The Role of the Pharmacist In the Emergency

Department/Critical Care/Trauma

Linda Y. Radke, Pharm.D., BCPS, FASHPSalina Regional Health Center

Salina, Kansas USA

Learning Objectives

• Describe opportunities for pharmacist involvement in emergency medicine and critical care that allow pharmacists to contribute to positive patient outcomes by improving patient safety, preventing medication errors, and optimizing drug therapy in emergent patient care situations. • Review documentation of pharmacist interventions that demonstrate

increased responsibility and participation for pharmacists as active members of the healthcare team in the community hospital setting.

Salina, Kansas USA, Kansas

Salina Regional Health Center• 239 staffed inpatient beds• 18 bed Critical Care Unit (ICU)• 26 bed Emergency Department (ED)

• 24/7 pharmacist services (including code blue/trauma response)• 22 Pharmacists• 18 Pharmacy technicians• 2 PGY1 pharmacist residents

Clinical pharmacists positions include: • Critical Care, Internal Medicine, Cardiology, Emergency

Departments, Ambulatory Care Clinic, Oncology Clinic

Plan: Develop a Bedside Role for the Pharmacist in Emergent Patient Care Situations

• Cardiopulmonary arrest (Code Blue)

• Trauma/massive transfusion• Rapid sequence intubation• Procedural sedation• Myocardial Infarction (STEMI)• Stroke• Malignant Hyperthermia• Anaphylaxis• Sepsis

Bedside Role for the Pharmacist

• Prepare the medications for medical emergencies at the bedside• Calculate accurate drug

doses • Recommend medications

based on guidelines and protocols • Drug information resource

Training for Pharmacists

• Certification: Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) • “Buddy system”: two pharmacists

attended codes together • Case Simulations using Simulation Lab

mannequins and computers• Rapid Sequence Intubation Drugs• Conscious Sedation Drugs• Drug Preparation and Administration:

tranexamic acid, prothrombin complex concentrate, dantrolene, alteplase (tPA)

Simulation Lab for Training

Creation of the Emergency Department Pharmacist position• 1230-2100 Monday-Friday• Initiated July 2010• Position created to address increased

inpatient pharmacy workload in the evenings• Order entry/verification of physician orders• Physician dosing requests “Pharmacy to

Dose”

• Extended Code Blue coverage to 2100 (currently 24/7)

Promotion of Pharmacist Value to the Emergency Department• Promote safe and effective medication use in the emergency

department• Target high-risk patients and procedures• Ensure evidence-based medication use and adherence to national

guidelines• Streamline medication delivery, emergent and non-emergent

patients• Serve as technology transition resource to nurses and physicians

with development of the Electronic Health Record (EHR)

Primary Role of the Emergency Medicine Pharmacist: Medication Safety

• Nurses: compatibility, administration, adverse effects• Physicians: drug information,

dose calculation, antibiotic recommendations • Patients: medication education,

accurate medication histories and reconciliation• Students and Residents: serve

as mentor and preceptor

Team participation: Medication expert• Code Blue Team: ACLS protocol drug preparation• Stroke Team: contraindications to tPA• STEMI patients: medication administration prior to Cath Lab• Sepsis: start antibiotics after cultures and within one hour• Rapid Sequence Intubation: drug selection and dosing• Trauma: antibiotics, tetanus vaccine• Massive Transfusion: transexamic acid, PCC• Pediatric Emergencies: weight-based dose calculation and preparation

The pharmacist is a member of the patient care team: if the patient needs a blanket, get the blanket!

Documentation of Interventions

• Intervention software utilized to document pharmacist clinical interventions and enhance communication between pharmacists for patient follow-up• ED pharmacist: recorded 3251 interventions in 2014• Example: December 2014 patients diagnosed with suspected sepsis

Pharmacist Present

Pharmacist Not Present

Goal

% time patients received antibiotics within 60 minutes

79% 44% 60%

Door to antibiotic (minutes)

57 minutes 67 minutes 60 minutes

Intervention:Code/intubation/procedure attended

Code/Intubation/Procedure Attended0

50

100

150

200

250

300

350

400

450

180

275

365

425

2011 2012 2013 2014

• Code Blue• Rapid Sequence Intubation• Conscious Sedation• Massive Transfusion

Protocol• Malignant Hyperthermia

Antibiotic “Pharmacy to Dose” Recommendations Requests

Antibiotic recommendations0

200

400

600

800

1000

1200

451505

908

1127

2011 2012 2013 2014

Dosing requests by physician0

500

1000

1500

2000

2500

11421346

1725

2248

2011 2012 2013 2014

Future Plans: Increase Coverage and Services• Hire our current PGY1 resident• Expand emergency department

pharmacist coverage to 7 days a week• 1100-2300 Monday-Friday• 1230-2100 Saturday-Sunday

• Offer emergency medicine and critical care clinical rotations to pharmacy students• Oversee medication reconciliation

technician program

Emergency Medicine Pharmacist Services: American Society of Health-system Pharmacists Guidelines

• Developed through the ASHP Section of Clinical Specialists and Scientists Advisory Group on Emergency Care• Approved by ASHP Board of Directors on July 8, 2011• www.ashp.org/DocLibrary/BestPractices/SpecificGdlEmergMed.aspx• Defined the role of the Emergency Medicine Pharmacist (EMP)• Guidelines based on primary literature, therapeutic and practice

guidelines, national standards, and the consensus of experts in the field of EM pharmacy practice• References

Thank you!ขอบคุ�ณคุ�ะ

Self-Assessment Questions

#1. Pharmacists can contribute to improved patient outcomes by: A. Decreasing the time from patient presentation to alteplase (tPA) administration in patients

diagnosed with thrombotic strokeB. Contributing to appropriate and timely initial antibiotic selection and dosing in patients

presenting with pneumonia or sepsisC. Calculating and preparing weight-based doses to expedite accurate administration of

pediatric cardiopulmonary resuscitation medicationsD. All of the above

#2. Pharmacist documentation of interventions provides validation and support for including the pharmacist as a contributing and valuable member of the healthcare team.

TrueFalse