Article

Using pharmacists to optimize patient outcomes and costs in the ED

a b s t r a c t

Participation of hospital clinical pharmacists in the care of inpatients is widespread, often encouraged by the dicta promulgated by regulatory bodies. For years, clinical pharmacists have ventured out of the pharmacy to participate in rounds and, otherwise, in the care of patients on hospital floors and in intensive care units. In fact, it has been well documented in many research studies published in the last 20 years that having pharmacists prospectively involved with orders generates significant cost savings for the hospital and benefit to patients. Until recently, the emergency department (ED) seemed to be a hectic environment that would be inhospitable to the careful, meticulous, and usually deliberate process of many clinical pharmacists. The potential benefits were recognized, but the pace and costs seemed prohibitive. The addition of pharmacists in the ED has reduced Medication errors and provided numerous other benefits that will be discussed in this article. We will show that recent data indicate that using an ED clinical pharmacist promotes patient safety and is cost-effective.

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Medication errors: general

For many years, medication errors in hospitalized patients have been the subject of research and proven to be harmful. Medication errors have been documented since the 1970s within the ED and are an important part of the total iatrogenic risk to patients. Identified sources for medication errors within the inpatient system include systems, personnel, and equipment errors [1,2]. A long-standing approach to reducing systems and personnel errors is the prospec- tive review of Medication orders by clinical pharmacists stationed in the hospital pharmacy. This was not thought to be feasible in EDs because of the volume, nature, and pace of the practice. As described in the study by Patanwala et al [3] in the May 2012 Annals of Emergency Medicine, order review from a distance does not appear to be the most effective form of error prevention and detection for an ED. This was thought to be due to the fast pace of medication administration as compared with the delay in documented reasons for medication use, thereby warranting the physical presence of an ED clinical pharmacist to engage in active discussions with providers of the patient.

Medication errors: by process

A number of investigators have studied the ordering and administration of medications in EDs in various types of patients

* Corresponding author. Gabrielle Jacknin, PharmD, BCPS, 1609 Ridgeway Ave, Colorado Springs, CO 80906.

E-mail address: [email protected] (G. Jacknin).

including geriatric, adult, pediatric, and trauma. A schema suggested by Croskerry et al [4,5] is commonly used as an aid in analyzing medication errors. They detail the process of delivering a medica- tion to a patient as beginning with a sequence of prescribing, then transcribing, dispensing, administering, monitoring, and ending with the discharge of medications. Consistent with the above- described process, in 2010, Patanwala et al [6] described 178 errors in 192 patients during a 9-month period with the following breakdown in errors by phase and percentage: prescribing, 53.9 %; transcribing, 10.7%; dispensing, 0.6%; and administering, 34.8%. This impressive rate suggests many opportunities for improvement. Another 4-site prospective study by Patanwala et al [3] detected

364 errors during 16 446 patient visits. Just more than one-half (54.4%) were written or computerized orders, followed in frequency by verbal orders.

Medication errors: severity

Surprisingly, many studies document a low percentage of serious adverse medication errors detected during clinical practice, although many of the medication errors intercepted in these studies have the potential for significant harm [7-9. In one study, 67% were “significant” and 15% “serious.” However, most of them were rated medium or low probability with respect to its occurrence. Hence, although a large number of medication errors were labeled significant or serious, only a small amount of them were likely to actually cause harm [10. Although this statistic is true, oftentimes “errors” are associated with a discordance between provider opinion and regulatory standards.

http://dx.doi.org/10.1016/j.ajem.2013.11.031

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Medication errors: geriatric

