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Researching the Use of Emergency Pharmacists in the ED (Text Version)

Slide presentation from the AHRQ 2008 conference showcasing Agency research and projects.

Slide Presentation from the AHRQ 2008 Annual Conference


On September 8, 2008, Rollin J. (Terry) Fairbanks, M.D., M.S., F.A.C.E.P., made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (596 KB).


Slide 1

Researching the Use of Emergency Pharmacists in the Emergency Department (ED)

Rollin J (Terry) Fairbanks, MD, MS, FACEP
Assistant Professor of Emergency Medicine
University of Rochester School of Medicine
Rochester, New York

AHRQ 2008; Sept. 8, 2008

Slide 2

Acknowledgments

  • AHRQ—Partnerships in Patient Safety 2005-08
  • Co-PI: Manish N. Shah, MD, MPH
  • Advisory Board
    • Daniel J. Cobaugh, PharmD, FAACT, DABAT
    • Robert Wears, MD, MS, FACEP
  • Emergency Pharmacists (EPh)
    • Daniel Hays, Sarah Kelly-Pisciotti
  • Emergency Medicine Patient Safety Foundation
    • Career development grant (via SAEM) www.EMPSF.org

Slide 3

Objectives

  1. Briefly review pre-existing evidence supporting clinical pharmacist roles.
  2. Report findings from the Emergency Pharmacist Research Project.
  3. Describe some lessons learned.

Slide 4

Previous literature

Intensive Care Unit (ICU) Pharmacists Impact Medication Safety

  • 99% of Pharm recommendations accepted by physicians in ICU.
  • 66% decrease in preventable adverse drug events (ADEs) in ICU.

Folli HL, Poole RL, Benitz WE, Russo JC. Pediatrics 1987; 79(5)
Gattis WH, Whellan DJ. Arch Internal Med 1999. 159(16): p. 1939-1945.
Kane SL, Weber RJ, Dasta JF. Int Care Med 2003;29(5):691-8
Leape LL, Cullen DJ, Clapp MD, et al. JAMA 1999;282(3):267-70

Slide 5

Background

University of Rochester Emergency Department

  • EPh Program Since 2000
  • Accredited EPh residency
  • Anecdotally we found:
    • Medication adverse events reduced.
    • Staff consult the EPh often.
    • Staff seem to value EPh input.

Fairbanks RJ, Hays DP, Webster DF, Spillane LL, Clinical Pharmacy Service in an Emergency Department, American Journal of Health-System Pharmacy 2004; 61(9):934-937.

Slide 6

Role of the EPh

  • Clinical consultation—primary role.
  • At the bedside:
    • Critical patients, Trauma, Resuscitations.
  • Order screening—as able, high yield cases.
  • Education—patients, nurses, physicians.
  • Preparation of urgent medications.
  • MDs & RNs seek pharmacist advice.

Slide 7

Preliminary Data: Trauma Care

Improved key measures

  • Time to:
    • Pain meds
    • RSI, paralytics, sedation
  • ADEs: 9/51 with, 0/153 without

Hays D, Kelly-Pisciotti S, O'Brien T, Fairbanks RJ, et al. American Association for the Surgery of Trauma 2006 Annual Meeting, September 28-30, 2006; New Orleans, LA.
Kelly SJ, Hays D, et al. "Pharmacists Enhancing Patient Safety During Trauma Resuscitations." 2005 ASHP Best Practices Award

Slide 8

AHRQ Partnerships in Implementing Patient Safety (PIPS) Project: Program Objectives

  • Optimize role for patient safety (2005).
  • Study outcomes: P/ADE/Qual (2005-7).
  • Study staff perceptions (2006).
  • Study EM residency program use (2007).
  • Time-Motion Study (2007).
  • Study barriers to implementation (2007).
  • Develop tools for other hospitals (2005-7):
    • www.EmergencyPharmacist.org

Slide 9

Optimized Role Results

  • High visibility/easy access:
    • On duty/off duty signs.
    • Portable phone.
    • Frequent walk-rounds.
  • Patient centered roles only:
    • Minimal dispensing, no stocking.
  • Focus on ED patients:
    • Admitted boarders → inpatient pharmacy.

Slide 10

Optimized Role Results (continued)

  • Maintain surveillance of provider orders:
    • Mandatory review of pediatric orders:
      • Ex: patients <1 year or <10 kg.
  • Respond to all critical (traumas, medical).
  • Focus coverage on peak volume periods.
  • Minimize administrative responsibility:
    • Committees, etc.

