Transcript Emergency Room Pharmacy - Idaho Society of Health

Emergency Medicine
Pharmacist Services at
Saint Alphonsus Regional
Medical Center
Jeremy Crowfoot, PhD, PharmD, BCPS
Clinical Pharmacist
Saint Alphonsus Regional Medical Center
5 March 2016
Disclosures
• I have no conflicts of interest to disclose
Learning Objectives
• Describe why hospitals should consider placing a pharmacist
in their emergency departments.
• State the value emergency medicine physicians and nurses at
Saint Alphonsus found in their emergency medicine
pharmacists.
• Recognize the services provided by emergency medicine
pharmacists and their utility to the emergency department
staff.
• Distinguish quality education sources for emergency medicine
pharmacists from less stringently reviewed sources.
Describe why hospitals
should consider placing a
pharmacist in their
emergency departments.
Hazards of the ED
•
•
•
•
•
•
•
Fast-Paced
Overcrowded
High-acuity
Stressful environment
Many distractions
Incomplete patient information
Reliance on verbal orders
Acquisto, et al. Am J Health-Syst Pharm 2015;72:2092-6.
Hazards of the ED
•
•
•
•
•
•
•
The ED has the highest rate of preventable adverse events
Compared with inpatients, twice as many medication errors
14% of errors are at least “moderate” in clinical severity
5% experience an adverse drug event
70% are considered “preventable”
From 1996-2006, ED visits increased by 32%
Number of ED providers has declined
Hafner, et al. Ann Emerg Med 2002;39:258-67.
Santell, et al. Am Soc Health-Sys Pharm. 2004;June. [Abstract].
Fairbanks, et al. Agency for Healthcare Research and Quality (US) 2008 August.
Gokhman, et al. Resuscitation 2012;83:482-7.
Chin, et al. Acad Emerg Med 1999;6:1232-42.
Brennan, et al. N Eng J Med 1991;324:370-6.
Pharmacy Practice News. Closing the Med Safety Loop in the ED. 2012. Available at:
www.pharmacypracticenews.com/Technology/Article/11-12/Closing-the-Med-Safety-Loop-in-the-ED/22094.
National Center for Health Statistics. 2012. Available at:
www.cdc.gov/nchs/data/nhis/earlyrelease/emergency_room_use_january-june_2011.pdf.
National Center for Health Statistics. 2010. Available at: www.cdc.gov/nchs/data/nhsr/nhsr026.pdf.
A Brief History of
Emergency Pharmacy
• 1970s – First pharmacist roles in the ED
• 2000s – Substantial growth
• 2004 – Seminal paper describing pharmacists’ roles
• 2007 – www.emergencypharmacist.org
• 2007 – Patient Care Impact Program from ASHP
• 2008 – Emergency Medicine Practice and Research Netrwork
(PRN) group from ACCP
Acquisto, et al. Am J Health-Syst Pharm 2015;72:2092-6.
Fairbanks, et al. Am J Health-Syst Pharm 2004;61:934-7.
Organizations Who Endorse
Emergency Pharmacists
• The Joint Commission (TJC)
• National Academy of Medicine
(previously the Institute of Medicine)
• American Society of Health-System Pharmacists (ASHP)
• American College of Clinical Pharmacy (ACCP)
• American College of Emergency Physicians (ACEP)
Joint Commission on the Accreditation of Healthcare Organizations. 2006:MM-10.
Institute of Medicine of the National Academies. Hospital-based emergency care: at the breaking point. 2007.
American Society of Health-System Pharmacists. Am J Health-Syst Pharm 2008;65:2380-3.
American College of Emergency Physicians. Clinical pharmacy services in the emergency department. 2015.
Available at:
www.acep.org/Clinical---Practice-Management/Clinical-Pharmacist-Services-in-the-Emergency-Department/.
Identified Benefits of
Emergency Pharmacists
• Reduced rates of adverse events
• Improved medication time-to-administration
• Increased adherence to evidence-based guidelines
• Improved utilization of cost-effective drug therapies
Fairbanks, et al. Am J Health-Syst Pharm 2004;61:934-7.
Lada, et al. Am J Health-Syst Pharm 2007;64:63-8.
Aldridge, et al. Am J Health-Syst Pharm 2009;66:1943-7.
Rothschild, et al. Ann Emerg Med 2010;55:513-21.
Mills, et al. Emerg Med J 2010;27:911-5.
Randolph, et al. Am J Health-Syst Pharm 2011;68:916-9.
Pantawala, et al. Am J Health-Syst Pharm 2010;67:1536-8.