Geriatric patients are subject to a unique set of medication errors. The criteria by Beers [11] are a standard methodology for showing potential inappropriate medication (PIM) prescribing and have been used in several studies in elderly patients, defined as patients older than 65 years. This criterion was updated in 2012 with the specific aim of using a comprehensive, systematic review and grading of the evidence on drug-related problems and adverse drug events in older adults. This update defined the criteria of “Inappropriate prescribing” into 3 categories: Potentially inappropriate medications and classes to avoid in older adults, potentially inappropriate medications and classes to avoid in older adults with certain diseases and syndromes that the drugs listed can exacerbate, and medications to be used with caution in older adults. In a 1999 Chicago-based study, Chin et al [12] documented a 10.6% incidence of PIMs in their population. Some of the most commonly prescribed medications were diphen- hydramine, indomethacin, meperidine, and cyclobenzaprine. Ten years later in a Taiwanese study, 20% of geriatric ED patients received PIMs in similar antihistamine and muscle-relaxant groups [13]. Both Caterino et al [14] in 2004 and Meurer et al [15] 6 years later (covering 14 years in their studies combined) found 12.6% and 16.8%, respectively, of PIMs in elderly patients. Promethazine, diphenhydramine, and propoxyphene were among the offenders common to both studies.

Oftentimes inappropriate medication prescribing arises from a

lack of dose adjustment for renal function. This problem stems from the question of how to accurately predict Renal impairment in the elderly. There are 2 equations used for this function, the Cockcroft- Gault and the Modification of Diet in Renal Disease. There is much debate about the use of these 2 equations and their validity in predicting drug clearance in renal impairment. The Cockcroft-Gault uses the weight of the patient (adjust weight in morbidly obese patients), and the Modification of Diet in Renal Disease uses and adjusted body surface area. As the health care system continues to see more and more obese patients, the recommendations for Drug dosing continue to be increasingly difficult, especially in the elderly when renal dosage adjustments are more frequent and the implications of improper dosing have the potential for more Severe outcomes. Each drug has its own preferred dosing and parameters for calculation of degree of renal impairment, which is something the ED pharmacist will remain updated in and monitor for necessary changes in the ED patient’s drug regimens as well as educate the providers on the changes. New data and recommendations for this subject are constantly being made available and require someone who is diligently monitoring to stay on top of updates, and the ED pharmacist is arguably the most inclined and qualified to do such.

Many of the errors that occur in the ED itself are attributed to improper medication reconciliation or to the inability to reconcile because of the frequently incomplete databases available to the ED prescriber. Oftentimes these medication reconciliations are used for the slated inpatient medication prescribing, so errors in these can further result in medications the patient receives. Further down- stream, the patient can be discharged on these new medications, and again, if they are incorrect from the start, the error can be continued. This can result in huge costs both to the patient and to the health care system. Common among those that result in serious potential errors are medications prescribed for the control of diabetes and coagulation [16,17].

Medication history

An important component of correctly prescribing medications is knowing the medications that a patient is currently taking. Medica- tion reconciliation has been evaluated as a mechanism of reducing prescribing errors, and the ED is a natural place to have the

medication reconciliation process begin. In most EDs, a nurse either at triage or in the patient’s room (or hall) location obtains and charts patients’ medications. Mazer et al [18] studied the medication history obtained by nurses during ED triage as recorded in the electronic medical record. An independent review of this list discovered Errors of omission, commission, and discontinued medications. An alternative that some EDs are adopting is to employ a clinical pharmacist or pharmacy technician working under the direct supervision of a pharmacist to perform this function. Several studies have documented increased accuracy with this practice. Mills and McGuffie [19] found a decrease in prescribing errors per patient from 3.3 to 0.04 in their 2010 study via reconciliation. In 2009, Vasileff et al [20] studied medication histories obtained by a pharmacy researcher (clinical pharmacist, pharmacy intern, or pharmacy technician) as compared with that obtained by an emergency physician. The physicians’ histories had an average of 2.35 missed doses per patient as compared with 0.24 by clinical pharmacists. In addition, there were 1.04 incorrect doses administered per patient in the physician history arm compared with zero in the clinical pharmacist medication charting arm. De Winter et al [21] also documented the inaccuracy of the medication history obtained in the ED when obtained by physicians as compared with clinical pharmacists. The most common type of error was omission of a drug; the next most common was omission of a dose. The complete medication list with doses and schedule can help the ED providers with diagnosis, laboratory studies to order, and explanations for Abnormal test results. It is hypothesized that up to as many as 40% of hospitalizations may be the result of medication errors. If medication histories are not accurately collected, these errors cannot be identified. The patient may go home with the same medication, and the error can be repeated. Lastly, it helps streamline the admission process by providing the admitting groups with the same information.

