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Pharmacist in ED yields good results
[Editor's note: This is the first in a two-part series. This month we examine the performance improvements that one hospital achieved after placing a pharmacist in the ED. We also discuss how a pharmacist's recommendations to dispense a medication orally enabled the ED to save money and improve patient safety. In the August issue, we'll look at additional benefits these pharmacists offer, from the perspective of ED nurses and physicians.]
Placing a pharmacist in the ED is not yet common practice, but the experiences of the University of Rochester (NY) Medical Center which began its program in 2000, indicate that more EDs should be considering such a strategy.
For example, when the center had an ED pharmacist involved in antimicrobial stewardship, the percentage of patients who received the most appropriate therapy increased from about the mid-80% to 100%.
"We started that program in October 2008," recalls Nicole M. Acquisto, Pharm D, BCPS, the emergency medicine clinical pharmacy specialist, who is based in the critical care/resuscitation section of the ED. "Previously mid-level providers took care of follow up on any cultures for ED patients who were treated and released, but we found that because they have to deal with other patients coming in, these follow-ups did not get as high a priority as they should have."
So the follow-ups were taken over by the ED pharmacist, who would contact the patient or the primary care physician when there were positive cultures. "We found our median time [for follow-up] was three days; before, it was as much as 15 days," says Acquisto. The only reason the average times after giving the process to pharmacists were so "long" was that there are no pharmacists in the ED on the weekend, so follow-up on weekends still was handled by the mid-level providers, she says.
There was also the aforementioned improvement in prescribing the proper antibiotic for the proper organism. "In the past, the lab would call the ED with positive blood cultures; they'd call the secretary or the provider that ordered the culture," Acquisto explains. However, she notes, the doctor in question might no longer be in the ED, or the doctor might not be taking phone calls. "So, we collaborated with ED leadership and determined that the calls would go to this one area where we have clinical nurses," Acquisto explains. "They would then call me, and I would follow up."
This area is not the only one where the pharmacist in the ED has proved his or her worth, adds Rollin J. (Terry) Fairbanks, MD, MS, FACEP, assistant professor of emergency medicine and of community and preventive medicine at the University of Rochester School of Medicine. "We've done a couple of studies on time to definitive care in heart attack and time to definitive pain medications in trauma, and they were faster with the pharmacist in the ED," Fairbanks notes.
Acquisto says, "When we looked at patients coming in with heart attack or STEMI, we found that when the pharmacist was involved, the patient actually moved through more quickly and with a decreased amount of adverse affects. There was an 11-minute decrease in the mean door-to-balloon time."
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Oral, IV meds can have equal efficacy
Rollin J. (Terry) Fairbanks, MD, MS, FACEP, assistant professor of emergency medicine and of community and preventive medicine at the University of Rochester School of Medicine in Rochester, NY, who works closely with the ED pharmacist at University of Rochester Medical Center, says the pharmacist showed him how he could save a considerable amount of money on medications without sacrificing efficacy.
"When a patient came into our ED with community acquired pneumonia, it was standard practice to give IV doses of both azithromax and ceftrixone," he recalls. "The pharmacist pointed out that the oral form of azithromax has equal efficacy to the IV form. The IV form is tremendously more expensive, and when you use the IV there is always a slightly increased risk in terms of adverse events."
Fairbanks and his team reviewed the literature, and there was equal efficacy. The ED changed its practice. "We saved a lot of money and did not change outcomes at all," says Fairbanks, noting that the department saves about $40 per dose by using the oral form of the drug.