Objectives - c.ymcdn.com · ROI 4 month study – 2150 interventions21 •1393 directly related to ADE’s •Cost avoidance of estimated $1,029,776 35 ... USP Patient Safety CAPS

1

Establishing Emergency Department

Pharmacy Services and Pharmacist

Impact

Glenn R. Oettinger, PharmD, BCPS

and

Robert S. Pugliese, PharmD, BCPS

1

The Pennsylvania Society of Health System Pharmacists

October 29th, 2015

Objectives

1) Explain justification for an Emergency Medicine

Pharmacist (EMP)

2) Describe the core roles of the EMP

3) Describe strategies for implementing an EMP position

4) Identify how to encourage growth in the specialty of

Emergency Medicine (EM) Pharmacy

5) Describe some ways in which EMPs can systematically

improve the care of patients in ED

6) Discuss other key administrative roles of EMPs

2

The Emergency Medicine

Pharmacist A Safety Measure for Hospitals

Glenn Oettinger, PharmD, BCPS

[email protected]

@GlennOettinger

3

Part 1

The Emergency Medicine Pharmacist: A Safety

Measure for Hospitals1

• Justification

• Role

• Implementation

4

JUSTIFICATION Overcoming skepticism

5

The Ideal ED

6

2

The Ideal ED

• No patient is overlooked

• Adequate support for all clinical staff

• Appropriate supervision of all residents and

students

• All patients rest assured medications ordered

are reviewed by a pharmacist

7

Reality

8

Reality

• ED is Vulnerable

• High volume and overcrowding

• Wide spectrum of diseases

• Frequent interruptions and distractions

• Fast paced

• Verbal orders

9

ED is Inherently a Patient Safety Risk2,3,4

• Established safety mechanisms missing from most EDs

• Pharmacy review of medications

• Pharmacy preparation of medications

• Pharmacist involvement in clinical decision making

• Medication-related adverse events in the ED

• 3.6% of ED patients receive inappropriate medication

• 5.6% of ED patients receive inappropriate discharge Rx

10

Gaps in the Average ED Medication

Use System5

11

Dispensing (pharmacist)

Data Entry and

Screening

Preparing, mixing,

compounding

Pharmacist double

check

Dispensing to Unit

Transcribing (Pharmacist, nurse,

unit clerk)

Receive order or

retrieve from MAR

Check if correct

Prescribing (physician, nurse

practitioner, pharmacist)

Clinical decision

making

Drug Choice

Drug regimen

determination

Medical Record

Documentation

Order (written,

verbal, electronic)

Monitoring (Nurse, physician,

pharmacist)

Assess for

therapeutic effect

and adverse affect

Review laboratory

results if necessary

Treat adverse drug

event if occurring

Medical record

documentation

Administering (nurse)

Drug preparation for

administering

Nurse verifies

orders

Drug administered

Documentation in

MAR

Most ED Medication Events are Preventable!

• ED has highest rate of preventable adverse

events in the US6

• 110 million ED visits annually in US

• 5% experience potential events = 550,000 potential

events per year

• 70% are PREVENTABLE = 38,500 preventable events

12

3

ED Systems are Stretched7,8 ED overcrowding = Reduced capacity to deliver safe care

• Over last decade

• ED visits 26%

• 9% of EDs closing nationwide

• 198,000 hospital beds closed

• Reduced capacity to deliver safe care

• Boarding inpatients

• Contributes to overcrowding and elevated risk

13

Safety Benefits of an ED Pharmacist Program

Providing an extra layer of protection

• Available for immediate high risk med review

• Respond to all traumas, resuscitations, and critical patients

• Pharmacotherapy consults with physicians for medication selection

• Staff education

14

Joint Commission Compliance9,10

ED Pharmacist improves JC compliance

• Increased oversight of high yield medications

• Increased monitoring of drug effect

• Enhanced degree of communication with nurses and

physicians

• Development of processes for managing high risk

medications (i.e. TPA, sepsis antibiotics, pediatric

meds)

