Pharmacy’s presence in the emergency department (ED) has significantly increased in recent years.1,2 More than one-fifth of hospitals indicate that they routinely assign pharmacists to the majority of patients in the ED.3 This expansion is due not only to the proven value of pharmacist services in the ED, but also to support from other disciplines for this practice. In fact, The American College of Emergency Physicians (ACEP) policy statement encourages the involvement of pharmacy in ED services: ACEP believes that pharmacists serve a critical role in ensuring efficient, safe, and effective medication use in the ED and advocates for health systems to support dedicated roles for pharmacists within the ED.4
Many of the roles a pharmacist can play in the ED are supported both in the literature and by regulatory bodies.1,5 Involving pharmacy in the ED environment is a positive step toward preventing medication errors, and there is significant opportunity for this role to evolve further. Certainly, increasing the presence of the pharmacist and pharmacy technician in the ED, or employing a dedicated Emergency Medicine Pharmacist (EMP), may deliver substantial dividends.
Opportunities for Pharmacy in the ED
Robust ED pharmacy services can help ensure the safety of high-risk medication orders and improve access to these medications for health care providers. Involvement may encompass bedside-related events such as code response, intubations, traumas, and other high-acuity situations. Additional responsibilities include patient education, medication history and reconciliation services, pharmacy consults and clinical interventions, interdisciplinary collaboration, antimicrobial stewardship and medication utilization review, integrated operational and medication safety support, and departmental leadership. Potential ED pharmacy services to consider, as well as specific roles for an EMP and a pharmacy technician in the ED, are detailed in TABLES 1 and 2.2
Both OhioHealth in Columbus, Ohio, and Wake Forest Baptist Medical Center (WFBMC) in Winston-Salem, North Carolina, have implemented pharmacy services in their EDs and have increased pharmacy’s presence in the ED in recent years. Case studies describing OhioHealth and WFBMC’s approaches to pharmacy involvement in the ED environment are discussed in the SIDEBAR.
The Role of the Emergency Medicine Pharmacist
The EMP brings medication therapy and pharmacy services to the bedside and is charged with designing collaborative, best practice programs that integrate pharmacy operations into direct, patient-centered care. With this approach, the EMP can provide services to patients with a broad range of disease states and needs in the ED units, and by participating in all aspects of the medication-use system, ensure that patients receive comprehensive, individualized pharmaceutical care.
Active membership and participation in multidisciplinary hospital committees is necessary, as is leadership in departmental clinical education and research activities. The EMP is responsible for actively identifying service-related issues that require evaluation, as well as facilitating research projects, quality improvement initiatives, and multidisciplinary team education, as needed, to advance practice. To ensure success, the EMP must work closely with pharmacy and ED leadership to develop goals and strategies for pharmacy involvement in the ED.
Leveraging the Pharmacy Technician in the ED
When supported with appropriate guidance, technicians can provide significant value in the ED environment. As such, it is critical to establish that all tasks performed by a pharmacy technician in the ED require pharmacist oversight.
Pharmacy technicians typically complete operational functions in the ED, such as refilling automated dispensing cabinets (ADCs) or hand-delivering patient-specific medications. Recently, there has been an increase in pharmacists and pharmacy technicians participating in medication reconciliation processes in the ED. A qualitative review of 12 studies, comparing the ability of pharmacy technicians to other disciplines when completing medication reconciliation, reports that pharmacy technicians are able to gather medication histories with similar completeness and accuracy to other health care professionals; thus, employing technicians in this role may be a viable strategy for expanding pharmacy services in the ED.6
The pharmacy technician can subjectively interview the patient, as well as utilize resources (eg, third-party prescription data, outpatient pharmacy data, primary care office information, etc) to validate the home medication list. Compared with staff in other disciplines, a pharmacy technician may have the ability to specifically focus on this work rather than juggling other tasks involved with providing comprehensive patient care. Pharmacy technicians are well positioned to lead inventory optimization in ADCs, conduct unit inspections to aid in regulatory compliance, monitor ADCs for overrides, identify narcotic discrepancies, manage waste, and monitor crash cart restocking and expiration date monitoring.
Additional opportunities to expand the role of the pharmacy technician in the ED should be investigated. To allow your pharmacists to work to the top of their licenses, consider exploring innovative roles for pharmacy technicians in the ED.
