YAJEM-57264; No of Pages 6

American Journal of Emergency Medicine xxx (2018) xxx–xxx

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

Clinical pharmacy services in the emergency department

Sofie Rahman Morgan, MD, MBA a, Nicole M. Acquisto, PharmD b,j,⁎, Zlatan Coralic, PharmD, BCPS c,k,
Vicki Basalyga, PharmD, BCPS, BCPPS d, Matthew Campbell, PharmD, BCPS, BCCCP e, John J. Kelly, DO f,
Kevin Langkiet, PhD(c), MSN, RN g, Claire Pearson, MD, MPH h,
Erick Sokn, PharmD, MS, BCPS e, Michael Phelan, MD i
a
Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
b
Department of Pharmacy, University of Rochester Medical Center, Rochester, NY, USA
c
Department of Pharmacy, University of California, San Francisco, CA, USA
d
American System of Health-System Pharmacists (ASHP), Bethesda, MD, USA
e
Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
f
Department of Emergency Medicine, Einstein Healthcare Network, Jefferson Medical College, Philadelphia, PA, USA
g
Department of Emergency Medicine, Benefis Health System, Great Falls, MT, USA
h
Department of Emergency Medicine, Wayne State University, Detroit, MI, USA
i
Emergency Services Institute, Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic Enterprise Quality, Cleveland, OH, USA
j
Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, USA
k
Department of Emergency Medicine, University of California, San Francisco, CA, USA

a r t i c l e i n f o a b s t r a c t

Article history: The emergency department (ED) is a fast-paced, high-risk, and often overburdened work environment. Formal
Received 16 November 2017 policy statements from several notable organizations, including the American College of Emergency Physicians
Received in revised form 17 January 2018 (ACEP) and the American Society of Health-System Pharmacists (ASHP), have recognized the importance of clin-
Accepted 18 January 2018
ical pharmacists in the emergency medicine (EM) setting. EM clinical pharmacists work alongside emergency
Available online xxxx
physicians and nurses at the bedside to optimize pharmacotherapy, improve patient safety, increase efficiency
Keywords:
and cost-effectiveness of care, facilitate antibiotic stewardship, educate patients and clinicians, and contribute
Pharmacists to scholarly efforts. This paper examines the history of EM clinical pharmacists and associated training programs,
Clinical the diverse responsibilities and roles of EM clinical pharmacists, their impact on clinical and financial outcomes,
Medication safety and proposes a conceptual model for EM clinical pharmacist integration into ED patient care. Finally, barriers to
Patient outcomes implementing EM clinical pharmacy programs and limitations are considered.
Emergency medicine © 2018 Elsevier Inc. All rights reserved.

1. Background Historically, hospital pharmacists focused on distributive func-

tions (e.g., medication procurement, preparation, and delivery to
1.1. Need for emergency medicine clinical pharmacists the patient bedside). Today's clinical pharmacists focus on patient
care that optimizes medication therapy and thereby promotes
Emergency medicine (EM) is a complex field. It demands manage- health, wellness, and disease prevention. Clinical pharmacists pro-
ment of diverse patient populations and medical problems that call vide expertise in the therapeutic use of medications and assume re-
upon a variety of clinical disciplines—from pediatrics to geriatrics and sponsibility and accountability for managing therapy in direct
primary care to critical care. Utilization of time-sensitive and high-risk patient care settings while collaborating with other healthcare pro-
medications is common in the emergency department (ED). These com- fessionals [8]. Their contributions to patient care and improved out-
plexities place the ED among the most high-risk patient care environ- comes have been well documented and include reductions in patient
ments [1]. Including EM clinical pharmacists in treatment decisions mortality, hospital readmission rates, and medication errors [2,4,5,9-
and in implementation of therapy mitigates some of the risk and de- 12]. They have also been shown to be highly valued team members in
creases medication errors [2-7]. EM clinical pharmacist services comple- an EM environment [13,14].
ment existing interprofessional teams of physicians, advanced practice
providers, nurses, respiratory therapists, and prehospital providers. 1.2. History of emergency medicine clinical pharmacists

⁎ Corresponding author. The introduction of clinical pharmacists in the ED was first reported
E-mail address: nicole_acquisto@urmc.rochester.edu (N.M. Acquisto). in the 1970s [15-17]. Initial publications described their role in terms of

https://doi.org/10.1016/j.ajem.2018.01.056
0735-6757/© 2018 Elsevier Inc. All rights reserved.