15

Adding Value

It has been shown that staff value the ED Pharmacist

• 26 item survey to random ED staff with 82%

response11

• 99% felt ED pharmacist improves quality of care

• 96% felt ED pharmacist was an integral part of ED team

• 95% indicated they had consulted with ED pharmacist at

least a few times during last 5 shifts

16

The ED Pharmacist – A Safety Measure in

Emergency Medicine

• ED pharmacist improves process measures such as:

• Time to cath lab, abx in pna, pain management, etc12

• Adds critical layer of safety to vulnerable patients13

• Adds cost-saving benefit to the ED14

17

Cost-savings in the Emergency Room:

A Four Month Study of ED Pharmacist

Interventions14 Type of

Intervention

No.Interventio

ns

Average Cost

Avoidance per Intervention ($)

Cost Avoidance ($)

Drug-drug or drug disease

interactions

or drug

incompatibilities identified

334 1,647 297,053

Therapeutic recommendation

523 1,188 273,383

Adverse drug event

prevented

48 1,098 23,190

Medication error prevented

488 1,375 436,150

Total 1393 5,308 $1,029,776 18

4

Role of the ED Pharmacist

19

Role of the ED Pharmacist

• Clinical Consultation Duties

• Responds to pharmacotherapy consultations

• Provides drug selection and dose recommendations

• Therapeutic substitutions

• Recognizes disease state specific pharmacotherapy

• Implements patient-specific pharmacokinetics

20

Other Clinical Duties

• Order screening

• Focus on allergies, drug interactions, and

appropriate dosing

• Selection and preparation of medications

• High Risk Medications, RSI, codes

• Resuscitations and trauma response

• ED pharmacist at bedside actively overseeing

medication use process

21

Pediatric ADE’s in the ED15

• For every 1000 pediatric patients

• 100 prescribing errors

• 39 administration errors

• 22% of acetaminophen doses incorrect

22

Pediatric patients at risk

• Most ED’s generally not well-prepared to

manage pediatrics16

• 6% “well” prepared nationwide

• Pediatrics account for 27% of ED visits

• All children need weight-based dosing, increasing the

likelihood for errors

23

ED Pharmacist – An Educator

• New medications

• Drug warnings

• Drug-drug interactions

• Provides current, evidenced-based information on

pharmacological therapy

• Simulation exercises

• Becomes an established authority through education

24

5

Benefits of Having an ED Pharmacist17,18,19

• Research and educational advancements

• Vulnerable populations

• i.e. Severe sepsis, severe trauma, patients

requiring sedation, pediatrics

• Patient safety

• Reduced rate of adverse events

• Medication selection, order screening, stat

bedside preparation

25

IMPLEMENTATION

26

National Implementation20

• 3-5% of EDs in U.S. have a dedicated clinical pharmacist

• 18.3% have attempted to gain funding for a pharmacist

position

• Primarily through pharmacy budget

• 30.1% plan to request funding

• demand

27

Bottom Line

• ED’s across America are in need of dedicated

pharmacy specialists

• Arrive with a plan and they will embrace you

28

Step I: Assess Individual ED Environment

• Size of hospital

• Academic center vs. non-academic

• Urban vs. rural

• Patient demographics

• Annual patient volume

• Trauma center

Have potential ED pharmacist candidate shadow medical staff

• Determine needs

29

Step 2: Recruitment

Finding a full time dedicated ED Pharmacist

• Education

• PharmD

• Residency – PGY1 preferred

• PGY2 accredited emergency pharmacist

programs emerging

• ACLS, PALS certification

30

6

Step 2: Recruitment

Experience

• Critical/acute Care

• Emergency Medicine

• Pediatrics

31

What to Look for

Characteristics

• Proactive – continually offers assistance

• Build relationships with all medical staff

• Actively seeks out patients that can benefit from

ED pharmacist intervention

• Ability to appear helpful and not confrontational

• Ability to work well under pressure and time

constraints

32

Step 3: Overcoming Challenges

Funding

• Grants

• EM department co-funding

• Couple implementation with a residency project

Staff Resistance

• Temporary response to change

33

Financial Challenges

Important to demonstrate return on investment

• ED pharmacist save money

• Recommend lower cost meds with equal or better efficacy

• Reduce adverse drug events

• Waste reduction

34

ROI

4 month study – 2150 interventions21

• 1393 directly related to ADE’s

• Cost avoidance of estimated $1,029,776

35

Availability, Accessibility, and Visibility

• Dedicated to the ED

• Physically located in ED (not isolated to a satellite)

