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Service Delivery Innovation Profile

Emergency Department–Based Clinical Pharmacist Improves Quality of Care


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Snapshot

Summary

The University of Rochester Medical Center placed a clinical pharmacist in the emergency department to serve as an integral member of the health care team, leading to an increase in quality care. The clinical pharmacist who works in the emergency department as a fully integrated member of the health care team provides clinical consultations, patient education, order screening, and other valuable services that are designed to reduce the potential for medication errors and adverse events.

Evidence Rating (What is this?)

Suggestive: The evidence consists of a post-implementation survey on staff satisfaction with the program.
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Developing Organizations

University of Rochester Medical Center
Rochester, NYend do

Use By Other Organizations

The American Society of Health-System Pharmacists has sponsored a Patient Care Impact Program each year from 2007 through 2012: A mentorship program to help hospitals start new emergency pharmacist programs. See http://www.ashp.org/menu/Education/Traineeships/PatientCare.aspx for more information. Several programs have existed for many years, and there are an increasing number of new programs around the country. There is no comprehensive list available; however, the following is a selection of existing programs:
  • Massachusetts General Hospital
  • Detroit Receiving Hospital
  • Cedar-Sinai Hospital, Los Angeles
  • Advocate Christ Medical Center, Oak Lawn, IL
  • Detroit Medical Center/Wayne State University
  • Medical Center of Aurora, CO
  • Johns Hopkins Hospital, Baltimore
  • University of Illinois, Chicago
  • Rutgers, Robert Wood Johnson Hospital
  • Children's Hospital, Dallas

Date First Implemented

2000

Problem Addressed

Adverse medication events in the emergency department (ED) and elsewhere are common but often preventable, exacting a large toll on the U.S. health care system.
  • According to the Institute of Medicine (IOM), the rates of adverse events, including adverse drug events, are too high in the United States.1
  • The ED is a fast-paced, chaotic, and stressful environment where critical decisions about medications must commonly be made in less-than-ideal circumstances. The IOM's 1999 report To Err is Human found that the ED had the highest rate of preventable adverse events, with as many as 3.8 million preventable events each year. Few EDs currently have a clinical pharmacist in place to assist with making and executing these decisions.1

What They Did

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Description of the Innovative Activity

The core component of the program is the creation of a new position—a full-time clinical pharmacist who works in the ED as a fully integrated member of the health care team, providing clinical consultations, patient education, order screening, drug dispensing, and other valuable services that are designed to reduce the potential for medication errors and adverse events.
  • Available hours and resources: The ED clinical pharmacist works all days of the week, with variable hours, with a focus on the hours between 10 a.m. and 2 a.m. The pharmacist has a dedicated computer with online references and a portable telephone.
  • Daily ED pharmacist role: The pharmacist is readily accessible to ED physicians and nursing staff, providing the following services: (1) clinical consultation; (2) patient education; (3) order screening; (4) medication preparation in emergency situations; (5) resuscitation response; (6) nursing, resident, and staff education; and (7) coordination with other pharmacists on inpatient transfers.
  • Periodic lectures to residents, research collaboration: To supplement the education provided as a part of regular duties, the pharmacist gives four lectures per year to the emergency medicine residents. The pharmacist also collaborates with physicians on their clinical research activities, which, thus far, has resulted in the publication of several research studies.

Context of the Innovation

The University of Rochester Medical Center is a 739-bed academic medical center; the ED clinical pharmacist program was pilot tested in the hospital’s level one trauma center ED, which has an annual patient volume of approximately 100,000. The program was started in 2000, then expanded and optimized for patient safety in 2005 as part of the Agency for Healthcare and Research Quality's (AHRQ's) Partnerships in Patient Safety grant program.

Did It Work?