Please cite this article as: Morgan SR, et al, Clinical pharmacy services in the emergency department, American Journal of Emergency Medicine
(2018), https://doi.org/10.1016/j.ajem.2018.01.056
2 S.R. Morgan et al. / American Journal of Emergency Medicine xxx (2018) xxx–xxx

medication distribution but also noted the provision of cognitive and 2. Current state assessment
consultative services based on the EM clinical pharmacist's unique
knowledge of pharmacology and therapeutics. In the first physician 2.1. Current roles and responsibilities
survey of EM clinical pharmacist services in a single center
study, all respondents (physician and nurses) supported the EM EM clinical pharmacists play a variety of roles in practice sites, rang-
clinical pharmacist as an integral team member, and 87% sup- ing from large academic and community centers to small and rural EDs.
ported pharmacist delivery of care to certain patients after physi- An updated guideline for EM pharmacist services published in 2011 de-
cian diagnosis [15]. In medical resuscitations, the role of the fined the role of the clinical pharmacist in the ED, suggested goals for
pharmacist included recognition as a drug therapy consultant for pharmacy services to meet institutional needs, and established best
clinicians [18]. practices [27]. Activities of EM clinical pharmacists have most recently
In more recent years, the role of the EM clinical pharmacist been summarized by a 2015 national survey study [19]. An extensive
has expanded to include an increasing emphasis on comprehen- list is available in Table 1. Fig. 1 introduces a conceptual model of inte-
sive direct patient care services. Such services are centered on gration of EM clinical pharmacists into ED patient care and maps these
bedside patient assessment with the EM medical team and timely activities in relation to ED patient flow; the majority take place at or
provision of patient-specific and disease-specific pharmacother-
apy recommendations. EM clinical pharmacists aid in medication
selection, optimal dosing and delivery, provision of drug informa-
Table 1
tion to patients and the interprofessional medical team, research Activities of emergency medicine clinical pharmacists [19,27,28].
and scholarly activities, and administrative and operational re-
Bedside clinical activities
sponsibilities to optimize the efficiency of care delivered to ED
● Emergency department resuscitation team (cardiopulmonary arrest, trauma
patients [19]. and burn resuscitation, myocardial infarction, stroke, sepsis)
In 2005, the Agency of Healthcare Research and Quality (AHRQ) ● Direct bedside care during high risk medication use (rapid sequence
funded a project titled “Emergency Department Pharmacist as a Safety intubation, procedural sedation)
Measure in Emergency Medicine” (HS015818). The goal was to opti- ● Pharmacotherapy consultation
○ Drug information
mize the role of the EM clinical pharmacist and to develop a toolkit to
○ Medication selection
aid institutions in the justification and creation of EM pharmacy ser- ○ Medication dose (based on patient specific factors; age, weight, route of
vices. This program, related publications from the grant, and an offshoot administration, renal function)
mentorship program [20] ultimately increased the national visibility ○ Medication therapy monitoring
and understanding of the value clinical pharmacists present in the ED,
● Drug interaction analysis
and this has contributed to the rapid expansion of their services over ● Drug identification
the past decade [13,21-23]. ● Drug compatibility for admixing or administration
● Error and adverse event reporting
● Patient counseling and education
● Toxicology recommendations
1.3. Non-pharmacist organizational support
