Core Competencies in Health-System Pharmacy: Pharmacy Practice in the Emergency Department

INTRODUCTION

The practice of emergency medicine is relatively new with first reports of organized practice in the 1960s. In subsequent decades, care provided in emergency departments (EDs) increased rapidly for a variety of reasons, some which are still present: disparities in health-insurance coverage, lack of physician access for the poor and minority patients, and easier access to care.

In this program, the history of emergency medicine clinical pharmacy practice is presented, along with related evidence of clinical, safety, and financial benefits of pharmacist activities in the emergency department.

EMERGENCY MEDICINE CLINICAL PHARMACY PRACTICE: A BRIEF HISTORY

The implementation of Medicare and Medicaid in 1965 was a primary factor in both creating and accelerating the demand for care in EDs, as rapid increase in insured patients caused a shortage of primary care providers who could care for them. This surge in patients led to a reorganization of existing health-systems supporting a specialized area of the hospital capable of handling not only emergencies, but many aspects of primary care as well.

In the late 1970s, emergency medicine was first recognized by the American Board of Medical specialties as a board-certified specialty. The federal government further ensured access for all patients to emergency care through the passage of the Emergency Medical Treatment and Labor Act (EMTALA).1 Over the following decades, emergency medicine further developed as a specialty in an effort to meet unique needs of patients, with subspecialties and advanced health care specialists emerging, and pharmacists increasingly joining the health care team in the ED.

The first report of pharmacy practice physically located within an emergency department was published in 1970s. Elenbaas et al.2 reported on an implementation of an emergency clinical pharmacist (EPh) in the ED. Results of a survey of ED personnel showed universal support of the pharmacist as a component of the department by the nursing and physician staff. Survey participants felt strongly that the EPh was an important team member in the ED and was beneficial to patient care and educational programs. Further, the ED providers supported the notion that the EPh could independently provide primary care once a diagnosis was established and charge for such services, and that such services could be replicated in other EDs.

While the early clinical pharmacy models in the ED focused on medication distribution, recognition and utilization of pharmacists as medication experts soon followed. The role of EPh broadened in the following decades to include direct patient care activities.3 For example, today it is common for EPhs to be involved in bedside assistance with patient evaluations, direct participation in resuscitations, and timely patient-specific consultation to providers, nurses, and patients and their families.4 EPhs are also involved in the care of patients discharged from the ED through antimicrobial stewardship culture assessments and patient follow-up.3

Recent studies and systematic reviews have thoroughly documented EPh’s positive impact on important patient and institution-level outcomes (i.e., clinical, safety, and financial).3,5 Nevertheless, in addition to direct patient care, the EPhs continue to provide usual pharmacy services (e.g., order processing, medication history reviews) and serve as liaisons between the departments of pharmacy and emergency medicine.4

The bedside presence of EPh has also steadily increased over the past few decades. Practicing EPhs today are found in both academic and community hospitals.4 While virtually no specialty residency training programs existed in the early 2000s, more than 70 postgraduate year 2 (PGY2) emergency medicine pharmacist training programs are now available to trainees in the United States.6

The patient benefit provided by having an onsite EPh in the ED did not go unnoticed by professional organizations and societies. In 2005, the Agency of Healthcare Research and Quality (AHRQ) funded an investigation into optimization of EPh practice and the development of a toolkit for justification of EPh practice in individual institutions. The publication and initiatives derived from this grant in subsequent years increased the EPh national visibility and contributed significantly to the expansion of EPh services.3

The American Society of Health-System Pharmacists (ASHP) soon followed with additional support providing resources and opportunities for continued EPh development. Additionally, the first guidelines on EPh practice were published by ASHP.7

In October 2014, the American College of Emergency Physicians (ACEP) unanimously passed Resolution 44 titled, “Support for Clinical Pharmacists as Part of The Emergency Medicine Team.” ACEP in 2020 formally recognized the historically important role that the EPh has had in the ED and advocated for dedicated pharmacists trained in emergency medicine.8

In October 2017, the American College of Medical Toxicology (ACMT) formally supported the practice of EPh with an organizational position statement.9 The ACMT recognized the benefits of EPh and called for dedicated EPhs staffing EDs 24 hours per day as well as research into pharmacy practice in urgent care areas and observational units.

