ASHP InterSections ASHP InterSections

July 22, 2015

Pharmacists Integrate into Geriatric Emergency Department

EDITOR’S NOTE: The American College of Emergency Physicians (ACEP) recently approved a policy supporting clinical pharmacy services in emergency departments (EDs). ACEP’s policy notes that pharmacists serve a “critical role in ensuring efficient, safe, and effective medication use,” and calls on health systems to support dedicated roles for pharmacists in the ED that involve pharmacists as active participants in patient care decisions, including resuscitations, transitions of care, and medication reconciliation. Members of the ASHP Section of Clinical Specialists and Scientists’ advisory group on emergency medicine worked with the ACEP’s New York affiliate to introduce and champion a resolution that led to the formal policy statement. The below story originally appeared in ASHP InterSections on Jan. 19, 2015.

ACEP recently endorsed the valuable role of pharmacists in the ED, including an active role in  resuscitations, transitions of care, and medication reconciliation.

ACEP recently endorsed the valuable role of pharmacists in the ED, including an active role in resuscitations, transitions of care, and medication reconciliation.


WHEN UPSTATE UNIVERSITY HOSPITAL in Syracuse, New York, began looking at adding a geriatric emergency department (ED) to Community Campus, the pharmacy department did not have to ask about participating, said director Beth Szymaniak.

“We were invited to be on the committee, and we were automatically assumed . . . to be a part of it,” Szymaniak said of the eight-bed geriatric ED, which opened in July 2013. “We just had to figure out how many FTEs [full-time equivalents] we wanted.”

The number of pharmacist FTEs in the geriatric ED is now 2, which was the pharmacy department’s original request, said the long-time director.

Pharmacist services should be an ancillary service of all geriatric EDs, according to a set of guidelines developed by two nonpharmacy organizations.

Approved in October 2012 by the American College of Emergency Physicians Geriatric Section and the Academy of Geriatric Emergency Medicine, the document “Geriatric Emergency Department Guidelines” supports dual goals for an ED specializing in the care of people 65 years of age or older:

•    Recognize the patients who will benefit from inpatient care.
•    Efficiently provide outpatient care to those who do not require inpatient resources.

The guidelines recommend completion of a medication list for all patients 65 years of age or older arriving to the ED.

The guidelines do not recommend a specific professional for completing the medication list. But they do recommend a multidisciplinary approach to managing patients who are taking more than five medications, using any “high-risk” medication, or experiencing signs or symptoms of an adverse drug event.

Nikolas Onufrak, one of the two pharmacists in Upstate University Hospital at Community Campus’s geriatric ED, said the multidisciplinary team strives to prevent initial hospitalizations and also repeat visits due to lack of comprehensive care.

Kelly_BrahamSo far, said pharmacist Kelly R. Braham, the admission rate for patients from the geriatric ED, which operates 8 a.m. to 10 p.m. daily, has decreased to 35% from an initial 42%.

Braham and Onufrak said their primary responsibility as geriatric emergency medicine pharmacists is to analyze patients’ medication regimens.

However, getting to the point of being able to analyze the regimens, Onufrak noted, requires “a little detective work.”

That means a lot of phone calls to pharmacies and physician offices and conversations with patients and family members, he said.

“We do the best we can to figure out what they actually are taking and reconcile that with the reason why they’re presenting to us,” he said. Then attention turns to assessing the appropriateness of all the medication regimens and determining whether any relate to the ED visit.

Braham said she and Onufrak pay particular attention to the overall anticholinergic burden of patients’ medications and use two tools—the STOPP (Screening Tool of Older People’s Prescriptions) and START (Screening Tool to Alert to Right Treatment) criteria—to identify potentially inappropriate prescribing in older people.

The two pharmacists also check for drug interactions before recommending interventions, she said.

And the pharmacists educate the patient as much as possible about every medication on the list and the drug’s purpose.

For a substantial percentage of the patients, said Onufrak, “there are significant [medication-related] interventions to be made at the point of care when they come into the ED.”

For a substantial percentage of the patients, there are significant [medication-related] interventions to be made at the point of care when they come into the ED.

Braham recounted one such case from just the previous week.

“He came in and he was taking both apixaban and rivaroxaban,” she said of the patient, who did not speak English.

“They were prescribed by two different providers; neither was his primary care doctor. However, he had been on this regimen since May.”

A computed tomography scan of the man’s head showed no sign of bleeding despite his taking the two anticoagulants for six months and recently falling down, Braham said.

“How he got by for that long I don’t know, but that’s something that we definitely rectified,” she said.

More common, Braham said, is the pharmacist’s recommendation to change a patient’s hypertension therapy to avoid a medication that causes orthostatic hypotension, which is a fall risk.

Onufrak said he and Braham typically see 20–30 patients over the course of a 10-hour workday. Not all of these patients are in the geriatric ED, however.

Nikolas_OnufrakAs time permits, the two pharmacists also see patients in the transitional care unit and general ED. Whether geriatric EDs lower costs remains uncertain, however.

An observational study at a community hospital in Ann Arbor, Michigan, found that after its geriatric ED opened in October 2010, patients 65 years of age or older had a lower risk of hospital admission than when that population was seen in the general ED.

But there were no differences in the risks of a repeat ED visit within 30 and 180 days. Neither was there a change in the average length of stay for those patients admitted to the hospital. The researchers reported that the pharmacists evaluated only selected patients in the geriatric ED.

A three-hospital study of geriatric EDs in Illinois, New Jersey, and New York is underway, funded with $12.7 million from the Centers for Medicare and Medicaid Services’ Innovation Center.

