COMMENTARIES
Emergency medicine pharmacy
Emergency medicine pharmacy: Still a new clinical frontier Nicole M. Acquisto and Daniel P. Hays Am J Health-Syst Pharm. 2015; 72:2092-6
T
he emergency department (ED) is a practice setting with inherent medication safety risks. It is a fast-paced, overcrowded, highacuity, stressful environment with many distractions—an environment where incomplete patient information is the norm and steps of the medication-use process are often omitted because of reliance on verbal medication orders, a lack of pharmacist contribution to the medication-use process (often due to pharmacists’ physical distance from the ED), and the need for emergent medication administration. In the 1970s, early pharmacist services in the ED focused on cost containment, inventory control, and dispensing. However, as hospital distribution practices changed, the role of the pharmacist developed into one that was more clinically focused. Emergency medicine (EM) clinical pharmacist services were first described in the mid1970s.1 The growth of EM clinical pharmacy services was slow over the next 20 years leading up to the Institute of Medicine’s influential 1999 report on medical errors.2 The
report identified the ED as an area of the hospital with high rates of preventable adverse drug events and one that could be expected to benefit from clinical pharmacy services. After that report, hospital deployment of pharmacists began to include the ED while the clinical role of the pharmacist in the ED was expanded to the bedside. Interest in what a pharmacist could accomplish in this realm grew. In order to continue to grow, this relatively new area of practice would need validation, accreditation, training, and guidelines for practice. Evolution of EM pharmacy practice. Early clinical pharmacy services in the ED focused on drug procurement during cardiac arrest, adverse drug event surveillance, and identification of medication-related adverse events during ED presentation. In 2001, a national survey was conducted using the ASHP pharmacy residency directory to evaluate the prevalence and characteristics of pharmacy services in the ED.3 Only 4 hospitals (3.4% of the 119 respondent facilities) reported having a dedicated pharmacist regularly
Nicole M. Acquisto, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacy Specialist and Assistant Professor, Departments of Pharmacy and Emergency Medicine, University of Rochester Medicine, Rochester, NY. Daniel P. Hays, Pharm.D., BCPS, FASHP, is Emergency Pharmacist, Maricopa Medical Center, Phoenix, AZ.
Address correspondence to Dr. Acquisto ([email protected]). The authors have declared no potential conflicts of interest.
2092
Copyright © 2015, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/15/1201-2092. DOI 10.2146/ajhp150622
Am J Health-Syst Pharm—Vol 72 Dec 1, 2015
assigned to the ED, and 13 others (10.9%) had a pharmacist whose primary responsibility was to provide services to the ED. Clinical services were broad and included optimizing medication orders, participating in cardiopulmonary resuscitations, and providing drug information, toxicology consults, ED inservices, and patient education. Clinical pharmacy services in the ED began to grow in the early 2000s. In 2004, Fairbanks et al.4 published a descriptive report on the roles of clinical pharmacists in the ED at one academic institution. In addition to the clinical activities already discussed, the pharmacist was involved in resuscitation activities, including trauma responses; provided care to patients with other highly time-dependent emergencies (e.g., stroke, myocardial infarction); provided education to EM attending physicians, residents, and nurses; and participated in protocol development, formulary optimization, and emergency preparedness. Based on that publication and related work, in 2007 Fairbanks and colleagues were awarded the “Emergency Department Pharmacist as a Safety Measure in Emergency Medicine” grant (HS015818-01) by the Agency for Healthcare Research and Quality to further study the role and benefit of the pharmacist in the ED. This grant also funded the Emergency Pharmacist Research Center website (www.emergency pharmacist.org), which has served as a resource for EM pharmacists looking for ways to demonstrate the value of their services in the ED. The number of dedicated EM pharmacy services in U.S. hospitals continues to expand. In the ASHP national survey of pharmacy practice in hospital settings, dedicated EM pharmacy
COMMENTARIES
services were reported by 6.8% and 16.4% of respondents in 2008 and 2013, respectively.5,6 Practice expansion and the role of pharmacy societies. ASHP has been instrumental in fostering and supporting the growth of EM pharmacy practice. Recognizing the ED as a new frontier for pharmacy practice, the society developed a position statement recommending that every hospital’s pharmacy department provide its ED with pharmacy services necessary for provision of safe and effective patient care.7 Furthermore, ASHP supported proposals that the expansion of pharmacy education and postgraduate training should include an emphasis on emergency care. ASHP also created the Section Advisory Group on Emergency Care within its Section of Clinical Scientists and Specialists. Members of this group went on to publish “ASHP Guidelines on Emergency Medicine Pharmacist Services.”8 The threefold purpose of this document was to define the role of the EM clinical pharmacist, suggest goals for providing services to meet institution-specific needs, and establish a definition of best practices for pharmacy services in the ED. The section advisory group continues to instate a diverse group of EM pharmacists every year. ASHP’s Emergency Care Resource Center provides pharmacists with articles and guidelines on selected disease states, resources for justifying pharmacists’ services in the ED, and recorded educational series.9 Members of the section advisory group also produce webinars and meeting programs related to pharmacy practice in the ED setting. Specifically, the “Emergency Medicine Clinical Pearls” session, which started in 2009, has become a staple of the ASHP Midyear Clinical Meeting and often requires an overflow room to accommodate attendees. Over 100 unique EM pharmacy
Emergency medicine pharmacy
clinical pearls have been presented to date. In 2007 ASHP developed and promoted the Patient Care Impact Program (PCIP): Introducing an Emergency Pharmacist to Your Institution, which mentored and guided pharmacists in the development of EM pharmacy services at their institutions.10 In the program’s first year, 19 pharmacists (chosen from among over 100 applicants) were tasked with initiating clinical pharmacy services in the ED at their institutions under the guidance of mentors. The PCIP continued to mentor pharmacists for several years, with interest in the program driven by a burst of new EM pharmacy programs; a total of 80 participants completed the program and started EM pharmacy services at their institutions. The “ASHP Connect” EM online community was created to allow pharmacists practicing or interested in EM to network and discuss practice-related issues, barriers, and successes; there are currently 287 members in this group. The ASHP Research and Education Foundation has funded several research grants focusing on EM pharmacy–related services, outcomes, and medication safety. ASHP and the ASHP Foundation continue to recognize EM pharmacy services through the Best Practices Award in Health-System Pharmacy program 11 (www.ashp.org/menu/ AboutUs/Awards/BestPracticesAward) and through Pharmacy Practice Research Awards bestowed as part of the Foundation’s Literature Awards program (www.ashpfoundation. org/MainMenuCategories/Awards/ ASHPFoundationLiteratureAwards).12 The American College of Clinical Pharmacy (ACCP) has been a strong supporter of the growth and development of clinical pharmacists practicing in the ED. In response to a formal application submitted by ACCP members with an interest in EM, ACCP developed the Emergency