Most recently, in 2020 the Board of Pharmacy Specialties formally recognized emergency pharmacy as a new pharmacy specialty. Practicing EPhs will be eligible for board certification starting in late 2022.10

The practice of EPh continues to be a rapidly expanding field. In the past few decades, overwhelming evidence has accumulated supporting patient and institutional benefits of EPh’s bedside presence. Furthermore, EPh practice has also spread outside of the United States, with similar reports from Canada, Australia, Europe, Africa, and the Middle East.11 With an aging population and an increasing complexity of patients’ medication regimens, there continues to be a clear need for widespread EPh practice.

EFFECTS OF EMERGENCY MEDICINE CLINICAL PHARMACISTS ON OUTCOMES

Barriers to Implementation and Financial Outcomes

One of the initial obstacles of starting a new EPh service is the concern over ED staff’s acceptance of the pharmacist. There may be concerns about delay in care due perceived delays that may come with pharmacist’s oversight of the medication use process in the ED. However, multiple studies have disproved this notion and shown that EPhs are highly valuable team members and that their work is perceived as worthwhile and cost-effective.12,13 Furthermore, as discussed later, EPhs have been proven to expedite care, especially in treating time-sensitive disease states.

Nevertheless, EPhs are expensive, and understandably, many health systems may hesitate in allocating resources for such a costly intervention. However, All of the financial outcomes data to date show that the benefits of EPhs far outweigh the associated costs.14–16 Ling et al.14 found that EPh’s interventions resulted in more than a half million dollars of annual cost avoidance. This was primarily achieved by clinical dosing corrections, consultations, allergy documentation, and formulary enforcement. A larger effect was found by Lada and Delgado,15 who reported an annual cost avoidance of more than $3 million was reported with similar interventions. Additionally, Aldridge16 reported close to $2 million in annualized cost savings with comparable interventions. While these studies must be interpreted in the light of their economic assumptions and limitations, multiple studies from a variety of emergency medicine settings have reported savings that more than justify an EPh’s salary.

Medication Safety

The ED is a unique clinical environment in which patients — including some who are critically ill — are frequently treated in a limited resource setting with timing to therapy and monitoring being critical (e.g., sepsis, stroke). The ED has been cited as an area of the hospital with frequent medication errors and adverse drug events.17 The reasons for this are multifactorial. For example, patients are seen 24 hours per day in an environment with frequent interruptions. Medications are often given at the point-of-care, bypassing the usual safety mechanisms offered to patients in other parts of the hospital (e.g., pharmacist verification, bar-code scanning). Recently, EDs have experienced prolonged waiting times, overcrowding, and increased boarding (i.e., patients admitted to the hospital but physically located in the ED for extended periods of time due to lack of hospital beds).

For those and other reasons, ED environments have been associated with decreased adherence to guideline-driven therapy, poorer patient outcomes, and an increase in medication errors.18,19 Additionally, ED encounters may be the patient’s first interaction with the health system. Such patients are often undifferentiated, with limited or unavailable past medical history. Patient’s medication lists may be incomplete or retrievable only from pharmacies or institutions that are not reachable at all times of the day. Medication errors in the hospital setting, including the ED, remain the most frequent type of error. The data support that the majority of medication errors do not result in obvious patient harm; however, when errors result in harm, it can be devastating.20

In the ED, errors may occur at multiple points in the medication use process. Most commonly, errors originate during prescribing. For example, a provider may prescribe an order to the wrong patient due to having multiple patient charts open in the electronic health record. In hospitals that do not use electronic health records, an error may also occur during transcribing. A pharmacist or nurse may misinterpret the physician’s order and dispense or administer an incorrect medication. Administration is yet another common area for medication errors. A task saturated nurse may inadvertently bypass the pump safety mechanisms and give a drug faster than the recommended rate (e.g., vancomycin resulting in infusion-related reactions). Additionally, a pharmacist may dispense an incorrect medication resulting in an error (e.g., dispensing hydralazine instead of hydroxyzine).

