1. 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

2. 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.

3. Salina, Kansas USA, Kansas.

4. 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

5. 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

6. 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

7. 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)

8. Creation of the Emergency Department Pharmacist position
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 (currently 24/7)

9. 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)
FY ,089 patients in the ED, FY ,486, predicted FY ,000

10. 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

11. 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

12. 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

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

14. 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 %
Levofloxacin %
Enoxaparin %
Piperacillin/Tazobactam 5%
Meropenem %
Other %

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

16. 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
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.

17. Thank you! ขอบคุณค่ะ Khob khun ka (female version of thank you)
Khob khun krab (male version of thank you)

18. 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