J. Med. Toxicol.

(2018) 14:114–116
https://doi.org/10.1007/s13181-017-0634-4

POSITION STATEMENT

The Role of Clinical Pharmacists in the Emergency Department

Received: 30 September 2017 / Accepted: 5 October 2017 / Published online: 26 October 2017
# American College of Medical Toxicology 2017

Background positioned outside the ED. Among EDs with dedicated phar-
macists, few have 24-h coverage. This position statement by
Clinical pharmacists are integral to the care and safety of pa- the American College of Medical Toxicology outlines the im-
tients in the hospital, particularly in specialty and high-risk portance of dedicated pharmacists in the ED to improve care
settings. Emergency departments (EDs) represent care envi- of adult and pediatric ED patients at all times.
ronments that carry unique risks that may be addressed
through the addition of clinical pharmacists specifically Importance ED Pharmacists have demonstrated a positive
trained and/or experienced as an ED pharmacist. Adult and impact on patient-specific outcome measures, timely medica-
pediatric patients present with undifferentiated medical, neu- tion administration, optimization of therapy, medication safe-
rological, traumatic, psychiatric, and surgical complaints 24 h ty, and cost of care.
a day, 7 days a week. Patients are generally unfamiliar to the
emergency care providers, may be unable to communicate
relevant medical information, and may require time-sensitive Timely Medication Administration
interventions. When present, ED crowding is associated with
increased risk for medication errors [1–4]. Other factors that Published data demonstrate that the presence of an ED pharma-
raise the risk for error include the expanding pharmacopeia, cist is associated with a reduction in time to antibiotic adminis-
the increasing complexity of patient drug regimens [5, 6], and tration for patients with sepsis [11–13], time to first analgesic in
problems related to health information technology [7–9]. trauma patients [14], time to sedation and analgesia after rapid
Despite the evidence supporting the role of pharmacists in sequence intubation [15, 16], time to thrombolysis for patients
the ED and support from national Emergency Medicine with acute ischemic stroke [17], and door-to-balloon time for
groups including the American College of Emergency patients with acute myocardial infarction [18].
Physicians [10], some hospitals rely on pharmacy personnel ED pharmacists also facilitate medication management for
other time-sensitive situations such as cardiac resuscitations
[19–22] and mass casualty events [23, 24]. This frees clini-
* Brenna M. Farmer cians from retrieval and medication preparation, allowing
[email protected] them to remain at the bedside to render care.

1
Division of Emergency Medicine, Weill Cornell Medical College of
Cornell University, New York, NY, USA Optimization of Therapy
2
Department of Pharmacy, Massachusetts General Hospital and
Department of Emergency Medicine, Harvard Medical School, Pharmacists are uniquely trained to verify medication orders
Boston, MA, USA for appropriateness, taking into account the indication, dosing
3
Department of Pharmacy, Boston Medical Center, Boston, MA, USA intervals, and adjustment for patient-specific variables such as
4
Department of Emergency Medicine, Rutgers New Jersey Medical weight, organ function, allergies, and drug interactions. In
School, Newark, NJ, USA addition, pharmacists can rapidly access documents regarding
J. Med. Toxicol. (2018) 14:114–116 115