Ernst, et al. Am J Emerg Med 2012;30:712-25.
Nana, et al. Am J Health-Syst Pharm 2012;69:1682-6.
Assessment Question #1
• Which of the following is the most recent – and most
substantial – major organization to declare their support for
emergency medicine pharmacists?
A.
B.
C.
D.
American College of Clinical Pharmacy (ACCP)
American College of Emergency Physicians (ACEP)
American Pharmacists Association (APhA)
American Society of Health-System Pharmacists (ASHP)
State the value emergency
medicine physicians and
nurses at Saint Alphonsus
found in their emergency
medicine pharmacists.
Initial Trial at SARMC
• Saint Alphonsus Regional Medical Center
•
•
•
•
•
•
•
•
•
•
Boise, Idaho
385-Bed community hospital
Level-2 Adult and Pediatric Trauma Center
Certified Stroke Center
Heart Center with catheterization labs
44,000 patient visits in 2011-2012 fiscal year
Four Pharmacists
1400 – 2200
Seven days per week
Six week trial
Initial Trial at SARMC
Other
19%
Dose Evaluation
Order Clarification
Medication Dosed
Treatment Consult
4%
4%
Provide Medications
5%
41%
6%
Drug Information
21%
Providers
Initial Trial at SARMC
Nurses
• ED Physicians and Nurses – Surveys
• How many times in your last 5 shifts did you consult a
pharmacist?
80%
70%
70%
60%
48%
50%
43%
40%
30%
20%
10%
9%
13%
17%
0%
Not at All
A few times
At least once per shift
Initial Trial at SARMC
• ED Physicians and Nurses – Surveys
• I made more use of a pharmacist when they were located in
the ED, as opposed to when I had to call the pharmacy.
• Physicians: 83% Agree/Strongly Agree
• Nurses: 87% Agree/Strongly Agree
• I find the emergency pharmacist to be useful for consultation
regarding medication reactions.
• Physicians: 88% Agree/Strongly Agree
• Nurses: 91% Agree/Strongly Agree
Providers
Initial Trial at SARMC
Nurses
• ED Physicians and Nurses – Surveys
• The presence of an emergency pharmacist improved quality of
care in the ED.
90%
83%
80%
70%
58%
60%
50%
40%
29%
30%
20%
10%
4%
0%
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
Providers
Initial Trial at SARMC
Nurses
• ED Physicians and Nurses – Surveys
• The presence of an emergency pharmacist during trauma and
medical resuscitations enhanced my ability to deliver safe, quality
care to patients.
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
78%
57%
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
Providers
Initial Trial at SARMC
Nurses
• ED Physicians and Nurses – Surveys
• Which of the following do you think was the emergency
pharmacists’ MOST IMPORTANT contribution to safety?
27%
Attend medical and trauma
resuscitations
39%
18%
Order review
9%
45%
48%
Being available for consult
Staff education
4%
9%
Patient education
0%
10%
20%
30%
40%
50%
60%
Initial Trial at SARMC
• ED Physician and Nurse Surveys Conclusions:
• Utilized the pharmacists more when the pharmacists are located
in the ED.
• Felt that the level of care was better and safer when a pharmacist
was in the ED.
• By the end of the trial, the pharmacists were considered part of
the ED team.
• There was overwhelming support to establish a permanent
pharmacist position.
Assessment Question #2
• Identify from the list below which service the physicians and
and nurses of the Saint Alphonsus ED stated was the
pharmacists’ most important contribution to safety:
A.
B.
C.
D.
Attend medical and trauma resuscitations
Order review
Being available for consult
Staff education
Recognize the services
provided by emergency
medicine pharmacists and
their utility to the emergency
department staff.
EMPs at Saint Alphonsus
• WHEN:
• 5 January 2014: Permanent coverage initiated
• 1300 – 2300
• Seven days per week
EMPs at Saint Alphonsus
• WHO:
• Four Pharmacists
• All four are residency trained
• All four are BCPS
• All four are ACLS certified
• Two are PALS certified
EMPs at Saint Alphonsus
• WHERE:
• LOACATION, LOCATION, LOCATION.
EMPs at Saint Alphonsus
• WHERE:
• Accessibility
• Companion phone
• Radio
• Pager
EMPs at Saint Alphonsus
• WHAT (we do):
• Significant Events
• Brain Attack
• Code Blue
• Code Sepsis
• Medical Trauma (overdose)
• STEMI
• Trauma
• Rapid responses; Cardioversions; Procedural sedations (especially
pediatric sedations), etc.