● Targeted disease state counseling (e.g., anticoagulation, anaphylaxis)
● Antimicrobial stewardship activities including microbiological culture and
In December 2013, the American Society of Health-System Pharma- susceptibility follow-up
cists (ASHP) Section of Clinical Specialists and Scientists Advisory Group ● Prospective medication order review and verification
on Emergency Care (SAG EC) began drafting an American College of ● Assistance with medication procurement/preparation (advanced knowledge of
medication storage and distribution and institutional policies and procedures)
Emergency Physicians (ACEP) resolution to recognize EM clinical phar- ● Medication administration
macists as valuable members of the interdisciplinary EM team and to ● Vaccine administration
create a policy statement supporting clinical pharmacy services in the ● Emergency preparedness
ED. The SAG EC is a volunteer group of practicing EM clinical pharma- ● Facilitation of medication histories
● Oversight of pharmacist extenders (e.g., technicians, students)
cists whose responsibilities include advancement of EM pharmacy prac-
Training and education
tice and creation of educational content [24]. In October 2014, SAG EC ● Medication therapy updates and education on optimal medication therapy for
and the American College of Clinical Pharmacy, Emergency Medicine ED team members (often takes place at the bedside or in the ED)
Practice and Research Network (ACCP EMED PRN), in collaboration ● Education through conference and pharmacology rotations for EM attend-
with and support of the ACEP's New York Chapter, submitted resolution ings and residents
● Implementation and execution of post-graduate EM pharmacy residency
44 (14) to the ACEP Council. Titled “Support for Clinical Pharmacists as training programs
Part of the Emergency Medicine Team,” the resolution was adopted ● Participation in interdisciplinary simulation
with strong support after a presentation to the ACEP Council Reference Performance improvement
Committee. A formal policy statement followed in June 2015 [25]. It rep- ● Guideline/protocol/process development
● Formulary management
resented the first time that ACEP formally recognized the critical role
● Medication dispensing cabinet optimization
EM clinical pharmacists play in ensuring efficient, safe, and effective ● Optimization of medication procurement workflows
medication use in the ED and advocated for dedicated clinical pharma- ● Medication safety initiatives
cists within the ED. ● Participation in root cause analysis (RCA) and failure mode and effects anal-
Furthermore in October 2017, the American College of Medical Tox- ysis (FMEA)
● Assistance with adherence to regulatory and institutional medication use
icology (ACMT) published a statement that clinical pharmacists are in- policies
tegral to the care and safety of adult and pediatric ED patients [26]. Scholarly activities
The organization highlights the benefits of EM clinical pharmacists in ● Interdisciplinary EM clinical research
time dependent emergencies, optimization of pharmacotherapy, safety, ● Identification of patients for enrollment of investigational drug studies
recruiting in the ED
and cost avoidance and supports 24-hour staffing of dedicated EM clin-
● Participation in interdisciplinary research committees that review ED
ical pharmacists in EDs. related research protocols
One additional mention is that clinical pharmacists have been ● EM related research grant preparation
elected to leadership positions in interprofessional societies that relate ● EM medical resident research projects or quality improvement projects
to EM such as the American College of Toxicology and the Society of ● Participation in articles, book chapters, case reports, or other collaborations
with EM physicians
Critical Care Medicine.

