervay, Pharm.D., BCPS, and Mary Finocchi, Pharm.D., BCPS, prepare to treat a patient.

IMAGINE A HOSPITAL EMERGENCY ROOM (ER) with no radiology services available. To emergency physician Tim Meehan, M.D., MPH, an ER or ED without an on-site pharmacist makes about as much sense.

“I don’t think you can provide appropriate emergency care without pharmacists present, or, at the very least, with 24-hour access to a pharmacist” if the facility is too small to support a dedicated ED position, said Dr. Meehan, who practices primarily at the University of Illinois Hospital in Chicago. “I find them to be indispensable team members. During periods when we didn’t have a dedicated ED pharmacist, it was rough going.”

A Growing Trend

Dr. Meehan’s assessment of the critical role that pharmacists play in the ED reflects a rising consensus among healthcare providers in hospitals and health systems across the country. Although pharmacists have long provided medication consultations to ED healthcare teams, the push for dedicated pharmacist positions within the setting itself is a growing trend.

“As members of interdisciplinary ED healthcare teams, pharmacists improve patient outcomes by ensuring appropriate and cost-effective medication use and leading system changes to reduce or eliminate medication errors,” said Erika L. Thomas, MBA, B.S.Pharm, director of ASHP’s Section of Inpatient Care Practitioners, adding that ASHP believes every hospital should include pharmacy services in the ED.

Katelyn Dervay, Pharm.D., BCPS

The addition of pharmacists to the ED or ER is often the result of other healthcare practitioners’ requests. After witnessing the range and scope of standard pharmacy services, ER staff at Tampa General Hospital asked for an augmented pharmacy presence, according to Katelyn Dervay, Pharm.D. BCPS, a clinical pharmacy specialist in emergency medicine and incoming chair of the ASHP Section Advisory Group for Emergency Care.Now, at least one ER pharmacist is on duty around the clock, and a satellite pharmacy serves the department, which treats more than 85,000 patients annually.

In addition to ensuring safe and effective medication use, Dr. Dervay and her colleagues assume less common tasks as well, such as geriatric consultations. Those consultations have twice revealed that a patient’s symptoms resulted from medication misuse, not illness. Her assessment precluded unnecessary tests and admission to the hospital.

“It’s always a big change for nurses who are new to our ER and aren’t used to having pharmacists on staff,” said Dr. Dervay. “At first, there’s a sense of losing control, but soon they realize the benefits that we provide and appreciate the fact that we free them up to focus on other acute duties while the pharmacist handles medication issues.” During a typical 24-hour weekday last spring, pharmacists conducted 45 consults, including medication adjustments, IV/PO conversions, and attending traumas and strokes.

The pharmacists also serve as information conduits—informally by answering drug-related questions from other ER staff, and more formally through inservices for nursing staff, residents, and staff physicians. In addition, she and her colleagues monitor antibiotic regimens and ensure that prescribed drugs are the best choices to treat a particular condition.

“Hybrid” Roles Showcase What Pharmacists Can Do

Megan Musselman, Pharm.D., BCPS, a clinical pharmacist specialist in emergency medicine and critical care, is the only ER pharmacist on staff at North Kansas City Hospital in Kansas City, MO, which treats more than 100,000 patients annually.

“I’m in a hybrid role and split my time between the ER and intensive care. It’s a great way to show the value of the ER pharmacy services,” said Dr. Musselman.

Megan Musselman,
Pharm.D., BCPS

Dr. Musselman sometimes feels like a frontline medication safety officer in a high-risk arena. “There are huge medication safety issues in the ER. It’s a fast-paced, high-acuity area. You need to be quick on your feet and recognize situations in which medication errors are likely to arise,” she said.

From April through June 2014, Dr. Musselman participated in an average of 202 interventions monthly.Another key responsibility is procuring drugs that may be in short supply. “If a medication is unavailable, and we need a different but equally effective choice, I research the options, put the medications in place, and educate other healthcare providers about how to use them safely and effectively,” she said.

