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Original Article

R Clin Pharm 2024; 2(1): 1-5

Published online June 30, 2024 https://doi.org/10.59931/rcp.24.0001

Copyright © Asian Conference On Clinical Pharmacy.

Introduction of an Emergency Medicine Pharmacist in the Emergency Department: Potential for Improved Patient Care

Jin Rui Nicholas Lim1 , Yew Jin Ian Wee1 , Hoon Chin Lim2

1Department of Pharmacy, Changi General Hospital, SingHealth, Singapore
2Department of Accient & Emergency, Changi General Hospital, SingHealth, Singapore

Correspondence to:Jin Rui Nicholas Lim
E-mail nicholas_lim@cgh.com.sg
ORCID
https://orcid.org/0000-0001-5079-5428

Received: February 7, 2024; Revised: March 29, 2024; Accepted: May 25, 2024

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Growing evidence demonstrates that emergency medicine pharmacists (EMPs) can positively improve patient care in the emergency department (ED). In Singapore, ED pharmacy is still generally limited to traditional roles, and EMPs are rarely included as part of the ED clinical team. We sought to investigate the impact of introducing an EMP into an ED.
Methods: From November 2019, we piloted a new, collaborative multidisciplinary model of care by introducing an EMP to provide clinical pharmacy services in the ED of our institution.
Results: The EMP’s roles and practices, as described in this report, included clinical and traditional non-clinical as well as administrative activities to support the multidisciplinary teams in the ED. On average, the EMP was involved in 1.2 documented pharmacist activities (involving medication-related enquiries or interventions) per hour spent in the ED.
Conclusion: Although our initial experience with introducing an EMP into our ED was mostly positive with tangible benefits in optimizing medication use and improving medication safety for ED patients, we also described the challenges that we faced in developing the service. Finally, the necessity of an EMP should be further examined, adapted to the local settings, and evaluated with respect to incorporation of this service into our local healthcare system by conducting further studies.

KeywordsEmergency medicine; Pharmacy; Clinical pharmacy service

Emergency medicine (EM) pharmacy is an area of pharmacy practice which has grown rapidly in the past decade [1]. There is an increasing body of evidence which indicates that emergency medicine pharmacists (EMPs) can positively improve patient care in the emergency department (ED) [2-4]. The American Society of Health-System Pharmacists (ASHP) recently published updated guidelines on EM pharmacy services following increased demand for them in the United States. These services are usually provided by dedicated EMPs stationed primarily in the ED, and the guidelines serve to provide a roadmap for developing functions that are vital to quality EM pharmacy services [5]. Additionally, the Board of Pharmaceutical Sciences recently approved EM pharmacy as a specialty program, thereby allowing eligible pharmacists to obtain accreditation as board-certified EMPs [6].

In Singapore, a recent study had observed that the presence of a pharmacist at the ED pharmacy positively impacted prescribing practices and improved medication use [7]. However, a survey of four public hospitals in Singapore revealed that ED pharmacy services were still generally limited to traditional prescription processing, dispensing of medications, and administrative roles, with staffing mostly provided by pharmacy technicians. Additionally, the presence of a dedicated clinical pharmacist embedded with ED multidisciplinary teams (MDTs) consisting of physicians and nurses at the patients’ bedside, was largely lacking [7]. The purpose of this pilot service aims to evaluate the possible roles and outcomes of having a clinical pharmacist in the ED of our hospital.

In order to explore and deliver a new, collaborative multidisciplinary model of care for patients admitted to our institution’s ED, we introduced a full-time EMP in November 2019 to provide clinical pharmacy services in our ED. Our institute, Changi General Hospital, Singapore, is a 1,000-bed tertiary hospital founded since 1998 and our ED provides 24 hour emergency medical care for patients living in the eastern side of Singapore. Our EMP role was assumed by an experience senior clinical pharmacist with background of working in the inpatient and critical care setting. The selected pharmacist also had advanced clinical training, having obtained a doctorate in pharmacy (PharmD) and was also a United States Board Certified Pharmacotherapy Specialist (BCPS). Unlike other pharmacy staff based in the ED dispensing pharmacy, the EMP was usually deployed at the patients’ bedside to participate directly in patient consultations with the ED MDTs.