Known as Geriatric Emergency Department Innovations in care through Workforce, Informatics, and Structural Enhancements (or GEDI WISE), the study is projected to yield $40.1 million in cost savings.

These savings, the study investigators stated, will come from reductions in hospital admissions, readmissions within 30 days, ED visits, repeat ED visits, and days in the intensive care unit.

“Geriatric Emergency Department Guidelines” is available from


 –By Cheryl A. Thompson, reprinted with permission from AJHP (Jan. 15, 2015; volume 72, pages 92, 94)

July 16, 2015

IT Wizardry Streamlines Hospital Discharges, TOC

Wing Liu, Pharm.D.

Wing Liu, Pharm.D.

THE TRANSITION OF CARE (TOC) after hospital discharge remains perhaps the most vexing stage in the healthcare continuum. Lapses during patient hand-offs between the hospital and a patient’s home or a post-acute care facility often include incomplete information about key aspects of care. For pharmacy care, such breakdowns typically show up as multiple, conflicting, and erroneous medication lists.

At Vanderbilt University Medical Center (VUMC) in Nashville, Tenn., patient care during TOC has improved with the use of a new software program designed by Wing Liu, Pharm.D., product manager for the inpatient computerized physician order entry (CPOE) system, and his IT team.

“We asked ourselves, ‘How can we do a better job of coordinating all aspects of the transition to ensure patient care remains uninterrupted at a high level, regardless of where patients go?’” Dr. Liu said.

The Discharge Wizard app pulls together all elements of TOC into a single application.

The Discharge Wizard app pulls together all elements of TOC into a single application.

Rolled out in 2012, the Discharge Wizard application pulls together all elements of TOC into a single application, including the often daunting process of medication reconciliation.

The solution links directly to VUMC’s electronic health record (EHR), allowing clinicians to merge and exchange key information between the two IT platforms, such as patient demographics, follow-up appointments, patient core measures (e.g., congestive heart failure), healthcare team members, current medical status, bed location, and diet and exercise regimens.

The application even compels users to conduct medication reconciliation to complete the discharge process.

“It’s designed well and is easy to use,” said Amy Myers, Pharm.D., BCPS, a clinical pharmacist at VUMC.

“During the medication reconciliation process, the system allows you to choose, medication by medication, which to stop and which to continue. The result is a single, accurate medication list, which is also accessible through the EHR. That’s a huge benefit.”

Easy-to-Read Discharge Plan Streamlines Patient Handoffs

Ultimately, the system produces a discharge plan. All patients receive an easily readable discharge letter that includes medication schedules, follow-up appointments, additional care instructions, and educational material. For patients headed to a post-acute care facility, the plan is transmitted to the new healthcare providers via fax, email attachment, or with an accompanying paper record.

Nicole Callendar, R.N.

Nicole Callendar, R.N.

“One of the best features of this solution is the option to customize the discharge report based on the patient’s destination,” said Nicole Callender, R.N., staff nurse and support liaison for the application. “The orders tell the patient exactly what is needed for his or her care.”

To encourage rapid adoption of the Discharge Wizard application into the current discharge workflow, Dr. Liu wanted the app to be a model of simplicity. By all accounts, he succeeded.

Although the application is optional, biweekly utilization reports show that clinicians use it in about 95 percent of discharges. The most useful feedback about the system’s impact on workflow and patient care, he added, comes from anecdotal reports by users vs. quantitative measures.

Any member of the care team can easily launch the application through the CPOE, but only healthcare providers and select clinical pharmacists can save information. The software guides them through a sequence of fields to gather all of the relevant information needed for a discharge report. At any point, the process can be paused and restarted by another clinician, for example, in the case that a pharmacist needs to get involved in the medication reconciliation component.

Applicability to Post-Acute Care Facility Transfers

Originally, the Discharge Wizard applied only to patients discharged home. But a Centers for Medicare & Medicaid Services grant called “IMPACT: Improved Post-Acute Care Transitions” highlighted the need for an expanded role for the system to include patients transferred to post-acute care facilities. This is a patient group that is typically burdened by complex, mutable drug regimens.

Amy Myers, Pharm.D., BCPS

Amy Myers, Pharm.D., BCPS

“This is a very vulnerable population, especially for medication errors, yet it’s often excluded from TOC studies, which typically focus on patients going home,” Dr. Myers said. “It became apparent that we needed to improve our system for sending transfer orders to the new facility.” The more robust application went live in fall 2014.

Once VUMC nurses realized that using the software application meant they didn’t have to handwrite discharge orders anymore, and that patients could actually read the reports, they were sold, said Nicole Callender.

“Now, it’s part of the culture and widely embraced,” noted Callender. “It’s at the point where, if you’re a bedside nurse who doesn’t have a printed discharge letter from the Discharge Wizard to give to the patient, that nurse is going to call the provider to ask for it.”

Allie D. Woods, Pharm.D., director of ASHP’s Section of Pharmacy Informatics and Technology, said that hospitals and health systems across the country need apps and systems like the Discharge Wizard to help reduce errors and improve medication reconciliation.

“It’s critical that TOC information is shared with all healthcare providers in a single location. This system is definitely a step in the right direction for healthcare technologies,” she added.

From the perspective of pharmacy informatics, the project has been eye opening, added Dr. Liu.

“As a pharmacist, I’ve been involved in creating an application for which my role was envisioning what it should do and how to get there,” he said. “It’s taken a team of four full-time software engineers working on it to get this far, and it’s been very gratifying to see the difference that it’s made for patients and healthcare providers alike.”

–By Steve Frandzel

Editor’s Note: The project described in this article was supported by Grant Number #1C1CMS331006 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

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