Quantifying the Value of ED Pharmacy Services

Showing the C-Suite that pharmacists make a difference in patient outcomes can be challenging, according to Dr. Musselman, because the monetary impact often comes primarily through cost avoidance, such as preventing an adverse drug event, vs. income.

But increasingly, hospitals recognize that ED pharmacists lead to more robust patient care and income statements, said Brenda Darling, Pharm.D., clinical pharmacy manager at Children’s Medical Center in Dallas.

The ER at Children’s treats more than 140,000 patients annually and employs 10 full-time emergency pharmacists, more than any hospital in the country.

“If a pharmacist catches one potentially serious error before it reaches the patient, that alone justifies their entire salary,” said Dr. Darling.

Rustin Morse, M.D., a pediatric emergency medicine physician and the hospital’s chief quality officer, has practiced for more than 15 years and joined the ER at Children’s two years ago. This is the first time that he has worked in an ER where pharmacists work side by side with physicians around the clock.

Katelyn Dervay, Pharm.D., BCPS and Mary Finocchi, Pharm.D., BCPS, works with the Tampa General Hospital ER team to ensure that a patient’s medication needs are met.

“They’re in the same locations, they see and talk to the patients and their families, so they have a full understanding of the clinical situation, instead of simply reviewing charts,” said Dr. Morse. “There’s also a world of difference between having a personal relationship with a pharmacist vs. just talking to him or her by phone.”

Sometimes that depth of understanding encompasses small details that make big differences, noted Dr. Darling, citing examples such as when a pharmacist learned that a child was more likely to take a crucial medication when it was mixed with applesauce, or that a drug prescribed for nighttime dosing caused fewer side effects if it was taken in the afternoon.

Such knowledge can be gleaned only by direct interaction with patients and families, according to Dr. Morse.

“ED pharmacists also play an important role in ensuring that the right medication gets to the right patient at the right time,” said Vicki Basalyga, Pharm.D., BCPS, director of ASHP’s Section of Clinical Specialists & Scientists.

ED pharmacists can ensure that important medications such as first-dose antimicrobials in septic-appearing patients are available, dosed, and administered correctly, she said. When speaking with patients, a pharmacist obtaining  a medication history can identify time-sensitive medications such as anti-epileptics and avoid potential adverse events if a dose is missed, Dr. Basalyga added.

And the benefits to the patient and fellow healthcare providers don’t stop there, according to Dr. Morse, adding that oral-to-intravenous dose conversions calculated by pharmacists are invaluable, time-saving measures for medical residents. ER pharmacists at Children’s train with respiratory therapists and conduct pre- and post-respiratory therapy assessments as well as review all positive bacterial cultures that originate in the ER and recommend suitable antibiotic treatment.

“Someone with this kind of expertise makes my life a lot easier by recommending the appropriate antibiotics,” said Dr. Morse.

The benefits of having pharmacists in the ER or ED can be as individual as the care setting and as dynamic as the healthcare problem that a patient is presenting. For example, Dr. Meehan at the University of Illinois Hospital in Chicago values many of the contributions of his ER pharmacist, including:

• Quickly performing accurate dose calculations and expediting delivery of essential drugs from the central pharmacy during the treatment of stroke or cardiac arrest patients who may need thrombolytic therapy,
• The ability to prepare medication doses quickly and accurately during code situations, and
• The fact that for  polypharmacy patients, pharmacists are naturally on heightened alert for the threat of dangerous drug interactions as well as complementary drug combinations. “Those considerations aren’t at the forefront for physicians, but pharmacists are intimately aware of them and able to intervene when necessary,” said Dr. Meehan.

The expansion of ED and ER pharmacy services is just beginning, added Dr. Musselman: “It’s becoming a necessity, and we’ll see the trend accelerate. Accrediting bodies will start asking why a hospital doesn’t have ER pharmacists rather than why they do.”

–By Steve Frandzel