In 1999, the Institute of Medicine published a national report, “To Err Is Human: Building a Safer Health System,” highlighting the problem of medical errors in U.S hospitals.20 Since then, many medication safety interventions and cognitive error reduction strategies have been studied and developed. Some examples include advancement of electronic health-records and data sharing, introduction of bar-code scanning at the point of care, and cognitive forcing strategies (e.g., distinct labeling, tall-man lettering). However, as patients’ medication regimens are increasing in complexity, medication errors still occur.

In many parts of the hospital, including the ED, the addition of clinical pharmacists to the medical teams has been proven as a systematic and cost-effective intervention that can reduce errors and improve patient outcomes. The inclusion of EPh on the ED team leads to increased error reporting, error interception, and a decrease in medication errors overall. A large body of prospective and retrospective evidence has shown important beneficial medication safety outcomes associated with the EPh’s bedside presence.3 Most errors in the ED are caught by the EPh during consultative activities or during prospective order review. The frequently reported areas where EPh intervene include dosing corrections, identifying drug omissions, and incorrect frequencies (e.g., adjustment for renal dysfunction). One study found an alarming rate (47.8%) of intercepted medication errors that could have led to significant patient harm.21

The presence of EPh is especially important in hospitals with training programs. In one study,22 the EPh frequently intervened on prescription errors written by emergency medicine residents compared with those written by attending physicians. The EPh expertise is also frequently used in departmental educational activities of physician and nursing trainees.3 Further, it is not uncommon for the EPh to be involved in national emergency medicine meetings providing education seminars on error reduction and pharmacotherapy optimization in the ED.

CLINICAL OUTCOMES

Stroke and Myocardial Infarction

The common adages in treatment of myocardial infarction and stroke are: “time is [heart] muscle,” and “time is brain [tissue],” conveying the importance of decreasing interruptions in getting the patients on definitive therapy that can minimize loss of brain and heart muscle tissue. The EPhs have been found to reduce times to treatment for both of these time-sensitive, devastating conditions.

The presence of EPh bedside presence has been correlated with decreased door-to-cardiac catheterization laboratory times. In one study, patients were stented 11.5 minutes faster when an EPh participated in an ST-segment elevation myocardial infarction, or STEMI, codes in the ED.23 Another study found that EPh participation in code strokes decreased door-to-alteplase times by an average of 20 minutes, and significantly increased the proportion of patients receiving treatment in less than 60 minutes (absolute increase of 15%).24

Acute ischemic stroke and myocardial infarction treatments are guideline-driven diseases with time-sensitive interventions that have a direct impact on patient outcomes. For example, rapid treatment of ischemic stroke with alteplase in qualifying patients has been associated with improved functional outcomes. Rapid reperfusion of coronary arteries in patients with ST-segment elevation myocardial infarctions is associated with decreased mortality and future morbidity. Nevertheless, the EDs are a resource limited environment and often delivering multiple interventions in a matter of minutes can be challenging.

The EPhs are involved with assistance with decision-making, drug preparation and administration, and anticipation of complications during the treatment of STEMI and stroke. Besides thrombolytics in stroke, patients have stringent inclusion and exclusion criteria that need to be addressed. The EPh often actively screens patients for medication-related issues (e.g., anticoagulation contraindications) and alerts the neurology and ED teams. Furthermore, patients presenting with ischemic stroke may often experience complications in need of acute treatment with medications, such as severely elevated blood pressure or need for emergent intubation in patients with an unstable airway. Patients presenting with hemorrhagic stroke are also often in need of similar interventions, including prompt reversal of anticoagulation with drug-specific reversal agents. The EPh involvement at the bedside and as part of a comprehensive and collaborative team clinically and administratively can streamline care and provide evidence-based interventions in these patients.

