Why More EDs Need to Capitalize on Pharmacist Expertise

May 10, 2017

Nadia Awad, PharmD, BCPS, is an emergency medicine pharmacist who for the past 4 years has been caring for patients in the emergency department (ED) of the Robert Wood Johnson University Hospital in New Brunswick, NJ.

Dr. Awad, who often coordinates the medication administration for 80 patients at a time, begins her shifts at 2 p.m. and often stays late into the night to help with the endless stream of patients who are rolled through the hospital’s doors.

She recently took a few minutes after a particularly grueling shift — which involved administering therapeutic hypothermia to a patient in cardiac arrest, providing assistance in the care of a trauma patient, and prepping naloxone for patients who overdosed on opioids — to talk about how ED pharmacists ensure medications are used safety and appropriately, and why more hospitals need to capitalize on the expertise of pharmacists in the delivery of emergent care.

Why is it so challenging to manage medication use in the ED?

The ED is prone to medication errors, because it’s a chaotic care environment where orders are often verbal. The sheer volume and the level of patient acuity also contribute to the challenges. We don’t have the complete story of a patient’s condition, so we try to focus on treating the one or two problems that could be life altering. As you gain experience and become more comfortable in the role, you see a lot of the same health issues over and over again, so that makes it easier to react appropriately. When more institutions begin to realize what pharmacists can do in the ED, they’ll realize the many benefits of having someone on the staff who can improve medication safety.

What specific role do you play?

My job is to anticipate the needs of the patients. Treatment options will often fall into generalized categories of where cases will progress. At that point, before the prescriber or nurse even asks for medications, I have the needed therapies ready at the bedside. I’m constantly ensuring that the appropriate therapies are ready for administration based on what pre-hospital providers say about the patient’s condition, the current medications patients are taking, and concomitant diseases and allergies they have.

How do you maintain that attention to detail when the cases begin to mount?

It demands prioritization. I look at the big board in the department and observe patients — especially those in resuscitation bays, where the sickest patients are kept. I’m constantly triaging patients in my mind and prioritizing where I’m needed most. I’m also requested to help care for less acute patients when providers have questions about which medications are safe for use in, for example, pediatric patients, pregnant women, or individuals with severe allergies. It took time to learn how to juggle those responsibilities and to develop a sixth sense of where I can be most helpful.

How can pharmacists help when a patient’s life is on the line?

By taking ownership in the medication aspect of care, pharmacists free up nurses and physicians to perform their duties and focus on their roles. For example, when a patient is in cardiac arrest, pharmacists can help the care team run through medication algorithms, which are based on recommendations from the American Heart Association and depend on the patient’s heart rhythm. The medications used during a cardiac arrest, such as epinephrine, are often high risk and require double-checking to ensure they’re given correctly. When heart rhythm is restored, pharmacists can help manage therapies such as norepinephrine and dopamine that provide blood pressure support. Some pharmacists are even trained to resuscitate patients — I’ve worked with pharmacy residents who have jumped in to start chest compressions on patients.

Are enough hospitals tapping into the expertise pharmacists provide in the ED?

I don’t think so. Only about 20% of hospitals in the U.S. have at least one dedicated pharmacists in the ED. It’s definitely an area of rapid growth and development and demand is growing for pharmacists to fill that role. But making it happen requires a lot of buy-in from hospital administrators, who often focus only on the bottom line of patient care. It’s difficult to quantify the economic benefit pharmacists provide in the ED, where inexpensive medications are commonly used. I’ve asked administrators to shadow me, so they get a sense of what I do on a daily basis and the clinical services I provide. They see that I make expert recommendations about medication use and optimize patients’ drug therapies. They’re not the only ones who notice what pharmacists bring to the table. When I return after a day off, ED nurses often tell me they could have really used my help in caring for patients.

—Dan Cook