• Easily accessible and visible to all staff with frequent

“walk-through”

36

7

Resources

Provide ED Pharmacist with necessary equipment (laptop,

cell phone, pager, computer space centrally located in ED)

37 38

Go Team ED!

References – Part One

1. Emergency Pharmacist Research Team, University of Rochester Department of Emergency Medicine. Rollin J. (Terry) Fairbanks, Principal Investigator; Karen E. Kolstee, Project Coordinator; Daniel P. Hays, Lead Pharmacist. www.EmergencyPharmacist.org Supported by The Agency for Healthcare Research and Quality, Partnerships in Patient Safety, Grant no. 1 U18 HS015818

2. Hafner JW, et al. Annals of Emergency Medicine, 2002; 39(3).

3. Leape LL, et al. JAMA, 1995; 27(1).

4. Sanders MS, et al. Human Factors Engineering and Design. 7th ed. McGraw Hill, Inc.,1993.

5. Aspden P et al, Preventing Medication errors: Quality Chasm Series. Nat’l Academy Press: 1st ed, 2007

6. USP Patient Safety CAPS

7. Institute of Medicine, The Future of Emergency Care. Nat’l Academies Press; 2007

8. Derlet RW. Overcrowding in emergency departments: increased demand and decreased capacity. Ann Emerg Med. 2002;39(4):430-2.

9. Fairbanks, Patel, and Shannon. EPh Time-Motion Study (2007). Results presented at AHSP Mid-Year Clinical Meeting, December 5, 2007. (available at www.emergencypharmacist.org/toolkit.html)

10. Conners GP, Hays D. Emergency Department Drug Orders: Does Drug Storage Location Make a Difference? Annals of Emergency Medicine. 2007;50:414-418

11. Fairbanks RJ, Hildebrand JM, Kolstee KE, Schneider SM, Shah MN. Medical and nursing staff value and utilize clinical pharmacists in the Emergency Department. Emergency Medicine Journal Oct 2007; 24:716-719.

12. Fairbanks RJ, Results of the AHRQ Emergency Pharmacist Outcomes Study. American Society of Health-System Pharmacists 42nd Mid-Year Clinical Meeting, Las Vegas: 12/5/07. (available at www.EmergencyPharmacist.org).

13. Fairbanks RJ et al, The Optimized Emergency Pharmacist Role, Presented at AHRQ Patient Safety & Health IT Conference, June 2006 (available at www.EmergencyPharmacist.org).

14. Lada P, Delgardo G. Documentation of Pharmacists' Interventions in an Emergency Department and Associated Cost Avoidance. Am J Health-Syst Pharm-Vol 64 Jan 1, 2007

15. Aspden P et al, Preventing Medication errors: Quality Chasm Series. Nat’l Academy Press: 1st ed, 2007

16. Institute of Medicine, The Future of Emergency Care. Nat’l Academies Press; 2007

17. Bond CA, et al, Pharmacotherapy, 1999; 19(6).

18. Leape LL, et al JAMA, Mar 2000; 283(10).

19. Gattis WH, et al, Arch Internal Med, 1999; 159(16).

20. Thomasset and Faris, Am J Health-Syst Pharm, Aug 2003; 60

21. Lada, P. et al, Am J Health-Syst Pharm, Jan 2007; 61(4)

39

The Emergency Medicine

Pharmacist Systematically improving patient care hospital wide

Robert S. Pugliese, PharmD, BCPS

[email protected]

@theEDpharmacist 40

Part 2

Emergency Medicine Pharmacists recognized by

American College of Emergency Physicians (ACEP)