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Results

A comparison study shows that the ED pharmacist improves quality of care and is highly valued by the nursing and physician staff in the ED.
  • Quality improvement: The study group has shown an improvement in several quality measures when the emergency pharmacist is present, such as time to the operating room in major trauma and time to the catheter lab in acute myocardial infarction. Preliminary work has also shown a trend toward improvement in quality measures such as allergy violations in antibiotic administration and pain management in fractures. Further research is necessary to determine improvement in outcome.
  • High staff satisfaction: Both physicians and nurses view the ED pharmacist as a tremendously valuable resource. A random sample of medical and nursing staff in an academic medical center ED with a dedicated emergency pharmacist program received a 26-item survey (82 percent return rate). Ninety-nine percent of respondents believed that the emergency pharmacist improves quality of care, 96 percent believe that they are an integral part of the team, and 93 percent had consulted the emergency pharmacist at least a few times during their last five shifts. Staff believed that the emergency pharmacist should be available for consults, attend resuscitations, and check orders. This study found that doctors and nurses overwhelmingly favor the presence of an emergency pharmacist in the ED, frequently seek their advice, and believe they improve quality of care.

Evidence Rating (What is this?)

Suggestive: The evidence consists of a post-implementation survey on staff satisfaction with the program.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Identifying and addressing potential barriers: These barriers included potential financial/resource constraints, staff resistance, and the pharmacist shortage. A comprehensive Web-based toolkit (http://www.emergencypharmacist.org/toolkit.html) describes the implementation process used by the University of Rochester Medical Center, including strategies to address identified barriers and generic slide presentations that can be adapted for use by other institutions.
  • Shadowing the medical staff: Before formally establishing the role, the potential ED pharmacist shadowed the medical staff to assess and understand the current process and identify potential areas for improvement. The shadowing experience also allowed the pharmacist to develop personal relationships with physicians and nurses, which was an important factor in gaining provider acceptance.

Resources Used and Skills Needed

  • Personnel: The program requires the addition of one full-time pharmacist. Sample job descriptions and qualifications can be found at http://www.emergencypharmacist.org/toolkit.html.
  • Costs: The costs of the program are almost exclusively in full-time equivalents for the clinical pharmacist positions, which depends on regional salary requirements. Smaller incidental startup costs might involve the addition of a workstation (computer and telephone) for the on-duty emergency pharmacist.
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Funding Sources

Agency for Healthcare Research and Quality
The program was funded in part by an AHRQ grant that was designed to evaluate the ED pharmacist as a safety measure. (AHRQ Grant Number: U18HS15818, RFA/PA: HS05-012 - Partnerships In Implementing Patient Safety, Start date: July 2005, End date: June 2008)end fs

Tools and Other Resources

Adoption Considerations

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Getting Started with This Innovation

  • Environmental assessment: Assess the ED environment as a guide to planning program operations (e.g., number of pharmacists needed, appropriate hours pharmacist should be available), taking into consideration the size and teaching status of the hospital and patient volume and demographics.
  • Job description: Develop and communicate a clear description of the new pharmacist position to ED staff and physicians, including appropriate roles and expectations.
  • Educational and professional attributes: Recruit emergency pharmacists who not only have the appropriate educational background and clinical experience, but also other desirable characteristics such as being proactive and able to build collaborative relationships with hospital staff and emergency physicians with collaborative and nonconfrontational approaches.
  • Staff education: Educate ED staff and physicians on the need for the program and the pharmacist’s role, emphasizing the new position as a valuable potential resource that will support their work that can lead to enhanced quality of care.
  • Preprogram implementation: Have the pharmacist shadow the medical staff before formal program implementation, as a means to better define the role and build relationships.

Sustaining This Innovation

  • Outcome effects: Continually monitor outcomes to demonstrate a return on investment from the program in terms of improved quality of care.
  • Clinical coverage: Ensure that pharmacist coverage is available, at a minimum, during high-volume periods in the ED.
  • Safety focus: Encourage the pharmacist, ED staff, and emergency physicians to focus on high-risk medications and patients.