drug resistance patterns, current therapeutic guidelines, and 52–54]. We support 24-h staffing of emergency departments
local hospital antibiograms to improve selection of antimicro- with dedicated ED pharmacists as part of the clinical care
bial therapy [6, 12, 15, 25]. In some settings, ED pharmacist team. ACMT also supports studies to further define the impact
review of post-discharge cultures allows regimen modifica- and value of pharmacists in the ED and other areas of ED
tions while also decreasing return visits and subsequent ad- expansion such as urgent care and observation units.
missions [26–30]. In addition, ED pharmacists routinely make
recommendations to optimize pharmacotherapy regimens par- Sources of Funding None.
ticularly in regard to high-risk therapeutic classes such as cen- Compliance with Ethical Standards
tral nervous system and cardiovascular medications, opioids,
insulin, anticoagulants, and thrombolytics [31–33]. Conflict of Interest None.
Pharmacists in the ED can review discharge prescriptions with
patients and providers to ensure optimal therapy [34] and im- Disclaimer The position of the American College of Medical
proved compliance for chronic illnesses such as asthma, Toxicology (ACMT) is as follows: clinical pharmacists are integral to
chronic obstructive pulmonary disease, and congestive heart the care and safety of emergency department (ED) patients. Emergency
failure [35]. ED pharmacists also work collaboratively with department pharmacists positively impact time to critical therapies, in-
cluding antibiotics for sepsis and door-to-balloon time for acute myocar-
emergency physicians and nurses, hospital pharmacists, med- dial infarction. Pharmacists optimize pharmacotherapy regimens involv-
ical toxicologists, and regional poison centers to manage pa- ing high-risk therapeutic classes, such as thrombolytics. Clinical pharma-
tients with toxic exposures [36]. As part of the care team, cists improve patient safety by intercepting prescription errors and recog-
pharmacists can recommend interventions that improve med- nizing adverse drug events. The potential cost avoidance of reducing
errors and meeting standards for reimbursement provides financial justi-
ication utilization and adherence to evidence-based medicine fication for dedicated ED clinical pharmacist staffing. We support 24-h
and national quality standards [31]. This has been particularly staffing of emergency departments with dedicated ED pharmacists.
important with the increasing prevalence of critical drug short- While individual practices may differ, this is the position of the
ages including antidotes [37, 38]. American College of Medical Toxicology (ACMT) at the time written,
after a review of the issue and pertinent literature.

Medication Safety
References
ED pharmacists provide real-time decision support and order
verification [39–41], and can intercept prescribing errors be- 1. Coil CJ, Flood JD, Beyeu BM, et al. The effect of emergency
fore patient harm occurs [33, 40, 42, 43]. Transitions of care boarding on order completion. Ann Emerg Med. 2016;67:730–6.
are improved through medication reconciliation [44], thereby 2. Kulstad EB, Sikka R, Sweis S, et al. ED overcrowding is associated
with an increased frequency of medication errors. Am J Emerg
reducing errors and outpatient treatment failures [29, 34, Med. 2010;28:340–9.
45–47]. Pharmacists may also recognize adverse drug events 3. Manias E, Gerdtz MF, Weiland TJ, Collins M. Medication use
that another provider has not identified [48]. Finally, across transition points from the emergency department: identifying
pharmacist-driven error reporting facilitates identification of factors associated with medication discrepancies. Ann
safety deficits [49]. Pharmacother. 2009;43(11):1755–64.
4. Marconi GP, Claudicus I. Impact of emergency department phar-
macy on medication omission and delay. Pediatr Emerg Care.
2012;28:30–3.
Impact on Cost of Care 5. Fairbanks RJ, Hays DP, Webster DF, et al. Clinical pharmacy ser-
vices in an emergency department. Am J Health Syst Pharm.
2004;61:934–7.
The potential cost avoidance in reducing errors, eliminating
6. Morganti KG, Bauhoff S, Blanchard JC, et al. The evolving role of
antibiotic redundancies, meeting quality standards for reim- emergency departments in the United States. Research report. Rand
bursement, improving patient satisfaction, and reducing ED Corporation 2013. http://www.rand.org/content/dam/rand/pubs/
revisits are important factors in the financial justification for research_reports/RR200/RR280/RAND_RR280.pdf. Accessed 22
dedicated ED staffing [50, 51]. Mar 2016.
7. Ash JS, Berg M, Coiera E. Some unintended consequences of in-
formation technology in health care: the nature of patient care in-
formation system-related errors. J Am Med Inform Assoc.
Summary 2004;11(2):104–12.
8. Farley HL, Baumlin KM, Hamedani AG, et al. Quality and safety
The ED is a unique setting with a diverse and complex patient implications of emergency department information systems. Ann
Emerg Med. 2013;62(4):399–407.
population presenting around the clock with urgent and emer- 9. Koppel R, Metlay JP, Cohen A, et al. Role of computerized physi-
gent needs. Emergency physicians readily utilize and value cian order entry systems in facilitating medication errors. JAMA.
the presence of ED pharmacists to aid in this care [10, 2005;293(10):1197–203.
116 J. Med. Toxicol. (2018) 14:114–116

