More pharmacist involvement needed in ED

Increased development of emergency department (ED) pharmacy services and increasing involvement of pharmacists in hospital EDs can contribute to improvements in ED shortcomings identified in a recent Institute of Medicine report on the future of emergency care in the U.S. health system. That's the conclusion of Umbreen Idrees, PharmD, at Baltimore's Johns Hopkins Hospital, and Elizabeth Clements, PharmD, Spectrum Health, Grand Rapids, MI. In a report in the Annals of Pharmacotherapy, they say pharmacy training programs must take the initiative to incorporate emergency care into their curricula to meet the predicted increase in demand for ED pharmacists. And pharmacy associations, administrators, and ED practitioners must direct research on the impact of pharmacists in EDs.

The most important issues identified by the Institute of Medicine report included ED overcrowding, fragmented emergency care system, a lack of disaster preparedness, and shortcomings in pediatric emergency care.

Idrees says those findings may be familiar to ED pharmacists, but many pharmacy departments don't routinely provide specialized care in the ED. "Pharmacists are recognized as established members of multidisciplinary teams throughout other areas of the hospital, and the impact of pharmacists on improving patient outcomes and reducing drug adverse events has been demonstrated in intensive care units, general medicine units, and ambulatory care settings," she says. "However, the ED has been an area that is largely neglected. In the 2005 American Society of Health-System Pharmacists' national survey of pharmacy practice in hospital settings, only 3.5% of hospitals had a pharmacist assigned to the ED for any period of time, with larger hospitals having a greater percentage of pharmacists assigned to the ED."

According to Idrees, the nature of care in the ED setting and the speed with which it must be rendered provide ample opportunity for medication errors. Unique system challenges in EDs that place patients at increased risk for medication errors include unfamiliarity with patients' medication; lack of pharmacist safety checks before drug administration; use of high-risk agents in emergency situations, such as thrombolytics, heparin, and concentrated electrolytes; and the use of verbal prescribing orders.

Many opportunities to improve care

"There are many opportunities for ED pharmacists to improve patient care and prevent medication errors," she says. "In addition, pharmacists in the ED can enhance patient care by providing clinical consultations, patient education, order screening, drug preparation and dispensing, resuscitation response, and staff education. Clinical pharmacy specialists in the ED can also contribute to emergency medicine research initiatives, develop medication-related procedures and protocols, promote cost-effective use of drugs, and assist in disaster planning,"

The number of people visiting U.S. EDs is growing, with a total of 110.2 million visits in 2004, while the total number of EDs to serve the population is decreasing. The Institute of Medicine said this situation can lead to serious overcrowding, which may result in patients being treated in the ED for prolonged periods of time.

ED pharmacists can review medication therapy for these patients and ensure that they receive pharmacy services similar to the services provided to patients in inpatient areas, she says. In addition, with ED overcrowding becoming a growing issue, hospital efficiency and patient flow must be maximized. "Pharmacy has an integral role in ensuring medication safety in the hospital, but these safety mechanisms are generally not extended to the ED," according to Idrees. "This could be due to either a perceived lack of need or fear of overburdening the flow in an overcrowded ED. In an already fast-paced environment, an ED pharmacist can assist with drug selection and monitoring and recommend the most safe and effective therapies."

The fragmented emergency care system is highlighted by an increase in ED management of chronic diseases and in incidence of polypharmacy issues. The episodic care many patients receive by routinely using the ED as their portal to health care has resulted in an opportunity for pharmacists to have a dramatic impact on the care of these usually underserved patients.

Address pediatric prescribing in the ED

The Report on Emergency Care for Children addresses the challenges associated with prescribing and administering medications to children in an emergency setting. Idrees says emergency care professionals have few evidence-based guidelines and information to assist with prescribing drugs for infants, children, and adolescents. She says most adverse drug events for pediatric patients are a result of errors at the prescribing stage and often involve incorrect dosing. Errors are common since doses for pediatric patients require calculations based on weight. In the pediatric emergency care setting, she says, an ED pharmacist can have a significant positive impact by providing therapeutic recommendations and assisting with dosing calculations.

"The positive impact pharmacists have demonstrated in caring for patients in critical care, internal medicine, and ambulatory departments can guide us in developing strategies to address the care provided to patients in the ED," Idrees concludes. "Since time is of the essence in ED, optimizing care for patients in this setting can reduce length of stay, morbidity, mortality, and cost."

Demand will grow

The Institute of Medicine report projects that the demand for pharmacists or pharmacy assistance will grow in the future, according to Idrees. Pharmacy associations, administrators, and ED practitioners must take the lead in defining the role of the pharmacist in this area, support initiatives to expand the role, and fund research to evaluate the impact of pharmacists in the ED. To prepare for this predicted need, pharmacy training programs should strive to incorporate emergency care into their practice sites and curricula.

The committee recommended that further assessment of emergency and trauma workforce capacity and future needs should consider optimal combinations of professional personnel, including ED pharmacists. "Many opportunities to improve patient care are available in the ED setting," she says. "Pharmacists should not only participate in, but also lead, some of these initiatives."

[Editor's note: Contact Dr. Idrees at uidrees1@jhmi.edu.]