Please cite this article as: Morgan SR, et al, Clinical pharmacy services in the emergency department, American Journal of Emergency Medicine
(2018), https://doi.org/10.1016/j.ajem.2018.01.056
 S.R. Morgan et al. / American Journal of Emergency Medicine xxx (2018) xxx–xxx 3

Fig. 1. Clinical pharmacist workflow in the emergency department.

near the bedside and involve face-to-face discussions with patients, increased. Beyond a professional doctorate degree, pharmacists are in-
physicians, nurses, and other team members. creasingly obtaining advanced certifications that reflect detailed knowl-
edge in an array of specialties, receiving board certification through the
2.2. Emergency medicine clinical pharmacy programs Board of Pharmacy Specialties accrediting body, and completing general
and specialty post-graduate residency training [37,38]. Post-graduate
The benefits of EM clinical pharmacists has received international residency addresses the need for cognitive and skill-based training
recognition (e.g., Canada, Spain, United Kingdom, France, Qatar, unique to the field and environment of emergency medicine (e.g.,
Australia) [29-34]. In the United States, EM clinical pharmacy programs knowledge of a broad range of diseases and treatments, understanding
have shown marked growth over the last 15 years. A 2003 national sur- ED workflow and practices, proficiency in working with the interdisci-
vey of the ASHP pharmacy residency directory reported that only 3.4% plinary ED team, execution of time-sensitive medication tasks like
(4/119 respondents) had dedicated pharmacists assigned to the ED, rapid medication preparation, comprehension of ED-specific treatment
and 10.9% had pharmacists whose primary responsibility was to provide goals).
pharmacy services to the ED [35]. A similar study conducted 10 years The first residency programs specific to emergency medicine phar-
later found that 16.4% (68/414 respondents) reported dedicated EM macy (Postgraduate Year Two, PGY2) emerged in the early 2000s, and
clinical pharmacists within the ED [36]. Likewise, a 2006–07 survey of a total of three programs were accredited by 2007. Less than ten years
99 EM physician residency programs reported that 30% of respondents later, the number had increased tenfold. By 2016, there were 36
had dedicated EM pharmacists within the ED [23]. ASHP-accredited PGY2 EM specialty pharmacy residency programs
The most recent national survey of clinical pharmacy practice in ED and by 2017 there were 46 programs and several more seeking accred-
settings took place in January 2015. It received a total 233 responses itation status. Residency program fill rates were 100% and 98% in 2016
(58% response rate) [19]. Over two thirds of institutions (68%) reported and 2017, respectively, highlighting continued interest in this specialty
more than 8 h of dedicated pharmacist coverage during weekdays, among pharmacy graduates [39]. Training for EM clinical pharmacy ser-
nearly half (49%) reported more than 8 h on the weekends, and most vices is also occurring in Postgraduate Year One (PGY1) residency pro-
provided swing (1300−0000) or midday (0900–1900) coverage to grams, which are traditionally non-specialized, and as electives in
focus on the high volume of patients during such hours [19]. Addition- schools/colleges of pharmacy. A recent national survey of schools/col-
ally, almost 10% of institutions reported 24-hour coverage on weekdays leges of pharmacy and PGY1 residency programs reported EM phar-
and weekends [19]. macy clinical rotation opportunities at 83% and 74.1% of responding
programs, respectively [40].
2.3. Training opportunities Growth in clinical pharmacists working in the ED has nonetheless
outpaced the number of PGY2 EM Specialty Pharmacy Residencies.
As pharmacists expand from distributive functions to more direct This has given rise to alternative pathways to training. Some EM phar-
patient care roles, educational and training requirements have macy programs now include an extensive orientation that entails

Please cite this article as: Morgan SR, et al, Clinical pharmacy services in the emergency department, American Journal of Emergency Medicine
(2018), https://doi.org/10.1016/j.ajem.2018.01.056
4 S.R. Morgan et al. / American Journal of Emergency Medicine xxx (2018) xxx–xxx

