The Role of the Pharmacist In
the Emergency
Department/Critical
Care/Trauma
Linda Y. Radke, Pharm.D., BCPS, FASHP
Salina Regional Health Center
Salina, Kansas USA
Learning Objectives
• Describe opportunities for pharmacist involvement in emergency
medicine and critical care that allow pharmacists to contribute to
positive patient outcomes by improving patient safety, preventing
medication errors, and optimizing drug therapy in emergent patient
care situations.
• Review documentation of pharmacist interventions that demonstrate
increased responsibility and participation for pharmacists as active
members of the healthcare team in the community hospital setting.
Salina, Kansas USA, Kansas
Salina Regional Health Center
• 239 staffed inpatient beds
• 18 bed Critical Care Unit (ICU)
• 26 bed Emergency Department (ED)
• 24/7 pharmacist services (including code blue/trauma response)
• 22 Pharmacists
• 18 Pharmacy technicians
• 2 PGY1 pharmacist residents
Clinical pharmacists positions include:
• Critical Care, Internal Medicine, Cardiology, Emergency
Departments, Ambulatory Care Clinic, Oncology Clinic
Plan: Develop a Bedside Role for the Pharmacist in
Emergent Patient Care Situations
• Cardiopulmonary arrest (Code
Blue)
• Trauma/massive transfusion
• Rapid sequence intubation
• Procedural sedation
• Myocardial Infarction (STEMI)
• Stroke
• Malignant Hyperthermia
• Anaphylaxis
• Sepsis
Bedside Role for the Pharmacist
• Prepare the medications for
medical emergencies at the
bedside
• Calculate accurate drug
doses
• Recommend medications
based on guidelines and
protocols
• Drug information resource
Simulation Lab for Training
Training for Pharmacists
• Certification: Basic Life Support (BLS) and
Advanced Cardiac Life Support (ACLS)
• “Buddy system”: two pharmacists attended
codes together
• Case Simulations using Simulation Lab
mannequins and computers
• Rapid Sequence Intubation Drugs
• Conscious Sedation Drugs
• Drug Preparation and Administration:
tranexamic acid, prothrombin complex
concentrate, dantrolene, alteplase (tPA)
Creation of the Emergency Department
Pharmacist position
• 1230-2100 Monday-Friday
• Initiated July 2010
• Position created to address increased
inpatient pharmacy workload in the
evenings
• Order entry/verification of physician orders
• Physician dosing requests “Pharmacy to
Dose”
• Extended Code Blue coverage to 2100
(currently 24/7)
Promotion of Pharmacist Value to the
Emergency Department
• Promote safe and effective medication use in the emergency
department
• Target high-risk patients and procedures
• Ensure evidence-based medication use and adherence to national
guidelines
• Streamline medication delivery, emergent and non-emergent
patients
• Serve as technology transition resource to nurses and physicians
with development of the Electronic Health Record (EHR)
Primary Role of the Emergency Medicine
Pharmacist: Medication Safety
• Nurses: compatibility,
administration, adverse effects
• Physicians: drug information,
dose calculation, antibiotic
recommendations
• Patients: medication education,
accurate medication histories
and reconciliation
• Students and Residents: serve
as mentor and preceptor
Team participation: Medication expert
•
•
•
•
•
•
•
•
Code Blue Team: ACLS protocol drug preparation
Stroke Team: contraindications to tPA
STEMI patients: medication administration prior to Cath Lab
Sepsis: start antibiotics after cultures and within one hour
Rapid Sequence Intubation: drug selection and dosing
Trauma: antibiotics, tetanus vaccine
Massive Transfusion: transexamic acid, PCC
Pediatric Emergencies: weight-based dose calculation and preparation
The pharmacist is a member of the patient care team: if the patient needs a
blanket, get the blanket!
Documentation of Interventions
• Intervention software utilized to document pharmacist clinical
interventions and enhance communication between pharmacists for
patient follow-up
• ED pharmacist: recorded 3251 interventions in 2014
• Example: December 2014 patients diagnosed with suspected sepsis
Pharmacist
Present
Pharmacist Not
Present
Goal
% time patients
received antibiotics
within 60 minutes
79%
44%
60%
Door to antibiotic
(minutes)
57 minutes
67 minutes
60 minutes
Intervention:
Code/intubation/procedure attended
450
400
350
300
250
200
150
100
50
0
425
365
275
180
Code/Intubation/Procedure Attended
2011
2012
2013
2014
• Code Blue
• Rapid Sequence Intubation
• Conscious Sedation
• Massive Transfusion
Protocol
• Malignant Hyperthermia
Antibiotic
Recommendations
1127
1200
1000
908
2500
1500
451
505
1725
1142
1346
1000
400
200
500
0
0
Antibiotic recommendations
2011
2248
2000
800
600
“Pharmacy to Dose”
Requests
2012
2013
2014
Dosing requests by physician
2011
2012
2013
2014
Future Plans: Increase Coverage and Services
• Hire our current PGY1 resident
• Expand emergency department
pharmacist coverage to 7 days a week
• 1100-2300 Monday-Friday
• 1230-2100 Saturday-Sunday
• Offer emergency medicine and
critical care clinical rotations to
pharmacy students
• Oversee medication reconciliation
technician program
Emergency Medicine Pharmacist Services:
American Society of Health-system Pharmacists
Guidelines
• Developed through the ASHP Section of Clinical Specialists and
Scientists Advisory Group on Emergency Care
• Approved by ASHP Board of Directors on July 8, 2011
• www.ashp.org/DocLibrary/BestPractices/SpecificGdlEmergMed.aspx
• Defined the role of the Emergency Medicine Pharmacist (EMP)
• Guidelines based on primary literature, therapeutic and practice
guidelines, national standards, and the consensus of experts in the
field of EM pharmacy practice
• References
Thank you!
ขอบคุณค่ะ
Self-Assessment Questions
#1. Pharmacists can contribute to improved patient outcomes by:
A.
Decreasing the time from patient presentation to alteplase (tPA) administration in
patients diagnosed with thrombotic stroke
B. Contributing to appropriate and timely initial antibiotic selection and dosing in
patients presenting with pneumonia or sepsis
C. Calculating and preparing weight-based doses to expedite accurate administration
of pediatric cardiopulmonary resuscitation medications
D. All of the above
#2. Pharmacist documentation of interventions provides validation and
support for including the pharmacist as a contributing and valuable member
of the healthcare team.
True
False