Medicine Practice and Research Network (PRN) group in August 2008.13 The purpose of the PRN group is to provide EM pharmacists with a forum to network and further promote research and education in this practice area. The PRN group includes a planning committee that creates educational content for the ACCP annual meeting and a media committee that distributes a biannual newsletter to members who practice or have an interest in EM pharmacy; currently, the PRN group includes 840 members. ACCP has created a number of other EM committees and programs to foster the development of EM clinical pharmacists (information available at www.accp. com), including the Collaborative Organization for Development of Emergency Medicine Pharmacists program, which provides pharmacists the opportunity to network and share ideas on how to promote and grow pharmacy services in the ED; a student committee to increase awareness of EM clinical pharmacy practice and provide leadership, advocacy, and resources for students to gain clinical and scholarly experience in EM pharmacy services; a Travel Award Committee, which each year provides funding for a student and a resident to travel to the ACCP annual meeting to present their EM-related research findings at the PRN business meeting. ACCP also has an Awards and Recognition Committee that facilitates nominations of EM clinical pharmacists for ACCP awards, as well as Emergency Medicine PRN awards, to recognize outstanding EM clinical pharmacy mentors and EM-related publications. Members of the PRN collaborate on research and scholarly activity; one important publication by PRN members was the 2011 article “Key Articles and Guidelines for the Emergency Medicine Pharmacist,”14 which provided a collection of literature for both new and experienced clinicians practicing in the ED.
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Securing physician support. EM physicians and nurses who work with pharmacists in the ED setting value the pharmacists’ role in improving quality of care and consider them integral members of the team.3,15 In 2014, a group of pharmacists brought together by the ASHP Section Advisory Group on Emergency Care drafted a resolution document asking that “ACEP [American College of Emergency Physicians] create a policy statement that supports clinical pharmacy services in emergency departments and collaboration among emergency medicine providers in order to promote safe, effective, and evidencedbased medication practices; to conduct emergency-medicine-related clinical research, and to foster an environment supporting emergency medicine pharmacy residency training”.16 In July 2014, the New York state chapter of ACEP voted to support the document and submit it to the ACEP council. On October 25, 2014, resolution 44(14) was presented by the chapter and an EM pharmacist (representing ASHP, ACCP, and EM pharmacists nationally) to the ACEP Council’s reference committee. There was overwhelming support by council members, and the following day the ACEP board of directors agreed to adopt the resolution; the board approved the final statement in June 2015.17 This was an exciting step for our specialty: to be recognized as integrated members of the interprofessional team by the largest EM organization in the world (32,000 members). Another important advance in terms of interprofessional acceptance took place in 2015, when the American Academy of Emergency Medicine (AAEM) accepted pharmacists as members of the organization’s Allied Health Professionals membership category. This allows pharmacists to serve on AAEM committees and obtain free registration for academy meetings.18 2094
International developments. The Society of Hospital Pharmacists of Australia (SHPA) recognizes EM pharmacy in its Committees of Specialty Practice and provides a listing of publications and presentations by Australian ED pharmacists and an online discussion forum for EM pharmacist members. In addition, ED pharmacist members of SHPA are eligible for a Young Pharmacist Award, as well as a research and development grant to travel to the United States to gain insight into strategies to expand and improve the efficiency of quality pharmacy service provision and exchange knowledge in clinical practice and research.19,20 In March 2015, England’s National Health Service expanded a pilot initiative to enlist pharmacists working as part of the interprofessional team in up to 36 EDs across England to enhance and improve emergency care through management of medicinerelated issues as part of the Royal Pharmaceutical Society’s Urgent and Emergency Care Campaign.21 Responsibilities of EM pharmacists. The responsibilities of EM pharmacists vary with the types of institutions in which they practice. EM pharmacists practicing in large academic medical centers or large community hospitals may have duties significantly different from those of EM pharmacists practicing in smaller community or rural hospitals. Until recently, no large surveys had been conducted to determine the patient care activities pharmacists engage in while physically present in the ED. In 2015, a national survey to characterize pharmacy practice in the ED in the United States was completed.22 An electronic survey was disseminated to members of the ASHP Connect Emergency Medicine group and the ACCP Emergency Medicine PRN to capture data on current pharmacy practices in the ED setting. A total of 187 pharmacists completed the survey. Large majorities of respondents were from community hospitals
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(60.4%) or academic institutions (35.4%). Overall, the median number of pharmacists practicing in the ED was 2.0 (interquartile range, [IQR], 1.0–2.5), and institutions reported a wide variety of ED pharmacist coverage periods (range, 1–24 hours), with coverage most often provided during afternoon and evening hours (1 p.m. to midnight) and two thirds of institutions also providing some ED pharmacist coverage on weekends. Pharmacists practicing in the ED reported involvement in a variety of activities and were asked to estimate the percentage of a typical day dedicated to those activities. On average, clinical activities (e.g., pharmacotherapy consults, drug information, toxicology recommendations, patient education, microbiology culture review) consumed 25% of a pharmacist’s time (IQR, 15–40%), followed by emergency response activities, such as participating in responses to medical cardiopulmonary and trauma resuscitation emergencies (15%; IQR, 10–20%); order processing (15%; IQR, 5–25%); medication reconciliation (10%; IQR, 5–25%); teaching (10%; IQR, 5–15%); and administrative activities (5%; IQR, 0–10%). These results showed that pharmacists practicing in academic and community EDs perform a variety of clinical, educational, and administrative activities. Postgraduate training. The first accredited postgraduate year 2 (PGY2) residency training program in EM pharmacy was established at Detroit Receiving Hospital; the second accredited program was launched shortly thereafter by the University of Rochester Medical Center. Both programs were established approximately 15 years ago, and there has been significant growth in residency training opportunities since then. There are currently 29 accredited PGY2 residency programs in EM pharmacy (some with multiple residency positions), with more programs awaiting conferral
