When patients are admitted through the ED, the medications they are taking do not always make it to the inpatient side.1-3 “The medication reconciliation process is important to ensure that critical chronic medications are continued at hospital admission,” says Lawrence Frazee, RPh, PharmD, pharmacy residency program director at Cleveland Clinic Akron (OH) General. Medication histories were more accurate when obtained by pharmacy technicians, according to a recent study.4

Of 183 patients admitted through the ED in 2017 and 2018, medication histories were accurate just 38% of the time with the usual process (typically, a nurse reviews the medication list and updates it accordingly) and 70% of the time with pharmacy technicians. “Medication discrepancies exist in the ED, and can be identified and resolved by dedicated and trained pharmacy personnel using multiple sources,” says Frazee, one of the study’s authors.

These include electronic health records, the patient, family members, community pharmacies, and extended care facilities. “Having an accurate medication list is critical for both diagnostic and therapeutic decision-making,” Frazee says. In the ED, providers need the best possible medication history for several reasons:

• Providers will know if a medication could be causing the patient’s presenting symptoms. This can prevent misdiagnosis. For example, a patient who recently started a new diabetes medication in the SGLT2 inhibitor class presents with nausea, vomiting, lethargy, and an anion gap acidosis. There are relatively normal blood sugars, but the patient could be experiencing euglycemic diabetic ketoacidosis. “This is a known side effect of this class of agents,” Frazee notes.

• Providers can avoid serious drug interactions when choosing a treatment for a presenting problem. For instance, a patient taking the skeletal muscle relaxant tizanidine should not receive ciprofloxacin, which can lead to significantly elevated tizanidine levels and a possible severe reaction.

• Providers can recognize a medication on the patient’s list was discontinued. Often, this is because of an adverse effect. “If the patient shows up in the ED with that medication still on the list, there is a possibility that the medication could be resumed in the ED,” Frazee says. Perhaps an elderly patient with urinary incontinence is taking an anticholinergic, but an outpatient provider recently discontinued this course over concerns about delirium. “If the provider is not in the same health system, the medication may not have been removed from the list and could be continued for admission,” Frazee explains.

There are many situations when ED patients’ medications are not fully conveyed to inpatient units. In code situations, medications are pulled out of the box on verbal orders. Designating a specific person to document these medications is a good practice, says Monika Smith, DO, MBA, chief of the ED at Virtua Our Lady of Lourdes in Camden, NJ.

Medications, such as lidocaine, might start in the prehospital setting, but no one communicates this to the inpatient side. Smith suggests assigning a specific person to obtain all the prehospital data and document it in the system.

Once on the inpatient unit, a patient’s chronic medications might not continue. “Patients on medications such as chronic steroids, if interrupted, can go into adrenal crisis and hemodynamic instability,” Smith cautions.

One way to reduce these risks is for ED providers to walk up to the inpatient units with patients taking medications such as heparin, insulin, or pressors, and directly sign off on the patient with the intake nurses.

In the ED, medications might start, but perhaps no one from the ED informs the inpatient unit staff. “High-priority meds, such as insulin, sedatives, and pressors, need frequent reassessment, adjustment, and titration — as often as every five to 15 minutes,” Smith says.

These medications, if unchecked for an extended time, can produce a detrimental outcome. Bad outcomes also are possible if a medication was given in the ED, and the inpatient side does not know about it — and gives the drug again. “[For] insulin, blood thinners, or cardiac meds, overdose can lead to hypoglycemia, bleeding, and hemodynamic instability,” Smith says. 

REFERENCES

  1. The Joint Commission. Transitions of care: The need for collaboration across entire care continuum. Hot topics in health care, Issue 2. 2013.
  2. Tam VC, Knowles SR, Cornish PL, et al. Frequency, type and clinical importance of medication history errors at admission to hospital: A systematic review. CMAJ 2005;173:510-515.
  3. Smith SB, Mango MD. Pharmacy-based medication reconciliation program utilizing pharmacists and technicians: A process improvement initiative. Hosp Pharm 2013;48:112-119.
  4. Do T, Garlock J, Williams A, et al. Pharmacy-facilitated medication history program at a community teaching hospital: A pre-post study in an emergency department. Am J Health Syst Pharm 2021;78:135-140.