shadowing clinical staff within the ED, understanding the job descrip- pharmacists are well equipped to correct the majority of prescription-
tion of the EM clinical pharmacist, reviewing the services of the role, in- related errors, especially those containing multiple medication orders
tegration into daily operations using ED specific information and clinical and those prescribed by EM residents [3]. A prospective multicenter
topics, pharmacy operations, and hospital policies [41]. In 2007, ASHP study of four geographically diverse academic and community EDs
developed the “Patient Care Impact Program (PCIP): Introducing an found EM pharmacists caught 364 medication errors during a 1000-
Emergency Pharmacist to Your Institution,” which provided experien- hour study period [4]. Most errors were identified during consultative
tial training and mentorship by EM clinical pharmacy specialists and activities and review of medication orders. Improper dosing proved to
an EM physician during initiation of EM clinical pharmacy services be the most common type of error corrected [4]. Another prospective
[20]. Over 80 participants have completed this program [42]. multicenter observational study found EM pharmacists caught 504
medication errors during an 800-hour study period [5]. The most com-
3. Supporting research mon were incorrect dosing, drug omission, and incorrect frequency—
alarmingly, almost half (47.8%) of intercepted errors were scored as se-
Reports of improved clinical, safety, and financial outcomes in EDs rious for having potential to cause organ injury or alter life function [5].
with EM clinical pharmacy services abound. A selection of various pub- Additional prospective studies in United States and Canada have also
lications is discussed below. demonstrated EM pharmacists intercept and significantly decrease
medication errors [2,3,5]. Retrospective studies have likewise shown
3.1. Clinical and consultative services EM pharmacists decrease medication errors [6,7] and increase medica-
tion error surveillance and reporting [56].
EM clinical pharmacists play an essential role in improving the clin- Medication errors are clinically significant, though many such errors
ical care provided in EDs, as highlighted in Table 2. The results docu- do not result in harm to the patient; those that result in harm are re-
ment improvement in areas such as disease-state specific outcomes ferred to as adverse drug events [1]. Although it is clear that the pres-
measures, compliance with organizational and national clinical practice ence of a pharmacist reduces the occurrence of medication errors,
guidelines, medication use evaluations, ED or hospital readmissions, more research is needed to determine whether this results in a clinically
and antimicrobial stewardship. significant reduction in clinically significant adverse drug events (ADE).
To this end, we encourage rigorous evaluations of outcomes to fully de-
3.2. Medication safety scribe the impact of EM clinical pharmacist practice.
Medication errors remain the most common error in medicine.
Medication errors are common in EDs and may arise during clinical Some result in no patient harm while others can be devastating and
decision-making, prescribing, transcribing, dispensing, or administra- costly [1]. Adding EM pharmacists to the ED has shown to increase iden-
tion of medications [2]. Including clinical pharmacists on the ED team tification, interception, and correction of many medication errors, in-
leads to increased error interception and fewer medication errors. ED cluding some that may cause permanent patient harm or death.
Additionally, EM clinical pharmacists have contributed to significant in-
creases in medication error event reporting which is necessary for sys-
Table 2
Impact of emergency medicine clinical pharmacists on clinical outcomes. tems optimization to reduce patient morbidity and mortality from
medication errors [58].
Topic Findings

Acute myocardial ● Reduction in door-to-cardiac catheterization lab time of

infarction 13.1 min and in door-to-balloon time of 11.5 min [43] 3.3. Financial implications
Acute ischemic ● Reduction in median door-to-rtPA of 20 min [44]
stroke
Sepsis ● Reduction in median time to appropriate antimicrobial Allocating pharmacists to the ED requires balancing the desire to im-
administration of 44 min [45] prove emergency care with the availability of health system resources.
● Increase in percentage of patients receiving guideline Research shows improvements in cost efficiency resulting from reduc-
adherent empiric antibiotics of 23.6% [46]
tions in adverse drug events, adherence to evidence-based guidelines,
Antimicrobial ● Reduction in median time to review positive cultures
stewardship and time to patient or physician notification of 1 day timely implementation of medication therapies, and increased use of
[47] cost-effective drug therapies. A selection of cost-avoidance data is listed
● Increase in percentage of interventions for inappropriate in Table 3.
antimicrobial therapy based on culture data of 30% [48]
● Reduction in percentage of unplanned readmissions to
Table 3
the ED after culture review of 12% [49]
Financial impact of emergency medicine clinical pharmacist program.
● Reduction in percentage of inappropriate revision of
antibiotics after culture review of 31.9% [50] Study Finding
● Reduction in percentage of return ED visits among unin-
sured after culture review of 12.9% [51] Ling 2005 [60] Four month period with 646 interventions by EM clinical
Rapid sequence ● Decreased mean time to post-intubation sedation by pharmacist estimated cost avoidance of $192,923 (annualized to
intubation 19 min and to analgesia by 23 min [52] $578,769)
● Intervention on a total of 10.1% of discharge prescrip-
Transitions of care tions for error prevention and optimization of therapy
• Most common interventions captured were formulary changes,
[53]
correcting a subtherapeutic dose or frequency, drug therapy
● Reduction in ED return visits by 50% for patients who
consultation, and documenting allergies.
were given free to-go antibiotics targeted at treatment
Lada 2007 Four month period with 1393 interventions by EM clinical
for urinary tract infection, pyelonephritis, cellulitis, or
[61] pharmacist in 1042 ED patients found cost avoidance of
dental infection at ED discharge [54]
$1,029,776 (annualized to $3,089,328)
● Improved medication and disease state education, iden-
tification of adherence issues, and medication therapy
optimization in patients with chief complaints of asthma • Most common interventions captured were drug information,
exacerbation, chronic obstructive pulmonary disease, or dose adjustment, nursing questions, formulary interchanges,
chronic heart failure [55] and suggest initiation of drug therapy.
Dose optimization ● Increase in percentage of patients receiving optimal Aldridge 2009 Six month period with 9568 interventions by EM clinical
phenytoin loading dose of 32% [56] [41] pharmacists showed cost savings of $845,592 (annualized to $1.7
Vaccination ● Four-fold increase in rate of influenza vaccination [57] million)

