Impact of an emergency medicine pharmacist on antibiotic dosing adjustment

Published:February 12, 2016DOI:



      Overall medication-related errors in the emergency department (ED) are 13.5 times more likely to occur in the absence of an emergency medicine pharmacist (EMP). Although the effectiveness of pharmacist-driven renal dosing adjustment has been studied in the intensive care unit, data are lacking in the ED setting. The aim of our study was to evaluate the appropriateness of antibiotic dosing when an EMP is physically present in the ED compared to when absent.


      This was a retrospective cohort study of patients treated in a level I trauma center with 75 adult and 12 pediatric beds and an annual census of 90 000 patients. The study period was from March 1 to September 30, 2014. An EMP was physically present in the ED from 11:00 to 01:30 and absent from 01:31 to 10:59. Male and female patients 18 years and older were considered for inclusion if cefazolin, cefepime, ciprofloxacin, piperacillin-tazobactam, or vancomycin was ordered. The primary outcome was the composite rate of correct antibiotic dose and frequency. Statistics included a multivariable logistic regression using age, sex, presence of EMP, and creatinine clearance as independent predictors of correct antibiotic use.


      A total 210 cases were randomly chosen for evaluation, half during times when EMPs were present and half when they were absent. There were 130 males (62%) with an overall mean age of 54 ± 18 years. Overall, 178 (85%) of 210 of the antibiotic orders were appropriate, with 95% appropriate when an EMP was present compared to 74% when an EMP was absent (odds ratio, 6.9; 95% confidence interval, 2.5-18.8). In a logistic regression model, antibiotic appropriateness was independently associated with the presence of the EMP and creatinine clearance.


      Antibiotics that require renal and/or weight dosing adjustment are 6.5 times more likely to be appropriate in the ED when an EMP is present. Prevalence of antibiotic dosing error is related to both the presence of EMPs and the degree of renal impairment.
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        • Elenbaas R.M.
        • Waeckerle J.F.
        • McNabney W.K.
        The clinical pharmacist in emergency medicine.
        Am J Hosp Pharm. 1977; 34: 843-846
        • Cohen V.
        • Jellinek S.P.
        • Hatch A.
        • et al.
        Effect of clinical pharmacists on care in the emergency department: a systematic review.
        Am J Health Syst Pharm. 2009; 66: 1353-1361
        • American Society of Health-System Pharmacists Council on Pharmacy Practice
        ASHP statement on pharmacy services to the emergency department.
        Am J Health Syst Pharm. 2008; 65: 2380-2383
      1. The future of emergency care in the United States. National Academy of Sciences;.
        2006 ([Available at: (accessed August 8, 2014)])
        • National Hospital Ambulatory Medical Care Survey
        Emergency department summary tables.
        2010 ([Available at: (accessed September 2, 2014)])
        • Ernst A.A.
        • Weiss S.J.
        • Sullivan 4th, A.
        • et al.
        On-site pharmacists in the ED improve medical errors.
        Am J Emerg Med. 2012; 30: 717-725
        • Jiang S.P.
        • Zhu Z.Y.
        • Wu X.L.
        • et al.
        Effectiveness of pharmacist dosing adjustment for critically ill patients receiving continuous renal replacement therapy: a comparative study.
        Ther Clin Risk Manag. 2014; 10: 405-412
        • Jiang S.P.
        • Zhu Z.Y.
        • Ma K.F.
        • et al.
        Impact of pharmacist antimicrobial dosing adjustments in septic patients on continuous renal replacement therapy in an intensive care unit.
        Scand J Infect Dis. 2013; 45: 891-899
        • Patanwala A.E.
        • Warholak T.L.
        • Sanders A.B.
        • et al.
        A prospective observational study of medication errors in a tertiary care emergency department.
        Ann Emerg Med. 2010; 55: 522-526
        • Patanwala A.E.
        • Sanders A.B.
        • Thomas M.C.
        • et al.
        A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department.
        Ann Emerg Med. 2012; 59: 369-373
        • Liu C.
        • Bayer A.
        • Cosgrove S.E.
        • et al.
        Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children.
        Clin Infect Dis. 2011; 52: e18-e55
        • Fuller B.M.
        • Mohr N.
        • Skrupky L.
        • et al.
        Emergency department vancomycin use: dosing practices and associated outcomes.
        J Emerg Med. 2013; 44: 910-918
        • Pines J.M.
        • Localio A.R.
        • Hollander J.E.
        • et al.
        The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia.
        Ann Emerg Med. 2007; 50: 510-516
        • Fee C.
        • Weber E.J.
        • Maak C.A.
        • et al.
        Effect of emergency department crowding on time to antibiotics in patients admitted with community-acquired pneumonia.
        Ann Emerg Med. 2007; 50 (509.e1): 501-509
        • Kane-Gill S.L.
        • Kirisci L.
        • Verrico M.M.
        • Rothschild J.M.
        Analysis of risk factors for adverse drug events in critically ill patients.
        Crit Care Med. 2012; 40: 823-828