Use By Other Organizations

The American Society of Health-System Pharmacists has sponsored a Patient Care Impact Program each year from 2007 through 2012: A mentorship program to help hospitals start new emergency pharmacist programs. See http://www.ashp.org/menu/Education/Traineeships/PatientCare.aspx for more information. Several programs have existed for many years, and there are an increasing number of new programs around the country. There is no comprehensive list available; however, the following is a selection of existing programs:
  • Massachusetts General Hospital
  • Detroit Receiving Hospital
  • Cedar-Sinai Hospital, Los Angeles
  • Advocate Christ Medical Center, Oak Lawn, IL
  • Detroit Medical Center/Wayne State University
  • Medical Center of Aurora, CO
  • Johns Hopkins Hospital, Baltimore
  • University of Illinois, Chicago
  • Rutgers, Robert Wood Johnson Hospital
  • Children's Hospital, Dallas

Additional Considerations

Over time, staff and physicians will increasingly utilize the emergency pharmacist as they see the value of the role they can have in helping the ED team care for patients.

More Information

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Contact the Innovator

Rollin J. (Terry) Fairbanks, MD MS FACEP
Adjunct Assistant Professor of Emergency Medicine
University of Rochester, Rochester, NY
Associate Professor of Emergency Medicine
Georgetown University, Washington, DC
Director, National Center for Human Factors Engineering in Healthcare
3007 Tilden Street NW, Suite 7M
Washington, DC 20008
Phone: (202) 244-9800
E-mail: terry.fairbanks@medicalhfe.org

Innovator Disclosures

Dr. Fairbanks has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Acquisto NM, Hays DP, Fairbanks RJ, et al. The outcomes of emergency pharmacist participation during acute myocardial infarction. J Emerg Med. 2012 Apr;42(4):371-8. [PubMed]

Baker SN, Acquisto NM, Dodds-Ashley E, et al. Pharmacist-managed antimicrobial stewardship program for patients discharged from the emergency department. J Pharm Pract. 2012 Apr;25(2):190-4. [PubMed]

Clancy CM. Practical approaches to improving safety in the ED environment. Patient Safety & Quality Healthcare Web site, July 25, 2007. Available at: http://www.psqh.com/enews/0707feature.html

Fairbanks RJ, Hays DP, Webster DF, et al. Clinical pharmacy services in an emergency department. Am J Health Syst Pharm. 2004;61:934-7. [PubMed]

Fairbanks RJ, Rueckmann EA, Kolstee KE, et al. Clinical pharmacists in emergency medicine. In: Henricksen K, Battles JB, Keyes MA, et al, eds. Advances in patient safety: new directions and alternative approaches. Vol. 4. Technology and Medication Safety (AHRQ Publication Number: 08-0034-4). Rockville, MD: Agency for Healthcare Research and Quality, August, 2008. Available at: http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4
/Advances-fairbanks_20.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)

Fairbanks RJ, Hildebrand JM, Kolstee KE, et al. Medical and nursing staff value and utilize clinical pharmacists in the emergency department. Emerg Med J. 2007;24(10):716-9. [PubMed]

Conners GP, Hays DP. Emergency department drug orders: does drug storage location make a difference? Ann Emerg Med. 2007;50(4):414-8. [PubMed]

Szczesiul JM, Fairbanks RJ, Hildebrand JM, et al. Survey of physicians regarding clinical pharmacy services in academic emergency departments. Am J Health Syst Pharm. 2009;66:576-9. [PubMed]

Witsil JC, Aazami R, Murtaza UI, et al. Strategies for implementing emergency department pharmacist services: results from the 2007 ASHP Patient Impact Care Program. Am J Health Syst Pharm. 2010 Mar; 67(5):375-9. [PubMed]

Footnotes

1 Fairbanks RJ, Hays DP, Webster DF, et al. Clinical pharmacy services in an emergency department. Am J Health Syst Pharm. 2004;61(9):934-7. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: June 23, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 16, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 21, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.