Rapid Sequence Intubation

Patients presenting to the ED with respiratory distress or arrest need emergent securing of their airway and breathing. Most often this is done with rapid sequence intubation, or RSI. During RSI, patients are rapidly administered a sedative and a neuromuscular blocker to facilitate placement of an endotracheal tube (colloquially referred to as a “breathing tube”). While RSI encompasses multiple sequential steps other than selection and administration of drugs, medications given before, during, and after RSI play a key part in this procedure.

The medications used for induction, such as a paralytic and an anesthetic, differ pharmacokinetically. A common combination is etomidate (an anesthetic) and rocuronium (a paralytic). Etomidate renders a patient unconscious, while rocuronium relaxes the muscles facilitating the passage of the endotracheal tube into the trachea without gag and potential aspiration. The procedure is uncomfortable; patients can experience significant anxiety and pain if conscious. Once the tube is secured, the effects of paralysis from rocuronium outlast the effects of etomidate. For an individual patient, this difference in duration of action translates into a patient regaining full consciousness while still paralyzed (not able to move or gesture, yet perceiving discomfort and pain). Thus, additional analgesia and sedation can be needed to ensure patients remain unconscious while still paralyzed. Even with shorter-acting paralytics (e.g., succinylcholine), providing adequate analgesia and sedation in the post-RSI period is an important step. The lack of adequate sedation may result in complications such as self-extubation, unaddressed pain, post-traumatic stress disorder, and myocardial infarction. Unfortunately, estimates show that only half of ED patients receive sedating medications post-RSI.25

After RSI, the inclusion of the EPh on the ED resuscitation team has been correlated with increased proportions of patients receiving analgesia and sedation and also decreasing the times to administration of analgesia and sedation.26,27 While the provider and nurse may be preoccupied with numerous tasks while performing the procedure on an unstable patient, the EPhs are in a unique position to optimize pharmacotherapy needed for the procedure. Interventions as simple as having the drugs immediately available in the room or priming anticipated drips can significantly impact resuscitations.

For this role, EPhs need a fundamental understanding of pharmacokinetics and pharmacodynamics of commonly used medications for RSI: etomidate, ketamine, midazolam, succinylcholine, rocuronium, vecuronium, propofol, fentanyl, and others. Besides knowledge, EPhs must be skilled in rapid drug preparation, equipment manipulation, interpretation of monitoring parameters, and drug administration. As patient responses during RSI are unpredictable (e.g., patient arresting during the procedure), medication optimization of pre-RSI conditions and rapid contingency implementation when the procedure does not go according to plan are an essential skill for the EPh.

During the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, proper intubation procedures have become even more challenging in the ED. It is important to note that the EPhs (together with ED, intensive care, and anesthesia colleagues) are exposed to a hazardous environment, especially during RSI. RSI is a high-risk procedure associated with potential aerosolization of patient's secretions that may be infectious. It is important for the EPh to follow strict garbing of personal protective equipment during RSI, especially when assisting with the intubation of patients suspected of being infected with SARS-CoV-2. Leaders of the departments of pharmacy need to recognize the unique hazardous environment the EPhs face and ensure adequate institutional, protective, and moral support.

Sepsis

Sepsis is a potentially life-threatening systemic response to an infection. Patients with sepsis commonly present to the ED with an estimated 850,000 presentations per year.28 The ED is an important clinical area in the treatment of sepsis as rapid recognition and initiation of fluids, antibiotics, and vasopressors have been associated with decreased mortality.

Studies have shown that the EPh presence in the ED has been associated with decreased time-to-antibiotic administration in patients diagnosed with sepsis.29 While prompt administration of antibiotics is paramount, the selection of the correct antibiotic is also an important factor. The EPh presence has also been associated with a higher rate of guideline appropriate antibiotic administration.29,30

In my institution, the EPhs are similarly involved in the treatment of patients suspected of sepsis. The EPh, pharmacy resident trainees, and pharmacy students actively screen the ED roster for patients who meet systemic inflammatory response syndrome criteria (i.e., temperature, tachycardia, white blood cell count, and respiratory rate). The screening is supplemented by the electronic health record, which flags the user whenever a threshold value is exceeded through a best practice advisory warning. When an abnormal value is identified, the patient record is reviewed by the EPh and additional information is sought from the patient, nurse, or the treating provider. If there is high suspicion for sepsis and antibiotics have not been ordered, the case and medication selection are discussed with the ED provider. If antibiotics are indicated, the pharmacy team expedites the approval and bedside delivery of the antibiotic.