“RESOLVED, That ACEP create a policy statement that

supports clinical pharmacy services in emergency

departments and collaboration among emergency medicine

providers to promote safe, effective, and evidence-based

medication practices, to conduct emergency-medicine-

related clinical research, and to foster an environment

supporting pharmacy residency training in emergency

medicine”2

41

Resolution 44

Emergency Medicine Pharmacists recognized by

American College of Emergency Physicians (ACEP)

“Any of us who’s ever had access to

clinical pharmacy services in the

[emergency room] know it’s really

important”

–Louise A Prince, President, ACEP New York1

42

http://www.EmergencyPharmacist.org

http://www.emergencypharmacist.org/toolkit.html



8

Surprise!?

• Many Emergency Departments:

• Overcrowded (primary care)

• Understaffed (5-to-1 nursing ratio!)

• Provide ICU level care (and fix tummy aches)

• Mixed population (inpatient/outpatient)

• Lack common medication safety protections

• Prospective medication order review not

mandated by Joint Commission

43

Do you

ED Pharmacist?

44

First mention of EM Pharmacy service was in 1977

published in American Journal of Hospital Pharmacy3

Yes 14%

No 86%

ER Pharmacist Survey 2000 (n=119)4

Yes 30%

No 70%

ER Pharmacist Survey 2007 (n=99)5

Pharmacy residency

programs surveyed Emergency Medicine

residency programs surveyed

45

Yes 62%

No 38%

?

Yes 14%

No 86%

ER Pharmacist Survey 2000 (n=119) 4

Yes 30%

No 70%

ER Pharmacist Survey 2007 (n=99) 5

Yes 62%

No 38%

Critical Care Pharmacist Survey 2006 (n=382) 6

Hospitals with ICUs surveyed 46

We need more Emergency Medicine

Pharmacists

216

27 0

50

100

150

200

250

Critical Care Emergency Medicine

ASHP Accredited PGY2 Residency Programs*

*Source: ASHP Online Residency Directory. Available at:

http://accred.ashp.org/aps/pages/directory/residencyProgramSearch.aspx. Accessed 1-8-2015

47

Emergency Medicine Pharmacy

A long road ahead 48

9

Emergency Medicine Pharmacists

are Great Collaborators! • ED pharmacists find themselves at the crossroads of the

hospital

• ED pharmacists often must act as intermediaries and facilitators in interdepartmental collaborations

• ED pharmacists are a trusted team member and are looked to when problems arise

• ED Pharmacists in unique position to identify systematic problems and develop solutions

• Many initiatives begin in the ED and we are there at the ground floor

49 50

Shouldn’t we go help

them?

Nah, it’s

the ER.

We don’t

go there

ASHP Guidelines on Emergency Medicine

Pharmacist Services

Essential/Desirable Administrative Roles of EM Pharmacists7

1. Medication and Patient Safety

2. Quality Improvement Initiatives

3. Leadership and Professional Service

4. Emergency Preparedness

5. Education

6. Research and Scholarly Activity

51

1. Medication and Patient Safety

• Intervention documentation

• ADE/ADR Reporting

• ED Performance Improvement (PI) Leadership

52

53

Emergency Medicine Pharmacist Impact

Conclusions

• A majority of interventions occurred through prospective

consults where EMPs assisted in determining patient

treatment.

• An average of 16 interventions occurred each day, roughly

equating to one intervention per hour between 0800 and 2330.

• All EMP interventions were accepted except for 1 of 478

(0.002%)

• Due to the fast paced nature of the ED, almost 100%

documentation capture was only possible with the support of

students documenting all EMP interventions

54

10

2. Quality Improvement Initiatives

• Jeff FAST Program – Facilitating Anticoagulation for Safer

Transitions

• Pediatric ED Workgroup – Develops and promotes evidence

based protocols for pediatric ED population

• Sepsis Initiative – ED Pilot now house wide evidence based

care bundle leading to mortality benefits

• Sickle Cell Workgroup – collaboration between outpatient

Sickle Cell Center and ED

• Stroke Committee – decreased time-to-TPA to <60 min; TPA

made centrally (not at the bedside) with average 11 min

turnaround

55

Quality Improvement Initiatives

56


57


58

59


60

11


61

Antibiotic Compatibilities in Sepsis Treatment

Amik Anid Azith Aztre Cefe Ceft Ceftri Dopa Epi Line Mero Met Mica Moxi Norepi P/T Tig Tobra Vanco