Roles and Best Practices of the Emergency Medicine Pharmacist

The EMP was on duty during weekdays from 8 am to 5 pm. As this was a pilot service, the EMP spent approximately 60% of the working day at the ED, with additional cross-coverage of inpatient wards when the need arose. The primary role of the EMP was providing direct pharmaceutical care to all patients at the ED with higher emphasis on those areas of higher acuity clinical acuity (including the resuscitation room and critical care areas). The EMP also participated in medical rounds at the ED observation medicine ward (Short Stay Unit) twice daily, as well as provided remote support to the ED Fever Facility where, at the height of the pandemic, patients infected with COVID-19 were housed. Table 1 summarises how the activities of the EMP in the ED fulfilled the roles stipulated in the ASHP guidelines for EM pharmacy services [5] in our institution.

Table 1 Roles of the emergency medicine pharmacist

Clinical roles and bedside
patient care activities
Examples and experiences
Provision of bedside prescribing advice (pharmacotherapy consults)• Provide recommendations for drug use (e.g., choice of drug, dose, route, volume of diluent, pregnancy/breastfeeding compatibility), especially in special populations such as paediatric, pregnant women, and elderly patients
Facilitate administration of time-sensitive drug orders
• Expedited drug placement at the bedside
• Support nursing staff to prepare, dilute and administer drugs safely and timely
• Remind MDTs concerning drug therapies based on standards and best practices
• Support emergency thrombolysis for acute ischaemic stroke patients while considering the care pathway
• Facilitate drug use in medical and traumatic resuscitations
• Administration of tranexamic acid within the first 3 hours in bleeding trauma patients
Monitoring of effectiveness of drugs
• Titrating drug dosages as necessary to achieve intended clinical effects. Recommending escalation or de-escalation
• Monitor and titrate the dosage of anti-hypertensive drug infusion to keep within targeted blood pressure range
• Titrate the dose of analgesia or recommending an additional analgesic drug to promote faster and adequate pain relief
• Ensure palliative pharmacotherapy safely achieves intended effects
Drug stewardship and medication safety
• Supporting better decision-making and improve anti-microbial stewardship
• High risk medications
• Fluid stewardship
• Advice appropriate second-line anti-microbial in the presence of antibiotic allergy
• Prepare of drugs for rapid sequence intubation, cardiac arrest, post-intubation care
• Advice and facilitate the use of balanced crystalloids in septic patients
• Assist with adherence to regulatory and institutional medication use policies
Medication reconciliation
• Complex medication regimes
• Ensure patient’s chronic medications are ordered accurately
Drugs and poisoning information and consultation• Conduct medication reconciliation to aid in identify of drug that was ingested, review the quantity of drug that was taken and inform about available antidote and toxicological management
Documentation and communication
• Ensure proper and complete documentation
• Communication with nurses, physicians
• Patient education and counselling
• Medication-related recommendations to MDTs recorded in the electronic health record system
• Update new allergies into electronic patient records
• Provide patient education and counselling for high-alert medications: e.g., oral anticoagulants, adrenaline auto-injector device
Non-clinical and administrative rolesExamples and experiences
Safety and quality improvement
• Medication error review and implementation of measures to prevent recurrences
• Provide drug-related information and support in protocol/ guidelines setup and implementation
• Medication safety initiatives: e.g., relocation of look-alike medication to prevent errors - relocating metoclopramide vials from beside haloperidol vials to another cabinet to prevent possible errors
• Optimization of medication procurement through adjusting of available ward stock: e.g., placement of Plasmalyte and ticagrelor in the P1 area as ward stock to facilitate supply and usage
• Assistance with adherence to regulatory and institutional medication use policies/ guidelines: e.g., assist in creation of a checklist to guide the use of peripheral norepinephrine in the ED; facilitate the switch of NAC dosing regimen for paracetamol poisoning to a newer and safer 2-bag regimen
Electronic health record systems
• CPOE (computerized provider order entry) enhancements
• Establishment of disease condition medication ordersets
• Assist in setting up electronic ordersets to facilitate and streamline ordering of medications: e.g., setting up of a preeclampsia orderset to facilitate ordering of medications; setting up orderset to facilitate switch to using inhalers instead of nebulisation for asthma/COPD exacerbations. Electronic ordersets for weight-based dosing for paediatric patients and specific drugs
Supply chain management
• Stockpiling
• Essential items depending on routine and unexpected surge needs
• Ensure the pharmacy keeps and maintain an adequate supply of antidotes and supportive treatments for emergencies: e.g., adjusting the par level of oxytocin kept in the hospital to ensure adequate supply for at least one case and reviewing the par level of oral methionine as an antidote for paracetamol poisoning
• Medication dispensing cabinet optimisation e.g., ensure commonly used medications like ticagrelor, balanced salt solutions are kept readily accessible in the acute areas
Research and education• Collaborating with ED physicians in research projects and providing drug information to enquires: e.g., conducted a survey on the current landscape of ED pharmacy services in Singapore and participation in journal reviews with the ED physicians and nurses