Please cite this article as: Morgan SR, et al, Clinical pharmacy services in the emergency department, American Journal of Emergency Medicine
(2018), https://doi.org/10.1016/j.ajem.2018.01.056
 S.R. Morgan et al. / American Journal of Emergency Medicine xxx (2018) xxx–xxx 5

Pharmacy departments generally fund EM clinical pharmacists, but an EM clinical pharmacist may vary based on institutional needs and re-
some EM departments, physician groups, and schools/colleges of phar- sources, all health systems should consider ways to support a dedicated
macy contribute partial funding [19]. Other organizations reallocate EM clinical pharmacist or EM pharmacy residency training program.
pharmacists to the ED after evaluating clinical priorities for the health
system [59]. Part of the AHRQ grant cited earlier was to develop a justi- Source of support
fication toolkit for EM clinical pharmacy services in the ED. This web-
based resource (available at http://www.ashp.org/emergencycare. None.
aspx) includes a selection of literature on clinical and safety outcomes.
Prior presentations
4. Barriers to implementation
None.
As with any new program or service, there are practical challenges to
starting a dedicated EM pharmacist role. Common obstacles include ap-
proval and funding support by hospital leadership, staffing beyond tra- Acknowledgements
ditional business hours, obtaining needed clinical support staff, defining
the role of EM pharmacist, and altering the workflow of the ED to in- The authors would like to acknowledge the following people for
clude the pharmacist [20]. For many institutions, the largest initial bar- their invaluable contributions to this paper: Rollin J. (Terry) Fairbanks,
rier may be the financial cost of including a pharmacist in the ED. MD, MS; Dickson Cheung, MD; David Nestler, MD, MS; Sam Torbati,
EM clinical pharmacists may seem an expensive resource [19]. The MD; Benjamin White, MD; Stephen Cantrill, MD; Alex Morgan, JD; Mar-
average annual salary for hospital-based pharmacists in the United garet Montgomery, RN, MSN; Julie Wassom; and the ACEP Emergency
States is around $120,000 [62]. Because EM clinical pharmacists do not Medicine Practice Committee. We also thank the following organiza-
provide a direct source of revenue, it is imperative for EM physicians tions for their support of EM clinical pharmacists: American College of
and administrators alike to value the many quality and efficiency bene- Emergency Physicians, American College of Medical Toxicology,
fits (and related savings) that EM clinical pharmacists provide. American Society of Health-System Pharmacists, American College of
The studies noted above lead us to firmly believe that the cost of Clinical Pharmacy, Agency of Healthcare Research and Quality, and the
adding dedicated clinical pharmacists to the ED is more than offset by Emergency Nurses Association.
increases in patient safety (and savings) that their presence brings
about. As value-based reimbursement and new payment models focus Conflict of interest disclosure
less on service quantity, the safety and efficiency value of the pharma-
cist relative to salary cost may further increase. SM, NA, ZC, VB, MC, JK, KL, CP, MP, ES report no conflicts of interest.

5. Limitations References
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Please cite this article as: Morgan SR, et al, Clinical pharmacy services in the emergency department, American Journal of Emergency Medicine
(2018), https://doi.org/10.1016/j.ajem.2018.01.056