What role do you see for a pharmacist in the ED?

[Dred Pirate]

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I am a pharmacist in a medium size community hospital ED (60k visits a year). We have staffed 24/7 in the ED for about 7 years. Sometimes I feel like we are in a total rut and spend most of our time verifying stupid easy one time pain med/nausea/fluid bolus orders that even a monkey could do. Now that being said ED MGMT always raves that we are up there, we do do a lot of RN education and preventing their mistakes.

I think some of our most valuable service is simply expediting drugs during codes/critical care patients, helping the RN's titrate drips. Those are the times I feel I actually add to care. Also I help with a lot of toxicology stuff. We have pharm tecs do med histories. We used to d a lot of coumadin education for new diagnosis DVT's, but that has really dropped off now that Xarelto is most commonly used (For us)

From an ED provider's view point, where do you see us being valuable? Where do you see us helping to add to paient care/make your life better?

 

[Caesar]

I love having a good pharmacist during a code, especially one that has run a few with me cause they know what I want and what is compatible with what. I bounce things off the pharmacist all the time for abx coverages with allergies, new meds on someone on coumadin. Ours make us Ketofol. They also do our verification.

 

[racerwad]

This was discussed a few weeks ago: http://forums.studentdoctor.net/threads/clinical-pharmacist-in-the-er-yes-no.1123002/

I think doing exactly what you described is fantastic. Was there something else you thought to contribute? <-that isn't supposed to sound snarky but I can't figure out how else to say it.

 

[Dred Pirate]

This was discussed a few weeks ago: http://forums.studentdoctor.net/threads/clinical-pharmacist-in-the-er-yes-no.1123002/

I think doing exactly what you described is fantastic. Was there something else you thought to contribute? <-that isn't supposed to sound snarky but I can't figure out how else to say it.

naw - just brain storming. Honestly I probably go to more codes that the MD's (there is one of me at a time and 6 of them at a time).

sometimes I feel like even thou I am in the ED - i spend 50% or more of my time either working on floor orders via CPOE or clicking away on one time ED orders that I maybe make an input 2% of the time - so I guess I need a busy trauma center type hospital, or a different job lol - just bored I guess.

thanks for that link

 

[racerwad]

naw - just brain storming. Honestly I probably go to more codes that the MD's (there is one of me at a time and 6 of them at a time).

sometimes I feel like even thou I am in the ED - i spend 50% or more of my time either working on floor orders via CPOE or clicking away on one time ED orders that I maybe make an input 2% of the time - so I guess I need a busy trauma center type hospital, or a different job lol - just bored I guess.

thanks for that link

As an student, I have gotten a lot out of having a pharmacist in the ED and all the attendings feel the same way. Maybe you'd like a change of scenery where teaching is available?

 

[fahimaz7]

Ours is awesome. Checks over orders, helps with dosing, gets us meds when we need them (dig fab for example), and contributes to our journal clubs and lectures. Very nice addition to our 100k/year place.

 

[Dred Pirate]

As an student, I have gotten a lot out of having a pharmacist in the ED and all the attendings feel the same way. Maybe you'd like a change of scenery where teaching is available?

I do all the things listed in that - maybe it is seasonal effective disorder lately 🙂 - I guess I have the same complaints of spending a lot of time doing boring things as the ED MD that has dealing with patients with chronic pain, hypodilaudism, anxiety, etc.

I do spend the time with my pharm student/residents making sure they are not "that pharmacist" that doesn't know how to use their brain and calls y'all on stupid things all day

 

[cofcemt]

Little things really go a long way.

Had a kid in status the other day refractory to benzos, phenobarbital and couldnt remember the starting dose for propofol sedation for these kids.

Like one of the above posters, our pharmacists are involved in sedations, especially peds. They mix our ketofol as well.

The complex sepsis patient with multiple allergies and prior esbl stuff... It's great to have our pharmacist guide abx.

During sick/complex patient resus, one of our pharmacists who has gotten to know me will premix push dose epi!

Really it is when SHTF and on complex patients you guys shine.

I know our pharmacists get bogged down by verifying simple orders; so when they are a huge help, I try to let them know. I certainly miss them when they leave for the night (they only cover 16 hours/day).