Between November 2019 to July 2021, our EMP spent a total of 1,600 hours at the ED. The EMP handled 1,011 physician enquiries, 172 nursing enquires, and was responsible for 771 clinical interventions. On average, our EMP was engaged with approximately 1.2 documented pharmacist activities (involving medication-related enquiries or interventions) per hour spent at the ED. Fig. 1 provides a quick breakdown of the documented pharmacist activities. Of the 771 clinical interventions, 98% (776) were accepted by the physicians. Antimicrobial-related interventions and enquires (total of 216) was most commonly encountered by the EMP while the least commonly encountered were paediatrics and gynaecological (total of 26).

Figure 1. Impact of the emergency medicine pharmacist.

Impact, Opportunities and Challenges for Future Development of Pharmacy Services in the ED

To the best of our knowledge, this is the first report in South-east Asia outlining the experiences associated with the introduction of a dedicated EMP. Although ED patients not usually being directly billed for EMP-provided services, the contributions of the EMP (within the auspices of an ED pharmacy service) represents a value-added means to optimise patient care. Indeed, a multidisciplinary model of care involving an EMP had been shown to lead to positive safety outcomes such as increased error interception and fewer medication errors, both of which translated to potential cost-savings for patients [8-10].

Recently, a cross sectional study in a hospital at Saudi Arabia showed that through the introduction of a single, full time ED EMP in their ED, significant positive improvement on medication optimisation and safety of ED patients [11]. Our institution’s EMP took on a similarly active role and contributed to a more holistic multi-disciplinary care for our patients as seen in the numerous clinical enquires from physicians and nurses and the number of clinical intervention made. While the number of clinical interventions may lag the enquires received, it shows the service was well received by the physicians and nurses and highlighted the importance of the EMP as a source of drug information and active educator in our ED. Nonetheless, it is expected that the enquires received by the EMP aided in the decision-making of the physicians and nurses for the clinical care of patients in the ED. Also, in the longer term, the impact of such interdisciplinary education will likely be compounded. Moving forward, it will be prudent to continue collecting such data of workload and contribution to quantify the service needs.

Internationally, emergency medicine pharmacists have also documented their contributions to specialised services, including antimicrobial stewardship, post-ED discharge cultures call-back services, pharmacist-led medication reconciliation service, medication therapy monitoring and consult services at transitional care settings [12-14]. The need for these services should be further explored for EDs in Singapore with the service being adapted to fit into our local settings and to justify whether the service may be mainstreamed.

As the Singapore population ages, better ED integration will be required due to the increased complexities of care for the “higher-risk” elderly population. This represents an opportunity for pharmacy services to adapt and evolve from traditional “behind the counter” roles such as compounding and dispensing medicines to include broader, patient-facing roles to deliver optimised pharmacotherapies the patients. Ideally, the EMP service should be always staffed by a team of clinical pharmacists at the ED to reduce service disruption. The EMPs should also work towards becoming an integral part of the ED MDTs by being actively involved in the care of patients in the ED. Through further research, the clinical impact and cost-effectiveness of the EMP may be quantified to provide evidence of it as an essential ED service.

Some challenges faced when introducing an EMP service included the need for additional staffing, defining the role of the EMP, and adjusting the ED workflow to include the pharmacist. These were gradually resolved out over time in our ED and the EMP had since been an integral part of the ED MDTs.