COMMENTARIES
of accreditation. Four EM pharmacy residency positions were created with the support of the ASHP Foundation’s Pharmacy Residency Expansion Grant Program.23 A great step toward unified training in this practice area was the creation and approval of standards for PGY2 EM pharmacy residencies by the ASHP Commission on Credentialing in 2012.24 Educational opportunities. There has been considerable growth in EM pharmacy practice over the last 15 years, and ASHP supports the expansion of EM pharmacy educational opportunities for pharmacy students and within postgraduate education. 7,8 Although there has been growth in PGY2 EM pharmacy residency training, it is likely that this alone cannot meet the need for EM-trained clinical pharmacists due to the high number of EDs in the United States. A national survey to describe the prevalence and nature of EM pharmacy training opportunities available to pharmacy students and residents was conducted in 2014.25 Electronic surveys were distributed to department of pharmacy practice chairs and experiential education representatives at Accreditation Council for Pharmacy Education–accredited colleges and schools of pharmacy as well as directors of ASHP-accredited postgraduate year 1 (PGY1) pharmacy residency programs. Twenty-one percent of the 57 survey respondents from colleges or schools of pharmacy reported that EM-focused introductory pharmacy practice experiences were available to students, and 83% reported that EMfocused advanced pharmacy practice experiences were available; many of these opportunities have been available for only five years or less. Only 15% of this group of respondents reported EM-related topics in the didactic curriculum, and only 8.5% reported an EM-oriented didactic elective course.
Emergency medicine pharmacy
The survey findings indicated that there were more training opportunities for PGY1 pharmacy practice residents. Among 286 residency program representatives who responded to the survey, 212 (74%) reported offering an EM rotation, and 60 had a required EM rotation. The majority of institutions offering these opportunities reported the use of dedicated clinical pharmacy services in the ED. Also, among programs with nonEM PGY2 pharmacy residents, over 50% indicated that an EM rotation is available to those residents. These results show that there is still a lot of work to be done to develop and standardize education and rotation opportunities for pharmacy students and residents to meet growing demand in this specialty area. Credentialing and privileging. Credentials in any practice area are important to document the knowledge, skills, and experience of pharmacists. As the role of pharmacists practicing in the ED continues to expand and become more complex, not only is ongoing professional education important, but the development and implementation of a framework for credentialing and privileging pharmacists practicing in this area will be necessary.26 Currently, there is not a defined credentialing track for EM clinical pharmacy; however, there are avenues for obtaining professional qualifications. These avenues may include PGY2 EM pharmacy residency training, PGY1 pharmacy practice training with EM pharmacy rotations, PCIP training, and certification. There are many national certifications that can be obtained by pharmacists practicing in this area. These include American Heart Association certification in advanced cardiac life support and pediatric advanced life support, American College of Surgeons certification in advanced trauma life support (audit), American Burn Association certification in advanced life support,
and Neurocritical Care Society certification in emergency neurologic life support and basic and advanced life support in hazardous materials– related emergencies. Also, as more pharmacists are practicing in the ED, many institutions have created privileging tracks and competency activities for these pharmacists. Board certification through the Board of Pharmacy Specialties (BPS) or “board eligibility” (if a specialty area exam is not available) is supported for all pharmacists with direct patient care and multidisciplinary team responsibilities, including EM clinical pharmacists.27 ASHP, with support from the leadership of ACCP’s Emergency Medicine PRN, in May 2013 submitted a preliminary request for BPS to consider a new specialty (emergency medicine). In June 2015, BPS announced approval of a role delineation study of a certification exam in EM pharmacy.28 Another avenue to board certification can be pursued through the American Board of Applied Toxicology (ABAT), a committee of the American Academy of Clinical Toxicology; pharmacists who fulfill certain eligibility requirements can sit for an examination to obtain the designation Diplomate of ABAT. Evidence of EM pharmacists’ impact. There are many published articles on the roles of EM pharmacists in cost-saving initiatives, improvement of clinical outcomes, and interception of medication errors. For example, pharmacist involvement in management of patients treated for cardiac arrest, trauma, stroke, acute myocardial infarction, or sepsis and pharmacists’ participation in reviewing microbiology culture results have been associated with improved guideline and clinical pathway compliance; improved medication administration, intervention, or followup times; and decreased medication errors and omissions.29 Two multicenter studies done in geographically
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Emergency medicine pharmacy
diverse locations focused on the impact of EM pharmacists in reducing medication errors and on pharmacist activities that lead to medication error interception.30,31 One of the studies indicated that EM pharmacists were able to prevent medication errors in 7.8 of every 100 patient cases and 2.9 of every 100 medications evaluated; these potential errors were often categorized as serious (47.8%) or significant (36.2%).30 The other study found that the pharmacist activities most frequently leading to medication error interception were consultative activities (51.4%) and medication order review (34.9%); problematic orders were most often handwritten or computerized orders (54.4%) or verbal orders (32.7%).31 These study results provide support for an expanded role for pharmacists in the ED in providing direct patient care at the bedside. Closing notes. EM clinical pharmacy practice is truly a new frontier that is continually evolving in the United States and worldwide. It is an exciting new area for pharmacists, and ASHP has provided the support to grow EM clinical pharmacy practice. Starting with the efforts of a small group of pioneers in the 1970s and continuing to the present day, we have seen amazing strides in all areas of EM clinical pharmacy. As our profession, healthcare systems, and medical practices continue to change, we will need to constantly adapt our methodology and roles on the EM healthcare team and sharpen our ability to improvise in a unique practice setting and make a major contribution to improved patient care. References 1. Elenbaas RM, Waeckerle JF, McNabney WK. The clinical pharmacist in emergency medicine. Am J Hosp Pharm. 1977; 34:843-6. 2. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, DC: National Academies; 1999.