Amikacin (Amik) - C - C C C - C C C - C - - - C C - C

Anidulafungin (Anid) C - - - C C C C C C C C - - C C - C C

Azithromycin (Azith) - - - - C - - - - - - - - - - - C - -

Aztreonam (Aztre) C C - - C C C C C C - - - - - C C C C

Cefepime (Cefe) C C C C - - - C - C - C - - - - C C C

Ceftazidime (Ceft) C C - C - - - C C C - C - - C - C C -

Ceftriaxone (Ceftri) - C - C - - - - - C - - - - - - C - C

Dopamine (Dopa) - C - C C C - - C C - C C - C C C - C

Epinephrine (Epi) - C - C - C - C - - - - - - C - C - C

Linezolid (Line) C C - C C C C C - - C C - - - C C C C

Meropenem (Mero) - C - - - - - - - C - - - - C - - - C

Metronidazole (Met) C C - - C C - C - C - - - - - C - - -

Micafungin (Mica) - - - - - - - C - - - - - - C - - - -

Moxifloxacin (Moxi) - - - - - - - - - - - - - - - - - - -

Norepinephrine (Norepi) - C - - - C - C C - C - C - - - C - -

Piperacillin/Tazobactam (P/T) C C - C - - - C - C - C - - - - C - C

Tigecycline (Tig) C - C C C C C C C C - - - - C C - C C

Tobramycin (Tobra) - C - C C C - - - C - - - - - - C - C

Vancomycin (Vanco) C C - C C - C C C C C - - - - C C C -


Severe Sepsis Initiative

63

Quality

Improvement

Initiatives –

Pediatric/ED

Workgroup

Triage• Vital Signs• Peak Flow• Pulse Ox

Physician Order SetPediatric Asthma• First series Bronchodilators (if not previously

ordered):• Albuterol q 20 min x3 +Ipratropium x 2

with 2nd and 3rd nebs• CXR if:

• Fever (Temp ≥ 100.4• Foreign Born• First-time Wheeze• Focal Lung Findings

• Assess Severity

Treatment• Oral

Steroids

Nursing ED FLOPediatric Wheezing• Peak Flow pre-Rx• First series Bronchodilators:

• Albuterol q 20 min x3• +Ipratropium x2 with 2nd and 3rd nebs

• Peak Flow post-Rx• O2 NC if < 93%

Mild• O2 Sat > 93%• RR WNL for age• If > 7 yrs PF >

70%

Meets ALL Discharge Criteria?• O2 Sat > 93%• RR WNL for age

Treatment• Oral Steroids• Second series bronchodilators:

• High dose albuterol q2h• Ipratropium q4h

• Peds consult 877-656-5559• Peds RT consult pager 2141• Admit

Moderate• O2 Sat > 93%• RR elevated for age• If > 7 yrs PF 40-70%

Home• Asthma action plan (can consult peds RT

to assist with plan and/or teaching)• F/U PMD within 1 week• Equipment at home (Spacer/nebulizer)• Prescriptions for Albuterol +/- ICS

Treatment• Steroids• Continuous albuterol• Magnesium• Peds consult• Peds RT consult• Admit

Severe• O2 Sat ≤ 93%• If > 7 yrs PF <

40%

Yes

No

Dangerous Pediatric

Respiratory rates 0-60 days over 60 60 days- 1year over 401-5 years over 305-18 years over 20

