Emergency Medicine Clinical Pharmacist Research Articles

Emergency Medicine Physician Residents' Perceptions of Emergency Medicine Clinical Pharmacists' Involvement in Their Training.

Although the clinical impact of emergency medicine clinical pharmacists (EMCPs) on patient care outcomes is well documented, their educational impact on resident physicians' training is not. To further highlight the utility of EMCPs, this study evaluated emergency medicine (EM) resident physicians' perceptions of EMCPs' involvement in their training. A voluntary, anonymous web-based survey was sent by email to all 44 EM resident physicians in July 2022. The survey included multiple choice, 5-point Likert scale, and free response questions derived from Accreditation Council for Graduate Medical Education pharmacotherapy competency-based milestones. Thirty-six of the 44 (82%) residents completed the survey and all 10 PGY-4 class residents completed the survey. Nearly half of the respondents (44.4%) reported they consulted/interacted with the EMCPs 3 to 5 times per week and this number increased with the level of training. Respondents most often consulted the EMCPs to obtain medication indications, antibiotic dosing, pediatric dosing, and contraindications. Overall, respondents primarily reported strongly agree to all survey questions. Nearly all respondents strongly agreed the EMCPs are an important part of the patient care team and provide education that is different from what a supervising physician provides. All respondents who completed the pharmacy elective strongly agreed the elective was valuable and strongly recommended other residents to complete it. Respondents reported EMCPs are an important part of the patient care team, play a significant role in their training, and provide education that is different from what a supervising physician provides. Our findings encourage other institutions to leverage physicians' views of EMCPs to expand their service line.

Impact of emergency medicine clinical pharmacist practitioner-driven sepsis antibiotic interventions

BackgroundThe 2021 Surviving Sepsis Campaign Guidelines recommend administration of antimicrobials within the first hour of recognition of sepsis. Over the last decade, several studies have demonstrated improved time-to-antibiotic administration and antibiotic appropriateness when a pharmacist was involved in the care of patients with sepsis. To our knowledge, no studies evaluating the appropriate use of antibiotics in sepsis driven entirely by an Emergency Medicine (EM) Clinical Pharmacist Practitioner (CPP) have been published. The purpose of this study is to evaluate the impact of an EM CPP-driven protocol on antimicrobial interventions in patients with sepsis in the emergency department (ED). MethodsThis was a retrospective comparison of patients with sepsis for whom antimicrobials were ordered in the ED without pharmacist intervention to patients whose antimicrobials were ordered by an EM CPP via a sepsis consult to pharmacy. An EM CPP reviewed individual patient profiles for pertinent historical admissions, culture data, and allergy profiles to guide antimicrobial selection for the suspected source of infection and entered orders under their scope of practice with formal documentation in the electronic medical record (EMR). The primary objective of this study was to compare the rates of appropriate empiric antibiotic utilization in septic patients admitted from the ED pre- and post-protocol implementation. Secondary endpoints included the following, broadening of ED-initiated empiric antibiotics on hospital admission, time-to-antibiotic administration, in-hospital mortality, Rapid Emergency Medicine Score (REMS) association with in-hospital mortality, and hospital length of stay. ResultsA total of 144 patients were included: 80 patients prescribed antibiotics without pharmacist intervention and 64 prescribed antibiotics by an EM CPP. Appropriate empiric antibiotic selection in the ED improved from 57.5% (46/80) to 86% (55/64) with EM CPP intervention (difference 28.5%; p < 0.01). Time-to-first antibiotic administration decreased by 64 min (p < 0.01). Administration of antibiotics within 60 min, broadening of antibiotics on admission, hospital length of stay, and in-hospital mortality did not significantly differ across groups. ConclusionsIn this small, single-center study, an EM Clinical Pharmacist Practitioner-driven protocol for patients with sepsis in the emergency department improved the rate of appropriate empiric antimicrobial selection and time-to-antibiotic administration.