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3. Thomasset KB, Faris R. Am J Health-Syst Pharm. 2003; 60:1561-4. 4. Fairbanks RJ, Hays DP, Webster DF, Spillane LL. Clinical pharmacy services in an emergency department. Am J HealthSyst Pharm. 2004; 61:934-7. 5. Pederson CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2008. Am J HealthSyst Pharm. 2009; 66:926-46. 6. Pederson CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2013. Am J HealthSyst Pharm. 2014; 71:924-42. 7. American Society of Health-System Pharmacists. ASHP statement on pharmacy services to the emergency department. Am J Health-Syst Pharm. 2008; 65:2380-3. 8. American Society of Health-System Pharmacists. ASHP guidelines on emergency medicine pharmacist services. Am J Health-Syst Pharm. 2011; 68:e8195. 9. American Society of Health-System Pharmacists. Emergency Care Resource Center. www.ashp.org/emergencycare. aspx (accessed 2015 Sep 23). 10. Witsil JC, Aazami R, Murtaza UI et al. Strategies for implementing emergency department pharmacy services: results from the 2007 ASHP Patient Care Impact Program. Am J Health-Syst Pharm. 2010; 67:375-9. 11. American Society of Health-System Pharmacists. Best Practices Award. www. ashp.org/menu/AboutUs/Awards/BestPracticesAward (accessed 2015 Sep 23). 12. ASHP Research and Education Foundation. ASHP Foundation Literature Awards. www.ashpfoundation.org/MainMenu Categories/Awards/ASHPFoundation LiteratureAwards (accessed 2015 Sep 23). 13. American College of Clinical Pharmacy. Practice and research networks. www. accp.com/about/prns.aspx (accessed 2015 Aug 31). 14. Thomas MC, Acquisto NM, Patanwala AE et al. Key articles and guidelines for the emergency medicine pharmacist. Pharmacotherapy. 2011; 31:1265. 15. Fairbanks RJ, Hildebrand JM, Kolstee KE et al. Medical and nursing staff highly value clinical pharmacists in the emergency department. Emerg Med J. 2007; 24:716-9. 16. American College of Emergency Physicians. 2014 annual council meeting. www.acep.org/uploadedFiles/ACEP/ About_Us/Leadership/Council/2014%20 Re s o lut i on s % 2 0 Com p en d iu m . p d f (accessed 2015 Jul 29). 17. American College of Emergency Physicians. Clinical pharmacy services in the emergency department. www.acep.org/ Clinical—Practice-Management/ClinicalPharmacist-Services-in-the-EmergencyDepartment/ (accessed 2015 Jul 29).
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18. American Academy of Emergency Medicine. Membership. www.aaem.org/ membership (accessed 2015 Sep 23). 19. Chan EW. International pharmacy preceptorship in emergency medicine. J Pharm Pract Res. 2010; 40:76-7. 20. Roman C. RDGAC grant reports. Acute trauma and resuscitation preceptorship. J Pharm Pract Res. 2014; 44:165-6. 21. Robinson S. Large expansion of NHS pilot project will see many more pharmacists working in emergency departments. Pharm J. 2015; 294:article 7847. 22. Thomas MC, Acquisto NM, Shirk MB, Patanwala AE. A national survey of emergency pharmacy practice in the United States. Am J Health-Syst Pharm. In press. 23. American Society of Health-System Pharmacists Research and Education Foundation. Pharmacy Residency Expansion Grant Program. www.ashpfoundation. org/MainMenuCategories/PracticeTools/ Pharmacy-Residency-Expansion-GrantPEG-Program (accessed 2015 Aug 31). 24. American Society of Health-System Pharmacists. Educational outcomes, goals, and objectives for postgraduate year two (PGY2) pharmacy residencies in emergency medicine. www.ashp.org/ DocLibrary/Accreditation/RegulationsStandards/Emergency-Medicine.pdf (accessed 2015 Jul 29). 25. Vollman KE, Adams CB, Acquisto NM. Survey of emergency medicine pharmacy education opportunities for students and residents. Hosp Pharm. In press. 26. Credentialing and privileging of pharmacists: a resource paper from the Council on Credentialing in Pharmacy. Am J Health-Syst Pharm. 2014; 71:1891900. 27. Maddux MS, for American College of Clinical Pharmacy. Board of Regents commentary. Qualifications of pharmacists who provide direct patient care: perspectives on the need for residency training and board certification. Pharmacotherapy. 2013; 33:888-91. 28. Board of Pharmacy Specialties. Board of Pharmacy Specialties announces plans for new role delineation studies (June 19, 2015). www.bpsweb.org/news/ pr_061615.pdf (accessed 2015 Jul 29). 29. Rudis MI, Attwood RJ. Emergency medicine pharmacy practice. J Pharm Pract. 2011; 24:135-45. 30. Rothschild JM, Churchill W, Erickson A et al. Medication errors recovered by emergency department pharmacists. Ann Emerg Med. 2010; 55:513-21. 31. Patanwala AE, Sanders AB, Thomas MC et al. A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department. Ann Emerg Med. 2012; 59:369-73.