While the majority of patients with sepsis are diagnosed clinically, EPh rounding and monitoring supplements the primary diagnostics and treatment carried out by the ED provider. In my institution, this collaborative effort aided by best-practice electronic advisory helps with antibiotic selection and expediency, leading to a decreased length of hospital stay in patients with sepsis.31 As patients with sepsis often receive multiple interventions (e.g., fluids, antibiotics, vasopressors), the EPhs are frequently consulted regarding additional interventions. For example, a frequent nurse consult in a patient with limited intravenous access is the compatibility of different medications administered simultaneously into the same line. Medical residents often seek EPh consults regarding medication selection, dosing, and navigation of local antibiograms and guidelines.

Antimicrobial Stewardship

Approximately 1 in 6 patients evaluated in and discharged from the ED are prescribed an antibiotic.32 During the index ED visit, such patients are evaluated, cultures of suspected site(s) of infection are collected, and patients are discharged home on an antibiotic regimen. Because cultures require time to incubate and yield results, prescribing of outpatient antibiotics from the ED is most often empiric without knowledge of causative organism or antibiotic sensitivities. Once culture and sensitivity results are available, clinicians need to interpret these promptly, re-evaluate the patient’s index visit, follow-up directly with the patient, and adjust antibiotic regimens. As patients presenting to the ED often do not have primary care follow-up, these actions become the responsibility of clinicians caring for them in this setting.

Inclusion of EPh in the culture follow-up programs has yielded impressive results. Dumkow et al.32 showed a significant decrease in patient hospital revisits at 72 hours and 30 days when the EPh was involved in evaluation and tailoring of antibiotic regimens post-ED discharge. The difference was especially significant for uninsured patients, for whom ED revisits had a 12.9% absolute reduction in the EPh group. Similar results were achieved by Randolph et al.,33 with a 12% absolute reduction of unplanned readmissions to the ED. Baker et al.34 showed that EPh involvement decreased the time to follow-up by 1 day and resulted in faster notification of patients and their primary care providers. Both Davis et al.35 and Miller et al.36 reported an approximately 30% increase in interventions of inappropriate antibiotic treatments.

The inclusion of the EPh in ED culture follow-up is common, but programs differ. For example, the EPh may be the only clinician tasked with coordination of culture follow-up. In my institution, the practice is collaborative, with a discharge nurse coordinator tasked with triaging of cultures and direct patient follow-up. All positive cultures are discussed with the EPh, and if the antibiotic action plan requires a change in therapy, an attending ED physician in charge is involved. This type of multidisciplinary approach as worked best in this busy ED environment as it minimizes interruptions to nurses, EPhs, and attending physicians.

EPh ED culture follow-up is a cognitive-heavy task. The EPh actions should at least involve evaluation of the patient’s index visit and past medical history, interpretation of initial diagnostics and treatment decisions, evaluation of laboratory values, current medications, drug interactions, and patient-specific issues (e.g., age, insurance coverage, follow-up). Additionally, these actions are time-sensitive and appropriate actions need to be implemented to prevent patient harm. For example, informing the patient of positive blood cultures and arranging an immediate return for reevaluation and treatment can be life-saving. Even intervening promptly on less concerning infections, such as an uncomplicated urinary tract infection, may decrease patients’ morbidity and need for additional follow-up. Robust evidence exists showing that the EPh’s presence at this critical junction is associated with positive outcomes.

