Institution A
Department of Pharmacy Proposal:
Decentral Clinical Pharmacist in the
Emergency Room
<Your Name>
<Date>
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Executive Summary
PROPOSAL
The purpose of this proposal is to request the approval of two clinical pharmacist full-time
equivalents to establish pharmacy services within the Institution A emergency department (ER).
The pharmacists will work twelve-hour shifts in a seven days on, seven days off rotation.
Proposed hours of coverage are from 1100 to 2300, representing the ER’s busiest times.
BENEFITS
1.
2.
3.
4.
5.
6.
7.
Improved patient care
Improved patient flow through the ER
Prescriber education and cost awareness
Improved customer satisfaction
Increased outpatient revenues
Reduced drug costs
Improved student/resident education
CURRENT OPERATIONS
Pharmacy services in the Institution A ER are limited to participation in code situations, stocking
of department medications, and dispensing of a very small number of outpatient prescriptions
from the Outpatient Pharmacy. It has been estimated that ninety percent of all ER visits include
the administration of a medication to treat the presenting disorder. Furthermore, the average
Institution A ER patient receives one to two prescriptions upon discharge. However, the
Institution A Outpatient Pharmacy currently only fills between 3-5 take home prescriptions for
ER patients per day. Approximately ninety-six percent of ER written prescriptions are filled at
non- Institution A pharmacies.
PROPOSED PHARMACIST ACTIVITIES
1.
2.
3.
4.
5.
6.
7.
Participate in code situations.
Patient admit medication histories.
Discharge medication patient consultation (new and old medications // oral and written).
Patient medication use review (as appropriate).
Mentor (to both students and residents of pharmacy, nursing and medicine).
Research (emergency room medication use findings // pharmacy intervention findings).
Facilitate processing ER patient prescriptions through the Institution A outpatient
Pharmacy.
8. Drug information source (easily accessible to all ER staff).
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9. Written medication order review for cost effectiveness and clinical appropriateness.
10. Implement cost-savings initiatives related to medication prescribing.
COST
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

$190,000 personnel expense (150,000 salary; $48,000 fringe benefit )
$2,000 one-time computer expense
Desk space
SUMMARY
A potential role for pharmacy exists in the ER. The ER would benefit from improved patient
care, improved drug information access, reduced costs and improved patient satisfaction.
BACKGROUND
The role of an emergency room (ER) pharmacist has developed significantly over the past
couple of decades and has been well documented in the literature.2 The impact has been
significant in terms of positive patient outcomes, increased quality of care, cost-savings and
increased outpatient prescription volumes 1-4; however, in light of other institution’s
success,1,2,4,5 the ER at the Institution A has been slow to adopt such a position.
Historically, pharmacy services in the Institution A ER have been limited. It has been estimated
that ninety percent of all ER visits include the administration of a medication to treat the
presenting disorder1; however, participation in code situations, stocking of department
medications and the dispensing of outpatient prescriptions encompasses most of what our
pharmacy department does there.
In the fiscal year 1999 to 2000, the Institution A ER cared for 31,740 patient visits, seventy-six
percent of which where discharged without ever seeing a pharmacist. The twenty-four percent
that did, did so because they were admitted to the hospital. Within the hospital, every patient
admitted for care is treated by a health care team that includes a pharmacist. The literature
clearly states the benefits of such an arrangement and is almost undisputed; however, the ER
population at the Institution A is treated by a health care team without a pharmacist.
Furthermore, from the outpatient pharmacy perspective, the average Institution A ER patient
receives one to two prescriptions upon discharge. According to the Institution A outpatient
pharmacy, they fill prescriptions for approximately three ER patients per day. This means
ninety-six percent of our ER written prescriptions walk out the door to be filled elsewhere.
Developed collaboratively by the ASHP Research and Education Foundation,
the ASHP Section of Pharmacy Practice Managers, and ASHP Advantage.
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PROPOSAL
The purpose of this proposal is to request the approval of two clinical pharmacist full-time
equivalents (FTEs) to establish pharmacy services within the Institution A emergency
department. The pharmacists will work twelve-hour shifts in a seven days on, seven days off
rotation. Therefore, pharmacy services will be available in the ER twelve hours per day. The
proposed hours of coverage are from 1100 to 2300, which represent the ER’s busiest times.
