ER Pharmacist

[nampa]

What are the main responsibilities of a solo ER pharmacist in a 50 bed ER, part of a 300 bed hospital? Are they tasked with med reconcillation? How much order/entry do they do? (Does physician o/e tend to get pushed on the pharmacist?) How much interaction with nurse and MD staff in the ER is there?

How does this compare to staffing in the central pharmacy? Is this a job that may pigeonhole a pharmacist into ER only vs. clinical/staffing hospital jobs?

I appreciate it!

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[JustFillIt]

Mostly you are a support for the staff during emergencies.

For example - when a code is called you are supposed to spring up and look like you are engaged in the emergency process. This usually means that you get to stand in the hallway and peer into the room with only your head poking around the door panel to ensure you are in no ones way while the physician/PA/NP perform the emergency services (cpr, etc).

It’s a very glorious job. Definitely one that requires a pgy6 or whatever you call it.

 

[rxkrafted]

Mostly you are a support for the staff during emergencies.

For example - when a code is called you are supposed to spring up and look like you are engaged in the emergency process. This usually means that you get to stand in the hallway and peer into the room with only your head poking around the door panel to ensure you are in no ones way while the physician/PA/NP perform the emergency services (cpr, etc).

It’s a very glorious job. Definitely one that requires a pgy6 or whatever you call it.

At our hospital, we actually tend to the crash cart and prepare the meds for the team, including any drips that need to be made.

 

[TheBlaah]

He's probably just being facetious.

At our hospital, similar sized community hospital, you do med recs if the nurse/doctor requests it. There's antibiotic phonecalls (basically calling patients with their labs, diagnosis, and what they need to follow up on). They attend codes. There's a lot of interaction with nurses/doctors.

But really, ER responsibilities are much more hospital-specific than most other positions.

 

[JustFillIt]

Haha yea.... I’m just kidding... kinda

 

[nampa]

At our hospital, we actually tend to the crash cart and prepare the meds for the team, including any drips that need to be made.

Even a big ER (50 beds) may only have a few codes in 24 hours. What are the main functions? How much order entry (are physicians supposed to do by law, but in reality what does the ER pharmacist turn into?), someone mentioned toxicology--that sounds dicey. Other than verify orders, what does the ER rph do all day?

 

[Dred Pirate]

you are going to get a wide range or answers based on many things - I am proud to say I built our EM program at my hospital (50 bed ED, 70k visits, 460 bed large community hospital as a reference).
We do
-staff 24/7
-order verification - we have zero auto verification in our ED, and have had so since 2007 - this is very rare. Pyxis machines are not on override (other than critical meds) - again, not common
-we respond to all codes (blue, stroke, sepsis, stemi) and respond house wide overnight
-dosing consult - we do a ton of abx, etc. Essentially we can adjust pretty much any medication (ED or admission) as needed based on renal fxn.
-housewide consults overnight
-We sit right next to the MD (like 5 feet away), so we have tons of interactions, etc. in a 10 hour shift once I kept track of MD questions, discussions, etc and it was over 30.
-Techs do med hx gathering 24/7, we check their work for obvious errors and clarify anything "odd" to save time before the admitting MD sees patient (this saves a ton of time tracking down an attending who signed and held the order 4 hours previously and has now gone home for the day.
-answer a million RN questions
-expedite requests from central pharmacy
-contact poison control for OD's (if needed)
-help the rest of the hospital with order verification (and they help us when we are busy)
-precept 5 residents a year
-precept 4-8 P4 students a year

 

[nampa]

you are going to get a wide range or answers based on many things - I am proud to say I built our EM program at my hospital (50 bed ED, 70k visits, 460 bed large community hospital as a reference).
We do
-staff 24/7
-order verification - we have zero auto verification in our ED, and have had so since 2007 - this is very rare. Pyxis machines are not on override (other than critical meds) - again, not common
-we respond to all codes (blue, stroke, sepsis, stemi) and respond house wide overnight
-dosing consult - we do a ton of abx, etc. Essentially we can adjust pretty much any medication (ED or admission) as needed based on renal fxn.
-housewide consults overnight
-We sit right next to the MD (like 5 feet away), so we have tons of interactions, etc. in a 10 hour shift once I kept track of MD questions, discussions, etc and it was over 30.
-Techs do med hx gathering 24/7, we check their work for obvious errors and clarify anything "odd" to save time before the admitting MD sees patient (this saves a ton of time tracking down an attending who signed and held the order 4 hours previously and has now gone home for the day.
-answer a million RN questions
-expedite requests from central pharmacy
-contact poison control for OD's (if needed)
-help the rest of the hospital with order verification (and they help us when we are busy)
-precept 5 residents a year
-precept 4-8 P4 students a year

This is very helpful, thanks. Can you elaborate on the issues to watch out for with the poison control and med reconcilliation?