The ED environment represents a challenging new area of practice for pharmacists and departs from the traditional roles of pharmacy practice. Though the value and cost-effectiveness of an ED EMP-delivered model requires further evaluation, our initial experience with introducing an EMP into our ED was a positive one with tangible benefits in optimising medication use, improving medication safety for ED patients and education of the ED MDTs.

No potential conflict of interest relevant to this article was reported.

  1. Roman C, Edwards G, Dooley M, Mitra B. Roles of the emergency medicine pharmacist: a systematic review. Am J Health Syst Pharm. 2018 Jun 1; 75(11): 796-806.
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  2. Wanbon R, Lyder C, Villeneuve E, Shalansky S, Manuel L, Harding M. Clinical pharmacy services in canadian emergency departments: a national survey. Can J Hosp Pharm. 2015 May-Jun; 68(3): 191-201.
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  3. Collignon U, Oborne CA, Kostrzewski A. Pharmacy services to UK emergency departments: a descriptive study. Pharm World Sci. 2010 Feb; 32(1): 90-6.
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  4. Fitzgerald C, Welch S, Taylor S, et al; SHPA Committee of Specialty Practice in Emergency Medicine. SHPA standards of practice in emergency medicine pharmacy practice. J Pharm Pract Res. 2015; 45(4): 423-30.
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  5. Ortmann MJ, Johnson EG, Jarrell DH, et al. ASHP guidelines on emergency medicine pharmacist services. Am J Health Syst Pharm. 2021 Jan 22; 78(3): 261-75.
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  6. Board of Pharmaceutical Specialties. Emergency medicine pharmacy recognized as new specialty [Internet]. Washington, DC: Board of Pharmaceutical Specialties; 2020 Feb 21 [cited 2022 Jun 20]. Available from: https://bpsweb.org/2020/02/21/emergency-medicine-pharmacy-recognized-as-new-specialty/.
  7. Lim JR, Lim HC. A Survey of pharmacy services in the emergency departments in Singapore [poster presentation]. Paper presented at: 20th Asian Conference on Clinical Pharmacy; 2021 Jul 1-4; Singapore. 2021.
  8. Patanwala AE, Warholak TL, Sanders AB, Erstad BL. A prospective observational study of medication errors in a tertiary care emergency department. Ann Emerg Med. 2010 Jun; 55(6): 522-6.
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  9. Rothschild JM, Churchill W, Erickson A, et al. Medication errors recovered by emergency department pharmacists. Ann Emerg Med. 2010 Jun; 55(6): 513-21.
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  10. Stasiak P, Afilalo M, Castelino T, et al. Detection and correction of prescription errors by an emergency department pharmacy service. CJEM. 2014 May; 16(3): 193-206.
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  11. Al-Kathiri WH, Abdelrazek HAH, Al-Jadhey HS. The impact of a clinical pharmacist in the emergency department of an academic hospital in the Kingdom of Saudi Arabia. J Pharm Pharmacol. 2018; 6: 752-9.
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  12. DeFrates SR, Weant KA, Seamon JP, Shirakbari A, Baker SN. Emergency pharmacist impact on health care-associated pneumonia empiric therapy. J Pharm Pract. 2013 Apr; 26(2): 125-30.
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  13. Randolph TC, Parker A, Meyer L, Zeina R. Effect of a pharmacist-managed culture review process on antimicrobial therapy in an emergency department. Am J Health Syst Pharm. 2011 May 15; 68(10): 916-9.
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  14. Layman SN, Elliott WV, Regen SM, Keough LA. Implementation of a pharmacist-led transitional care clinic. Am J Health Syst Pharm. 2020 Jun 4; 77(12): 966-71.
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Article

Original Article

R Clin Pharm 2024; 2(1): 1-5

Published online June 30, 2024 https://doi.org/10.59931/rcp.24.0001

Copyright © Asian Conference On Clinical Pharmacy.