Transitions of Care

When patients move from the ED to the inpatient setting or are discharged home, miscommunication and errors can occur. While such transitions of care can affect any patient, those who are underinsured or uninsured are particularly vulnerable. The ED providers treat all patients regardless of their ability to pay for the services provided. However, federal laws guiding provision of emergency care do not address issues arising during transfer out of the ED. Patients who are poor and who lack health care coverage may be affected by a sequential cascade of negative events and consequences. For example, patients who are homeless may find it hard to find food and water needed for taking their medications. Outpatient therapies, even at discounted prices, may be unaffordable. Patients also often do not have a primary care physician who can coordinate care. As such, it is not uncommon for the most vulnerable patients to frequently revisit the ED for the same complaints.

One way the EPhs have attempted to mitigate some of these issues is by creating “meds-in-hands” programs. Briefly, such programs discharge patients with a limited supply of medications upon discharge directly from the ED. Patients are able to complete a short treatment courses without additional charges or visiting an outpatient pharmacy. Hayes et al.37 reported on a successful implementation of such a program leading to 50% reduction in ED return visits measured 7 days after the index ED visit. The intervention was relatively simple and inexpensive. Common infectious conditions that can be easily treated with a course of antibiotics were identified: urinary tract infections, cellulitis, or dental infections. Upon discharge the patients were provided with free short courses of an antibiotic (penicillin, clindamycin, sulfamethoxazole-trimethoprim, and nitrofurantoin). The total cost of the program was approximately $1,100 per year, yielding a much higher annualized cost avoidance to the study hospital.

Furthermore, EPhs have made an impact in treating outpatient diseases that respond favorably to adherent medication regimens. Hohner et al.38 reported on a transition of care program for patients presenting to the ED with asthma exacerbation, congestive heart failure, or chronic obstructive pulmonary disease. Patients were identified by an EPh who provided detailed medication reviews, assessment, and education while patients were in the ED. The EPh addressed issues such as medication adherence, drug contraindications, vaccine status, medication administration techniques, and other patient-specific issues. Subsequently, patients were referred by the EPh to an ambulatory care pharmacy practice or other providers for further management. The program reported a 56% success rate with subsequent patient follow-up.

Provision of discharge prescriptions is a transition-of-care hospital process that usually does not receive inpatient pharmacy input. Providers can often send prescriptions directly to an outpatient pharmacy without a pharmacist’s evaluation and verification. While such prescriptions are ultimately reviewed by receiving pharmacists for appropriateness, outpatient pharmacists usually have less access to clinically important data that may be pertinent to medication selection and dosing. Cesarz et al.39 reported on an EPh review program of ED discharge prescriptions. During the study period the EPhs reviewed 674 adult and pediatric prescriptions. The EPh intervened on approximately 10% of prescriptions to avoid errors avoidance or optimize doses. The pediatric prescriptions were more likely to receive an EPh intervention compared to adults (23.6% vs. 8.5%, respectively). This study highlighted an important area in which the EPh can have a meaningful impact on patient care.

INTEGRATION OF EPH INTO THE ED WORKFLOW3

Each EPh program is tailored to the specific needs of the ED and the health system. While EPhs often perform similar or identical duties, subtle differences can be evident in practice. For example, EPh practice in a level I trauma center may differ from practice in trauma centers with lower designations or in EDs that do not specialize in treatment of trauma-related injuries. Likewise, EPhs working in small rural EDs may have responsibilities different from those in large academic institutions. Nevertheless, some EPh activities are common across these settings, including those described below.

Institutional Activities

The EPh serves as a liaison between the ED and the department of pharmacy. The unique position of EPhs enables them to observe the use of medications first-hand and identify ways to improve the medication-use processes. As such, EPhs are commonly involved in drug-use evaluation, medication safety, quality improvement, formulary optimization, pharmacy and therapeutics committees, hospital incident response and emergency preparedness, and departmental and trainee education. The EPh can be involved in precepting students and residents, particularly but not exclusively in academic centers. Many EPhs have affiliations as adjunct faculty with schools of pharmacy and medicine for which they provide a variety of educational activities (e.g., formal classroom teaching, bedside instruction, simulations).

