COMMENTARY
Pharmacy practice and medication reconciliation
ar
COMMENTARY
Emergency pharmacy practice and medication reconciliation Asad E. Patanwala Am J Health-Syst Pharm. 2014; 71:2167-8
I
n a recent national survey of pharmacy directors, Kern et al.1 reported that close to 90% of respondents agreed or strongly agreed that it is important for pharmacists to be involved in transition-of-care activities. The survey posed questions pertaining to the entire spectrum of transitions that typically occur during hospitalization and included questions on medication history taking in the emergency department (ED), medication reconciliation, and discharge counseling. The survey authors discussed barriers to increased pharmacist involvement in providing transition-of-care services and made recommendations on the reallocation of personnel to help close current gaps in such services. The survey results showed that most institutions are struggling with providing consistent services in this domain. However, as hospitals adapt in this metrics-driven era of pharmacy services, it is important to provide the clinician’s perspective, with a focus on the setting where the first transition of care during hospitalization often occurs: the ED. It is unlikely that emergency pharmacists would disagree that transition-of-care activities are important, but the real question is this: How important do they consider medication reconciliation to be relative to their other functions? Without a formal survey, we can only hypothesize what the answer might be.
Targeted versus comprehensive medication lists. There is a general misunderstanding regarding how medication reconciliation fits into emergency medicine practice, so some background explanation is warranted. The average length of stay in the ED is less than six hours. During this time, acute care is provided and the emergency physician decides on patient disposition; therefore, the patient interview for determining current medications may be somewhat narrowly focused. At this point, ascertaining the presence or absence of certain drugs (e.g., warfarin) in the patient’s current medication history would be as valuable as compiling a comprehensive list with medication dosages. However, certain clinical presentations, such as altered mental status or a possible drug-induced problem—caused, for example, by a drug interaction or adverse effects—may prompt further investigation of current medications in a targeted fashion.2 The need for comprehensive medication lists with dosages becomes more important when the decision is made to admit the patient to the hospital, transfer care to an Asad E. Patanwala, Pharm.D., BCPS, is Associate Professor, Department of Pharmacy Practice and Science, The University of Arizona, Tucson ([email protected]. edu). The author has declared no potential conflicts of interest.
Layar
inpatient team, or continue care for a prolonged period in the ED. Thus, the process of medication reconciliation and obtaining comprehensive lists typically begins in earnest with admitting teams rather than ED providers. A comprehensive drug list compiled early on (i.e., within one to two hours of ED triage) is, in contrast to targeted medication history taking, unlikely to alter decisionmaking for most chief complaints during acute management in the ED. However, at the time of hospital admission, thorough medication reconciliation can detect discrepancies and prevent medication errors, so an effective and systematic approach is needed. But does this activity need to be done by the emergency pharmacist? Is that the best use of pharmacy resources? Barriers to increased pharmacist involvement. One barrier to performing detailed medication reconciliation in the ED is a lack of desire to perform the task among personnel trained in acute care. The specialty of emergency medicine originated with caring for the injured, and emergency physicians have differentiated themselves as experts in resuscitation. ED pharmacists have similarly modeled their expertise. They help treat patients with cardiac arrest, trauma, stroke, or acute coronary syndrome and participate in toxicological emergencies, intubation, and procedural sedation. They serve as bedside consultants for timeCopyright © 2014, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/14/1202-2167. DOI 10.2146/ajhp140266
Am J Health-Syst Pharm—Vol 71 Dec 15, 2014
2167
COMMENTARY
Pharmacy practice and medication reconciliation
sensitive drug therapy decisionmaking. I have asked dozens of pharmacy students and pharmacy residents what they find appealing about emergency medicine, and the nearly universal answer is that they like the fast-paced environment and the unpredictability of the next clinical decisions they will have to face. It takes a unique set of personality traits to practice in this setting. Pharmacy residents choosing an ED experience have never told me that they like to obtain complete medication lists or that the opportunity to do so was the reason that they chose an ED rotation. Of course, it is the patient outcome—not what pharmacists find to be intellectually gratifying— that is important, so let us examine some pertinent data in terms of patient safety. A growing body of evidence, including a multicenter study led by my own institution,3 has shown that pharmacists are able to successfully intercept errors and prevent harm in the ED through clinical consultations with staff and medication order review before drug administration. On the other hand, in a study by Johnston et al.,4 pharmacy technicians were able to obtain a medication history with as much accuracy and completeness as pharmacists. To obtain results such as those reported by Johnston et al., pharmacy technicians would have to be trained, but allocating emergency pharmacists’ time to an activity that can be done by well-trained pharmacy technicians does not seem to be a prudent use of resources. A role for pharmacy technicians? I encourage clinicians involved in making administrative decisions regarding transition-of-care models to spend a day in the ED obtaining
2168