Introduction of an Emergency Medicine Pharmacist in the Emergency Department: Potential for Improved Patient Care

Jin Rui Nicholas Lim1 , Yew Jin Ian Wee1 , Hoon Chin Lim2

1Department of Pharmacy, Changi General Hospital, SingHealth, Singapore
2Department of Accient & Emergency, Changi General Hospital, SingHealth, Singapore

Correspondence to:Jin Rui Nicholas Lim
E-mail nicholas_lim@cgh.com.sg
ORCID
https://orcid.org/0000-0001-5079-5428

Received: February 7, 2024; Revised: March 29, 2024; Accepted: May 25, 2024

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background: Growing evidence demonstrates that emergency medicine pharmacists (EMPs) can positively improve patient care in the emergency department (ED). In Singapore, ED pharmacy is still generally limited to traditional roles, and EMPs are rarely included as part of the ED clinical team. We sought to investigate the impact of introducing an EMP into an ED.
Methods: From November 2019, we piloted a new, collaborative multidisciplinary model of care by introducing an EMP to provide clinical pharmacy services in the ED of our institution.
Results: The EMP’s roles and practices, as described in this report, included clinical and traditional non-clinical as well as administrative activities to support the multidisciplinary teams in the ED. On average, the EMP was involved in 1.2 documented pharmacist activities (involving medication-related enquiries or interventions) per hour spent in the ED.
Conclusion: Although our initial experience with introducing an EMP into our ED was mostly positive with tangible benefits in optimizing medication use and improving medication safety for ED patients, we also described the challenges that we faced in developing the service. Finally, the necessity of an EMP should be further examined, adapted to the local settings, and evaluated with respect to incorporation of this service into our local healthcare system by conducting further studies.

Keywords: Emergency medicine, Pharmacy, Clinical pharmacy service

Body

Emergency medicine (EM) pharmacy is an area of pharmacy practice which has grown rapidly in the past decade [1]. There is an increasing body of evidence which indicates that emergency medicine pharmacists (EMPs) can positively improve patient care in the emergency department (ED) [2-4]. The American Society of Health-System Pharmacists (ASHP) recently published updated guidelines on EM pharmacy services following increased demand for them in the United States. These services are usually provided by dedicated EMPs stationed primarily in the ED, and the guidelines serve to provide a roadmap for developing functions that are vital to quality EM pharmacy services [5]. Additionally, the Board of Pharmaceutical Sciences recently approved EM pharmacy as a specialty program, thereby allowing eligible pharmacists to obtain accreditation as board-certified EMPs [6].

In Singapore, a recent study had observed that the presence of a pharmacist at the ED pharmacy positively impacted prescribing practices and improved medication use [7]. However, a survey of four public hospitals in Singapore revealed that ED pharmacy services were still generally limited to traditional prescription processing, dispensing of medications, and administrative roles, with staffing mostly provided by pharmacy technicians. Additionally, the presence of a dedicated clinical pharmacist embedded with ED multidisciplinary teams (MDTs) consisting of physicians and nurses at the patients’ bedside, was largely lacking [7]. The purpose of this pilot service aims to evaluate the possible roles and outcomes of having a clinical pharmacist in the ED of our hospital.

METHODS

In order to explore and deliver a new, collaborative multidisciplinary model of care for patients admitted to our institution’s ED, we introduced a full-time EMP in November 2019 to provide clinical pharmacy services in our ED. Our institute, Changi General Hospital, Singapore, is a 1,000-bed tertiary hospital founded since 1998 and our ED provides 24 hour emergency medical care for patients living in the eastern side of Singapore. Our EMP role was assumed by an experience senior clinical pharmacist with background of working in the inpatient and critical care setting. The selected pharmacist also had advanced clinical training, having obtained a doctorate in pharmacy (PharmD) and was also a United States Board Certified Pharmacotherapy Specialist (BCPS). Unlike other pharmacy staff based in the ED dispensing pharmacy, the EMP was usually deployed at the patients’ bedside to participate directly in patient consultations with the ED MDTs.

RESULTS

Roles and Best Practices of the Emergency Medicine Pharmacist

The EMP was on duty during weekdays from 8 am to 5 pm. As this was a pilot service, the EMP spent approximately 60% of the working day at the ED, with additional cross-coverage of inpatient wards when the need arose. The primary role of the EMP was providing direct pharmaceutical care to all patients at the ED with higher emphasis on those areas of higher acuity clinical acuity (including the resuscitation room and critical care areas). The EMP also participated in medical rounds at the ED observation medicine ward (Short Stay Unit) twice daily, as well as provided remote support to the ED Fever Facility where, at the height of the pandemic, patients infected with COVID-19 were housed. Table 1 summarises how the activities of the EMP in the ED fulfilled the roles stipulated in the ASHP guidelines for EM pharmacy services [5] in our institution.