Emergency medicine pharmacy
Emergency medicine pharmacy: Still a new clinical frontier Nicole M. Acquisto and Daniel P. Hays Am J Health-Syst Pharm. 2015; 72:2092-6
T
he emergency department (ED) is a practice setting with inherent medication safety risks. It is a fast-paced, overcrowded, highacuity, stressful environment with many distractions—an environment where incomplete patient information is the norm and steps of the medication-use process are often omitted because of reliance on verbal medication orders, a lack of pharmacist contribution to the medication-use process (often due to pharmacists’ physical distance from the ED), and the need for emergent medication administration. In the 1970s, early pharmacist services in the ED focused on cost containment, inventory control, and dispensing. However, as hospital distribution practices changed, the role of the pharmacist developed into one that was more clinically focused. Emergency medicine (EM) clinical pharmacist services were first described in the mid1970s.1 The growth of EM clinical pharmacy services was slow over the next 20 years leading up to the Institute of Medicine’s influential 1999 report on medical errors.2 The
report identified the ED as an area of the hospital with high rates of preventable adverse drug events and one that could be expected to benefit from clinical pharmacy services. After that report, hospital deployment of pharmacists began to include the ED while the clinical role of the pharmacist in the ED was expanded to the bedside. Interest in what a pharmacist could accomplish in this realm grew. In order to continue to grow, this relatively new area of practice would need validation, accreditation, training, and guidelines for practice. Evolution of EM pharmacy practice. Early clinical pharmacy services in the ED focused on drug procurement during cardiac arrest, adverse drug event surveillance, and identification of medication-related adverse events during ED presentation. In 2001, a national survey was conducted using the ASHP pharmacy residency directory to evaluate the prevalence and characteristics of pharmacy services in the ED.3 Only 4 hospitals (3.4% of the 119 respondent facilities) reported having a dedicated pharmacist regularly
Nicole M. Acquisto, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacy Specialist and Assistant Professor, Departments of Pharmacy and Emergency Medicine, University of Rochester Medicine, Rochester, NY. Daniel P. Hays, Pharm.D., BCPS, FASHP, is Emergency Pharmacist, Maricopa Medical Center, Phoenix, AZ.
Address correspondence to Dr. Acquisto ([email protected]). The authors have declared no potential conflicts of interest.
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Copyright © 2015, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/15/1201-2092. DOI 10.2146/ajhp150622
Am J Health-Syst Pharm—Vol 72 Dec 1, 2015
assigned to the ED, and 13 others (10.9%) had a pharmacist whose primary responsibility was to provide services to the ED. Clinical services were broad and included optimizing medication orders, participating in cardiopulmonary resuscitations, and providing drug information, toxicology consults, ED inservices, and patient education. Clinical pharmacy services in the ED began to grow in the early 2000s. In 2004, Fairbanks et al.4 published a descriptive report on the roles of clinical pharmacists in the ED at one academic institution. In addition to the clinical activities already discussed, the pharmacist was involved in resuscitation activities, including trauma responses; provided care to patients with other highly time-dependent emergencies (e.g., stroke, myocardial infarction); provided education to EM attending physicians, residents, and nurses; and participated in protocol development, formulary optimization, and emergency preparedness. Based on that publication and related work, in 2007 Fairbanks and colleagues were awarded the “Emergency Department Pharmacist as a Safety Measure in Emergency Medicine” grant (HS015818-01) by the Agency for Healthcare Research and Quality to further study the role and benefit of the pharmacist in the ED. This grant also funded the Emergency Pharmacist Research Center website (www.emergency pharmacist.org), which has served as a resource for EM pharmacists looking for ways to demonstrate the value of their services in the ED. The number of dedicated EM pharmacy services in U.S. hospitals continues to expand. In the ASHP national survey of pharmacy practice in hospital settings, dedicated EM pharmacy
COMMENTARIES
services were reported by 6.8% and 16.4% of respondents in 2008 and 2013, respectively.5,6 Practice expansion and the role of pharmacy societies. ASHP has been instrumental in fostering and supporting the growth of EM pharmacy practice. Recognizing the ED as a new frontier for pharmacy practice, the society developed a position statement recommending that every hospital’s pharmacy department provide its ED with pharmacy services necessary for provision of safe and effective patient care.7 Furthermore, ASHP supported proposals that the expansion of pharmacy education and postgraduate training should include an emphasis on emergency care. ASHP also created the Section Advisory Group on Emergency Care within its Section of Clinical Scientists and Specialists. Members of this group went on to publish “ASHP Guidelines on Emergency Medicine Pharmacist Services.”8 The threefold purpose of this document was to define the role of the EM clinical pharmacist, suggest goals for providing services to meet institution-specific needs, and establish a definition of best practices for pharmacy services in the ED. The section advisory group continues to instate a diverse group of EM pharmacists every year. ASHP’s Emergency Care Resource Center provides pharmacists with articles and guidelines on selected disease states, resources for justifying pharmacists’ services in the ED, and recorded educational series.9 Members of the section advisory group also produce webinars and meeting programs related to pharmacy practice in the ED setting. Specifically, the “Emergency Medicine Clinical Pearls” session, which started in 2009, has become a staple of the ASHP Midyear Clinical Meeting and often requires an overflow room to accommodate attendees. Over 100 unique EM pharmacy
Emergency medicine pharmacy
clinical pearls have been presented to date. In 2007 ASHP developed and promoted the Patient Care Impact Program (PCIP): Introducing an Emergency Pharmacist to Your Institution, which mentored and guided pharmacists in the development of EM pharmacy services at their institutions.10 In the program’s first year, 19 pharmacists (chosen from among over 100 applicants) were tasked with initiating clinical pharmacy services in the ED at their institutions under the guidance of mentors. The PCIP continued to mentor pharmacists for several years, with interest in the program driven by a burst of new EM pharmacy programs; a total of 80 participants completed the program and started EM pharmacy services at their institutions. The “ASHP Connect” EM online community was created to allow pharmacists practicing or interested in EM to network and discuss practice-related issues, barriers, and successes; there are currently 287 members in this group. The ASHP Research and Education Foundation has funded several research grants focusing on EM pharmacy–related services, outcomes, and medication safety. ASHP and the ASHP Foundation continue to recognize EM pharmacy services through the Best Practices Award in Health-System Pharmacy program 11 (www.ashp.org/menu/ AboutUs/Awards/BestPracticesAward) and through Pharmacy Practice Research Awards bestowed as part of the Foundation’s Literature Awards program (www.ashpfoundation. org/MainMenuCategories/Awards/ ASHPFoundationLiteratureAwards).12 The American College of Clinical Pharmacy (ACCP) has been a strong supporter of the growth and development of clinical pharmacists practicing in the ED. In response to a formal application submitted by ACCP members with an interest in EM, ACCP developed the Emergency
