Hospitals hiring more ED pharmacists

Model works well for all

Five or 10 years ago, few pharmacists would have been able to gain experience as an emergency department pharmacist, even if they had thought about that field as a specialty. But times are changing.

There are increasing numbers of emergency pharmacy residency programs. And the National College of Clinical Pharmacy (NCCP) has an emergency practice program that quickly grew from 20 members to more than 200 members in the first year of its existence.

"What we're seeing right now, and what we'll continue to see is one of the biggest growth areas for acute care pharmacy, which is a specialty in emergency medicine," says Curtis E. Haas, PharmD, FCCP, BCPS, director of pharmacy at the University of Rochester Medical Center in Rochester, NY. The medical center created the emergency pharmacist position in 2000. It also has one of the nation's earliest pharmacy emergency residency programs. Its ED has 95,000-100,000 visits each year.

"It wasn't that long ago that it was rare to have pharmacists working in the emergency department, and when you did it was as a dispensing satellite," Haas says. "What we're seeing across the country now are more and more organizations adding emergency pharmacy programs."

Emergency pharmacy residents are in very high demand when they graduate, and they have their pick of where to go in the country, Haas says.

Hospitals are scrambling to add emergency pharmacy programs, and this specialty will continue to grow rapidly, he predicts.

Emergency pharmacy medicine was such a new area a decade ago, that one emergency pharmacist says he was unfamiliar with what such a job involved when he began his hospital career as a clinical staff pharmacist, says James Jensen, BS, PharmD, emergency department clinical coordinator at Advocate Christ Medical Center in Oak Lawn, IL.

Jensen moved into emergency pharmacy as soon as the opportunity arose.

"I think it's a great area for pharmacy," he says. "It's exciting to be in the ER, and it's challenging on a day-by-day basis."

One of the chief factors pushing the increasing demand for emergency pharmacists is evidence that this can prevent medication errors, increase ED team satisfaction, and improve patient outcomes.

A recent study that observed emergency department pharmacists found that they identified 7.8 recovered medication errors per 100 patients and 2.9 per 100 medications. Most of these recovered errors involved potential adverse drug events, which were averted by the pharmacists' review of medication orders. And most of the errors were serious or significant.1

Some hospitals and studies also find cost savings with having this program.2

The use of an emergency pharmacist undoubtedly prevents some unnecessary patient care and extended lengths of stay.

But putting a dollar amount to that utilization impact is difficult, Haas notes.

"I have trouble selling those soft numbers to my administrators," he says. "They want a hard number based on actual costs and outcomes."

And the ED typically uses less expensive drugs than those used in other areas of the hospital, so showing significant hard cost improvements in drug use is challenging, he adds.

Instead, Haas focuses on how the hospital can use an emergency pharmacist to impact some of the quality markers that are important to the Centers for Medicare & Medicaid Services (CMS).

"Can we work with the ED folks to improve quality measures that we're scored publicly on?" he says.

For instance, one quality measure is how quickly the ED can move an acute myocardial infarction (MI) patient from entering the door to diagnosis and to being taken to the cardiac catheterization laboratory, says Nicole M. Acquisto, PharmD, BCPS, clinical pharmacist specialist in emergency medicine at the University of Rochester Medical Center.

Acquisto led a study into acute MI outcomes with a pharmacist present.

"What they found was that when a pharmacist is present and involved in care, then it results in patients moving through the system more quickly," Haas says. "It shortens the time from diagnosis to cath lab and from door to balloon [angioplasty] time."

The study found that when an emergency pharmacist is present, it took an average of 11 minutes less for the patient to be taken to the cardiac catheterization laboratory.

In another measure of how fast an acute MI patient receives a balloon angioplasty, the mean difference from door-to-balloon angioplasty when a pharmacist is present is 14 minutes less time, she adds.

For acute MI, 90 minutes is considered a marker for significant mortality risk. Acquisto and co-investigators found that when an emergency pharmacist was present, these patients were 3.8 times more likely to meet an adjusted door/electrocardiogram to balloon angioplasty time of less than 90 minutes. They also were three times more likely to meet an adjusted door/ECG to cardiac catheterization laboratory time of less than 30 minutes.3

The study found that having a pharmacist present was one of three factors that independently impacted the time factor for acute MI patients. The other factors were whether the >hospital had catheterization lab staff present and whether the patient arrived by ambulance, as opposed to walking into the ED, Acquisto says.

"At the time we did this study, an acute MI was a very medication-dependent emergency," Acquisto notes. "We ran heparin infusions and got the patient aspirin and beta blockers."

Now patients are moved more quickly from the ED to the cath lab, bypassing some of the interim drugs, she adds.

"The idea is to find out how to further shorten the time to get patients to the cath lab," Haas says.

References

  1. Rothschild J, Churchill W, Erickson A, et al. Medication errors recovered by emergency department pharmacists. Ann Emerg Med 2009; Epub ahead of print; doi: 10.1016/j.annemergmed.
  2. Fairbanks RJ. The emergency pharmacist: Safety measure in emergency medicine. Emerg Pharm 2007; Published online by University of Rochester Department of Emergency Medicine.
  3. Acquisto NM, Hays DP, Fairbanks RJ, et al. Pharmacists enhancing the time to cardiac catheterization laboratory and patient safety during acute myocardial infarction presentation to the emergency department. Abstract received a Best Practices Award in Health-System Pharmacy from the American Association of Health-System Pharmacists.