What sort of nurse and MD questions are common? For instance, other than questions about them not knowing how to enter orders or consults, what do you normally get? Additionally, does it get harry when you change an order remotely and have to call the pharmacy to make sure they cancel it?

 

[Dred Pirate]

This is very helpful, thanks. Can you elaborate on the issues to watch out for with the poison control and med reconcilliation?

What sort of nurse and MD questions are common? For instance, other than questions about them not knowing how to enter orders or consults, what do you normally get? Additionally, does it get harry when you change an order remotely and have to call the pharmacy to make sure they cancel it?

poison control - any overdose you can think of
med rec - duplicate drug classes (protonix and pepcid), xr vs regular release
questions - anything under the sun, but most common
MD- anything abx based, do we have xxx on formulary, what pressors to use in different situations. Can any drugs on their profile cause condition X (thrombocytopenia, bradycardia, muscle aches, qtc prolongation, etc), how the heck do enter this med?
RN - how fast do I give this? do I dilute it? are drug x and y compatible, how do I get this drug (pyxis, central , etc)
I don't change outpatient rx's, only inpatient, BUT i review discharge rx's and then tell the MD to change it after they wrote it.

 

[sakigt]

you are going to get a wide range or answers based on many things - I am proud to say I built our EM program at my hospital (50 bed ED, 70k visits, 460 bed large community hospital as a reference).
We do
-staff 24/7
-order verification - we have zero auto verification in our ED, and have had so since 2007 - this is very rare. Pyxis machines are not on override (other than critical meds) - again, not common
-we respond to all codes (blue, stroke, sepsis, stemi) and respond house wide overnight
-dosing consult - we do a ton of abx, etc. Essentially we can adjust pretty much any medication (ED or admission) as needed based on renal fxn.
-housewide consults overnight
-We sit right next to the MD (like 5 feet away), so we have tons of interactions, etc. in a 10 hour shift once I kept track of MD questions, discussions, etc and it was over 30.
-Techs do med hx gathering 24/7, we check their work for obvious errors and clarify anything "odd" to save time before the admitting MD sees patient (this saves a ton of time tracking down an attending who signed and held the order 4 hours previously and has now gone home for the day.
-answer a million RN questions
-expedite requests from central pharmacy
-contact poison control for OD's (if needed)
-help the rest of the hospital with order verification (and they help us when we are busy)
-precept 5 residents a year
-precept 4-8 P4 students a year

This is exactly what I do, minus the staff 24/7 and overrides, everything is on override so you have to keep up or you miss important ****. We don't have med recs tech so I review basically every admission and fix errors the RNs did (this should be changing soon).

Its a very weird job. You basically have to be ok doing order verification and then dropping everything to be in a code or adjusting sedation on a patient for like an hour and a half. Know the dosing and drugs for crazy stuff off the top of your head. Getting asked random MacGyver type ****.

The poking the head in the doorway watching in fear are what the boomers do.

 

[Dred Pirate]

Its a very weird job. You basically have to be ok doing order verification and then dropping everything to be in a code or adjusting sedation on a patient for like an hour and a half. Know the dosing and drugs for crazy stuff off the top of your head. Getting asked random MacGyver type ****.

this is why I love it - I have a great relationship with the ED MD's and the hospitalists (known many of them for 10 years +) - you never know what random crap comes in the door and what you may be asked. Most of the time there is so much grey area because you don't have the full picture yet, there is not necessarily a right or wrong (well there are obviously very wrong answers at times) but you actually get to use your brain and your opinion vs reciting some guideline.

 

[nampa]

poison control - any overdose you can think of
med rec - duplicate drug classes (protonix and pepcid), xr vs regular release
questions - anything under the sun, but most common
MD- anything abx based, do we have xxx on formulary, what pressors to use in different situations. Can any drugs on their profile cause condition X (thrombocytopenia, bradycardia, muscle aches, qtc prolongation, etc), how the heck do enter this med?
RN - how fast do I give this? do I dilute it? are drug x and y compatible, how do I get this drug (pyxis, central , etc)
I don't change outpatient rx's, only inpatient, BUT i review discharge rx's and then tell the MD to change it after they wrote it.

How much is order entry part of the job? Also, for med rec, is the pharmacist getting a drug history from the patient, or is the nurse still doing that, and the pharmacist just makes sure it's okay upon verification?

What does a typical afternoon shift look like? I would appreciate specifics, as I am considering this. What is the verification rate like? This is a 54 bed ED with just one man on the afternoon shift.
I assume vanc and heparins are first dosed by pharmacy in this setting, or is that done by the central pharmacy once the attending gives pharmacy permission to dose by protocol?
Sedation med adjustment?

 

[nampa]

He's probably just being facetious.