The ER pharmacists will work collaboratively with physicians, nurses and other emergency room
personnel to provide the following valuable services:
 Participation in code situations. The ER pharmacist will provide medication related
information and recommendations to the emergency blue cart teams. Also, dosing of
emergency medications in these situations would be rapidly calculated and prepared by the
pharmacist for immediate administration.
 Direct patient care. On average, an ER patient spends 160 minutes in the ER if they are not
admitted to the Institution A and 230 minutes if they are. This provides ample time for a
pharmacist to assess patient medication use, allergies and medication compliance. This will
provide the pharmacist with the information necessary to make recommendations for
physician written prescriptions and possibly determine the reason for the patient’s ER visit.
If necessary, laboratory tests will be followed-up on by the pharmacist after the patient is
discharged. Additionally, for patients being admitted to the hospital, the pharmacist will
complete a medication history to facilitate the patients transfer to the hospital wards. For
patients being discharged, the pharmacist will provide oral and written medication
consultation.
 Review all written medication orders. All written medication orders in the ER will be
reviewed by the pharmacist. Ultimately, this will reduce medication errors and adverse
drug events and check for clinical appropriateness and cost-effectiveness.
 Outpatient prescription capture. The ER pharmacist will be responsible for facilitating the
processing of patient take home prescriptions from the Institution A Outpatient Pharmacy.
The prescriptions will be filled in a timely fashion that will not prolong the patients visit
time. Any patient medication co-pays or charges will be collected by the pharmacist at the
time of dispensing.
 Education of ED staff. The pharmacist will be an important source of up-to-the-date drug
information regarding new medications, medication and/or monitoring guidelines,
formulary issues and protocols. This will help in assuring patients get placed on the
appropriate hospital critical pathways.
 Drug information source. It is noted in the literature that most ER nurses and physicians
will not page a pharmacist for a routine drug information question and wait for a call back
for the reply, so the question might be overlooked and/or forgotten.2 Having a pharmacist
in the ER will help reduce this occurrence. Drug information the pharmacist will provide is as
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follows, but is not limited to: drug-drug/food/disease interactions, dosing
guidelines/intervals, identification of unknown medications, poison/overdose/toxicology
information, pharmacokinetic consults, formulary issues, medication side effects and
precautions, drug incompatibilities, dosing adjustments, therapeutic drug monitoring,
appropriate medication routes, therapeutic interchanges, therapeutic options, medication
cost issues/pharmacoeconomics and laboratory-drug interactions.
 Mentoring. The ER pharmacist will participate as a pharmacy preceptor to pharmacy
students/residents. This will further increase service to ER physicians, nurses and patients.
Additionally, the pharmacist will act as a pseudo-preceptor to medical and nursing
students/residents. The pharmacist will teach the students/residents important
pharmacotherapy and pharmacology information they did not receive in school. As an
academic medical center, this is an important service.
 Implement cost-savings initiatives related to medication prescribing. The ER pharmacist
will work with physicians to develop guidelines for cost-effective prescribing among the
different classes of medications, and to implement Institution A P&T cost savings initiatives.
 Research related opportunities. Pharmaceutical interventions will be recorded by the
pharmacist along with outcomes as they become available. This information may provide
insight to what medications work best in ER situations. This information could be published
and give the Institution A further recognition.
BENEFITS
1. Improved patient care. Pharmacists will work collaboratively with nurses and physicians to
improve drug therapy decision making and medication compliance. They will promote
better patient understanding of all aspects of their medications and ultimately increase the
likelihood of desired patient outcomes. Additionally, this will save physician and nursing
time and allow for increased patient visits.
2. Improved prescriber education. An ER pharmacist creates easy access to drug information,
guidelines and protocols. This will result in improved drug therapy selection.
3. Improved customer satisfaction. Patients will receive more complete medication
information in regard to new and/or old medications. This could improve prescription fill
rates, medication compliance and customer satisfaction. Customer satisfaction is important
because a portion of our patient population uses the ER as their only form of medical care.