Gaining Buy-In for ED Pharmacy Services
It is clear that involving pharmacists in patient care in the inpatient hospital setting results in safer, more effective medication use.7 Justifying similar pharmacy services in the ED can be challenging, but helpful resources are available.8 ASHP provides a wealth of guidance for establishing pharmacy services in the ED in their Emergency Care Resource Center: www.ashp.org/Pharmacy-Practice/Resource-Centers/Emergency-Care
To overcome objections to ED pharmacy services, a particularly challenging task for organizations with smaller EDs, focus on the benefits pharmacy can bring to the ED. This is an excellent opportunity for a resident research project, which can be used as leverage for additional FTEs. Consider tapping into interdisciplinary leadership to co-support the expansion effort. Utilizing pilot projects, either with residents or through virtual means, can help illustrate the value of these services. Encourage frontline staff to be innovative and develop practice advancement initiatives, which could then be presented to the C-suite. Passion and interdisciplinary support, along with quality metrics and return on investment data, can prove to be the tipping point to ensuring approval.
Once the EMP position has been established, finding the right candidate is critical. Ideal candidates will have completed training in a PGY1 pharmacy residency followed by a PGY2 EM pharmacy residency or critical care pharmacy residency, or have experience practicing in an ED environment. PGY2 EM pharmacy residency programs have expanded in recent years, as evidenced by the 230% growth in the last 5 years, which can help to expand the pool of qualified applicants.9 It is important to ensure that selected candidates have the appropriate certifications and credentials to be successful in the role for which they are applying. For example, required certifications may include Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), or credentials such as board certification from the Board of Pharmacy Specialties.
ED Pharmacy Service Models
When considering implementing ED pharmacy services, it is important to ensure that the chosen model will properly support the institution’s operational goals; the model should encompass clinical, distributive, and administrative work. In some circumstances, it may be useful to leverage technology to facilitate virtual services at offsite locations (ie, a freestanding ED [FSED] or a critical access hospital). Common models include 24-hour pharmacist coverage, 24-hour pharmacist coverage utilizing a satellite pharmacy, pharmacist coverage for a portion of the day, or pharmacist coverage offsite utilizing ADCs for drug dispensing. All of these models could include integration of pharmacy technicians for various roles.
The Role of Technology in ED Pharmacy
Depending on the facility’s size and patient volume, it may be prudent to dedicate an entire FTE to ED pharmacy services. In situations where volume does not support an FTE, consider leveraging technology to assist in supporting the ED. OhioHealth’s two medical campuses each have a 16-bed ED and 24/7 pharmacist and technician services. In these spaces, we are able to provide extensive ED pharmacy services. With an average daily census of about 100, these locations experience downtime overnight and early to mid-morning. During these periods, the ED pharmacy teams provide virtual services for other EDs within the health system.
For example, the medical campus EMPs at OhioHealth provide dual verification of pediatric and other high-risk medications for sites with only one pharmacist. Sharing the same EHR and policies and procedures facilitates seamless coverage. Additionally, webcam technology allows the EMP to visually verify IV compounding that is completed by nurses at our eight-bed FSEDs, which enables real-time feedback, ensuring that all steps in the process are completed to deliver a safe, accurate compound. Utilizing this same device, pharmacy technicians complete virtual medication histories for two of our smaller community hospitals. Technicians interact directly with the patient and family, which allows them to make a personal connection during the interview. With the telecommunications system, a user at any location has the ability to call an associate at another site via a simple voice command. The system also allows pharmacists to answer drug information questions, complete antimicrobial stewardship, and manage the post-discharge culture review. Finally, because the ADCs use a virtual server, the user can view inventory and make adjustments from a remote location. In addition, our medical campus pharmacy teams can quickly respond to and troubleshoot any ADC issues at remote locations.
OhioHealth and WFBMC are continually seeking ways to maximize resources and expand pharmacy’s productivity in the ED. Opportunities for pharmacy services within the ED are vast, and additional roles may be determined in the near future. It is imperative that health systems share their best practices for advancement in this area to facilitate further growth. Consider trialing an ED pharmacy service expansion at your institution; networking through professional organizations can provide a starting point. Pharmacy can play an integral role in this key point in the transition of care and can significantly contribute to the provision of comprehensive, patient-focused care in the ED.
Tyler A. Vest, PharmD, MS, BCPS, is a pharmacy system manager of inpatient operations and ED services at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina. He completed his health-system pharmacy administration residency at the University of North Carolina (UNC) Medical Center and received his Master’s Degree from the UNC Eshelman School of Pharmacy. Tyler earned his Doctor of Pharmacy Degree from the University of Cincinnati James L. Winkle College of Pharmacy. His professional interests include acute care operations, leadership development, practice advancement, pharmacy practice models, productivity and monitoring, the medication use process, and oncology.
Kellie L.E. Musch, PharmD, MS, is the pharmacy site manager for freestanding emergency departments and the system float pool at OhioHealth in Columbus, Ohio. She received her Doctor of Pharmacy from Ohio Northern University. After graduation, Kelly completed a PGY1/PGY2 health-system pharmacy administration residency at OhioHealth Grant Medical Center. Concurrently, she completed her Master’s Degree in Health-System Pharmacy Administration at the Ohio State University. Kellie’s professional interests include value-driven leadership, advocating for women in the workplace, financial management, pharmacy technician advancement, emerging technology, transitions of care, and development of new practitioners.