EMPs at Saint Alphonsus
• WHAT (we do):
• Meetings and Committees:
• ED Operations Meeting
• Idaho Emergency Physicians (IEP) Department Meeting
• Additional participation with:
• Trauma rounds
• Sepsis review group
• Brain Attack committee
EMPs at Saint Alphonsus
• WHAT (we do):
• Counseling Patients
• Anticoagulation
• Pregnant and breastfeeding women
• Patients with allergies
EMPs at Saint Alphonsus
Successful Intervention
• WHAT (we do):
• Antimicrobial Stewardship
Time
EMPs at Saint Alphonsus
• WHAT (we do):
• Antimicrobial Stewardship
• Start initiative to proper therapy before admission to the
hospital.
• Removed vancomycin from our ADCs
• Most were receiving 1 g doses
• Often vancomycin was the first antibiotic administered
• Reduced the number of “vanc then discharge”
• Non-biased source of information regarding new antibiotics
EMPs at Saint Alphonsus
• WHAT (we do):
• Structured education for our physicians and nurses
• Twice monthly updates on drug shortages, including
recommendations for alternative therapies
• In-services to our nursing staff at least four times a year
• Attend multidisciplinary education
• Emergency Medicine Pharmacist Letters
EMPs at Saint Alphonsus
• WHAT (we do):
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Ketamine for Pain
Animal Bites
Codeine and Pediatric Patients
Urine Toxicology Screens
Post-Exposure Prophylaxis
Tramadol
Low-dose Naloxone
STEMI Updates
Cannabinoid Hyperemsis
Beta-Lactam Allergies
Antiemetics
Antiplatelet Reversal
America’s Opioids
Idarucizumab (Praxbind®)
...
EMPs at Saint Alphonsus
• WHAT (we do):
• Protocol establishment and revision
• Sub-dissociative ketamine
• Adult critical care order set
• Post-intubation pain and sedation
• Phenylephrine IV push
EMPs at Saint Alphonsus
• What we DO NOT DO:
• We DO NOT attach IV tubing to a patient’s IV line, nor do we
push medications.
• We DO NOT regularly help move patients.
• We DO NOT complete medication reconciliation for patients,
except in unusually complicated situations.
• We DO NOT regularly verify orders for our ED.
EMPs at Saint Alphonsus
• What we do not do (yet):
• We do not manage culture follow-up, but this may soon
change.
• The pharmacist may be the ideal person to manage culture
follow-up from the ED.
• Reduced time to action on positive results
• Significantly reduces readmissions
• HOWEVER, can be time-consuming without a good system.
Baker, et al. J Pharm Pract;2012:190-4.
Randolph, et al. Am J Health-Syst Pharm;2011:916-9.
EMPs at Saint Alphonsus
• Resources:
• Through the hospital’s computers:
• Lexicomp®
• UpToDate®
• On my phone:
Baker, et al. J Pharm Pract;2012:190-4.
Randolph, et al. Am J Health-Syst Pharm;2011:916-9.
Assessment Question #3
• For all the services that emergency medicine pharmacists
provide, there are several tasks that are recommended
against. Select from the following list the task that is most
discouraged:
A.
B.
C.
D.
Administering a medication in a code situation
Assisting nurses or techs with moving or rolling patients
Providing culture review services for discharged patients
Verification of all orders placed by ED providers
Distinguish quality education
sources for emergency
medicine pharmacists from
less stringently reviewed
sources.
Education of EMPs
• Currently there are 29 accredited PGY2 residency programs.
• Emergency Medicine has two bibles:
• Rosen’s Emergency Medicine: Concepts and Clinical Practice
• Tintinalli’s Emergency Medicine Manual
• Specified Professional Networking Groups
• ASHP
• ACCP
• FOAMed
Acquisto, et al. Am J Health-Syst Pharm 2015;72:2092-6.
Pharmacy Times. 4 Things to Know Before You Become an Emergency Medicine Pharmacist. 2016. Available at:
www.pharmacytimes.com/contributor/craig-cocchio-pharmd/2016/01/4-things-to-know-before-you-become-anemergency-medicine-pharmacist.
Education of EMPs
• FOAMed (Free Open Access Medical Education)
• Blogs, podcasts, various social media platforms
• Create, share, discuss anything
• Dissemination of the most progressive information
• For Better and Worse
• Pharmacists must be aware of these discussions
Pharmacy Times. 4 Things to Know Before You Become an Emergency Medicine Pharmacist. 2016. Available at:
www.pharmacytimes.com/contributor/craig-cocchio-pharmd/2016/01/4-things-to-know-before-you-become-anemergency-medicine-pharmacist.