medication histories, calling multiple pharmacies for each patient, and then trying to make sense of all the information. Although the task is important, it need not be performed by an individual with board certification, residency training, or even a doctor of pharmacy degree. Pharmacy students, in their introductory pharmacy practice experiences, are able to do this task well in most cases, although some populations, such as pediatric patients, may represent exceptions to that general rule because of the complexity of the dosages and formulations used in their care. To their credit, Kern et al.1 discussed the use of pharmacy extenders to help perform medication history taking and related activities during transitions of care. In my view, pharmacy technicians should be assigned primary responsibility for performing these tasks in the ED; the emergency pharmacist could be consulted in complex cases or help adjudicate decisions during the reconciliation process if needed. Refining the role of ED pharmacists. Obtaining focused medication histories early on in the care process is necessary, especially in large EDs. However, if ED pharmacists were to focus primarily on medication reconciliation and assume responsibility for doing it consistently, that might result in the exclusion of other activities, with the potential for professional dissatisfaction. Moreover, some small EDs may simply not be busy enough to justify dedicating a pharmacist to perform clinical activities; in such cases, pharmacists may opt to spend their “downtime” obtaining medication lists, but, while that may be beneficial, it cannot ensure the consistent provision of medication reconciliation services—a need I believe can be met
Am J Health-Syst Pharm—Vol 71 Dec 15, 2014
by properly trained pharmacy technicians. In any event, however, not all transition-of-care activities should be delegated to technicians. It is still critical for pharmacists to counsel patients when they are discharged home, especially those receiving high-risk medications. I would emphasize that these comments pertain only to the ED and should not be extrapolated to other settings. Close to a decade ago, the Joint Commission required that pharmacists review medication orders for patients in the ED. This spurred growth in emergency pharmacy services. There is evidence that medication review improves patient safety when combined with consultative activities by onsite emergency pharmacists. Now there is impetus to improve transitions of care and reduce hospital readmissions, but let us not allow it to force emergency pharmacists to abandon what they do best. They are experts in resuscitation and provide critical and timesensitive consultations for the most vulnerable populations. That surely cannot be delegated. References 1. Kern KA, Kalus JS, Bush C et al. Variations in pharmacy-based transition-of-care activities in the United States: a national survey. Am J Health-Syst Pharm. 2014; 71:648-56. 2. Hohl CM, Yu E, Hunte GS et al. Clinical decision rules to improve the detection of adverse drug events in emergency department patients. Acad Emerg Med. 2012; 19:640-9. 3. 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. 4. Johnston R, Saulnier L, Gould O. Best possible medication history in the emergency department: comparing pharmacy technicians and pharmacists. Can J Hosp Pharm. 2010; 63:359-65.
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Pharmacy practice and medication reconciliation
ar
COMMENTARY
Emergency pharmacy practice and medication reconciliation Asad E. Patanwala Am J Health-Syst Pharm. 2014; 71:2167-8
I
n a recent national survey of pharmacy directors, Kern et al.1 reported that close to 90% of respondents agreed or strongly agreed that it is important for pharmacists to be involved in transition-of-care activities. The survey posed questions pertaining to the entire spectrum of transitions that typically occur during hospitalization and included questions on medication history taking in the emergency department (ED), medication reconciliation, and discharge counseling. The survey authors discussed barriers to increased pharmacist involvement in providing transition-of-care services and made recommendations on the reallocation of personnel to help close current gaps in such services. The survey results showed that most institutions are struggling with providing consistent services in this domain. However, as hospitals adapt in this metrics-driven era of pharmacy services, it is important to provide the clinician’s perspective, with a focus on the setting where the first transition of care during hospitalization often occurs: the ED. It is unlikely that emergency pharmacists would disagree that transition-of-care activities are important, but the real question is this: How important do they consider medication reconciliation to be relative to their other functions? Without a formal survey, we can only hypothesize what the answer might be.
Targeted versus comprehensive medication lists. There is a general misunderstanding regarding how medication reconciliation fits into emergency medicine practice, so some background explanation is warranted. The average length of stay in the ED is less than six hours. During this time, acute care is provided and the emergency physician decides on patient disposition; therefore, the patient interview for determining current medications may be somewhat narrowly focused. At this point, ascertaining the presence or absence of certain drugs (e.g., warfarin) in the patient’s current medication history would be as valuable as compiling a comprehensive list with medication dosages. However, certain clinical presentations, such as altered mental status or a possible drug-induced problem—caused, for example, by a drug interaction or adverse effects—may prompt further investigation of current medications in a targeted fashion.2 The need for comprehensive medication lists with dosages becomes more important when the decision is made to admit the patient to the hospital, transfer care to an Asad E. Patanwala, Pharm.D., BCPS, is Associate Professor, Department of Pharmacy Practice and Science, The University of Arizona, Tucson ([email protected]. edu). The author has declared no potential conflicts of interest.