Medicine Practice and Research Network (PRN) group in August 2008.13 The purpose of the PRN group is to provide EM pharmacists with a forum to network and further promote research and education in this practice area. The PRN group includes a planning committee that creates educational content for the ACCP annual meeting and a media committee that distributes a biannual newsletter to members who practice or have an interest in EM pharmacy; currently, the PRN group includes 840 members. ACCP has created a number of other EM committees and programs to foster the development of EM clinical pharmacists (information available at www.accp. com), including the Collaborative Organization for Development of Emergency Medicine Pharmacists program, which provides pharmacists the opportunity to network and share ideas on how to promote and grow pharmacy services in the ED; a student committee to increase awareness of EM clinical pharmacy practice and provide leadership, advocacy, and resources for students to gain clinical and scholarly experience in EM pharmacy services; a Travel Award Committee, which each year provides funding for a student and a resident to travel to the ACCP annual meeting to present their EM-related research findings at the PRN business meeting. ACCP also has an Awards and Recognition Committee that facilitates nominations of EM clinical pharmacists for ACCP awards, as well as Emergency Medicine PRN awards, to recognize outstanding EM clinical pharmacy mentors and EM-related publications. Members of the PRN collaborate on research and scholarly activity; one important publication by PRN members was the 2011 article “Key Articles and Guidelines for the Emergency Medicine Pharmacist,”14 which provided a collection of literature for both new and experienced clinicians practicing in the ED.
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Securing physician support. EM physicians and nurses who work with pharmacists in the ED setting value the pharmacists’ role in improving quality of care and consider them integral members of the team.3,15 In 2014, a group of pharmacists brought together by the ASHP Section Advisory Group on Emergency Care drafted a resolution document asking that “ACEP [American College of Emergency Physicians] create a policy statement that supports clinical pharmacy services in emergency departments and collaboration among emergency medicine providers in order to promote safe, effective, and evidencedbased medication practices; to conduct emergency-medicine-related clinical research, and to foster an environment supporting emergency medicine pharmacy residency training”.16 In July 2014, the New York state chapter of ACEP voted to support the document and submit it to the ACEP council. On October 25, 2014, resolution 44(14) was presented by the chapter and an EM pharmacist (representing ASHP, ACCP, and EM pharmacists nationally) to the ACEP Council’s reference committee. There was overwhelming support by council members, and the following day the ACEP board of directors agreed to adopt the resolution; the board approved the final statement in June 2015.17 This was an exciting step for our specialty: to be recognized as integrated members of the interprofessional team by the largest EM organization in the world (32,000 members). Another important advance in terms of interprofessional acceptance took place in 2015, when the American Academy of Emergency Medicine (AAEM) accepted pharmacists as members of the organization’s Allied Health Professionals membership category. This allows pharmacists to serve on AAEM committees and obtain free registration for academy meetings.18 2094
International developments. The Society of Hospital Pharmacists of Australia (SHPA) recognizes EM pharmacy in its Committees of Specialty Practice and provides a listing of publications and presentations by Australian ED pharmacists and an online discussion forum for EM pharmacist members. In addition, ED pharmacist members of SHPA are eligible for a Young Pharmacist Award, as well as a research and development grant to travel to the United States to gain insight into strategies to expand and improve the efficiency of quality pharmacy service provision and exchange knowledge in clinical practice and research.19,20 In March 2015, England’s National Health Service expanded a pilot initiative to enlist pharmacists working as part of the interprofessional team in up to 36 EDs across England to enhance and improve emergency care through management of medicinerelated issues as part of the Royal Pharmaceutical Society’s Urgent and Emergency Care Campaign.21 Responsibilities of EM pharmacists. The responsibilities of EM pharmacists vary with the types of institutions in which they practice. EM pharmacists practicing in large academic medical centers or large community hospitals may have duties significantly different from those of EM pharmacists practicing in smaller community or rural hospitals. Until recently, no large surveys had been conducted to determine the patient care activities pharmacists engage in while physically present in the ED. In 2015, a national survey to characterize pharmacy practice in the ED in the United States was completed.22 An electronic survey was disseminated to members of the ASHP Connect Emergency Medicine group and the ACCP Emergency Medicine PRN to capture data on current pharmacy practices in the ED setting. A total of 187 pharmacists completed the survey. Large majorities of respondents were from community hospitals
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(60.4%) or academic institutions (35.4%). Overall, the median number of pharmacists practicing in the ED was 2.0 (interquartile range, [IQR], 1.0–2.5), and institutions reported a wide variety of ED pharmacist coverage periods (range, 1–24 hours), with coverage most often provided during afternoon and evening hours (1 p.m. to midnight) and two thirds of institutions also providing some ED pharmacist coverage on weekends. Pharmacists practicing in the ED reported involvement in a variety of activities and were asked to estimate the percentage of a typical day dedicated to those activities. On average, clinical activities (e.g., pharmacotherapy consults, drug information, toxicology recommendations, patient education, microbiology culture review) consumed 25% of a pharmacist’s time (IQR, 15–40%), followed by emergency response activities, such as participating in responses to medical cardiopulmonary and trauma resuscitation emergencies (15%; IQR, 10–20%); order processing (15%; IQR, 5–25%); medication reconciliation (10%; IQR, 5–25%); teaching (10%; IQR, 5–15%); and administrative activities (5%; IQR, 0–10%). These results showed that pharmacists practicing in academic and community EDs perform a variety of clinical, educational, and administrative activities. Postgraduate training. The first accredited postgraduate year 2 (PGY2) residency training program in EM pharmacy was established at Detroit Receiving Hospital; the second accredited program was launched shortly thereafter by the University of Rochester Medical Center. Both programs were established approximately 15 years ago, and there has been significant growth in residency training opportunities since then. There are currently 29 accredited PGY2 residency programs in EM pharmacy (some with multiple residency positions), with more programs awaiting conferral