Emergency medicine pharmacist interventions reducing exposure to costs (EMPIRE-C)

Emergency Medicine (EM) pharmacists are considered essential healthcare providers in the Emergency Department (ED). Limited data are available representing the types of interventions performed by ED pharmacists, especially in community-based health systems. Retrospective, multi-centered, observational review of documented EM clinical pharmacist interventions into the electronic medical record (EMR) across five separate EDs between July 1, 2020 and June 30, 2021. Interventions were separated into three categories: ED Intervention, ED Outpatient Culture Review, and ED Discharge Antimicrobial Review. Interventions with supporting literature related to cost avoidance were also analyzed. A total of 23,794 interventions were logged by the EM pharmacy team between the three categories. Of those, 9181 were cost avoidance interventions resulting in $5,350,755.63 in total cost avoidance, or $582.81 per intervention. EM pharmacists practicing in community settings have a substantial impact on patients as evidenced by the large quantity and variety of interventions logged which also results in significant cost avoidance to the healthcare system.

PHarmacist Avoidance or Reductions in Medical Costs in Patients Presenting the EMergency Department: PHARM-EM Study.

A multicenter, prospective, observational study was performed between August 2018 and January 2019. Community and academic hospitals in the United States. Emergency medicine clinical pharmacists. Recommendations classified into one of 38 intervention categories associated with cost avoidance. Eighty-eight emergency medicine pharmacists at 49 centers performed 13,984 interventions during 917 shifts that were accepted on 8,602 patients and generated $7,531,862 of cost avoidance. The quantity of accepted interventions and cost avoidance generated in six established categories were as follows: adverse drug event prevention (1,631 interventions; $2,225,049 cost avoidance), resource utilization (628; $310,582), individualization of patient care (6,122; $1,787,170), prophylaxis (24; $22,804), hands-on care (3,533; $2,836,811), and administrative/supportive tasks (2,046; $342,881). Mean cost avoidance was $538.61 per intervention, $875.60 per patient, and $8,213.59 per emergency medicine pharmacist shift. The annualized cost avoidance from an emergency medicine pharmacist was $1,971,262. The monetary cost avoidance to pharmacist salary ratio was between $1.4:1 and $10.6:1. Pharmacist involvement in the care of patients presenting to the emergency department results in significant avoidance of healthcare costs, particularly in the areas of hands-on care and adverse drug event prevention. The potential monetary benefit-to-cost ratio for emergency medicine pharmacists is between $1.4:1 and $10.6:1.

Pandemic exerts emotional toll.

In areas that have been hit hard by COVID-19, pharmacists acknowledge feeling strained and worried about what lies ahead. “We have seen a lot of cases,” said Karan Raja, infectious disease clinical pharmacy specialist at Clara Maass Medical Center in Belleville, NJ. He described the intensity of the pandemic as “a very trying time.” Megan Rech, emergency medicine clinical pharmacist at Loyola University Medical Center in Maywood, IL, likewise said her hospital has “seen a lot of COVID-19 patients,” and the workplace is “more stressful than normal.” New Jersey and Illinois were the second and third states, after New York, to report 100,000 COVID-19 cases. Cook County, which includes Maywood, had the nation’s highest cumulative COVID-19 case count in late May and ranked fourth nationally in deaths, according to county-level data from Johns Hopkins University. Essex County, NJ, home to Bellville, ranked 10th nationally in COVID-19 deaths and was in the top 20 in case counts.

Physostigmine for Antimuscarinic Toxicity

Raghad Saadi is an Emergency Medicine Clinical Pharmacist at Robert Wood Johnson University Hospital, New Brunswick, NJ, and Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ. Kristin Bohnenberger is a Clinical Assistant Professor and a Clinical Pharmacist/Toxicologist at Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, and Penn Medicine Princeton Medical Center, Plainsboro Township, NJ.

Emergency medicine clinical pharmacist's impact on ordering of vancomycin loading doses

ObjectiveTo determine the impact of an emergency medicine clinical pharmacist's (EMCP) intervention on physicians' prescribing of vancomycin loading doses at an institution with limited EMCP services. MethodsThis was a retrospective, pre-post intervention study conducted at an academic Level 1 trauma center. Adult patients who were ordered vancomycin and a broad spectrum antimicrobial at the same time, within 12 h of arrival to the emergency department were included. During the three week intervention phase the EMCP lectured physicians and pharmacists on appropriate vancomycin loading doses, posted flyers in the ED physicians' work rooms, and uploaded a handout to the department of pharmacy's website. Primary analysis compared the number of appropriate vancomycin loading doses ordered before and after the EMCP intervention. ResultsThirty and 31 orders from the pre- and post-intervention study periods were included in data analysis, respectively. The number of appropriate vancomycin orders prescribed significantly increased from 2 (6.7%) to 11 (35%) following the intervention (p < 0.05). ConclusionsFollowing an EMCP intervention there was a statistically significant increase in the number of appropriate vancomycin loading dose orders prescribed by emergency medicine physicians. The EMCP's unique skill set and role within the emergency department permitted the EMCP to recognize and resolve a discrepancy in vancomycin prescribing practices. This study further highlights the importance of having dedicated clinical pharmacists in the emergency department and encourages institutions to develop, expand, and maintain EMCP positions.