Expected 70% 40%Height (cm) Peak Flow Expected Expected

43 (108) 147 103 5944 (112) 160 112 6445 (114) 173 121 6946 (117) 187 131 7547 (119) 200 140 8048 (122) 214 150 8649 (124) 227 159 9150 (127) 240 168 9651 (130) 254 178 10252 (132) 267 187 10753 (135) 280 196 11254 (137) 293 205 11755 (140) 307 215 12356 (142) 320 224 12857 (145) 334 234 13458 (147) 347 243 13959 (150) 360 252 14460 (152) 373 261 14961 (155) 387 271 15562 (157) 400 280 16063 (160) 413 289 16564 (163) 427 299 17165 (165) 440 308 17666 (168) 454 318 18267 (170) 487 341 195

Pediatric Wheezing/Asthma ED Pathway

Pts <20kg Albuterol 2.5mg q20min x3 +

Ipratropium 0.5mg q20min x2

Pts >20kg Albuterol 5mg q20min x3 +

Ipratropium 0.5mg q20min x2

Pts <20kg Albuterol 5mg q2h

Pts >20kg Albuterol 10mg q2h

Pts <20kg 5mg/hr

Pts >20kg 10mg/hr

Prednisone 2mg/kg MAX 60mg PO

Prednisolone Sol 2mg/kg MAX 60mg PO

Methylprednisolone 2mg/kg MAX 60mg IV

Magnesium Sulfate 50mg/kg MAX 2gm IV

administer over 20 minutes

First Series Bronchodilators

Second Series Bronchodilators

First Dose Steroids

Adjunct Medication

High Dose Albuterol

Continuous Albuterol

Issue Date January 2013 64

Quality

Improvement

Initiatives –

Pediatric/ED

Workgroup

65

Pathway – Neonate/Infant 0-90d Fever ED Management Algorithm

Definitions

o Neonate: 0 – 28 days of life

o Infant: 29 – 90 days of life

o Fever: Rectal temperature ≥ 38ºC (100.4 ºF)

Obtain IV access Initiate Medications (C) Admit to pediatrics

Rectal temperature ≥ 38ºC (100.4 ºF)

Neonates 0 – 28 days old

Initiate Neonate/Infant Fever Pathway

(Assure FLO orders are placed if not done)

Call pediatric consult (CC)

Obtain IV access Initiate Medications (B) UA and urine culture (use Cath Kit) Blood culture x1 LP with HSV PCR Stool culture if diarrhea CXR, Flu antigen, RSV PCR if respiratory symptoms Admission to pediatrics

ESI 2 Notify Physician FLO/Nurse initiated orders -Heelstick for CBC + diff -Accucheck for glucose -Lido 4% cream x1 prn IV place (A) -Sucrose Sol oral (Sweet-Ease) prn for painful procedures

Infants 29 – 60 days old


(Assure FLO orders are place if not done)

Call pediatric consult (CC) UA and urine culture (use Cath Kit) Blood culture x1 LP with Enterovirus PCR Stool culture if diarrhea CXR, Flu antigen, RSV PCR if respiratory symptoms

Infants 61 – 90 days old


(Assure FLO orders are place if not done)

Call pediatric consult (CC) UA and urine culture (use Cath Kit) Blood culture x1 LP (if NOT Low Risk) with Enterovirus PCR Stool culture if diarrhea CXR, Flu antigen, RSV PCR if respiratory symptoms

Is the patient LOW risk?

Clinical criteria:

Previously healthy

Term infant with uncomplicated nursery stay

Nontoxic clinical appearance

No focal bacterial infection on examination (EXCEPT otitis media)

Laboratory criteria:

WBC count 5 – 15,000/mm3

Bands <20%

Negative gram stain of unspun urine (preferred) OR negative leukocyte esterase and nitrite, OR <5 WBCs/hpf in stool (if diarrhea)

If LP done o CSF <8 WBCs/mm3 AND negative gram stain o Corrected: <1 WBC/500 RBC

Social criteria:

Reliable care taker

Assured follow up within 24 hours

A) Lidocaine 4% Cream (Anecream/LMX-4) Dosing: 1 gram = 5 cm ribbon = 40 mg lidocaine

Wt(kg) Recommended Dose (Amount of Cream Applied) Per Site

Max Dose (Amount of Cream Per Application)

