The Role of the Pharmacist In the Emergency Department/Critical Care/Trauma Linda Y. Radke, Pharm.D., BCPS, FASHP Salina Regional Health Center Salina, Kansas USA

Learning Objectives Describe opportunities for pharmacist involvement in emergency medicine and critical care that allow pharmacists to contribute to positive patient outcomes by improving patient safety, preventing medication errors, and optimizing drug therapy in emergent patient care situations. Review documentation of pharmacist interventions that demonstrate increased responsibility and participation for pharmacists as active members of the healthcare team in the community hospital setting.

Salina, Kansas USA, Kansas .

Salina Regional Health Center 239 staffed inpatient beds 18 bed Critical Care Unit (ICU) 26 bed Emergency Department (ED) 24/7 pharmacist services (including code blue/trauma response) 22 Pharmacists 18 Pharmacy technicians 2 PGY1 pharmacist residents Clinical pharmacists positions include: Critical Care, Internal Medicine, Cardiology, Emergency Departments, Ambulatory Care Clinic, Oncology Clinic 26 bed ED but one is used for SANE/SART

Plan: Develop a Bedside Role for the Pharmacist in Emergent Patient Care Situations Cardiopulmonary arrest (Code Blue) Trauma/massive transfusion Rapid sequence intubation Procedural sedation Myocardial Infarction (STEMI) Stroke Malignant Hyperthermia Anaphylaxis Sepsis Design services to best meet the needs of the institution’s emergency and pharmacy department Optimal services: 24/7

Bedside Role for the Pharmacist Prepare the medications for medical emergencies at the bedside Calculate accurate drug doses Recommend medications based on guidelines and protocols Drug information resource

Training for Pharmacists Simulation Lab for Training Certification: Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) “Buddy system”: two pharmacists attended codes together Case Simulations using Simulation Lab mannequins and computers Rapid Sequence Intubation Drugs Conscious Sedation Drugs Drug Preparation and Administration: tranexamic acid, prothrombin complex concentrate, dantrolene, alteplase (tPA)

Creation of the Emergency Department Pharmacist position 1230-2100 Monday-Friday Initiated July 2010 Position created to address increased inpatient pharmacy workload in the evenings Order entry/verification of physician orders Physician dosing requests “Pharmacy to Dose” Extended Code Blue coverage to 2100 (currently 24/7)

Promotion of Pharmacist Value to the Emergency Department Promote safe and effective medication use in the emergency department Target high-risk patients and procedures Ensure evidence-based medication use and adherence to national guidelines Streamline medication delivery, emergent and non-emergent patients Serve as technology transition resource to nurses and physicians with development of the Electronic Health Record (EHR) FY2009 27,089 patients in the ED, FY2014 35,486, predicted FY2015 38,000

Primary Role of the Emergency Medicine Pharmacist: Medication Safety Nurses: compatibility, administration, adverse effects Physicians: drug information, dose calculation, antibiotic recommendations Patients: medication education, accurate medication histories and reconciliation Students and Residents: serve as mentor and preceptor

Team participation: Medication expert Code Blue Team: ACLS protocol drug preparation Stroke Team: contraindications to tPA STEMI patients: medication administration prior to Cath Lab Sepsis: start antibiotics after cultures and within one hour Rapid Sequence Intubation: drug selection and dosing Trauma: antibiotics, tetanus vaccine Massive Transfusion: transexamic acid, PCC Pediatric Emergencies: weight-based dose calculation and preparation The pharmacist is a member of the patient care team: if the patient needs a blanket, get the blanket! Brooke Bitner, PharmD, BCPS Clinical Pharmacy Specialist-Emergency and Trauma, PGY1 Pharmacy Preceptor Coordinator Stormont-Vail Healthcare Topeka, KS

Documentation of Interventions Intervention software utilized to document pharmacist clinical interventions and enhance communication between pharmacists for patient follow-up ED pharmacist: recorded 3251 interventions in 2014 Example: December 2014 patients diagnosed with suspected sepsis Pharmacist Present Pharmacist Not Present Goal % time patients received antibiotics within 60 minutes 79% 44% 60% Door to antibiotic (minutes) 57 minutes 67 minutes 60 minutes Patients triaged as Level 2 based on SIRS criteria

Intervention: Code/intubation/procedure attended Code Blue Rapid Sequence Intubation Conscious Sedation Massive Transfusion Protocol Malignant Hyperthermia

Antibiotic “Pharmacy to Dose” Recommendations Requests Review culture and sensitivity reports Appropriate drug and dose recommendations Pediatric dose calculations Renal dosing Review allergies and adverse reaction precautions Guideline-based therapy recommendations Antimicrobial stewardship 6461 Dosing Requests: Vancomycin 50% Levofloxacin 9% Enoxaparin 8% Piperacillin/Tazobactam 5% Meropenem 2% Other 26%

Future Plans: Increase Coverage and Services Hire our current PGY1 resident Expand emergency department pharmacist coverage to 7 days a week 1100-2300 Monday-Friday 1230-2100 Saturday-Sunday Offer emergency medicine and critical care clinical rotations to pharmacy students Oversee medication reconciliation technician program

Emergency Medicine Pharmacist Services: American Society of Health-system Pharmacists Guidelines Developed through the ASHP Section of Clinical Specialists and Scientists Advisory Group on Emergency Care Approved by ASHP Board of Directors on July 8, 2011 www.ashp.org/DocLibrary/BestPractices/SpecificGdlEmergMed.aspx Defined the role of the Emergency Medicine Pharmacist (EMP) Guidelines based on primary literature, therapeutic and practice guidelines, national standards, and the consensus of experts in the field of EM pharmacy practice References ASHP Guidelines defined the role of the EMP to suggest goals for providing services to meet institution-specific needs, and to establish a definition of best practices for the ED.

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Self-Assessment Questions #1. Pharmacists can contribute to improved patient outcomes by: Decreasing the time from patient presentation to alteplase (tPA) administration in patients diagnosed with thrombotic stroke Contributing to appropriate and timely initial antibiotic selection and dosing in patients presenting with pneumonia or sepsis Calculating and preparing weight-based doses to expedite accurate administration of pediatric cardiopulmonary resuscitation medications All of the above #2. Pharmacist documentation of interventions provides validation and support for including the pharmacist as a contributing and valuable member of the healthcare team. True False