The nation’s emergency departments (EDs) treat over 110 million patients per year.1 Increasingly, patients are “boarded” in EDs for prolonged periods of time until an inpatient bed becomes available.2 The boarding of inpatients is a major contributor to the current ED overcrowding crisis and a significant stressor for an overburdened emergency care system. Another contributor is the use of the ED as a primary care site by many patients. The combination of critically ill patients, boarded inpatients, and those seeking primary care makes the ED one of the busiest and most chaotic of hospital environments.
In the midst of this chaos, ED patients are at risk for receiving suboptimal medication therapy compared with that provided in inpatient and ambulatory care settings. In 1999, the Institute of Medicine reported that EDs had the highest rate of preventable adverse events in hospitals.3 In an effort to minimize risks posed to patients, accrediting bodies attempt to ensure that pharmacists are involved in the medication-use process in hospitals and health systems. For example, the Joint Commission on Accreditation of Healthcare Organizations requires pharmacist review of all medication orders in hospitals unless a licensed independent practitioner controls the ordering, preparation, and administration of the medication. However, many hospitals use a liberal interpretation of this requirement to limit pharmacist involvement in the care of patients in the ED, with a resultant negative impact on patient safety. It is unreasonable to believe that, in an overcrowded ED, emergency physicians can adequately oversee the medication-use process.
The absence of consistent real-time pharmacist review of medication orders and consultation has the potential for catastrophic consequences in the ED. Chin and colleagues4 reported that 3.6% of ED patients received an inappropriate medication and 5.6% were prescribed an inappropriate medication on ED discharge. Rivera et al.5 recently reported a telling example of a four-year-old girl who received 391 mL of intravenous rather than naso-gastric GoLYTELY after ingesting 6-mercaptopurine. Would these types of errors occur if pharmacists were members of the team that provides emergency care?
There is a long, but unfortunately limited, history of pharmacist involvement in emergency care. In 1977, Elenbaas and colleagues6 described a model for integrating pharmacists into the ED. For many years, institutions such as the University of Illinois at Chicago, the Detroit Receiving Hospital, and the University of Rochester Medical Center have led efforts to develop and sustain ED-based pharmacy services. However, only a small number of hospitals currently include pharmacists on the emergency care team.7
The evolution of clinical pharmacy practice and the ongoing changes in pharmacy education provide a framework for emergency pharmacists to contribute to all aspects of emergency services, including direct patient care, emergency preparedness, health professional education, and emergency medicine research.
As in the inpatient and ambulatory care settings, emergency pharmacists should provide an additional layer of safety in the patient safety system. They should have responsibility for all aspects of the medication-use process in the ED, including comprehensive order review and dispensing. In addition, emergency pharmacists should provide drug information consultation services to providers and other clinicians, monitor patient responses to therapy, and provide patient and caregiver education.
At the community and organizational levels, emergency pharmacists should be involved in all aspects of antiterrorism and disaster planning and response. Integration of health-system pharmacy departments into organizational and community emergency-preparedness efforts is imperative. Given the nature of terrorism agents and the pharmacologic approaches to treatment of victims, a natural fit exists for the involvement of the emergency pharmacist to ensure safe and effective medication use in this setting.
Educational programs in both the outpatient care environment and the ED should allow emergency pharmacists to serve in faculty positions. The educational experiences of paramedics, medical students, and residents could be enhanced significantly if emergency pharmacists contributed to students’ understanding of medication use.
Pharmacists should also continue to make contributions to research in emergency care. A key area of focus should be the effect of emergency pharmacists’ services on patient outcomes.
Along with contributing to the body of emergency medicine research, emergency pharmacists should follow the lead of other pharmacists who are actively involved in policies related to emergency medicine.8 Emergency pharmacists should continue and grow in their roles in national organizations as they advocate for optimizing all aspects of emergency care.
Increasing the number of emergency pharmacists cannot occur without an increase in the number of ED-based training opportunities for pharmacy students and pharmacy residents. To achieve much of what we have described above, pharmacists’ expertise in the care of patients in emergency settings must be cultivated. More ED-based pharmacy residency programs need to be established. Postdoctoral training of pharmacists will provide a pipeline of clinicians, educators, and scientists who are committed to quality emergency care.
However, in assuming this role, emergency pharmacists will be challenged by a lifestyle that medical students confront when pursuing a career in emergency medicine. Emergency care is a 24–7 responsibility, and EDs are often busiest during evenings and weekends. Emergency pharmacists, like emergency physicians, will need to accept the inconveniences of working shifts in a physically grueling environment to provide patient care when it is needed most. Hospital administrators and pharmacy directors must recognize this patient care need as emergency pharmacist programs are developed.
It is time for health-system pharmacists, emergency medicine physicians, emergency nurses, and hospital executives to correct this patient safety risk that plagues our emergency care system and integrate emergency pharmacists into the patient care team.
- Copyright © 2005. American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/04/0602-1242$06.00