TOTAL AMT USED ON ALL SITES*

Max Application Time (hr)

< 5 0.5 g (2.5 cm) 1 g (5 cm) 1

5-10 0.5-1 g (2.5-5 cm) 2 g (10 cm) 2

11-20 1-2 g (5-10 cm) 10 g (50 cm) 2

> 20 1-2 g (5-10 cm) 20 g (100 cm) 2

*Maximum amount of cream per application may be repeated in 2 hours; not to be applied more than 3 times in a 24 hour period / NO MORE THAN 2 SITE APPLICATIONS

B) Medications 0 – 28 days old (x1 doses only in ED)

-Ampicillin

0-7 days: 100 mg/kg/dose IV q8h (max: 2 grams/dose)

8-28 days: 75 mg/kg/dose IV q6h (max: 2 grams/dose) -Cefotaxime

0-7 days: 50 mg/kg/dose IV q12h (max: 2 grams/dose)

8-28 days: 50 mg/kg/dose IV q8h (max: 2 grams/dose) -Acyclovir 20 mg/kg/dose IV q8h

-Sodium Chloride 0.9% Bolus (20 ml/kg) prn dehydration -Acetaminophen 15mg/kg/dose PO or PR q6h prn fever ≥100.4°F

C) Medications 29 – 90 days old (x1 dose in ED) -Vancomycin 15 mg/kg/dose IV q6h (max: 500 mg/dose) -Cefotaxime 75 mg/kg/dose IV q6h (max: 2 grams/dose)

-Sodium Chloride 0.9% Bolus (20 ml/kg) prn dehydration -Acetaminophen 15mg/kg/dose PO or PR q6h prn fever ≥100.4°F

D) Medication for Low Risk patients (post-LP)

-Ceftriaxone 50 mg/kg/dose IM once (max: 1000 mg/dose)

Was LP done?

NO YES

Medication (D) Discharge Reevaluation in 24 hours Reevaluation in 24 hours

HIGH RISK

LOW RISK

No Medication

Discharge Reevaluation in 24 hours Reevaluation in 24 hours

66

WINNER!

Pediatric/ED

Workgroup

12

3. Leadership and Professional Service

• ED Medication Reconciliation

Project (Coming Soon!)

• Goal is to establish a model for

technician/intern based

medication reconciliation for

100% of patients coming

through the ED

• LEAN Leaders – Interdepartmental LEAN ED Medication

Distribution Project

• Pharmacy Techs are content experts

67

Interprofessional Med Rec

Design Project

68

Leadership and Professional

Service

69

Patient's Pharmacy (and cross street):___________________________

Please write down the medications you take. If you do not remember your medication names, you can call your pharmacy, ask a caregiver/family

member, or ask a staff member for help.

Medication History

Drug and Food allergies (describe what happens when you have a reaction):

Pharmacy Phone Number:________________________

Patient Name:________________________________ Date of Birth: ___/___/_____ Recently hospitalized at Jefferson? ○ Yes ○ No Do you see a physician at Jefferson? ○ Yes ○ No

ED Staff Only: Med Rec Start Time and Date: Med Rec Completion Time: Notes:

○ Once daily ○ Twice daily ○ Other ________________

○ By mouth ○ Other: ________________

○ By mouth ○ Other: ________________

○ By mouth ○ Other: ________________

List any Over the Counter (OTC) medications you take and when you last took them (for example: Aspirin or Benadryl):

Prescription Medication Name and Dose

List any herbal supplements or vitamins you take and when you last took them (for example: St. Johns Wort or Fish Oil products):

○ By mouth ○ Other: ________________

○ By mouth ○ Other: ________________





Last dose?

○ By mouth ○ Other: ________________

○ By mouth ○ Other: ________________



How do you take the medication? How Often?