 

[AvocadoLover]

Hey Dred Pirate, sounds like you are doing all of the most important stuff! I was an ED pharmacist turned ED resident. Some other non-essential things we would do: Get a daily report of any culture results on discharged patients and follow-up to make sure the ABX choices were appropriate/get changes made PRN. We would also field calls from outpatient pharmacies on clarification orders (most of the time I could just pull the answer to their question from the EMR). Peds errors were of concern before pharmacy came into the ED so we would also do verification of peds dosing (It was dept policy that another RN or PharmD check to verify the dose drawn up was actually the dose ordered on all peds meds). Keep up the good work!

 

[The White Coat Investor]

Didn't we just do this thread? I searched but only found this older one.

http://forums.studentdoctor.net/threads/what-do-emergency-room-pharmacists-do.653325/

 

[The White Coat Investor]

Hey Dred Pirate, sounds like you are doing all of the most important stuff! I was an ED pharmacist turned ED resident. Some other non-essential things we would do: Get a daily report of any culture results on discharged patients and follow-up to make sure the ABX choices were appropriate/get changes made PRN. We would also field calls from outpatient pharmacies on clarification orders (most of the time I could just pull the answer to their question from the EMR). Peds errors were of concern before pharmacy came into the ED so we would also do verification of peds dosing (It was dept policy that another RN or PharmD check to verify the dose drawn up was actually the dose ordered on all peds meds). Keep up the good work!

Hmmm...cultures- done by nurses. Field calls- done by clerks who then ask me if I really wanted to prescribe 12 percocet to a lady who just filled a script for 180 of them. Dose verification- done by nurses. Don't get me wrong. I would love to have an extra body in the ED to do anything, but I'm not sure the extra body I need most is a pharmacist.

 

[The White Coat Investor]

Ours is awesome. Checks over orders, helps with dosing, gets us meds when we need them (dig fab for example), and contributes to our journal clubs and lectures. Very nice addition to our 100k/year place.

How many 100K EDs are there in the country? It's got to be less than 100, maybe less than 50. We don't have a single one in my state. It's just really hard for a "typically sized" ED to afford one. The ideal ratio of nurses to pharmacists can't be 3:1, but I've only got 3 nurses for 10 hours a day, and never more than 6.

How often are you using dig fab? I mean, I'm only 9 years out and have NEVER given it. I suppose it's a daily thing though in a 100K ED. 🙂

 

[RTC19]

Didn't we just do this thread? I searched but only found this older one.

http://forums.studentdoctor.net/threads/what-do-emergency-room-pharmacists-do.653325/

Is this what you were looking for, WCI?

http://forums.studentdoctor.net/threads/clinical-pharmacist-in-the-er-yes-no.1123002/

 

[njac]

naw - just brain storming. Honestly I probably go to more codes that the MD's (there is one of me at a time and 6 of them at a time).

sometimes I feel like even thou I am in the ED - i spend 50% or more of my time either working on floor orders via CPOE or clicking away on one time ED orders that I maybe make an input 2% of the time - so I guess I need a busy trauma center type hospital, or a different job lol - just bored I guess.

thanks for that link

I would say that I am a lot of things at work, but I am never bored.

I am lucky enough to work in one of those >100K visit/yr EDs and don't have to verify ED orders (I verify admission orders if I have time, but depends on the day) other than meds not in the Pyxis that need pharmacist approval. My resident is doing a pilot med Rec project right now, but that is expected to get absorbed by a pharmacy tech or intern.

We have tons of "dosing per pharmacy" protocols on admission that I make sure get started appropriately (ie - we don't keep Vanco in our ED Pyxis because 1gm is an inappropriate first dose in 80% of our patients). I also have students and residents and end up doing a lot of QI work identifying cost and time savings. Any time the physician group wants to add something to formulary (kcentra, dalbavancin vs ortavancin) I create the P&T proposal as well as any associated policies and protocols (procedural sedation, DKA, post intubation analgesia and sedation all came up in the last few years) and end up taking them to all the meetings for approval.

I do a ton of Formal (and informal) RN education, feels like spitting in the wind sometimes, but occasional they remember something we discussed and they make me proud.

 

[The White Coat Investor]

we don't keep Vanco in our ED Pyxis because 1gm is an inappropriate first dose in 80% of our patients).

Educate me on this topic- Too high, too low? What's the issue? How far off is 1 gram from what you think should be given? Are you simply using something like this every time?

http://clincalc.com/vancomycin/

 

[TooMuchResearch]

Educate me on this topic- Too high, too low? What's the issue? How far off is 1 gram from what you think should be given? Are you simply using something like this every time?

http://clincalc.com/vancomycin/

I'm dosing it at 15-20 mg/kg most of the time.