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of accreditation. Four EM pharmacy residency positions were created with the support of the ASHP Foundation’s Pharmacy Residency Expansion Grant Program.23 A great step toward unified training in this practice area was the creation and approval of standards for PGY2 EM pharmacy residencies by the ASHP Commission on Credentialing in 2012.24 Educational opportunities. There has been considerable growth in EM pharmacy practice over the last 15 years, and ASHP supports the expansion of EM pharmacy educational opportunities for pharmacy students and within postgraduate education. 7,8 Although there has been growth in PGY2 EM pharmacy residency training, it is likely that this alone cannot meet the need for EM-trained clinical pharmacists due to the high number of EDs in the United States. A national survey to describe the prevalence and nature of EM pharmacy training opportunities available to pharmacy students and residents was conducted in 2014.25 Electronic surveys were distributed to department of pharmacy practice chairs and experiential education representatives at Accreditation Council for Pharmacy Education–accredited colleges and schools of pharmacy as well as directors of ASHP-accredited postgraduate year 1 (PGY1) pharmacy residency programs. Twenty-one percent of the 57 survey respondents from colleges or schools of pharmacy reported that EM-focused introductory pharmacy practice experiences were available to students, and 83% reported that EMfocused advanced pharmacy practice experiences were available; many of these opportunities have been available for only five years or less. Only 15% of this group of respondents reported EM-related topics in the didactic curriculum, and only 8.5% reported an EM-oriented didactic elective course.
Emergency medicine pharmacy
The survey findings indicated that there were more training opportunities for PGY1 pharmacy practice residents. Among 286 residency program representatives who responded to the survey, 212 (74%) reported offering an EM rotation, and 60 had a required EM rotation. The majority of institutions offering these opportunities reported the use of dedicated clinical pharmacy services in the ED. Also, among programs with nonEM PGY2 pharmacy residents, over 50% indicated that an EM rotation is available to those residents. These results show that there is still a lot of work to be done to develop and standardize education and rotation opportunities for pharmacy students and residents to meet growing demand in this specialty area. Credentialing and privileging. Credentials in any practice area are important to document the knowledge, skills, and experience of pharmacists. As the role of pharmacists practicing in the ED continues to expand and become more complex, not only is ongoing professional education important, but the development and implementation of a framework for credentialing and privileging pharmacists practicing in this area will be necessary.26 Currently, there is not a defined credentialing track for EM clinical pharmacy; however, there are avenues for obtaining professional qualifications. These avenues may include PGY2 EM pharmacy residency training, PGY1 pharmacy practice training with EM pharmacy rotations, PCIP training, and certification. There are many national certifications that can be obtained by pharmacists practicing in this area. These include American Heart Association certification in advanced cardiac life support and pediatric advanced life support, American College of Surgeons certification in advanced trauma life support (audit), American Burn Association certification in advanced life support,
and Neurocritical Care Society certification in emergency neurologic life support and basic and advanced life support in hazardous materials– related emergencies. Also, as more pharmacists are practicing in the ED, many institutions have created privileging tracks and competency activities for these pharmacists. Board certification through the Board of Pharmacy Specialties (BPS) or “board eligibility” (if a specialty area exam is not available) is supported for all pharmacists with direct patient care and multidisciplinary team responsibilities, including EM clinical pharmacists.27 ASHP, with support from the leadership of ACCP’s Emergency Medicine PRN, in May 2013 submitted a preliminary request for BPS to consider a new specialty (emergency medicine). In June 2015, BPS announced approval of a role delineation study of a certification exam in EM pharmacy.28 Another avenue to board certification can be pursued through the American Board of Applied Toxicology (ABAT), a committee of the American Academy of Clinical Toxicology; pharmacists who fulfill certain eligibility requirements can sit for an examination to obtain the designation Diplomate of ABAT. Evidence of EM pharmacists’ impact. There are many published articles on the roles of EM pharmacists in cost-saving initiatives, improvement of clinical outcomes, and interception of medication errors. For example, pharmacist involvement in management of patients treated for cardiac arrest, trauma, stroke, acute myocardial infarction, or sepsis and pharmacists’ participation in reviewing microbiology culture results have been associated with improved guideline and clinical pathway compliance; improved medication administration, intervention, or followup times; and decreased medication errors and omissions.29 Two multicenter studies done in geographically
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Emergency medicine pharmacy
diverse locations focused on the impact of EM pharmacists in reducing medication errors and on pharmacist activities that lead to medication error interception.30,31 One of the studies indicated that EM pharmacists were able to prevent medication errors in 7.8 of every 100 patient cases and 2.9 of every 100 medications evaluated; these potential errors were often categorized as serious (47.8%) or significant (36.2%).30 The other study found that the pharmacist activities most frequently leading to medication error interception were consultative activities (51.4%) and medication order review (34.9%); problematic orders were most often handwritten or computerized orders (54.4%) or verbal orders (32.7%).31 These study results provide support for an expanded role for pharmacists in the ED in providing direct patient care at the bedside. Closing notes. EM clinical pharmacy practice is truly a new frontier that is continually evolving in the United States and worldwide. It is an exciting new area for pharmacists, and ASHP has provided the support to grow EM clinical pharmacy practice. Starting with the efforts of a small group of pioneers in the 1970s and continuing to the present day, we have seen amazing strides in all areas of EM clinical pharmacy. As our profession, healthcare systems, and medical practices continue to change, we will need to constantly adapt our methodology and roles on the EM healthcare team and sharpen our ability to improvise in a unique practice setting and make a major contribution to improved patient care. References 1. Elenbaas RM, Waeckerle JF, McNabney WK. The clinical pharmacist in emergency medicine. Am J Hosp Pharm. 1977; 34:843-6. 2. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, DC: National Academies; 1999.
