Pharmacists in the Emergency Department: Feasibility and Cost

The study by Ling and colleagues was performed in an ED setting more closely matching this study’s setting and was a larger, well powered study. As with the Lee study, it was difficult if not impossible to obtain exact numbers on the expenses each pharmacist recommendation spared the hospital and/or patients.³¹ Not all drug interactions avoided would have led to symptoms, reevaluation, or hospitalization.³⁵ Not all drug “allergies” avoided are true allergies (as seen dramatically by Raja and colleagues), and thus this action may not have spared any cost at all.³⁶ In the end, however, the estimates provided by both studies are averaged over many patients and thus provided the best numbers available.

Unlike the Lee study, this pilot did not evaluate the medication cost differences between original treatment and the new recommended treatment. Given the small number of patients with whom significant changes were made in this study, evaluating the cost differences between the treatments would likely be insignificant. A larger study, such as Lee, was much more sufficiently powered to evaluate such a figure.³⁰

Of note, in this pilot there were no cases seen in which there was any change in route of delivery, ie, IV to equivalent po treatments. This is typically a large source of cost savings secondary to reduction in equipment and nursing time. The Lada study found 66 such changes among 2,150 pharmacist interventions in the ED.¹⁵ The authors hypothesize that had their pilot been conducted over a longer period, significant cost savings would have resulted from similar interventions.

In this pilot, a significant number of patients presented for prescription refills. Veterans often prefer to fill medications at the VA pharmacy because of reduced cost and often bring prescriptions written by private sector physicians. These veterans are required to have a primary care physician assigned within the VA, but until they have their initial intake appointment, they use the ED for these prescriptions. Additionally, veterans from other VA locations presenting as visitors to the area or relocating to the city and not yet assigned to a primary care physician require their medication lists from other location(s) be accessed and reentered into intrafacility computerized ordering systems. Given these particulars of VA operation, the authors’ facility assuredly sees more patients presenting for prescription refill than nongovernment facilities. Thus our savings with this particular task may not be generalizable to settings outside the VA, at least in as high a number of encounters.

CONCLUSIONS

About 37,000 veterans received care at the ED of the Atlanta VAMC in 2011. Given these numbers and the evidence that EDs have some of the highest rates of preventable ADEs of any clinical environment, the presence of a clinical pharmacist in the ED is a necessary intervention, based on safety considerations alone. In addition to providing a needed layer of safety in the vulnerable ED environment, a clinical pharmacist likely provides a cost saving benefit to the ED, as demonstrated by this pilot and other studies. Further, the overwhelmingly positive response to this pilot by the veterans who participated shows that they want and need this service. Adding a clinical pharmacist to the ED is integral to the VA mission of providing patient-centered care. A larger study to obtain a more precise cost savings benefit within the VA system should be considered.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.