10. American College of Emergency Physicians (ACEP). Clinical phar- 34. Cesarz JL, Steffenhagen AL, Svenson J, Hamedani AG. Emergency
macist services in the emergency department. Ann Emerg Med. department discharge prescription interventions by emergency medi-
2015;66:444–5. cine pharmacists. Ann Emerg Med. 2013;61(2):209–14.
11. DeFrates SR, Weant KA, Seamon JP, et al. Emergency pharmacist 35. Hohner E, Ortmann M, Murtaza U, Chopra S, et al. Implementation
impact on health care-associated pneumonia empiric therapy. J of an emergency department-based clinical pharmacist transitions-
Pharm Pract. 2013;26:124–30. of-care program. Am J Health Syst Pharm. 2016;73(15):1180–7.
12. Flynn JD, McConeghy KW, Flannery AH, et al. Utilization of phar- 36. Thomas MC, Acquisto NM, Shirk MB, Patanwala AEA. National
macist responders as a component of a multidisciplinary sepsis survey of emergency pharmacy practice in the United States. Am J
bundle. Ann Pharmacother. 2014;48:1145–51. Health Syst Pharm. 2016;73:386–94.
13. Moussavi K, Nikitenko V. Pharmacist impact on time to antibiotic 37. Mazer-Amirshahi M, Hawley KL, Zocchi M, et al. Drug shortages:
administration in patients with sepsis in an ED. Am J Emerg Med. implications for medical toxicology. Clin Toxicol. 2015;53(6):519–24.
2016;34(11):2117–21. 38. Rosoff PM, Patel KR, Scates A, Rhea G, Bush PW, Govert JA.
14. Montgomery K, Hall AB, Keriazes G. Pharmacist’s impact on acute Coping with critical drug shortages. Arch Intern Med.
pain management during trauma resuscitation. J Trauma Nurs. 2012;172(19):1494–6.
2015;22:87–90. 39. Patanwala AE, Hays DP, Sanders AB, et al. Severity and probability
15. Amini A, Faucett EA, Watt JM, et al. Effect of pharmacist on timing of harm of medication errors intercepted by an emergency depart-
of postintubation sedative and analgesic use in trauma resuscita- ment pharmacist. Int J Pharm Pract. 2011;19:358–62.
tions. Am J Health Syst Pharm. 2013;70:1513–7. 40. Patanwala AE, Sanders AB, Thomas MC, et al. A prospective,
16. Johnson EG, Meier A, Shirakbari A, et al. Impact of rocuronium multicenter study of pharmacist activities resulting in medication
and succinylcholine on sedation initiation after rapid sequence in- error interception in the emergency department. Ann Emerg Med.
tubation. J Emerg Med. 2015;49:43–9. 2012;59:369–73.
17. Montgomery K, Hall AB, Keriazes G. Impact of an emergency 41. Sin B, Yee L, Claudio-Saez M, et al. Implementation of a 24-hour
medicine pharmacist on time to thrombolysis in acute ischemic pharmacy service with prospective medication review in the emer-
stroke. Am J Emerg Med. 2016;34(10):1997–9. gency department. Hosp Pharm. 2015;50:134–8.
18. Acquisto NM, Hays DP, Fairbanks RJ, et al. The outcomes of 42. Brown JN, Barnes CL, Beasley B, et al. Effect of pharmacists on
emergency pharmacist participation during acute myocardial in- medication errors in an emergency department. Am J Health Syst
farction. J Emerg Med. 2012;42:371–8. Pharm. 2008;65:330–3.
19. Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing,
43. Stasiak P, Afilalo M, Castelino T, et al. Detection and correction of
and hospital mortality rates. Pharmacotherapy. 2007;27:481–93.
prescription errors by an emergency department pharmacy service.
20. Ernst AA, Weiss SJ, Sullivan A, et al. On-site pharmacists in the ED
CJEM. 2014;16:193–206.
improve medical errors. Am J Emerg Med. 2012;30:717–25.
44. Pevnick JM, Shane R, Schnipper JL. The problem with medication
21. Groth CM, Acquisto NM. Pharmacists as members of the rapid
reconciliation. BMJ Qual Saf. 2016;25:726–30.
response team. J Pharm Pract. 2016;29(2):116–20.
45. Ajdukovic M, Crook M, Angley C, et al. Pharmacist elicited medica-
22. Porter E, Barcega B, Kim TY. Analysis of medication errors in simulated
