Pharmacists in the Emergency Department: Feasibility and Cost

Pharmacists

Pharmacy services were provided by 5 residency-trained doctors of pharmacy employed by the medical center working as clinical pharmacists with the inpatient medical teams at the time of the pilot. The pilot was conducted over a 2-week period in December 2011, Monday through Friday, for a total of 10 days. The clinical pharmacists divided the days among themselves. Each pharmacist provided services for a total of 2 days, 3 hours per day, from about 3 pm to 6 pm. The pharmacists were given a room previously used as a physician workroom in which to evaluate patients.

Patient Selection

Patients to be seen by the clinical pharmacist were chosen by the triage nurse, the charge nurse, the ED physician, the urgent care provider (physician or midlevel provider), or by the pharmacists. The triage nurse or charge nurse, based on chief medical problem and acuity, chose patients directly out of triage. Only patients with triage acuity level 4 or 5 were taken directly from triage without first seeing a physician or midlevel provider. These patients presented with the chief problem of medication refill or coumadin/International Normalized Ratio check. Once chosen as appropriate for the clinical pharmacist, the charge nurse helped with patient flow, and if the pharmacist was occupied with other patients, the nurse redirected the patient to urgent care.

Additional patients were chosen to see the clinical pharmacist after an evaluation of their initial problem was completed by a physician or midlevel practitioner in the urgent care or main ED. Patients whom the provider felt could benefit from any of the following services were directed to the clinical pharmacist: anticoagulation consult, diabetic education, pharmacokinetic consult, medication history, medication reconciliation, formulary management, medication refills, therapeutic interchange, screening for drug interactions, allergy review, and nonformulary or restricted medications requests. Additionally, the clinical pharmacist reviewed the charts of patients in the main ED whom they were not asked to see. They offered assistance when needed in all the aforementioned areas and for order clarification, assuring IV compatibility, reporting medication errors and ADEs, promotion of safe medical practices, and elimination of duplicate/redundant medications.

Data Collection

The pharmacists developed a log to record their activities. The log included the date and time of the intervention, number of minutes spent with the patient, the reason for intervention, and recommendations, if applicable. They categorized their interventions into 16 categories: anticoagulation, pharmacokinetics, drug information, order clarification, medication reconciliation, therapeutic interchange, formulary management, medication history, IV compatibility, screening for drug interactions, patient education, allergy documentation, promotion of safe medical practices, reporting of medication error/ADEs, nonformulary and restricted medication requests, and prescription refills. Patients could receive more than 1 intervention.

Though not a focus of this pilot, all patients seen by a pharmacist received a postencounter survey seeking their opinion on whether the pharmacist improved the value of their visit.

Review Process

At the conclusion of the pilot, 2 independent reviewers, both physicians, reviewed the logs, and each task was reassigned to 1 of 8 categories. These categories included either medication refills or 1 of 7 other areas that had established cost avoidance estimates from 2 other well accepted studies (Lee and colleagues and Ling and colleagues).^30,31 These 7 categories included adjusting dose or frequency of medication, elimination of duplication of therapy, education/information inquiry, formulary management, prevention and management of ADEs, prevention or management of allergies, and therapeutic interchange. If the independent reviewers did not have initial concordance of classification of the intervention, they discussed the intervention and came to an agreement.

Cost Analysis

Cost avoidance estimates for 7 individual interventions were made, using data from Lee and colleagues and Ling and colleagues.^30,31 Four of these came from the study by Lee and colleagues: prevent or manage drug allergy, adjust dosage or frequency, prevent or manage ADEs, and eliminate duplication of therapy.³⁰ Lee and colleagues’ “drug interaction” group was not clearly defined, thus this was included with the “prevent or manage ADE” group. Ling and colleagues provided data for the 3 additional groups of interventions that pharmacists performed: education and information inquiry, formulary management, and therapeutic interchange.³¹

Financial estimates of cost avoidance were adjusted for inflation, using the consumer price index (CPI) of the U.S. Bureau of Labor Statistics.³² The Lee study was conducted in 2002, and estimates for cost avoidance using their model were adjusted to 2011 values using the CPI inflation rate of 25%. The Ling study was conducted in 2005, and estimates for cost avoidance using their model were adjusted for 2011 values using the CPI rate of inflation of 15.2%.³²