 

[njac]

Educate me on this topic- Too high, too low? What's the issue? How far off is 1 gram from what you think should be given? Are you simply using something like this every time?

http://clincalc.com/vancomycin/

For first dose I'm giving a loading dose of 20-25 mg/kg (based on total body weight, capping at 2.5gm). The guidelines say to consider 25-30mg/kg for life threatening infections, but I think the required doses there might cause some chest pain.

The issue here is filling the volume of distribution (roughly 0.7L/kg for vancomycin) - for serious infections we're targeting a trough concentration of 15-20 mcg/ml. If you give a 70kg pt (and how many of those do we see anymore...) 1gm of Vanco, you're only getting a peak of (1000mg/(70kg*.7L/kg)) 20.4 mcg/ml - that was right when the infusion ended. The healthiest patients aren't going to see another dose for a minimum of 6 hours, and more likely 12 hours, so your Vanco hasn't been at an effective dose the majority of that dosing interval. If you give 1500mg you'll get a peak closer to 30, and you'll spend more time in the therapeutic range.

This is true even for dialysis or acute renal patients - you can always wait 24-48 hours to give more vancomycin, but you need to "fill the tank" in the first place in order for your antibiotics to work.

 

[The White Coat Investor]

So giving the fatties 2g instead of 1 would be a better rule of thumb then huh. Cool, learned something today.

 

[link2swim06]

Definitely helpful and useful in a high volume ED. We have fellowship trained pharmacists to try to maximize the antibiotic stewardship for the hospital.

 

[The White Coat Investor]

Definitely helpful and useful in a high volume ED. We have fellowship trained pharmacists to try to maximize the antibiotic stewardship for the hospital.

That's noble to spend money on that cause. My hospital won't be doing that any time soon.

 

[njac]

That's noble to spend money on that cause. My hospital won't be doing that any time soon.

The state of California now mandates all hospitals have an antimicrobial stewardship plan. Of course the definitions vary from site to site.

But there's definitely an aspect to this in my job - keeping the mid levels from ordering ertapenem on every diabetic foot, the plastics guy from zosyn on every fresh dog bite.

 

[The White Coat Investor]

The state of California now mandates all hospitals have an antimicrobial stewardship plan. Of course the definitions vary from site to site.

But there's definitely an aspect to this in my job - keeping the mid levels from ordering ertapenem on every diabetic foot, the plastics guy from zosyn on every fresh dog bite.

Sure. I'll bet most of those antimicrobial stewardship plans don't require a pharmacist in the ED. More like an email that goes out once a year.

 

[njac]

Sure. I'll bet most of those antimicrobial stewardship plans don't require a pharmacist in the ED. More like an email that goes out once a year.

Right, but parts of my job encompass details of the antimicrobial stewardship plan.

The department of pharmacy pays for me, not the ED. If nothing else I earn my keep by deferring phone calls from the main pharmacy. Anything beyond that is probably a bonus in my boss' eyes.

 

[link2swim06]

That's noble to spend money on that cause. My hospital won't be doing that any time soon.

They tried to force us to 'let the EMR' choose the antibiotic for awhile but a lot of people hated that and just figured out ways to circumvent the system when the medicine didn't follow their cookbook. Regardless our antibiotic pharmacists will hound the crap out if you are ordering something that isn't optimal. Which I have no problem with because our c diff rate remains higher than comparable hospitals.

At my hospital emailing everyone once a year or even once a month hasn't really changed practice patterns much. People seem to just do whatever they want until they get called or paged by somebody to clarify the order. Granted they often get the first dose and admitted before the antibiotic pharmacist reviews it.

Our hospital does have high volume which probably allows them to hire more than most hospitals (>170K ER visits per year and a half dozen ICUs).

 

[Psai]

They tried to force us to 'let the EMR' choose the antibiotic for awhile but a lot of people hated that and just figured out ways to circumvent the system when the medicine didn't follow their cookbook. Regardless our antibiotic pharmacists will hound the crap out if you are ordering something that isn't optimal. Which I have no problem with because our c diff rate remains higher than comparable hospitals.

At my hospital emailing everyone once a year or even once a month hasn't really changed practice patterns much. People seem to just do whatever they want until they get called or paged by somebody to clarify the order. Granted they often get the first dose and admitted before the antibiotic pharmacist reviews it.

Our hospital does have high volume which probably allows them to hire more than most hospitals (>170K ER visits per year and a half dozen ICUs).

Let the emr choose? Because it has a medical degree? I'm not sure I understand