tion histories in the emergency department: identifying patient groups
pediatricresuscitationbyresidents.WestJEmergMed.2014;15:486–90.
at risk of medication misadventure. Pharm Pract. 2007;5(4):162–8.
23. Erickson K. An emergency department pharmacist’s experience at the
Boston Marathon. Am J Health Syst Pharm. 2013;70(19):1652,1654. 46. Becerra-Camargo J, Martinez-Martinez F, Garcia-Jimenez EA.
24. Sylvester KW, Rocchio MA, Belisle C, et al. Pharmacy response to Multicenter, double-blind, randomised, controlled, parallel-group
the Boston Marathon bombings at a tertiary academic medical cen- study of the effectiveness of a pharmacist-acquired medication history
ter. Ann Pharmacother. 2014;48(8):1082–5. in an emergency department. BMC Health Serv Res. 2013;13:337.
25. Weant KA, Baker SN. Emergency medicine pharmacists and sepsis 47. Okere AN, Renier CM, Tomsche JJ. Evaluation of the influence of a
management. J Pharm Pract. 2012;26:401–5. pharmacist-led patient-centered medication therapy management
26. Baker SN, Acquisto NM, Ashley ED, et al. Pharmacist-managed and reconciliation service in collaboration with emergency depart-
anticmicrobial stewardship program for patients discharged from ment physicians. J Manag Care Spec Pharm. 2015;21:298–306.
the emergency department. J Pharm Pract. 2012;25:190–4. 48. Hohl CM, Zed PJ, Brubacher JR, Abu-Laban RB, et al. Do emergency
27. Dumkow LE, Kenney RM, MacDonald NC, et al. Impact of a physicians attribute drug-related emergency department visits to
multidisciplinary culture follow-up program of antimicrobial ther- medication-related problems? Ann Emerg Med. 2010;55:493–502.
apy in the emergency department. Infect Dis Ther. 2014;3:45–53. 49. Weant KA, Humphries RL, Hite K, et al. Effect of emergency
28. Miller K, McGraw MA, Tomsey A, et al. Pharmacist addition to medicine pharmacists on medication-error reporting in an emergen-
post-ED visit review of discharge antimicrobial regimens. Am J cy department. Am J Health Syst Pharm. 2010;67:1851–5.
Emerg Med. 2014;32:1270–4. 50. Hamblin S, Rumbaugh K, Miller R. Prevention of adverse drug
29. Randolph TC, Parker A, Meyer L, et al. Effect of a pharmacist- events and cost savings associated with PharmD interventions in
managed culture review process on antimicrobial therapy in an an academic level I trauma center: an evidence-based approach. J
emergency department. Am J Health Syst Pharm. 2011;68:916–9. Trauma Acute Care Surg. 2012;73:1484–90.
30. Van Devender EA. Optimizing antimicrobial therapy through a 51. Lada P, Delgado G Jr. Documentation of pharmacists’ interventions
pharmacist-managed culture review process in the ED. Am J in an emergency department and associated cost avoidance. Am J
Emerg Med. 2014;32(9):1138. Health Syst Pharm. 2007;64:63–8.
31. Abu-Ramaileh AM, Shane R, Churchill W, et al. Evaluating and 52. Coralic Z, Kanzaria HK, Bero L, et al. Staff perceptions of an on-
classifying pharmacists’ quality interventions in the emergency de- site clinical pharmacist program in an academic emergency depart-
partment. Am J Health Syst Pharm. 2011;68:2271–5. ment after one year. West J Emerg Med. 2014;15:205–10.
32. Bakhsh HT, Perona SJ, Shields WA, et al. Medication errors in 53. Fairbanks RJ, Hildebrand JM, Kolstee KE, et al. Medical and nurs-
psychiatric patients boarded in the emergency department. Int J ing staff highly value clinical pharmacists in the emergency depart-
Risk Saf Med. 2014;26:191–8. ment. Emerg Med J. 2007;24:716–9.
33. Rothschild JM, Churchill W, Erickson A, et al. Medical errors re- 54. Nana B, Lee-Such S, Allen G. Initiation of an emergency depart-
covered by emergency department pharmacists. Ann Emerg Med. ment pharmacy program during economically challenging times.
2010;55:513–21. AJHP. 2012;69:1682–6.