N e ws Emergency physicians group supports ED clinical pharmacy services


he nation’s largest professional organization of emergency medicine physicians decided at its recent annual meeting to create a policy statement that supports clinical pharmacists as a part of the emergency medicine team. This policy statement, according to the American College of Emergency Physicians (ACEP), will support “clinical pharmacy services in emergency departments and collaboration among emergency medicine providers to promote safe, effective, and evidence-based medication practices, to conduct emergency-medicinerelated clinical research, and to foster an environment supporting pharmacy residency training in emergency medicine.” The decision to create the policy statement stemmed directly from the late-October passage of a resolution submitted by ACEP’s New York chapter. New York ACEP President Louise A. Prince said her board of directors had an easy decision to make when a longtime, active member asked the group to submit the resolution. Louise Prince “Any of us who’s ever had access to clinical pharmacy services in the [emergency room] knows it’s really important,” Prince said. The resolution, she said, addresses collaboration and collective research and, just as importantly, specialty training. “Emergency medicine is its own brand of pharmacy, if you will,” Prince said. Thus, emergency medicine needs clinical pharmacists who have been trained to practice that specialty. “It’s a really specialized, unique area,” said the residency-trained emer-


gency department (ED) physician. “And we need the kind of collaboration that occurs at the bedside at the time that the patient is being taken care of and not from a distance and not spread out over time. We have to make a decision immediately.” Maria Raven, a member of the board of directors of California ACEP, said her group supported the resolution. During a hearing at ACEP’s recent annual meeting, Raven spoke in favor of the resolution’s approval. “I worked for 10 years in a public hospital system in New York City, and we did not have pharmacists on our team,” said the ED physician, now at University of California, San Francisco (UCSF) Medical Center. “So I got to UCSF, and it was sort of a novel concept. But it is so amazing.” Raven said she told the assemblage at the hearing about the clinical pharmacists working in her ED and how they enhance the team in unique ways. Zlatan Coralic is one of those pharmacists. Coralic, who started UCSF Medical Center’s ED pharmacy service in late 2009, said he raised Zlatan Coralic the idea of pursuing a national-level policy statement a year ago at the ASHP Midyear Clinical Meeting. After all, he reasoned, critical care pharmacists had succeeded a decade earlier in getting national recognition as members of the intensive care unit team. “We’ve been accumulating data for the past three or four decades in emergency medicine,” Coralic said. “We have

Am J Health-Syst Pharm—Vol 71 Dec 15, 2014

a substantial amount of data that we can present to ACEP.” So at the 2013 Midyear Clinical Meeting, he voiced his idea to the ASHP Section of Clinical Specialists and Scientists’ Advisory Group on Emergency Care. The response, he said, was “extremely supportive.” Fellow advisory group member Nicole Acquisto acted quickly. Sandra M. Schneider, former chair of the emergency medicine depart- Nicole Acquisto ment at the University of Rochester Medical Center in New York, where Acquisto works, happened to be a presenter at an educational session later in the week. The emergency medicine physician also happened to be a past president of ACEP and past board member of New York ACEP. Acquisto said she approached Schneider after the session, explained the advisory group’s idea, and asked whether the idea was good and how to proceed through ACEP’s policymaking process. In the end, Acquisto said, the advisory group decided some of its members would write the resolution. Schneider offered to present that resolution to New York ACEP. When New York ACEP presented the resolution at the national organization’s annual Council Meeting, physicians from elsewhere in the nation, including California, stepped up to the microphone to voice support, Coralic said. Acquisto, with the permission of the chair of the committee conducting the hearing, stepped up to the microphone as well. “There was pretty much no opposition” to adoption of the resolution, she said.


Also at the hearing were advisory group chair Katelyn Dervay of Tampa General Hospital and former advisory group member Suprat S. Wilson of Detroit Receiving Hospital. Prince said New York ACEP’s members strongly believe that “having 24-hour-

a-day pharmacists in our emergency departments is a good safety practice.” But that safety practice, she added, can be “very expensive.” A policy statement by ACEP in support of clinical pharmacy services in the ED may encourage hospital systems to

NIOSH revamps hazardous drugs update


he National Institute for Occupational Safety and Health (NIOSH), in its latest revision to the list of hazardous drugs in healthcare facilities, has adopted an approach that takes into account workers’ exposure risks and categorizes hazardous drugs by type. “This is a huge step forward in presenting the information,” said Annie Lambert, pharmacy manager for oncology and ambulatory infusion services at MultiCare Health System in Tacoma, Washington. Unlike the 2012 version, Annie Lambert the 2014 edition of the NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings divides hazardous drugs into three groups, with some overlap: antineoplastic drugs, nonantineoplastic drugs, and drugs whose hazards primarily pose reproductive risks to certain men or women. Exposure to drugs in the latter category may not pose a serious risk to some workers, according to NIOSH. But the agency noted that it has not attempted to define exposure limits or perform risk assessments for any hazardous drug. The 2014 document states that some dosage formulations of hazardous drugs, such as capsules and coated tablets, may not pose a “significant” exposure risk to healthcare workers who handle the medications without altering them. But crushing tablets or preparing solutions

of hazardous drugs may increase the exposure risk. NIOSH stated that all hazardous drugs, regardless of their formulation, should be labeled as hazardous to prevent improper handling. To help healthcare facilities manage exposure risks, the 2014 update contains recommendations for the use of personal protective equipment (PPE) in specific situations. According to NIOSH, a single set of gloves may be all the PPE necessary for a healthcare worker to administer an intact tablet or capsule from unit dose packaging. But preparing an i.v. solution of a hazardous drug may require double gloves, a protective gown, eye and respiratory protection, and the use of a biological safety cabinet and closed-system drugtransfer device. ASHP, in its official comments to NIOSH about the proposed 2014 update, generally supported the agency’s approach to revising the document and providing recommendations for the use of PPE. The list and PPE recommendations are particularly relevant to Lambert in her work on a subcommittee to implement a 2011 Washington state law that protects healthcare workers against exposure to hazardous drugs. That law requires employers in healthcare facilities where workplace exposures may occur to implement a

consider paying for those services for safety purposes, Prince said. —Cheryl A. Thompson DOI 10.2146/news140084

hazardous drugs control program by January 2015 that is consistent with the NIOSH recommendations. “Here in Washington state . . . we must adopt the NIOSH list,” Lambert said. “We can always add things to it, but we have to take the NIOSH list for what it is.” But she said healthcare facilities in the state have “a lot of leeway” to craft policies for the use of PPE to protect workers in settings and situations with different exposure risks. At her hospital, she said, “everyone agrees that we’re going to gown up and glove up and do everything we can to protect our workers during the highestrisk activities, such as i.v. chemotherapy compounding and administration.” But in the health system’s community pharmacies and standard nursing units, she said, elaborate gowning and masking is probably “excessive,” and she expects policies for those areas to reflect that. California and North Carolina in 2013 enacted laws that require healthcare facilities to develop policies and procedures to protect workers from hazardous drugs. But the regulations apply only to NIOSH-designated antineoplastic drugs, not all drugs deemed hazardous by NIOSH. The United States Pharmacopeial Convention (USP) is developing a general chapter (chapter 800) on the handling of hazardous drugs in the workplace. A proposed version of the chapter that was released for comment this past March required healthcare settings to designate as hazardous all drugs on the NIOSH list.

Am J Health-Syst Pharm—Vol 71 Dec 15, 2014


Emergency physicians group supports ED clinical pharmacy services.

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