The impact of an emergency medicine clinical pharmacist on nursing satisfaction.

In the United States, emergency medicine clinical pharmacists have become more common over the last several decades. Despite being a vital component of the emergency department interdisciplinary team, there is very limited information published regarding the direct impact emergency medicine clinical pharmacists have on other emergency department-based professions. To determine if the addition of an emergency medicine clinical pharmacist improves nursing satisfaction with pharmacy services. The study was conducted at a 422-bed urban teaching hospital consisting of approximately 60 emergency medicine nurses. This was a prospective study that evaluated nursing satisfaction prior to the initiation of an emergency medicine clinical pharmacist and one year after implementation. The survey consisted of 29 questions and was designed to assess three areas of pharmacy: general pharmacy, pharmacy information technology, and emergency medicine clinical pharmacy services. For the majority of questions, a 5-point Likert scale ranging from 1 representing strongly disagree to 5 representing strongly agree was utilized. Responses for the 5 point Likert scale were further tabulated into either positive or negative responses. All emergency department nurses employed during the study period (September 2015 and 2016) were eligible to participate anonymously. The main outcome assessed was the difference in satisfaction scores between study periods. A total of 52 surveys were returned over the course of the study (22 [36.7%] in the pre-intervention group versus 30 [50%] in the post-intervention group). All general pharmacy questions were improved at one year with timely resolution of pharmacy related issues, medication procurement, and satisfaction with pharmacy services achieving statistical significance. Pharmacy information technology questions were significantly improved with respect to satisfaction with the automated medication dispensing system inventory, prevention and resolution of medication stock outs, and ease of medication removal compared to baseline. The perceived impact of emergency medicine clinical pharmacy services in the pre-intervention group was validated after the one-year implementation period. An emergency medicine clinical pharmacist increases nursing satisfaction with central pharmacy and pharmacy technology services and was able to maintain the nurses' perceived expected role of the clinical pharmacist.

A study of time saved by emergency medicine physicians through working with clinical pharmacists in the emergency department

PurposeTo describe quantitatively the impact on physician efficiency when an Emergency Medicine Clinical Pharmacist (EMCP) is available to Emergency Department (ED) physicians while working under a collaborative care agreement in a Michigan-based Health System. MethodsFour EMCPs each logged and categorized their time during 14 ten hour shifts, for a total of 56 shifts or 560 total hours worked. There were nine categories observed including: culture call back, urine, blood, or other culture follow up, antibiotic changes, patient call-backs, pharmacy call backs, critically ill, and general questions. ResultsEMCPs saved ED physicians an average of 75 min per shift, with the highest yield categories being general questions (25.2 min per shift (mps), standard error (SE) = 2.67), critically ill patient service (11.5 mps, SE = 2.66), and urine culture follow-ups (11.3 mps, SE = 1.05). ConclusionsEMCPs in the ED save physicians a significant amount of time per shift, and categorically the most time saved was in fielding general questions, time spent with critically ill patients, and following up on urine cultures. The time saved by physicians could translate into more patients seen per shift.

Clinical pharmacy services in the emergency department

The emergency department (ED) is a fast-paced, high-risk, and often overburdened work environment. Formal policy statements from several notable organizations, including the American College of Emergency Physicians (ACEP) and the American Society of Health-System Pharmacists (ASHP), have recognized the importance of clinical pharmacists in the emergency medicine (EM) setting. EM clinical pharmacists work alongside emergency physicians and nurses at the bedside to optimize pharmacotherapy, improve patient safety, increase efficiency and cost-effectiveness of care, facilitate antibiotic stewardship, educate patients and clinicians, and contribute to scholarly efforts. This paper examines the history of EM clinical pharmacists and associated training programs, the diverse responsibilities and roles of EM clinical pharmacists, their impact on clinical and financial outcomes, and proposes a conceptual model for EM clinical pharmacist integration into ED patient care. Finally, barriers to implementing EM clinical pharmacy programs and limitations are considered.

