The nature of the emergency department (ED), given its hectic environment, frequent interruptions, and constant flow of new patients, requires specialized pharmacy services. Pharmacists must collaborate with emergency physicians, nurses, and other ED staff to develop and monitor evidence-based systems that promote safe and effective medication use in this dynamic setting. Utilizing the services of ED pharmacists along with profiled automated dispensing cabinets (ADCs) actively promotes appropriate medication management in the ED, thereby improving the quality of patient care.
The University of Arizona Medical Center—University Campus in Tucson is a 479-bed academic medical center and Level I trauma center serving southern Arizona. The ED houses 61 beds and treats approximately 80,000 patients each year. Recognizing the importance and necessity of pharmacy oversight in the ED, the hospital instituted the position of ED pharmacist in 2008 to ensure ED medication security and patient safety. Administration supported the adoption of this new position as a means to help prevent medication errors, while simultaneously managing pharmaceutical costs.
Bringing Pharmacy Review to the ED
In the fast-paced setting of the ED, the importance of providing medication rapidly must be balanced against the necessity of safeguarding against incorrect administration or diversion. Likewise, ensuring medication availability while eliminating expired or outdated medications is key. The ED pharmacist’s main responsibility is to make certain that the medication use process maintains full accountability so that drugs are administered in a timely manner to patients, while preventing medications from being incorrectly administered or diverted.
To help address these challenges, we instituted profiled ADCs in the ED, thus allowing pharmacy to remotely review and approve new medication orders entered in CPOE before the nurse can access the medications. This process was already in use elsewhere in our hospital, so extending it to the ED was a logical next step. As such, we did not seek formal approval or develop new policies and procedures; rather, pharmacy simply introduced the same profiling approach in the ED that has been used successfully throughout the facility.
The implementation went smoothly and although we had a pharmacist available around the clock for the first few days of the transition in case any staff members needed assistance in understanding the process, no issues arose. Nurses were initially concerned that profiling would delay patient treatment, but after using the process and seeing that there were no significant delays with the new system, acceptance has grown significantly. This reinforced our experience elsewhere in the hospital where we found that the introduction of profiling created no delays in patient care. To promote efficient benchmarking with this approach, pharmacy established a goal of reviewing every order within 15 minutes.
The only ED area without profiled ADCs is the trauma bay, where cases are particularly time-sensitive and acute. To provide safety in this setting, pharmacy maintains tight control over the inventory and only allows emergent medications to be accessed directly. The emergency pharmacist reviews the inventory periodically to ensure that no medications have been added to this area without pharmacy’s oversight. Any non-emergent medications used in the trauma bay must be accessed from the other ADCs in the ED, thus requiring pharmacy review for access.
The override function is available in all of the ED ADCs for situations when there is an acute patient status change that requires urgent action. We took a liberal approach to permitting overrides; basically any medications that could be of use in an urgent situation (eg, antiemetics, antihistamines, opioids, cardiac arrest medications, etc) are available on override. Nonetheless, we have found that the staff uses the function sparingly, with fewer than 5% of medications being removed via override.
Maintaining an adequate inventory and sustaining a balance of availability between emergent and non-emergent medications is our biggest challenge. With so many patients boarding in our ER, we need to stock routine medications, all of them on profile, while also providing an adequate supply of emergent medications. In addition, we have a large psychiatric patient population, and it is common for these patients to be held in the ED for several days, so we also have to take into account the proper stocking and profiling of psychiatric medications.
We review each ADC’s inventory on a monthly basis against the pharmacy formulary to determine utilization rates, and then restock each ADC accordingly, adding or removing medications as needed. Although we do not currently have BCMA in place at the bedside, we do utilize bar code scanning for ADC restocking—the pharmacy technician first scans one item per pocket and then the corresponding cabinet pocket to ensure accuracy during the refilling process. In addition, each medication is checked prior to leaving the inpatient pharmacy.
With the highest rate of narcotics usage in the hospital, the ED presents a constant risk for diversion. As professionals, we want to trust our staff; nevertheless, proactive vigilance is necessary. Those who aim to divert medications often take clever approaches; we had one staff member who was switching Percocet tablets with ibuprofen tablets in the ADC. Hence the count in the pocket was correct, but upon closer inspection, it was the wrong medication.
To address such situations, we track usage patterns, conduct random chart audits, and monitor staff whose usage patterns fall outside the standard deviation. Profiled ADCs help limit access to medications. We also use biometric fingerprint recognition on the ADCs to prevent staff from sharing or stealing passwords. In addition, one of the benefits of having a pharmacist in the ER is that we can personally observe usage trends and when diversion is suspected, maintain closer scrutiny of that person.
We have already seen a number of benefits from profiling the ADCs in the ED, including decreased medication errors. For example, medications that are contraindicated due to allergies are caught prior to the nurse accessing the medication. Likewise, if a medication order includes an incorrect dosage, we no longer need to rely on the nursing staff to notice the problem when they retrieve the dose. Although our nurses always have been quick to flag doses that seem incorrect, it is simply too dangerous to not have a formal safety check in place prior to the medication administration phase. Given the large quantity of controlled substances utilized in the ED, diversion risk in this setting also is quite high. With the implementation of profiling, we are confident in the additional control this has brought to narcotic management within the ED.
While dynamic inventory can pose a challenge, implementing and managing profiling in the ED has been a very successful venture. Our experience has shown that profiled ADCs and ED pharmacists have combined to make medication administration in this busy environment a safer and more efficient process for both staff and patients.
Daniel P. Hays, PharmD, BCPS, is an emergency department pharmacist and director of the emergency medicine pharmacy residency program at the University of Arizona Medical Center in Tucson. He received his doctor of pharmacy degree from the University of Minnesota in 2000. Daniel is the past chair of the American Society of Health-System Pharmacists emergency pharmacists section advisory group for the clinical scientists and specialists network.
Current Medication Distribution Models
For all hospitals, with the exception of the smallest facilities, point-of-care distribution with a strong reliance on ADCs is well established as the preferred approach. This distribution method has continued to gain in popularity as it meets pharmacy’s requirements for control, while also providing nursing with the access they desire. Overall 48% of all hospitals nationwide use this model and we expect point-of-care distribution to break the 50% mark in the next few years.
Point-of-care model: 80% or more of inpatient beds receive medications from ADCs on the patient unit, which are restocked from central pharmacy
Centralized: 80% or more of inpatient beds receive medications from the central pharmacy and/or robot/carousel is the main dispensing platform to unit dose carts
Decentralized, supported by satellite pharmacy: 80% more of inpatient beds receive medications from satellite pharmacies and/or ADCs restocked from satellite pharmacies
Hybrid: a combination of dispensing methods, meeting none of the conditions above
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