Two Approaches to Emergency Medicine Pharmacy
OhioHealth is a nationally recognized, not-for-profit, charitable health care outreach of the United Methodist Church. Based in Columbus, Ohio, the health system is a network of 11 hospitals, 60+ ambulatory sites, hospice, home health, and other health services spanning a 47-county area.
Clinical pharmacy services were established in the early 1960s and have evolved in large part due to our residency programs and their graduates. Currently, OhioHealth has 20 residents at 5 hospitals. Each care site has its own practice model, which allows us to be nimble as a broader team by learning from one another, piloting programs with different patient populations, and finding the right fit for the care site. Our two larger hospitals, Grant Medical Center (GMC) and Riverside Methodist Hospital, have utilized dedicated ED pharmacists for a number of years. In 2015, these campuses added medication history pharmacy technicians. Since then, OhioHealth has expanded the EMPs and ED pharmacy technicians to seven hospitals and two medical campuses, many operating 24/7.
In 2017, OhioHealth embarked on a journey to build five 8-bed, freestanding EDs (FSEDs) located in active communities. As a result of the proven value pharmacy had shown at our hospital care sites, we were able to secure 2.0 FTE pharmacists and 2.0 FTE pharmacy technicians to support drug distribution, regulatory audits, inventory management, order verification, drug information, clinical patient review, medication safety strategy development, and post-discharge culture review and management. These pharmacists also participate in emergency response and oversee IV compounding via virtual technology.
Our dedicated FTE technicians work Monday, Tuesday, Thursday, and Friday from 5am to 3:30pm and deliver medications to each site twice weekly from OhioHealth GMC. These technicians drive to each FSED and use their time on-site to complete the unit inspection, perform regulatory duties, refill products, and also serve as our “eyes and ears” on the ground. The technicians are able to problem solve, educate, and escalate needs for process improvement.
Dedicated FTE pharmacists work Monday through Friday from 7am to 11pm. The day shift pharmacist works from OhioHealth GMC to provide operational oversight of the pharmacy technicians, including physical product selection and acting as the power of attorney for narcotic drug ordering. The remainder of the coverage responsibilities occur exclusively in a virtual fashion during this time frame. When the pharmacist works from GMC, the post-discharge review occurs in a central location where patients can call 24/7 to speak to a pharmacist about their results.
Upon hiring of our evening shift pharmacist, who has previous PGY1 residency training and internship experience in the ED, we were able to explore live staffing at each location 1 day per week. On-site staffing helps facilitate a positive relationship with nursing, providers, and advanced practice providers, while also highlighting the value of pharmacy services in the ED. The second shift pharmacist provides more customer-focused activities, such as bedside compounding, emergency response, and patient education. From the site the pharmacist is staffing, they virtually support the other 4 FSEDs. Taking advantage of downtime at our medical campuses is critical to providing complete 24/7 ED services.
Productivity captured through order verification, documentation of clinical interventions, and regulatory oversight help to maintain our dedicated 4.0 FTEs for the 5 eight-bed FSEDs, but the relationships we have built and the practice advancements we have implemented are the true drivers of the program. We are extremely fortunate to work with excellent interdisciplinary teams who continue to promote our EM pharmacy team to senior leaders in the organization.
Wake Forest Baptist Medical Center
Located in Winston-Salem, North Carolina, Wake Forest Baptist Medical Center (WFBMC) is a Level I adult and pediatric trauma and burn center. An integrated system licensed for 885 acute care, rehabilitation, and psychiatric care beds, WFBMC has been recognized in US News & World Report as among the nation’s finest for eight specialties.1
WFBMC has a long history of clinical excellence and innovation in pharmacy practice. Over 500 pharmacists, technicians, interns, and administrative support staff provide comprehensive pharmacy services spanning the continuum of care across multiple patient populations. The department provides decentralized clinical services to more than 37 inpatient services and a variety of ambulatory clinics. Pharmacists and technicians partner to ensure safe transitions of care during patient admission and discharge and assist patients in accessing medications. In the ambulatory setting, pharmacy provides community and specialty outpatient services as well as home infusion.
Clinical pharmacy services were established in the ED in the late 1990s. The ED pharmacy team includes pharmacists and technicians who are available 24/7, 365 days a year. The team participates in bedside events (eg, codes, strokes, intubations), medication preparation, order verification, inventory management and optimization, and general department of pharmacy initiatives and committees. Additionally, the ED pharmacy team maintains a fully functional satellite pharmacy, which also operates 24/7.