If they are satisfied with there first visit they will most likely return if necessary. This in turn
also increases continuity of care.
4. Increased outpatient revenues. The ER pharmacist will be responsible for facilitating the
filling of ER take home prescriptions at our outpatient pharmacy. This could generate a
large increase in business for the outpatient pharmacy (see financial analysis below).
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5. Reduced costs. Improving drug therapy decision making and identifying medication related
problems as they occur will reduce the need for other medical services such as further ER
visits, hospital stays, surgical procedures, additional medications and/or physician visits.
6. Improved student/resident education. The pharmacist will be able to teach the future
healthcare professionals good drug therapy decision making skills.
FINANCIAL IMPLICATIONS
The costs of the proposal would include two full time pharmacists and a new designated
pharmacy computer and possibly a cash register in the ER. The two yearly pharmacist salaries
would cost $150,000, plus $48,000 in fringe benefits. Computer costs would be under $2,000.
Additionally, dedicated desk space would be necessary.
In terms of “soft” money, we can predict that the pharmacist position will justify its cost based
on cost avoidance (therapeutic substitution, allergy avoidance, formulary control, drug
interaction, adverse reaction avoidance, etc.). The prediction of cost avoidance dollar savings is
difficult, but should be considered.
In terms of quantifiable dollars, the following summarizes new prescription business we
estimated in the Outpatient Pharmacy as a result of this service:
 20 new prescriptions per day (based on data from ER physicians estimating 20 prescriptions
written per shift).
 Average revenue/prescription is $45.00 ($328,500/year).
 Average cost/prescription is $33.00 ($240,900/year).
 New income of $87,600/year.
SUMMARY
A potential role for a clinical pharmacist exists in the Institution A ER. The ER benefits from
improved patient care, improved drug information access, reduced costs and improved patient
satisfaction.
Developed collaboratively by the ASHP Research and Education Foundation,
the ASHP Section of Pharmacy Practice Managers, and ASHP Advantage.
Visit www.pharmacycsuitetoolkit.org
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REFERENCES
1. Schaube JL. Comprehensive emergency pharmacy services. Top Hosp Pharm Manage.
1998;8:20-28.
2. Levy DB. Documentation of clinical and cost saving pharmacy interventions in the
emergency room. Hosp Pharm. 1993;28:624-627,630-634,653.
3. Barone JA, Lafin S. Pharmacy services in an emergency department. U.S. Pharmacist.
1992;17:H2-H6,H8,H10-H13,H15-H16.
4. Whalen FJ. Cost justification of decentralized phamaceutical services for the emergency
room. Am J Hosp Pharm. 1981;38:684-687.
5. Gill AW, High JL, Silvernale DJ. Clinical pharmacy in an emergency medicine setting.
Contemp Pharm Pract. 1981;4:227-230.
Developed collaboratively by the ASHP Research and Education Foundation,
the ASHP Section of Pharmacy Practice Managers, and ASHP Advantage.
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APPENDIX-A
LITERATURE
The following literature provides support for staffing clinical pharmacists in the emergency
department (ED).
1. Schaube JL. Comprehensive emergency pharmacy services. Top Hosp Pharm Manage.
1998;8:20-28.
2. Levy DB. Documentation of clinical and cost saving pharmacy interventions in the
emergency room. Hosp Pharm. 1993;28:624-627,630-634,653.
3. Barone JA, Lafin S. Pharmacy services in an emergency department. U.S. Pharmacist.
1992;17:H2-H6,H8,H10-H13,H15-H16.
4. Whalen FJ. Cost justification of decentralized phamaceutical services for the emergency
room. Am J Hosp Pharm. 1981;38:684-687.
5. Tafreshi MJ, Melby MJ, Kaback KR, Nord TC. Medication related visits to the emergency
department: a prospective study. Ann Pharmacother. 1999;33:1252-1257.
Developed collaboratively by the ASHP Research and Education Foundation,
the ASHP Section of Pharmacy Practice Managers, and ASHP Advantage.
Visit www.pharmacycsuitetoolkit.org
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