○ By mouth ○ Other: ________________

○ By mouth ○ Other: ________________


4. Emergency Preparedness

• Disaster Management Workgroup – ED

Pharmacists act as department liaisons for

disaster management support

• Antidote Inventory Management – Developed

formulary antidote database to identify critical

antidotes, identify storage locations, set supply

par levels, and monitor stock

70

5. Education

• Pharmacy Resident Rotation

• ED rotation provides unique environment for resident

to work on a wide range of skills

• Always opportunities for research in the ED

• Many residency grads are finding opportunities as ED

pharmacists

• Pharmacy Student Rotations (IPPE/APPE)

• #1 most requested rotation site at TJU

• Students get the opportunity to apply concepts in a

wide range of disease states

• Formal Lectures

71


• Nitrous oxide toxicity case report – AJHP8

• The Jeff FAST Program – Presentation to National

Anticoagulation Forum

• The Jeff FAST Program – Journal of Hospital Practice9

• ED Interventions Student Poster - ASHP Midyear

• The Sepsis Initiative – Critical Care Medicine (Abstract)

• The Sepsis Initiative - Presentation to University Health

System Consortium and IHI National Meetings

• The Sepsis Initiative - ASHP Foundation for Medication

Use Excellence Finalist 72

13


Pharmacy Resident Research Manuscripts

• Post Intubation Sedation ED Protocol

• Establishing the Jeff FAST Program

• ED Pharmacist Effect on Sepsis Protocol

Adherence

• Pharmacy Led Med Rec in ED

• Improving the Pharmacologic Management of

Severe Sepsis

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6. Research and Scholarly

Activity


• Social Media and FOAMed?

• Blogs/Podcasts – ALiEM, EMPharmD, LITFL

• Twitter - @PharmERToxGuy, @ASHP_EMPharm, @theEDpharmacist

• Instagram

• YouTube

• Facebook

• WikiEM

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ASHP Emergency Care

Section Advisory Group

Questions?

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References – Part Deux

1. American College of Emergency Physicians. 2014 Council Resolutions, Chicago. Resolution 44: Support for Clinical Pharmacists as Part of the Emergency Medicine Team. Available at: https://www.acep.org/uploadedFiles/ACEP/About_Us/Leadership/Council/2014%20Resolutions%20Compendium.pdf. Accessed January 8, 2015.

2. Cheryl A. Thompson. Pharmacy News: Emergency Physicians Group Supports ED Clinical Pharmacy Services. AJHP News. December 15, 2014. Available at: http://www.ashp.org/menu/News/PharmacyNews/NewsArticle.aspx?id=4140. Accessed January 8, 2015.

3. Elenbaas RM, Waeckerle JF, Mcnabney WK. The clinical pharmacist in emergency medicine. Am J Hosp Pharm. 1977;34(8):843-6.

4. Thomasset KB, Faris R. Survey of pharmacy services provision in the emergency department. Am J Health Syst Pharm. 2003;60(15):1561-4.

5. Szczesiul JM, Fairbanks RJ, Hildebrand JM, Hays DP, Shah MN. Survey of physicians regarding clinical pharmacy services in academic emergency departments. Am J Health Syst Pharm. 2009;66(6):576-9.

6. Maclaren R, Devlin JW, Martin SJ, Dasta JF, Rudis MI, Bond CA. Critical care pharmacy services in United States hospitals. Ann Pharmacother. 2006;40(4):612-8.

7. Eppert HD, Reznek AJ. ASHP guidelines on emergency medicine pharmacist services. Am J Health Syst Pharm. 2011;68(23):e81-95.

8. Pugliese RS, Slagle EJ, Oettinger GR, Neuburger KJ, Ambrose TM. Subacute combined degeneration of the spinal cord in a patient abusing nitrous oxide and self-medicating with cyanocobalamin. Am J Health Syst Pharm. 2015;72(11):952-7.

9. Falconieri L, Thomson L, Oettinger G, et al. Facilitating anticoagulation for safer transitions: preliminary outcomes from an emergency department deep vein thrombosis discharge program. Hosp Pract (1995). 2014;42(4):16-45.

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Documents

Objectives - c.ymcdn.com · ROI 4 month study – 2150 interventions21 •1393 directly related to ADE’s •Cost avoidance of estimated $1,029,776 35 ... USP Patient Safety CAPS