At our hospital, similar sized community hospital, you do med recs if the nurse/doctor requests it. There's antibiotic phonecalls (basically calling patients with their labs, diagnosis, and what they need to follow up on). They attend codes. There's a lot of interaction with nurses/doctors.

But really, ER responsibilities are much more hospital-specific than most other positions.

this is why I love it - I have a great relationship with the ED MD's and the hospitalists (known many of them for 10 years +) - you never know what random crap comes in the door and what you may be asked. Most of the time there is so much grey area because you don't have the full picture yet, there is not necessarily a right or wrong (well there are obviously very wrong answers at times) but you actually get to use your brain and your opinion vs reciting some guideline.

Can you elaborate on auto verification? Also, what about order entry? Do MDs abuse the ER pharmacist by making them enter the orders on a regular basis?

-order verification - we have zero auto verification in our ED, and have had so since 2007 - this is very rare.

 

[rxkrafted]

Dred Pirate pretty much covered everything you need to know. Other questions are more facility specific. Where do you currently work? Were you given a offer for this ED position or thinking about applying? If you haven't already been interviewed, you should just ask them...

 

[Dred Pirate]

Nampa - every institution is going to be very different when it comes to protocols and what you can do - so I couldn't answer for yours.
I can tell you our ED RPh's verify 300-500 orders per shift. Just last week I did 400 orders, 14 consults, and 4 codes in one night - it was very busy.

autoverification is what many ED's do - any order that MD enters does not require RPh approval - it crosses right over to the Emar and that RN can administer. It cuts out the Rph has a safety net at the expense of convenience.

 

[nampa]

Unfortunately, I don't have any other resources to ask questions. What is the ED rph verifying if the MD does autoverification? This is afternoon shift, so it would be solo. How many rph at your facility are in the ED for that level of verification?
These jobs seem to prefer residency trained rphs. Why is this so? Wouldn't a hybrid staff pharmacist in the central pharmacy need a larger knowledge base?
What protocols tend to be done in ED? From my understanding, patients usually only spend a few hours before they go to the floor, the exception being if there is no room on the floor like during pneumonia season.

 

[nampa]

This is exactly what I do, minus the staff 24/7 and overrides, everything is on override so you have to keep up or you miss important ****. We don't have med recs tech so I review basically every admission and fix errors the RNs did (this should be changing soon).

Its a very weird job. You basically have to be ok doing order verification and then dropping everything to be in a code or adjusting sedation on a patient for like an hour and a half. Know the dosing and drugs for crazy stuff off the top of your head. Getting asked random MacGyver type ****.

The poking the head in the doorway watching in fear are what the boomers do.

Perhaps it may be more illuminating for me to get a few samples of the macgyver questions you mentioned. In a completely centralized hospital, we got very little questions from the ed.

 

[KidPharmD]

ER's can be very different. Your questions might not have the same answers for many different institutions. The practice isn't consistent enough for us all to be doing the exact same thing.

Unfortunately, I don't have any other resources to ask questions. What is the ED rph verifying if the MD does autoverification? This is afternoon shift, so it would be solo. How many rph at your facility are in the ED for that level of verification?
These jobs seem to prefer residency trained rphs. Why is this so? Wouldn't a hybrid staff pharmacist in the central pharmacy need a larger knowledge base?
What protocols tend to be done in ED? From my understanding, patients usually only spend a few hours before they go to the floor, the exception being if there is no room on the floor like during pneumonia season.

ER's with autoverification don't have pharmacists that are doing a lot of verifying. Some ER's only have certain meds on autoverification. Most Autoverified meds still need review after the fact.
I am confused about what you mean about residency training and larger knowledge bases. Is this position you are talking about in the central pharmacy or in the ER? Are you saying residents have too much knowledge or not enough?
Usually protocols in the ER are initiated with other pharmacists continuing them over the course of the admission.

 

[Sparda29]

you are going to get a wide range or answers based on many things - I am proud to say I built our EM program at my hospital (50 bed ED, 70k visits, 460 bed large community hospital as a reference).
We do
-staff 24/7
-order verification - we have zero auto verification in our ED, and have had so since 2007 - this is very rare. Pyxis machines are not on override (other than critical meds) - again, not common
-we respond to all codes (blue, stroke, sepsis, stemi) and respond house wide overnight
-dosing consult - we do a ton of abx, etc. Essentially we can adjust pretty much any medication (ED or admission) as needed based on renal fxn.
-housewide consults overnight
-We sit right next to the MD (like 5 feet away), so we have tons of interactions, etc. in a 10 hour shift once I kept track of MD questions, discussions, etc and it was over 30.
-Techs do med hx gathering 24/7, we check their work for obvious errors and clarify anything "odd" to save time before the admitting MD sees patient (this saves a ton of time tracking down an attending who signed and held the order 4 hours previously and has now gone home for the day.
-answer a million RN questions
-expedite requests from central pharmacy
-contact poison control for OD's (if needed)
-help the rest of the hospital with order verification (and they help us when we are busy)
-precept 5 residents a year
-precept 4-8 P4 students a year

Would you say someone who is exclusively an ED pharmacist would have to have residency traiining or would you be comfortable tossing in someone who only has centralized staffing experience?