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3. Thomasset KB, Faris R. Am J Health-Syst Pharm. 2003; 60:1561-4. 4. Fairbanks RJ, Hays DP, Webster DF, Spillane LL. Clinical pharmacy services in an emergency department. Am J HealthSyst Pharm. 2004; 61:934-7. 5. Pederson CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2008. Am J HealthSyst Pharm. 2009; 66:926-46. 6. Pederson CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2013. Am J HealthSyst Pharm. 2014; 71:924-42. 7. American Society of Health-System Pharmacists. ASHP statement on pharmacy services to the emergency department. Am J Health-Syst Pharm. 2008; 65:2380-3. 8. American Society of Health-System Pharmacists. ASHP guidelines on emergency medicine pharmacist services. Am J Health-Syst Pharm. 2011; 68:e8195. 9. American Society of Health-System Pharmacists. Emergency Care Resource Center. www.ashp.org/emergencycare. aspx (accessed 2015 Sep 23). 10. Witsil JC, Aazami R, Murtaza UI et al. Strategies for implementing emergency department pharmacy services: results from the 2007 ASHP Patient Care Impact Program. Am J Health-Syst Pharm. 2010; 67:375-9. 11. American Society of Health-System Pharmacists. Best Practices Award. www. ashp.org/menu/AboutUs/Awards/BestPracticesAward (accessed 2015 Sep 23). 12. ASHP Research and Education Foundation. ASHP Foundation Literature Awards. www.ashpfoundation.org/MainMenu Categories/Awards/ASHPFoundation LiteratureAwards (accessed 2015 Sep 23). 13. American College of Clinical Pharmacy. Practice and research networks. www. accp.com/about/prns.aspx (accessed 2015 Aug 31). 14. Thomas MC, Acquisto NM, Patanwala AE et al. Key articles and guidelines for the emergency medicine pharmacist. Pharmacotherapy. 2011; 31:1265. 15. Fairbanks RJ, Hildebrand JM, Kolstee KE et al. Medical and nursing staff highly value clinical pharmacists in the emergency department. Emerg Med J. 2007; 24:716-9. 16. American College of Emergency Physicians. 2014 annual council meeting. www.acep.org/uploadedFiles/ACEP/ About_Us/Leadership/Council/2014%20 Re s o lut i on s % 2 0 Com p en d iu m . p d f (accessed 2015 Jul 29). 17. American College of Emergency Physicians. Clinical pharmacy services in the emergency department. www.acep.org/ Clinical—Practice-Management/ClinicalPharmacist-Services-in-the-EmergencyDepartment/ (accessed 2015 Jul 29).
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18. American Academy of Emergency Medicine. Membership. www.aaem.org/ membership (accessed 2015 Sep 23). 19. Chan EW. International pharmacy preceptorship in emergency medicine. J Pharm Pract Res. 2010; 40:76-7. 20. Roman C. RDGAC grant reports. Acute trauma and resuscitation preceptorship. J Pharm Pract Res. 2014; 44:165-6. 21. Robinson S. Large expansion of NHS pilot project will see many more pharmacists working in emergency departments. Pharm J. 2015; 294:article 7847. 22. Thomas MC, Acquisto NM, Shirk MB, Patanwala AE. A national survey of emergency pharmacy practice in the United States. Am J Health-Syst Pharm. In press. 23. American Society of Health-System Pharmacists Research and Education Foundation. Pharmacy Residency Expansion Grant Program. www.ashpfoundation. org/MainMenuCategories/PracticeTools/ Pharmacy-Residency-Expansion-GrantPEG-Program (accessed 2015 Aug 31). 24. American Society of Health-System Pharmacists. Educational outcomes, goals, and objectives for postgraduate year two (PGY2) pharmacy residencies in emergency medicine. www.ashp.org/ DocLibrary/Accreditation/RegulationsStandards/Emergency-Medicine.pdf (accessed 2015 Jul 29). 25. Vollman KE, Adams CB, Acquisto NM. Survey of emergency medicine pharmacy education opportunities for students and residents. Hosp Pharm. In press. 26. Credentialing and privileging of pharmacists: a resource paper from the Council on Credentialing in Pharmacy. Am J Health-Syst Pharm. 2014; 71:1891900. 27. Maddux MS, for American College of Clinical Pharmacy. Board of Regents commentary. Qualifications of pharmacists who provide direct patient care: perspectives on the need for residency training and board certification. Pharmacotherapy. 2013; 33:888-91. 28. Board of Pharmacy Specialties. Board of Pharmacy Specialties announces plans for new role delineation studies (June 19, 2015). www.bpsweb.org/news/ pr_061615.pdf (accessed 2015 Jul 29). 29. Rudis MI, Attwood RJ. Emergency medicine pharmacy practice. J Pharm Pract. 2011; 24:135-45. 30. Rothschild JM, Churchill W, Erickson A et al. Medication errors recovered by emergency department pharmacists. Ann Emerg Med. 2010; 55:513-21. 31. Patanwala AE, Sanders AB, Thomas MC et al. A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department. Ann Emerg Med. 2012; 59:369-73.