Slide 11

Time-Motion Results

  • Rounding pattern noted (21% total time).
  • EPh highly utilized (sought after):
    • 46% questions related to medication choice, dose, interactions, side effects, availability.
  • Communication: 45% tasks, 22% Time:
    • Vast majority RN (14%) or MD (22%) tasks.

Slide 12

Survey: URMC ED Staff Perceptions

  • #1 role: "being available for a consult."
  • 96%—EPh is integral part of the team.
  • 100% —use EPh more than if not in ED.
  • 73%—Value EPh order screening.
  • 85%—EPh should check all high risk meds.
  • 99%—EPh improves quality of care.
    • 100% physicians agree.

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.

Slide 13

Impact Evaluation Study: 10,224 cases reviewed

  • Hypothesis: EPh improves medication safety and quality of care.

Study Design:

  • Prospective enrollment.
  • Random selection for chart review
    • Critically ill, pediatric, geriatric.
  • 2 groups: EPh absent vs. EPh Present:
    • Blinded, so unable to determine whether EPh was actually involved in the care of individual patients.

Slide 14

Impact Evaluation Study

Outcome Measures [definitions]

  • Adverse drug event (ADE), Potential ADE (PADE).
  • Quality measures: list developed
    • Specific to Emergency Medicine.
    • Literature review & expert consensus.

Methods

  • Harvard Medical Practice Study (HMPS) methods (acknowledgmentt: David Bates, Diane Seger).
    • Data abstracted—nurse reviewers.
    • Suspicion for ADE/PADE identified by RNs.
    • Confirmed and classified by MDs.

Brennan, Leape, Laird et al. NEJM 1991; 324(6).

Slide 15

Impact Evaluation: Results

Results

  • Total enrollment: 10,224
    • Pediatrics (<19) 5098
      • (Peds Critical: 144)
    • Geriatrics (>64): 2873
      • (Geriatric Critical: 819)
    • Critical: 3245
      • 144 pediatric, 819 geriatric.
      • One missing age.

Slide 16

Overall Event Rates: ALL Patients

Overall [see details]

  • ADE 1.56% (159/10224)
  • PADE 1.58%

Compare:
1997 study of 13,000 ED patients, retrospective chart review
1.7% ADE Rate [included outpatient causes]
(PADEs were excluded)

Hafner et al, Ann Emerg Med 2002;39(3):258-267.

Slide 17

Overall Event Rates

  • Pediatric (5099)
    • ADE 0.47%—PADE 1.12%
  • Critical Care (3245)
    • ADE 3.45%—PADE 2.00%
  • Critical Care (2873)
    • ADE 2.61%—PADE 1.98%

All are higher than inpatient published rates [see details]

Slide 18

Impact Evaluation: EPh vs no EPh Results

EPh = Pharmacist Present
No EPh = Not Present

Characteristics of Groups:

  • Similar sex, race, payor status.
  • Mean age 38 EPh vs. 34 no EPh.

Slide 19

Difference between groups: Time of arrival

ED Pharmacist as Safety Measure—Analysis by Visit (10/24/07)
Examining Arrival Time by EPH-A Grouping

Screen shot of two graphs comparing differences between the No EPh and EPh groups.

The first graph shows the percent of "No EPh" between the arrival time of 0:00-23:22
Range: 0-approximately, 0.2%

The second graph shows the percent of "EPh" between the arrival time of 0:00-23:22
Range: 0-approximately, 0.5%

Slide 20

Time of arrival

ED Pharmacist as Safety Measure—Analysis by Visit (10/24/07)

Screen shot of the two graphs from the previous slide. It show an 8 am to 8 pm subgroup analysis with a focus on that time period. Both graphs show peak activity during this time span.

Slide 21

Pharmacist Present—vs. Pharmacist Not Present

Overall EPh (2111) No EPh (8113) p
Events Rate Events Rate t-test
ADE Events 35 1.66% 124 1.53% 0.699
ADE-Preventable 21 0.99% 76 0.94% 0.821
ADE-Non-Preventable 14 0.66% 48 0.59% 0.730
PADE Events 46 2.18% 116 1.43% 0.036
PADE—Non-Intercepted 39 1.85% 89 1.10% 0.021
PADE-Intercepted 7 0.33% 27 0.33% 0.993
Medication Errors 21 0.99% 69 0.85% 0.548
 