Bedside Patient Care Activities

According to the ED staff, the most valued aspect of an EPh is their immediate availability in the department.12 With barriers to pharmacist accessibility removed, the EPhs are frequently consulted for medication-related issues.

The EPhs universally participate in trauma and medical resuscitation codes. EPh activity may include assistance with decision making, emergent medication procurement and preparation, assistance with administration, and patient monitoring. For example, a patient suspected of a toxic ingestion may need rapid access to reversal agents that are used infrequently. The EPh can rapidly guide the team on drug and dose selection and physically provide the antidote. For toxic ingestions, the EPh may also coordinate the initial care between the ED providers, the admitting team(s), and the local poison control center. Additionally, in resuscitation rooms, the EPhs are commonly involved with high-risk medication use in time-sensitive clinical situations (e.g., thrombolytics for stroke or pulmonary embolism, RSI during respiratory distress).

The EPh’s expertise is called upon for nonemergent issues as well. The EPh may assist with medication selection, dosing, and monitoring during procedural sedation. Nursing and physician colleagues often consult the EPh on administration details, compatibility issues, drug interactions, appropriateness of therapy, discharge medications for conditions such as hypertension or diabetes, or patient questions and concerns. In certain institutions, the EPh may also help the admitting teams with focused medication history collection.

In preparation for patient discharge from the ED, the EPhs may provide patient counseling and education. The most common patient education involves appropriate inhaler device use, epinephrine auto injector administration technique, and instructions surrounding the initiation of outpatient anticoagulation (e.g., initiating a novel anticoagulant for a newly diagnosed deep vein thrombosis). It is not uncommon for ED providers to consult the EPh to clarify insurance coverage issues prior to discharge. As described earlier, the EPh are also involved with the culture-and-sensitivity review process once the patient has been discharged from the ED.

The EPhs are involved in many aspects of patient care in the ED. From institutional policy development to bedside care of the patient, their presence is highly valued and provides meaningful improvements in medical care.

FUTURE STUDIES OF EPH PRACTICE

Available data support the positive impact of an EPh’s bedside presence on multiple important financial, clinical, and safety outcomes. The perceived disadvantages of pharmacist involvement in the ED (e.g., acceptance, finances) have been studied and disproven. However, further studies are needed to confirm benefits identified in research conducted within single institutions or facilities. While systematic reviews have combined individual studies with similar results,5 the quality of supportive evidence could be improved. Additionally, specific areas of EPh’s effects should be evaluated.

As discussed, EPh have had a profound impact on medication error identification, reporting, and interception. While medication errors remain the most common error in the ED, not all errors result in patient harm (i.e., not all errors produce adverse drug events, or ADEs). At this time, less is known about the impact of EPh on ultimate reduction of ADEs. Many ADEs remain unavoidable, and a study in an ED setting is challenging. Future rigorous studies are needed to address the EPh’s impact on this important patient safety outcome.3

At this time, EPhs are not available in all EDs, and most institutions with an EPh do not have 24-hour coverage. In a study of 187 hospitals, only 10% of respondents reported the presence of the EPh around the clock yearlong. Most respondents provided EPh services for at least 8 hours per day, usually during swing shifts or midday coverage (0900-0000).4 In busy ED environments, such as at my institution, the EPhs are used as drug experts providing frequent consultations. One of the risks of such a service is heavy reliance on the EPh for medication-related issues or “cognitive off-loading” of complicated medication-related tasks.

Upon completion of postgraduate training, residents and other new practitioners often move to hospitals with limited or no EPh coverage, potentially placing them at a disadvantage. However, most EPhs are often involved in trainee education, and this concern may be offset by formal and bedside teaching provided by the EPh. Future studies should address the validity of this concern and explore the most effective educational activities for the EPh.

CONCLUSION

The EPh has been present in EDs since the 1970s. Since then, overwhelming evidence has accumulated supporting the benefit of EPh practice in the ED. EPhs have been formally recognized by numerous professional organizations, societies, and now through board certification. The EPhs remain an invaluable health-system asset whose bedside presence reduces errors and improves important patient-specific clinical, safety, and financial outcomes.

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