Education of EMPs
•
•
•
•
•
Peer-reviewed
Team of 16 PharmDs, 3 MDs
Started July 2015
New Capsule monthly
Free
Available at: www.aliemu.com
• Physician-targeted education
Education of EMPs
Recorded
Emergency
Pharmacist
educational
Series (REPS)
•
•
•
•
ASHP-certified
Started 2013
12 topics currently
Coordinated by the Section
Advisory Group on
Emergency Care
• Must be a member of ASHP
Available at: www.ashp.org/menu/PracticePolicy/ResourceCenters/EmergencyCare/REPS
Education of EMPs
• EMP-targeted discussions
• Initiated by Craig Cocchio
and Nadia Awad
• Started 2012
• Over 150 posts
• Free
Available at: www.empharmd.blogspot.com
• Not peer-reviewed, but well
referenced and leaders in
the field.
Education of EMPs
• Critical Care Pharmacisttargeted
• From “Pharmacy Joe”
• Started July 2015
• New episode Mondays and
Thursdays
• Free
Available at: www.pharmacyjoe.com
• Not peer-reviewed, but very
well referenced.
• Conservative
recommendations
Education of EMPs
• Bryan D. Hayes (@PharmERToxGuy)
• EMP, toxicologist, and clinical assistant professor at U. of Maryland
• ALiEM, Capsules, UMEM Pearls
• Craig Cocchio (@EMPharmD)
• EMP, clinical assistant professor, Tyler, TX
• EMPharmD blog, Capsules, regular Pharmacy Times contributor
• Nadia I. Awad (@Nadia_EMPharmD)
• EMP, Robert Wood Johnson University Hospital
• EMPharmD blog, Capsules
• Meghan Groth (@Empharmgirl)
• EMP, Burlington, VT
• Capsules
• Jill Logan (@EMPharm)
• EMP, Baltimore Washington Medical Center
• Capsules
Available at: www.twitter.com
Education of EMPs
• FOAM Highlights (@FOAM_Highlights)
• Daily updates on noteworthy FOAMed for emergency medicine
• ASHP Emergency Care (@ASHP_EMPharm)
• ASHP Advisory Group on Emergency Care
• Will tweet key points from talks at ASHP conferences
• ACCP EMED PRN (@accpemedprn)
• From the ACCP emergency medicine PRN
• Will tweet key points from talks at ACCP conferences
• Pharmacy Joe (@PharmacyJoe)
• From the Elective Rotation from Pharmacy Joe
• Academic Life in EM (@ALiEMteam)
• Oficial account of ALiEM and ALiEMU
• @ALiEMconf will tweet key points from EM conferences
Available at: www.twitter.com
Assessment Question #4
• From the list below, identify the peer-reviewed, medicationfocused, emergency medicine education platform that is free
to access:
A.
B.
Capsules, from Academic Life in Emergency Medicine (ALiEM)
Emergency Medicine PharmD, from Craig Cocchio and Nadia
Awad
C. Recorded Emergency Pharmacist educations Series (REPS),
from ASHP
D. The Elective Rotation, from Pharmacy Joe
A few closing thoughts
Final Comments
• Pharmacists are calming
• Do not run
• Use a strong voice
• Work at your own pace
• Maintain safety
• Your pace is probably faster than it feels
• Keep a couple of NS flushes in your pocket
Final Comments
• Stay Healthy
“In no other department are you more directly
involved with patients and their families who are at
the worst moments of their lives and depending on
you to maintain your professionalism and do your job.”
Pharmacy Times. 4 Things to Know Before You Become an Emergency Medicine Pharmacist. 2016. Available at:
www.pharmacytimes.com/contributor/craig-cocchio-pharmd/2016/01/4-things-to-know-before-you-become-anemergency-medicine-pharmacist.
Final Comments
• Stay Healthy
• Physically: Healthy Diet and Exercise
• Mentally:
• Counseling; Share Experience
• Daily Mandatory Break
• The Dreaded Burnout
Pharmacy Times. 4 Things to Know Before You Become an Emergency Medicine Pharmacist. 2016. Available at:
www.pharmacytimes.com/contributor/craig-cocchio-pharmd/2016/01/4-things-to-know-before-you-become-anemergency-medicine-pharmacist.
Thank You
• My family and my wife Molly
• Mark Phillips, Director of Pharmacy at Saint Alphonsus
• Chris Oswald and Alicia Surber
• Dr. Eric Elliot and Dr. Heather Hammerstedt, IEP
• Justin Day and the ED nursing managers
• Karl Clough, Manager of Clinical Services
• Arielle Martin and Kyle Roberts