Balanced Coverage (8a-8p) EPh (1922) No EPh (4447) p
Events Rate Events Rate t-test
ADE Events 30 1.56% 62 1.39% 0.646
ADE-Preventable 18 0.94% 38 0.85% 0.772
ADE-Non-Preventable 12 0.62% 24 0.54% 0.704
PADE Events 43 2.24% 58 1.30% 0.018
PADE-Non-Intercepted 36 1.87% 45 1.01% 0.016
PADE-Intercepted 7 0.36% 13 0.29% 0.652
Medication Errors 16 0.83% 33 0.74% 0.710

Slide 22

Pharmacist Present—vs. Pharmacist Not Present (continued)

Pediatric EPh (922) No EPh (4107) p
Events Rate Events Rate t-test
ADE Events 5 50% 19 0.46% 0.864
ADE-Preventable 1 0.10% 7 0.17% 0.561
ADE-Non-Preventable 4 0.40% 12 0.29% 0.611
PADE Events 16 1.61% 41 1.00% 0.159
PADE-Non-Intercepted 12 1.21% 32 .78% 0.253
PADE-Intercepted 4 0.40% 9 0.22% 0.396
Medication Errors 7 0.71% 18 0.44% 0.349
 
Geriatric EPh (691) No EPh (2182) p
Events Rate Events Rate t-test
ADE Events 18 2.60% 57 2.61% 0.992
ADE-Preventable 14 2.03% 36 1.65% 0.573
ADE-Non-Preventable 4 0.58% 21 0.96% 0.282
PADE Events 19 2.75% 38 1.74% 0.164
PADE-Non-Intercepted 16 2.32% 33 1.51% 0.230
PADE-Intercepted 3 0.43% 5 0.23% 0.449
Medication Errors 9 1.30% 28 1.28% 0.970

Slide 23

Pharmacist Present—vs. Pharmacist Not Present (continued)

Critical EPh (660) No EPh (2585) p
Events Rate Events Rate t-test
ADE Events 29 4.39% 83 3.21% 0.211
ADE-Preventable 17 2.58% 61 2.36% 0.776
ADE-Non-Preventable 12 1.82% 22 0.85% 0.102
PADE Events 17 2.58% 48 1.86% 0.318
PADE-Non-Intercepted 15 2.27% 32 1.24% 0.119
PADE-Intercepted 2 0.30% 16 0.62% 0.241
Medication Errors 15 2.27% 35 1.35% 0.143

Slide 24

Results: Quality Measures

Trend towards improvement, not statistically significant:

  • Acute myocardial infarction (AMI) time to cath lab.
  • Contraindicated antibiotic administration.
  • Time to operating room (OR).
  • Time to first antibiotics in C.A. Pneumonia.
  • Time to first analgesic in fracture.

Limitation: Study powered for ADEs

Slide 25

Lessons Learned & Limitations

  • One Emergency Department.
  • Contamination between 2 groups:
    • Staff memory/education.
    • Patients who's stay extends between 2 groups.
    • Patients in "EPh present" group never interacted.
    • Proactive medication selection. (Conners and Hays. Ann Emerg Med 2007 Oct;50(4):414-8.)
  • EPh- increase ADEs awareness/charting?
  • Underpowered for quality measures:
    • Baseline ADE rate too low to detect changes?

Slide 26

Bottom Line

  • Pharmacists have been shown to improve quality and safety:
    • Shown in other areas of hospital.
  • Staff perceive this in ED as well:
    • ALL of the staff in an EPh ED agree.
    • More EDs are implementing.
  • More research is necessary before conclusions can be drawn.

Slide 27

What's next?

Future Research

  • Further evaluation of the EPh database.
  • Evaluation in smaller, non-academic EDs.
  • Head-to-head: central screening vs. EPh.
  • The use of telemedicine: Remote EPh?
  • Study effect and consequences of 100% order screening.

Slide 28

Final Quote

"I will never forget being in the scanner with an intubated pediatric trauma, running around trying to keep the patient properly sedated and cared for when Dan Hays walks into the scanner with an infusion pump on a portable IV pole. 2 channels were attached, both programmed with my sedation meds, meds hung, tubing primed, and all I had to do was hook it up to the patient and press "Start." No med calculations, no worries about properly diluting, no worries about compatibilities, no worries at all! That is a feeling that I am sure many nurses have felt when Dan was on their shift. Thanks Dan for all that you do, and thanks for making my job (especially that day) so much more enjoyable!"
Kathryn Augustino, RN, URMC Pediatric Emergency Department

Slide 29

Rollin J. (Terry) Fairbanks, MD, MS, FACEP
Assistant Professor
Department of Emergency Medicine
University of Rochester School of Medicine
Rochester, New York
www.MedicalHumanFactors.com

www.EmergencyPharmacist.org

Slide 30

Appendices: Supplemental Slides

Slide 31

Definitions

Adverse Drug Event (ADE): A preventable or non-preventable injury resulting from medical intervention related to a drug. (Bates, Cullen, Laird et al. JAMA 1995;274(1))

Potential ADE (PADE): An incident that could have but didn't cause injury due to intervention, chance, or special circumstances.