Antimicrobial Therapy for Pneumonia in the Emergency Department: The Impact of Clinical Pharmacists on Appropriateness.

IntroductionPneumonia impacts over four million people annually and is the leading cause of infectious disease-related hospitalization and mortality in the United States. Appropriate empiric antimicrobial therapy decreases hospital length of stay and improves mortality. The objective of our study was to test the hypothesis that the presence of an emergency medicine (EM) clinical pharmacist improves the timing and appropriateness of empiric antimicrobial therapy for community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP).MethodsThis was a retrospective observational cohort study of all emergency department (ED) patients presenting to a Midwest 60,000-visit academic ED from July 1, 2008, to March 1, 2016, who presented to the ED with pneumonia and received antimicrobial therapy. The treatment group consisted of patients who presented during the hours an EM pharmacist was present in the ED (Monday-Friday, 0900–1800). The control group included patients presenting during the hours when an EM clinical pharmacist was not physically present in the ED (Monday–Friday, 1800–0900, Saturday/Sunday 0000–2400 day). We defined appropriate empiric antimicrobial therapy using the Infectious Diseases Society of America consensus guidelines on the management of CAP, and management of HCAP.ResultsA total of 406 patients were included in the final analysis (103 treatment patients and 303 control patients). During the hours the EM pharmacist was present, patients were significantly more likely to receive appropriate empiric antimicrobial therapy (58.3% vs. 38.3%; p<0.001). Regardless of pneumonia type, patients seen while an EM pharmacist was present were significantly more likely to receive appropriate antimicrobial therapy (CAP, 77.7% vs. 52.9% p=0.008, HCAP, 47.7% vs. 28.8%, p=0.005). There were no significant differences in clinical outcomes.ConclusionThe presence of an EM clinical pharmacist significantly increases the likelihood of appropriate empiric antimicrobial therapy for patients presenting to the ED with pneumonia.

Strategies for reducing medication errors in the emergency department.

Medication errors are an all-too-common occurrence in emergency departments across the nation. This is largely secondary to a multitude of factors that create an almost ideal environment for medication errors to thrive. To limit and mitigate these errors, it is necessary to have a thorough knowledge of the medication-use process in the emergency department and develop strategies targeted at each individual step. Some of these strategies include medication-error analysis, computerized provider-order entry systems, automated dispensing cabinets, bar-coding systems, medication reconciliation, standardizing medication-use processes, education, and emergency-medicine clinical pharmacists. Special consideration also needs to be given to the development of strategies for the pediatric population, as they can be at an elevated risk of harm. Regardless of the strategies implemented, the prevention of medication errors begins and ends with the development of a culture that promotes the reporting of medication errors, and a systematic, nonpunitive approach to their elimination.

Pharmacist-Managed Antimicrobial Stewardship Program for Patients Discharged From the Emergency Department

Positive outcomes of antimicrobial stewardship programs in the inpatient setting are well documented, but the benefits for patients not admitted to the hospital remain less clear. This report describes a retrospective case–control study of patients discharged from the emergency department (ED) with subsequent positive cultures conducted to determine whether integrating antimicrobial stewardship responsibilities into practice of the emergency medicine clinical pharmacist (EPh) decreased times to positive culture follow-up, patient or primary care provider (PCP) notification, and appropriateness of antimicrobial therapy. Pre- and post-implementation groups of an EPh-managed antimicrobial stewardship program were compared. Positive cultures were identified in 177 patients, 104 and 73 in pre- and post-implementation groups, respectively. Median time to culture review in the pre-implementation group was 3 days (range 1-15) and 2 days (range 0-4) in the post-implementation group (P = .0001). There were 74 (71.2%) and 36 (49.3%) positive cultures that required notification in the pre- and post-implementation groups, respectively, and the median time to patient or PCP notification was 3 days (range 1-9) and 2 days (range 0-4) in the 2 groups (P = .01). No difference was seen in the appropriateness of therapy. In conclusion, EPh involvement reduced time to positive culture review and time to patient or PCP notification when indicated.