Table 1 . Roles of the emergency medicine pharmacist.

Clinical roles and bedside
patient care activities
Examples and experiences
Provision of bedside prescribing advice (pharmacotherapy consults)• Provide recommendations for drug use (e.g., choice of drug, dose, route, volume of diluent, pregnancy/breastfeeding compatibility), especially in special populations such as paediatric, pregnant women, and elderly patients
Facilitate administration of time-sensitive drug orders
• Expedited drug placement at the bedside
• Support nursing staff to prepare, dilute and administer drugs safely and timely
• Remind MDTs concerning drug therapies based on standards and best practices
• Support emergency thrombolysis for acute ischaemic stroke patients while considering the care pathway
• Facilitate drug use in medical and traumatic resuscitations
• Administration of tranexamic acid within the first 3 hours in bleeding trauma patients
Monitoring of effectiveness of drugs
• Titrating drug dosages as necessary to achieve intended clinical effects. Recommending escalation or de-escalation
• Monitor and titrate the dosage of anti-hypertensive drug infusion to keep within targeted blood pressure range
• Titrate the dose of analgesia or recommending an additional analgesic drug to promote faster and adequate pain relief
• Ensure palliative pharmacotherapy safely achieves intended effects
Drug stewardship and medication safety
• Supporting better decision-making and improve anti-microbial stewardship
• High risk medications
• Fluid stewardship
• Advice appropriate second-line anti-microbial in the presence of antibiotic allergy
• Prepare of drugs for rapid sequence intubation, cardiac arrest, post-intubation care
• Advice and facilitate the use of balanced crystalloids in septic patients
• Assist with adherence to regulatory and institutional medication use policies
Medication reconciliation
• Complex medication regimes
• Ensure patient’s chronic medications are ordered accurately
Drugs and poisoning information and consultation• Conduct medication reconciliation to aid in identify of drug that was ingested, review the quantity of drug that was taken and inform about available antidote and toxicological management
Documentation and communication
• Ensure proper and complete documentation
• Communication with nurses, physicians
• Patient education and counselling
• Medication-related recommendations to MDTs recorded in the electronic health record system
• Update new allergies into electronic patient records
• Provide patient education and counselling for high-alert medications: e.g., oral anticoagulants, adrenaline auto-injector device
Non-clinical and administrative rolesExamples and experiences
Safety and quality improvement
• Medication error review and implementation of measures to prevent recurrences
• Provide drug-related information and support in protocol/ guidelines setup and implementation
• Medication safety initiatives: e.g., relocation of look-alike medication to prevent errors - relocating metoclopramide vials from beside haloperidol vials to another cabinet to prevent possible errors
• Optimization of medication procurement through adjusting of available ward stock: e.g., placement of Plasmalyte and ticagrelor in the P1 area as ward stock to facilitate supply and usage
• Assistance with adherence to regulatory and institutional medication use policies/ guidelines: e.g., assist in creation of a checklist to guide the use of peripheral norepinephrine in the ED; facilitate the switch of NAC dosing regimen for paracetamol poisoning to a newer and safer 2-bag regimen
Electronic health record systems
• CPOE (computerized provider order entry) enhancements
• Establishment of disease condition medication ordersets
• Assist in setting up electronic ordersets to facilitate and streamline ordering of medications: e.g., setting up of a preeclampsia orderset to facilitate ordering of medications; setting up orderset to facilitate switch to using inhalers instead of nebulisation for asthma/COPD exacerbations. Electronic ordersets for weight-based dosing for paediatric patients and specific drugs
Supply chain management
• Stockpiling
• Essential items depending on routine and unexpected surge needs
• Ensure the pharmacy keeps and maintain an adequate supply of antidotes and supportive treatments for emergencies: e.g., adjusting the par level of oxytocin kept in the hospital to ensure adequate supply for at least one case and reviewing the par level of oral methionine as an antidote for paracetamol poisoning
• Medication dispensing cabinet optimisation e.g., ensure commonly used medications like ticagrelor, balanced salt solutions are kept readily accessible in the acute areas
Research and education• Collaborating with ED physicians in research projects and providing drug information to enquires: e.g., conducted a survey on the current landscape of ED pharmacy services in Singapore and participation in journal reviews with the ED physicians and nurses