Medication errors: education

At least some medication errors are inevitable in the unique setting of the ED for numerous reasons [22]. Emergency physicians do not have the luxury of patient continuity; they must frequently administer potentially dangerous medication, and medication orders given verbally in critical patient situations could be misinterpreted or misunderstood by the nursing staff [23. A number of authors have noted that clinical pharmacists, compared with other providers, are more likely to detect medication errors. This ability to recognize errors is important for helping to unearth system-wide problems that can be prevented in the future. Ratz et al [24] studied reporting of suspected Adverse drug reactions (ADRs) in Israeli ED patients comparing a baseline phase of physician reporting to an interventional phase in which the reviewer was a clinical pharmacist and found greatly increased reporting. There were similar results when studied by others: emergency physicians did not even report 86.2% of 29 ADRs that the clinical pharmacists rated as moderate in severity [25]. Pharmacy personnel, compared with other personnel, captured significantly more errors: 94.5% vs 5.7%, P b .001 [26].

In an extensive study, Rothschild et al [27] evaluated medication errors prospectively and retrospectively and judged degree, if any, of harm. They found medication misadventures in 7.8 per 100 patients, with potentially serious implications in 47.8% and significant in 36.2%. Brown et al [28] were able to reduce medication errors in ED patients with prospective pharmacy review by having a clinical pharmacist available in the ED for consultation; these were related to dosage calculations (29%); inappropriate dosages, drugs, routes, or schedules (26%); order clarifications (16%); and drug allergies (12%). Marconi and Claudius [29] found that a clinical pharmacist could reduce medication omission and delays in pediatric patients with more than 8-hour length of stays. Abu-Ramaileh et al [30] studied the interventions made by an ED clinical pharmacist and found that 2.3

quality interventions per 100 patients were made and importantly that the clinicians had a 93% overall rate of acceptance. Ernst et al [31] showed that when their ED clinical pharmacist was present, a 13-fold decrease in medication errors occurred.

By providing real-time monitoring and discussions of medica- tion prescribing, ED clinical pharmacists have the potential to reduce these errors a priori via nurse, physician, and advanced practitioner (including physician assistant and nurse practitioners) education. The clinical pharmacist can maximize the educational opportunities with concentration in high-risk areas determined by quality assurance studies of ED ADRs that reveal institution- specific patterns.

Value-added activities

Regulatory bodies and current regulations do not require the real- time presence of an ED clinical pharmacist but do require review of medication use and reconciliation. The many studies cited previously have shown that this can be accomplished by an ED clinical pharmacist providing real-time consultation on site and easily accessible (physically and via portable phone). When present, the clinical pharmacist can respond to all urgent alerts such as trauma, medical, stroke, myocardial infarction, and others, and can anticipate the patients’ medication needs based on current literature and hospital protocol and participate in discussions regarding medication choice based on physician findings. They can operate as a second check to all dosing and can help to keep the nurse at the patients’ bedside by preparing the medications in the room and obtaining any medications that are not immediately available in the department.

Errors in discharge prescriptions are of concern even in the modern era of technology. In a recent single-center study by Cesarz, the ED discharge prescription intervention rate by a pharmacist was more than 10%, even while using electronic prescribing, which catch all drug-drug and drug-allergy interactions, suggesting that comput- erized provider Order entry does not replace the need for a pharmacist [32]. It also exemplifies the need for oversight of prescriptions as well as inpatient orders prior to the patient receiving the medication by a pharmacist.

Along those lines, another major issue of concern to the Joint Commission is providing continuity of care for patients who are seen in the ED and discharged back into the community. The ED clinical pharmacist can help with this continuity by providing patient consultation on both the medications they are currently taking at home and new medications they are prescribed. To address National Patient Safety Goal (NPSG) 03.05.01 (take extra care with patients who take medicines to thin their blood), the clinical pharmacist should be intimately involved with all patients who are discharged on low-molecular-weight heparins with or without oral anticoagulants in the capacity of patient counseling. Not only do many foods and Over-the-counter products interact with these medications, but many patients are uncomfortable with the self-administration of an injection, both of which can be addressed by the clinical pharmacist. In addition, consultation of patients on new medications they are being discharged with helps to address the patient-centered initiative set forth by the patient surveys and scores.