Problem Drug Order: Drug order which would have minimal potential for injury if carried out.

Slide 32

10 Most Commonly Given Medication Doses (n=21,378)

Medication Count % of total
Morphine 2386 11.2%
Albuterol 1554 7.3%
Ibuprofen 1454 6.8%
Propofol 806 3.8%
Midazolam 757 3.5%
Acetaminophen 730 3.4%
Tetanus diphtheria vaccine 688 3.2%
Fentanyl 687 3.2%
Hydromorphone 678 3.2%
Nitroglycerin 588 2.8%

Slide 33

Most Common Medications with Events

ADE Medication % of ADEs PADE Medication % of PADEs
Morphine 16.9% Hydromorphone 8.1%
Propofol 11.5% Acetaminophen 7.4%
Midazolam 7.7% Morphine 5.2%
Hydromorphone 7.7% Phenytoin 5.2%
Nitroglycerin 7.7% Promethazine 5.2%
Phenytoin 4.6% Cefazolin 4.4%
Fentanyl 4.6% Fentanyl 3.7%
Metroprolol 3.8% Aspirin 3.7%
Pip/Tazo 3.8% Ibuprofen 3.7%
Lorazepam 3.8% Hydrocodone/APAP 3.0%
Hydrocodone/APAP 2.3% Prochlorperazine 3.0%
Ciprofloxicin 2.3% Labetalol 3.0%

Slide 34

Overall Event Rates: ALL Patients

Overall Total
Events Visits Rate
ADE Events 159 10224 1.56%
ADE-Preventable 97 10224 0.95%
ADE-Non-Preventable 62 10224 0.61%
PADE Events 162 10224 1.58%
PADE—Non-Intercepted 128 10224 1.25%
PADE—Intercepted 34 10224 0.33%
Medication Errors 90 10224 0.88%

Compare:
1997 study of 13,000 ED patients, retrospective chart review
1.7% ADE Rate [included outpatient causes]
(PADEs were excluded)
Hafner et al, Ann Emerg Med 2002;39(3):258-267.

Slide 35

Overall Event Rates: Pediatric Patients

Pediatric Total
Events Visits Rate
ADE Events 24 5099 0.47%
ADE-Preventable 8 5099 0.16%
ADE-Non-Preventable 16 5099 0.31%
PADE Events 57 5099 1.12%
PADE—Non-Intercepted 44 5099 0.86%
PADE—Intercepted 13 5099 0.25%
Medication Errors 25 5099 0.49%

Compare:
Of 10,778 medication orders for inpatient pediatrics:
0.24% ADEs
1.1% PADEs
Kaushal et al, JAMA 2001; 285(16):2114-2120

Slide 36

Overall Event Rates: Critical Care ED Patients

Critical Total
Events Visits Rate
ADE Events 112 3245 3.45%
ADE-Preventable 78 3245 2.40%
ADE-Non-Preventable 34 3245 1.05%
PADE Events 65 3245 2.00%
PADE—Non-Intercepted 47 3245 1.45%
PADE—Intercepted 18 3245 0.55%
Medication Errors 50 3245 1.54%

Compare:
ICU Inpatients PADE Rate (per patient day)
1.04% before pharmacist
0.35% after pharmacist
Leape et al, JAMA 1999;282(3):267-270.

Slide 37

Overall Event Rates: Geriatric Patients

Geriatric Total
Events Visits Rate
ADE Events 75 2873 2.61%
ADE-Preventable 50 2873 1.74%
ADE-Non-Preventable 25 2873 0.87%
PADE Events 57 2873 1.98%
PADE—Non-Intercepted 49 2873 1.71%
PADE—Intercepted 8 2873 0.28%
Medication Errors 37 2873 1.29%
Compare:
HMPS (Leape 1991): Drug related adverse event rates
Rate per 100 discharges, by age, for entire hospital
Of 71 Adverse Events (not just ADEs) 70.4% were deemed "due to negligence."
Age 0-15 16-44 45-64 >65
ADE Rate 0.24% 0.39% 1.12% 1.15%
Current as of February 2009
Internet Citation: Researching the Use of Emergency Pharmacists in the ED (Text Version). February 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/news/events/conference/2008/Fairbanks.html

 

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