Between November 2019 to July 2021, our EMP spent a total of 1,600 hours at the ED. The EMP handled 1,011 physician enquiries, 172 nursing enquires, and was responsible for 771 clinical interventions. On average, our EMP was engaged with approximately 1.2 documented pharmacist activities (involving medication-related enquiries or interventions) per hour spent at the ED. Fig. 1 provides a quick breakdown of the documented pharmacist activities. Of the 771 clinical interventions, 98% (776) were accepted by the physicians. Antimicrobial-related interventions and enquires (total of 216) was most commonly encountered by the EMP while the least commonly encountered were paediatrics and gynaecological (total of 26).

Figure 1. Impact of the emergency medicine pharmacist.

DISCUSSION

Impact, Opportunities and Challenges for Future Development of Pharmacy Services in the ED

To the best of our knowledge, this is the first report in South-east Asia outlining the experiences associated with the introduction of a dedicated EMP. Although ED patients not usually being directly billed for EMP-provided services, the contributions of the EMP (within the auspices of an ED pharmacy service) represents a value-added means to optimise patient care. Indeed, a multidisciplinary model of care involving an EMP had been shown to lead to positive safety outcomes such as increased error interception and fewer medication errors, both of which translated to potential cost-savings for patients [8-10].

Recently, a cross sectional study in a hospital at Saudi Arabia showed that through the introduction of a single, full time ED EMP in their ED, significant positive improvement on medication optimisation and safety of ED patients [11]. Our institution’s EMP took on a similarly active role and contributed to a more holistic multi-disciplinary care for our patients as seen in the numerous clinical enquires from physicians and nurses and the number of clinical intervention made. While the number of clinical interventions may lag the enquires received, it shows the service was well received by the physicians and nurses and highlighted the importance of the EMP as a source of drug information and active educator in our ED. Nonetheless, it is expected that the enquires received by the EMP aided in the decision-making of the physicians and nurses for the clinical care of patients in the ED. Also, in the longer term, the impact of such interdisciplinary education will likely be compounded. Moving forward, it will be prudent to continue collecting such data of workload and contribution to quantify the service needs.

Internationally, emergency medicine pharmacists have also documented their contributions to specialised services, including antimicrobial stewardship, post-ED discharge cultures call-back services, pharmacist-led medication reconciliation service, medication therapy monitoring and consult services at transitional care settings [12-14]. The need for these services should be further explored for EDs in Singapore with the service being adapted to fit into our local settings and to justify whether the service may be mainstreamed.

As the Singapore population ages, better ED integration will be required due to the increased complexities of care for the “higher-risk” elderly population. This represents an opportunity for pharmacy services to adapt and evolve from traditional “behind the counter” roles such as compounding and dispensing medicines to include broader, patient-facing roles to deliver optimised pharmacotherapies the patients. Ideally, the EMP service should be always staffed by a team of clinical pharmacists at the ED to reduce service disruption. The EMPs should also work towards becoming an integral part of the ED MDTs by being actively involved in the care of patients in the ED. Through further research, the clinical impact and cost-effectiveness of the EMP may be quantified to provide evidence of it as an essential ED service.

Some challenges faced when introducing an EMP service included the need for additional staffing, defining the role of the EMP, and adjusting the ED workflow to include the pharmacist. These were gradually resolved out over time in our ED and the EMP had since been an integral part of the ED MDTs.

CONCLUSION

The ED environment represents a challenging new area of practice for pharmacists and departs from the traditional roles of pharmacy practice. Though the value and cost-effectiveness of an ED EMP-delivered model requires further evaluation, our initial experience with introducing an EMP into our ED was a positive one with tangible benefits in optimising medication use, improving medication safety for ED patients and education of the ED MDTs.

ETHICAL APPROVAL

Not required for this report.

FUNDING

None.

ACKNOWLEDGMENTS

None.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

Fig 1.

