Pharmacists in the Emergency Department: Feasibility and Cost

Clinical pharmacists have expanded their role over the past few decades in both outpatient and inpatient settings and are now members of an interdisciplinary health care team that includes nutritionists, physical therapists, physicians, and nurses.^1,2 The emergency department (ED), however, has lagged behind in the inclusion of pharmacists.³ Despite well documented financial and ED operational benefits of pharmacists and the recommendation of their inclusion by the Institute of Medicine, only about 30% of academic EDs in a 2009 survey employed a pharmacist.^4-8 A larger 2005 survey of 510 hospital pharmacy directors revealed that only 3.5% of hospitals sampled (academic and nonacademic) provided clinical pharmacy services in the ED.⁹

About 3.8 million annual preventable medical errors occur in the ED, giving the ED the highest rate of medication errors among all hospital departments.⁴ In 2000, Schenkel found that 3% of all inpatient medication errors were initiated in the ED.¹⁰ Similarly, Chin and colleagues found that 3.6% of elderly patients were administered an inappropriate medication in the ED with 5.6% receiving an inappropriate prescription at discharge.¹¹

In a 2008 study conducted at the Durham VAMC in North Carolina, Hastings and colleagues found that suboptimal pharmacy was common among elderly veterans discharged from the ED (11%) and that potentially inappropriate medication use was associated with a 32% greater risk of repeat ED visits, hospitalization, or death (P = .10).¹² In 2010, Rothschild and colleagues found 7.8 medication errors per 100 ED patients or 2.9 errors per 100 prescribed medications.¹³ Despite this unacceptably high rate of medication errors, most EDs do not employ pharmacy specialists or have a pharmacist easily available for consultation—options that could not only streamline ED operations, but also reduce patient risk.

The pharmacist role in the ED has changed considerably. In the 1970s, ED pharmacists were used mainly to dispense medicine, maintain inventories, and participate in cardiopulmonary resuscitation.^3,14,15 Today, following the guidelines set by the American Society for Health-System Pharmacists, emergency pharmacists have an expanded, more direct role in patient care and evaluation and support of the physicians and other ED staff who work alongside them.^4,14,16,17 Pharmacists gather accurate and complete medication histories, review and reconcile medication lists, and screen ED medication orders for errors or anticipated drug interactions.^13,18-23 They adjust medication doses on a patient-by-patient basis, accounting for renal and hepatic clearance and closely monitor patients for treatment response. They also provide one-on-one patient education on medication dosing, administration, adverse drug events (ADEs), and interactions, increasing patients’ drug knowledge and adherence.^17,24 Pharmacists provide information to patients on vaccinations and medication assistance programs, which is unlikely to be shared by other providers.^3,19,20 Pharmacists in the ED reduce medication delays and omissions that occur in admitted patients staying in the ED.^25,26

Aside from patient education, clinical pharmacists have an important role in providing education and consultation to ED physicians, midlevel providers, and house staff on topics that include availability of new medications and local antibiotic resistance patterns.^14,27-29 Additionally, pharmacists monitor drug supplies and restock medications to avoid shortages during critical moments, offer the ED perspective in hospital formulary reviews, and increase efficiency and throughput in the ED while decreasing costs by evaluating and treating patients who present simply for prescription refills alongside a supervising physician.¹⁴

With this in mind, the ED of the Atlanta VAMC in Decatur, Georgia, conducted a pilot study to assess the financial and logistic feasibility of a full-time pharmacist in the ED setting with the hope that a pharmacist would integrate well into the health care team, reducing overall departmental expense and the risk of medication error associated with patient harm and simultaneously improving patient satisfaction and departmental efficiency.

Methodology

The ED of the Atlanta VAMC is part of a tertiary care teaching hospital affiliated with both the Emory and Morehouse schools of medicine. At the time of the pilot, the facility had 128 acute care medical/surgical beds, 12 inpatient palliative care beds, 40 acute care psychiatric beds, 24 medical surgical intensive care unit beds, and 60 inpatient nursing home beds. The ED provides care to > 37,000 veterans annually, and in December 2011 when this study was conducted, 3,195 veterans were seen in the ED.

The ED was divided into the main ED and the urgent care. Patient intake occurred through a centralized triage, and based on acuity, patients were sent to the appropriate setting for treatment. The ED used a 5-tier triage system. Patients with triage levels 1, 2, and 3 were sent to the main ED, and patients with triage levels 4 and 5 were sent to the urgent care.