The ability of the ED clinical pharmacist to assist in antibiotic usage depends on the Scope of practice in that state. Oftentimes pharmacists can enter into collaborative practice agreements with physicians that enable the pharmacist to review, evaluate, and follow-up on cultures that are resulted after the patients are discharged, thereby directing antimicrobial therapy. If the results suggest further treatment is indicated, the clinical pharmacist can make antibiotic treatment recommendations that are safe and cost-effective after assessing history, renal and Hepatic function, and allergies. He/She can correlate objective data from the patients’ visit with telephone calls to ascertain the patients’ current status. The ED pharmacist is also involved with

counseling the patients on diagnoses that are confirmed with a positive culture, particularly Sexually transmitted diseases.

The role of the ED clinical pharmacist can also involve the now- common situation of drug shortages. He/She understands the needs of the ED and can assess what alternatives are available and make those readily accessible and, on a hospital-wide basis, help to allocate medications to the ED that are necessary for patient safety. Because these shortages often occur with little notice, the ED clinical pharmacist can provide immediate, real-time, and didactic on-site education of the substitute medications’ indications, pharmacology, and monitoring parameters.

Protocol development, management of medication inventory within the department, and committee involvement in the ED and inpatient hospital are all within the scope of the ED clinical pharmacist. Medications can be prepared on site and shorten the Time to administration of critical drugs in real time. He/She can also create processes that speed the administration of drugs by creating standardized protocols that are complementary to protocols in the hospital at large and providing education to nursing staff to allow safe administration. The ED clinical pharmacist fills gaps that are unique within the practice of medicine. Implementation of pharmacy services in the ED serves as a system-level solution to major medical problems.

Regulatory influences

The NPSGs were established in 2002 by the Joint Commission (TJC) with the goal of improving patient safety related to all aspects of the patient experience in venues ranging from acute care hospitals to outpatient venues [33]. This is further mentioned in Table. Over the intervening 12 years, goals involving various aspects of patient care were released including those related to medications. Many of the medication-related goals were not required in the ED, although the inherent risk of medication delays, omissions, and other mishaps was recognized to occur in the hectic ED environment. It is assumed that this is because of the potential cost of requiring the country’s hospitals to hire sufficient numbers of registered nurses and clinical

Table

Review of NPSG in relation to ED pharmacy

2006 o NPSG Goal 8 (NPSG.08.01.01) purported to “Accurately and completely reconcile medications across the continuum of care” but was not well accomplished in the ED because of “the complexity of the ED environment and the potential inaccuracy of home Medication lists…[and that] medica- tion lists…[and that] medication reconciliation lends itself to being a resource intensive process” [37].

2009 o NPSG addressed medication administration and was enacted to “improve the safety of medications,” and specifically to “maintain & communicate accurate patient medication information …to resolve discrepancies [and] provide written information and education …at discharge” [38].

2011 o It was felt that the 2009 NPSG “was too prescriptive and detailed” so elements were revised “to remove very specific requirements and allow for the use of new accepted clinical practices” (NPSG.03.06.01), which be- came effective July 1, 2011 [36].

  • One element of performance “allows the hospital to define for itself the minimum amount of medication information that must be captured in non-24-hour settings. Such TJC- indicated settings include the emergency room.” Thus, each hospital is empowered to facilitate the administration and reconciliation of medications without specific TJC oversight [39].

pharmacists to supervise in real-time medication administration and reconciliation to the more than 120 million ED patients seen annually. In addition to NPSGs, TJC publishes and enforces medication management (MM) Standards that govern review of medications. The American College of Emergency Physicians in March 2008 reviewed and agreed with the following MM Standards: MM.4.10, MM.8.10, and MM.4.15 regarding “Pharmacist Review of Medication Orders in the Emergency Department” [34]. These standards allow hospitals and their EDs to select prospective or retrospective review by clinical pharmacists in a sample size that they deem appropriate as long as medications are appropriately ordered by health care professionals.