 

[Rockinacoustic]

Would you say someone who is exclusively an ED pharmacist would have to have residency traiining or would you be comfortable tossing in someone who only has centralized staffing experience?

I am biased but a residency trained or experience floor pharmacist knows what care looks like upstairs and can aid in the transition from the ED to the floors.

 

[nampa]

I am biased but a residency trained or experience floor pharmacist knows what care looks like upstairs and can aid in the transition from the ED to the floors.

I have had conflicting feedback on what is more clinically challenging, central pharmacist or ed pharmacist.

 

[rxkrafted]

ED pharmacists are challenged more clinically compared to a central pharmacist. There are more interactions with physicians and nurses while in the ED because you are literally right there with them. The ED is the first line of contact before admission so anything new will be seen there first in many cases. This is just from my perspective having worked as a centralized pharmacist, decentralized, and in the ED.

 

[sakigt]

Central pharmacy gets hit with random questions but only if the dayshift/specialty pharmacists aren't around. ER Pharmacists are the first line for weird stuff which falls to central if we aren't here.

 

[Rockinacoustic]

I have had conflicting feedback on what is more clinically challenging, central pharmacist or ed pharmacist.

This is going to vary between hospital staffing structure and also depends on the person. You may find it more clinically challenging to work on a pediatric dilution or TPN while someone else may find it more challenging to assist with a code or tox case.

Both settings are good areas to be a "jack of all trades" and not necissarily specialized in one patient population or disease state

 

[Dred Pirate]

Would you say someone who is exclusively an ED pharmacist would have to have residency traiining or would you be comfortable tossing in someone who only has centralized staffing experience?

i am not residency trained, but have 15 years experience. i may be biased, but experience trumps residency, but not all experience is equal. if all you do is check product, that doesn't relate to er work.
i precept pgy1 and pgy2 residents, and have seen great ones and bad ones, so i can't really answer that question with a blanket statement.

 

[Sparda29]

I am biased but a residency trained or experience floor pharmacist knows what care looks like upstairs and can aid in the transition from the ED to the floors.

Don't all pharmacists know what care looks like upstairs? We all took internal med rotations. I guess on my rotations I took more initiative to spend my time there with the med students or 1st year residents rather than being downstairs working on "journal club". They routinely asked me to assist on procedures, (the craziest **** I was allowed to do was a thorancentesis (attending pretty much guided me through it).

 

[Dred Pirate]

Don't all pharmacists know what care looks like upstairs? We all took internal med rotations. I guess on my rotations I took more initiative to spend my time there with the med students or 1st year residents rather than being downstairs working on "journal club". They routinely asked me to assist on procedures, (the craziest **** I was allowed to do was a thorancentesis (attending pretty much guided me through it).

short answer is no.
Every hospital is different, at the largest, often "brand name" hospitals that a are a decent number of RPh's who only check stock - they get zero phone calls other than "my drug is missing". Our our institution isn't like that, but I know many that are

 

[greenteapanacea]

Don't all pharmacists know what care looks like upstairs? We all took internal med rotations. I guess on my rotations I took more initiative to spend my time there with the med students or 1st year residents rather than being downstairs working on "journal club". They routinely asked me to assist on procedures, (the craziest **** I was allowed to do was a thorancentesis (attending pretty much guided me through it).

I've noticed that many smaller community hospitals have staff pharmacists do a blend of upstairs clinical work and downstairs order entry. My experience with larger hospitals is similar to what Dred Pirate said.

 

[nampa]

Those must be pretty large hospitals, say over 500 beds? 100 beds do a lot of clinical, there just isn't much beyond the bread and butter stuff. The 200-400 seem to be all over place, with everything there, except maybe transplant, and few clinical.

 

[nampa]

i am not residency trained, but have 15 years experience. i may be biased, but experience trumps residency, but not all experience is equal. if all you do is check product, that doesn't relate to er work.
i precept pgy1 and pgy2 residents, and have seen great ones and bad ones, so i can't really answer that question with a blanket statement.

Just found out this is a new ED position, It has been rotatingly staffed for about four months. I wonder what kind of development of the position they could want, protocols, etc.?

 

[Dred Pirate]

Just found out this is a new ED position, It has been rotatingly staffed for about four months. I wonder what kind of development of the position they could want, protocols, etc.?

if it is a new position, you have the chance to really grown it and make it what you want - that was my situation- I picked it up after we sort of just "were there" for a few years. I was given a lot of freedom in how I wanted to build the team.

 

[Dred Pirate]

where is the position?