Layar
inpatient team, or continue care for a prolonged period in the ED. Thus, the process of medication reconciliation and obtaining comprehensive lists typically begins in earnest with admitting teams rather than ED providers. A comprehensive drug list compiled early on (i.e., within one to two hours of ED triage) is, in contrast to targeted medication history taking, unlikely to alter decisionmaking for most chief complaints during acute management in the ED. However, at the time of hospital admission, thorough medication reconciliation can detect discrepancies and prevent medication errors, so an effective and systematic approach is needed. But does this activity need to be done by the emergency pharmacist? Is that the best use of pharmacy resources? Barriers to increased pharmacist involvement. One barrier to performing detailed medication reconciliation in the ED is a lack of desire to perform the task among personnel trained in acute care. The specialty of emergency medicine originated with caring for the injured, and emergency physicians have differentiated themselves as experts in resuscitation. ED pharmacists have similarly modeled their expertise. They help treat patients with cardiac arrest, trauma, stroke, or acute coronary syndrome and participate in toxicological emergencies, intubation, and procedural sedation. They serve as bedside consultants for timeCopyright © 2014, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/14/1202-2167. DOI 10.2146/ajhp140266
Am J Health-Syst Pharm—Vol 71 Dec 15, 2014
2167
COMMENTARY
Pharmacy practice and medication reconciliation
sensitive drug therapy decisionmaking. I have asked dozens of pharmacy students and pharmacy residents what they find appealing about emergency medicine, and the nearly universal answer is that they like the fast-paced environment and the unpredictability of the next clinical decisions they will have to face. It takes a unique set of personality traits to practice in this setting. Pharmacy residents choosing an ED experience have never told me that they like to obtain complete medication lists or that the opportunity to do so was the reason that they chose an ED rotation. Of course, it is the patient outcome—not what pharmacists find to be intellectually gratifying— that is important, so let us examine some pertinent data in terms of patient safety. A growing body of evidence, including a multicenter study led by my own institution,3 has shown that pharmacists are able to successfully intercept errors and prevent harm in the ED through clinical consultations with staff and medication order review before drug administration. On the other hand, in a study by Johnston et al.,4 pharmacy technicians were able to obtain a medication history with as much accuracy and completeness as pharmacists. To obtain results such as those reported by Johnston et al., pharmacy technicians would have to be trained, but allocating emergency pharmacists’ time to an activity that can be done by well-trained pharmacy technicians does not seem to be a prudent use of resources. A role for pharmacy technicians? I encourage clinicians involved in making administrative decisions regarding transition-of-care models to spend a day in the ED obtaining
2168
medication histories, calling multiple pharmacies for each patient, and then trying to make sense of all the information. Although the task is important, it need not be performed by an individual with board certification, residency training, or even a doctor of pharmacy degree. Pharmacy students, in their introductory pharmacy practice experiences, are able to do this task well in most cases, although some populations, such as pediatric patients, may represent exceptions to that general rule because of the complexity of the dosages and formulations used in their care. To their credit, Kern et al.1 discussed the use of pharmacy extenders to help perform medication history taking and related activities during transitions of care. In my view, pharmacy technicians should be assigned primary responsibility for performing these tasks in the ED; the emergency pharmacist could be consulted in complex cases or help adjudicate decisions during the reconciliation process if needed. Refining the role of ED pharmacists. Obtaining focused medication histories early on in the care process is necessary, especially in large EDs. However, if ED pharmacists were to focus primarily on medication reconciliation and assume responsibility for doing it consistently, that might result in the exclusion of other activities, with the potential for professional dissatisfaction. Moreover, some small EDs may simply not be busy enough to justify dedicating a pharmacist to perform clinical activities; in such cases, pharmacists may opt to spend their “downtime” obtaining medication lists, but, while that may be beneficial, it cannot ensure the consistent provision of medication reconciliation services—a need I believe can be met
Am J Health-Syst Pharm—Vol 71 Dec 15, 2014
by properly trained pharmacy technicians. In any event, however, not all transition-of-care activities should be delegated to technicians. It is still critical for pharmacists to counsel patients when they are discharged home, especially those receiving high-risk medications. I would emphasize that these comments pertain only to the ED and should not be extrapolated to other settings. Close to a decade ago, the Joint Commission required that pharmacists review medication orders for patients in the ED. This spurred growth in emergency pharmacy services. There is evidence that medication review improves patient safety when combined with consultative activities by onsite emergency pharmacists. Now there is impetus to improve transitions of care and reduce hospital readmissions, but let us not allow it to force emergency pharmacists to abandon what they do best. They are experts in resuscitation and provide critical and timesensitive consultations for the most vulnerable populations. That surely cannot be delegated. References 1. Kern KA, Kalus JS, Bush C et al. Variations in pharmacy-based transition-of-care activities in the United States: a national survey. Am J Health-Syst Pharm. 2014; 71:648-56. 2. Hohl CM, Yu E, Hunte GS et al. Clinical decision rules to improve the detection of adverse drug events in emergency department patients. Acad Emerg Med. 2012; 19:640-9. 3. 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. 4. Johnston R, Saulnier L, Gould O. Best possible medication history in the emergency department: comparing pharmacy technicians and pharmacists. Can J Hosp Pharm. 2010; 63:359-65.
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