The data must be used to identify risk points and conduct quality improvement at least yearly.

In contradistinction, the American Society of Health-System Clinical Pharmacists feels that what is needed is a new NSPG that addresses medication issues in the ED rather than revisions to the standard because “Other patient care areas besides the ED face many of the same challenges experienced by ED practitioners. These areas may understandably feel entitled to similar exceptions, which if permitted, will eliminate the safety and control conferred by standardized processes as well as create disparities in care.” In addition, in the same document, the American Society of Health- System Clinical Pharmacists recommends “the incorporation of a pharmacist into the interdisciplinary care team in order to fully optimize the safety and effectiveness of the ED medication use process….There is an acute need for this level of service in current overburdened and understaffed ED environments, which goes beyond the basic function of prospective order review and facilitates safer, more efficient, and more effective care” [35].

Barriers

The perceived barrier to the implementation of the ED clinical pharmacist role is almost exclusively financial. It is important to note that a true pharmacoeconomic model that predicts Cost Avoidance associated with implementation of a clinical pharmacist in the ED does not currently exist. Most hospital business models rely on generated hospital charges to justify additional resources rather than patient safety and cost avoidance. The use of national data sets correlated with local data has been used to extrapolate the cost avoidance impact made by clinical pharmacist interventions. In one study, preventable medication errors incurred a median increased cost of $268 per patient [36]. In a Veteran’s Hospital, implementation of an ED clinical pharmacist was estimated to produce more than $1.5 million in cost savings, with the most common interventions related to either preventing or managing adverse drug events [37].

The financial benefit of using clinical pharmacists to reduce the risk of medication errors in patients being discharged after an inpatient stay has been shown in a randomized controlled trial by Gillespie et al [38], who found that including the clinical pharmacist in the discharge process in the intervention group compared with a standard discharge process produced a significant reduction in return visits, including ED visits and drug-related readmissions, and resulted in a cost savings of

$230 per patient. Currently, there are not any real-time studies involving clinical pharmacists’ effect on medication errors in geriatric ED patients but that group would logically have a high potential for benefit. Emergency department crowding provides another opportu- nity for clinical pharmacists to decrease error rates. Periods of crowding have been shown to have increased rates of medication errors [39,40].

Other studies have shown similar benefits of an ED pharmacist with cost avoidance using different models, estimating anywhere between $41 thousand to $3 million annually [41-45]. These data fully support the funding to staff clinical pharmacists in EDs and does not even consider the proven benefit to the safety and quality of care the patients receive.

Acceptance

Acceptance of the emergency clinical pharmacist in the ED is a critical component of any program and a potential challenge. In a Veterans Affairs hospital, ED staff initially showed resistance when clinical pharmacists were implemented into the workflow of the department. However, when surveyed 6 months later, the overall satisfaction by staff members, which included attending physicians, nurses, and medical residents, was shown to be 98% [37]. In another study, more than 90% of providers and nursing staff in an ED reported having consulted the clinical pharmacist on duty at least a few times in their last 5 shifts, and more than 98% agreed, or strongly agreed, that quality of care in the ED was improved by the presence of an emergency clinical pharmacist [46]. The experience in our ED is consistent with a very high degree of satisfaction with the functions of the ED clinical pharmacist; the implementation is appropriately managed, and this should be almost universally true for other EDs.

Conclusion

Implementation of an ED clinical pharmacist has anecdotally increased patient safety; facilitated the selection, preparation, and administration of drugs in our patients, particularly those who are critically ill; decreased the workload of physicians, physician assistants, and registered nurses; encouraged the use of medications that are more clinically appropriate and cost-effective; helped meet regulatory requirements directly relating to reimbursement rates; and reduced pharmacy costs. The literature substantiates many of these effects, as we have discussed throughout this discussion. In conclusion, having a clinical pharmacist is an essential part of the function of an ED, and the literature supports the cost of using such a position as well as the added layer of safety for the ED patient.

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