Figure 1.Impact of the emergency medicine pharmacist.
Research in Clinical Pharmacy 2024; 2: 1-5https://doi.org/10.59931/rcp.24.0001

Table 1 Roles of the emergency medicine pharmacist

Clinical roles and bedside
patient care activities
Examples and experiences
Provision of bedside prescribing advice (pharmacotherapy consults)• Provide recommendations for drug use (e.g., choice of drug, dose, route, volume of diluent, pregnancy/breastfeeding compatibility), especially in special populations such as paediatric, pregnant women, and elderly patients
Facilitate administration of time-sensitive drug orders
• Expedited drug placement at the bedside
• Support nursing staff to prepare, dilute and administer drugs safely and timely
• Remind MDTs concerning drug therapies based on standards and best practices
• Support emergency thrombolysis for acute ischaemic stroke patients while considering the care pathway
• Facilitate drug use in medical and traumatic resuscitations
• Administration of tranexamic acid within the first 3 hours in bleeding trauma patients
Monitoring of effectiveness of drugs
• Titrating drug dosages as necessary to achieve intended clinical effects. Recommending escalation or de-escalation
• Monitor and titrate the dosage of anti-hypertensive drug infusion to keep within targeted blood pressure range
• Titrate the dose of analgesia or recommending an additional analgesic drug to promote faster and adequate pain relief
• Ensure palliative pharmacotherapy safely achieves intended effects
Drug stewardship and medication safety
• Supporting better decision-making and improve anti-microbial stewardship
• High risk medications
• Fluid stewardship
• Advice appropriate second-line anti-microbial in the presence of antibiotic allergy
• Prepare of drugs for rapid sequence intubation, cardiac arrest, post-intubation care
• Advice and facilitate the use of balanced crystalloids in septic patients
• Assist with adherence to regulatory and institutional medication use policies
Medication reconciliation
• Complex medication regimes
• Ensure patient’s chronic medications are ordered accurately
Drugs and poisoning information and consultation• Conduct medication reconciliation to aid in identify of drug that was ingested, review the quantity of drug that was taken and inform about available antidote and toxicological management
Documentation and communication
• Ensure proper and complete documentation
• Communication with nurses, physicians
• Patient education and counselling
• Medication-related recommendations to MDTs recorded in the electronic health record system
• Update new allergies into electronic patient records
• Provide patient education and counselling for high-alert medications: e.g., oral anticoagulants, adrenaline auto-injector device
Non-clinical and administrative rolesExamples and experiences
Safety and quality improvement
• Medication error review and implementation of measures to prevent recurrences
• Provide drug-related information and support in protocol/ guidelines setup and implementation
• Medication safety initiatives: e.g., relocation of look-alike medication to prevent errors - relocating metoclopramide vials from beside haloperidol vials to another cabinet to prevent possible errors
• Optimization of medication procurement through adjusting of available ward stock: e.g., placement of Plasmalyte and ticagrelor in the P1 area as ward stock to facilitate supply and usage
• Assistance with adherence to regulatory and institutional medication use policies/ guidelines: e.g., assist in creation of a checklist to guide the use of peripheral norepinephrine in the ED; facilitate the switch of NAC dosing regimen for paracetamol poisoning to a newer and safer 2-bag regimen
Electronic health record systems
• CPOE (computerized provider order entry) enhancements
• Establishment of disease condition medication ordersets
• Assist in setting up electronic ordersets to facilitate and streamline ordering of medications: e.g., setting up of a preeclampsia orderset to facilitate ordering of medications; setting up orderset to facilitate switch to using inhalers instead of nebulisation for asthma/COPD exacerbations. Electronic ordersets for weight-based dosing for paediatric patients and specific drugs
Supply chain management
• Stockpiling
• Essential items depending on routine and unexpected surge needs
• Ensure the pharmacy keeps and maintain an adequate supply of antidotes and supportive treatments for emergencies: e.g., adjusting the par level of oxytocin kept in the hospital to ensure adequate supply for at least one case and reviewing the par level of oral methionine as an antidote for paracetamol poisoning
• Medication dispensing cabinet optimisation e.g., ensure commonly used medications like ticagrelor, balanced salt solutions are kept readily accessible in the acute areas
Research and education• Collaborating with ED physicians in research projects and providing drug information to enquires: e.g., conducted a survey on the current landscape of ED pharmacy services in Singapore and participation in journal reviews with the ED physicians and nurses

References

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Asian Conference On Clinical Pharmacy

Vol.2 No.2
December 2024

eISSN 2983-0745
Frequency: Biannual

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