Cristina Roman

SHPA Standards of Practice in Emergency Medicine Pharmacy Practice

These standards describe the activities consistent with good practice for the provision of clinical pharmacy services in the specialty area of emergency medicine (EM). They should be read in conjunction with the current Society of Hospital Pharmacists of Australia (SHPA) Standards of Practice for Clinical Services. EM pharmacy practice encompasses clinical care for patients in the emergency department (ED) and may include pre-hospital care, toxicology and disaster planning. An ED is defined as a unit managing acute, urgent and time-critical aspects of illness and injury presenting from the community. Approximately one-quarter of patients who present to an ED will require an inpatient admission. EM pharmacists may therefore provide early pharmaceutical care to both patients who are admitted to hospital and those who are discharged back to community care directly from the ED. EM pharmacists have been shown to reduce hospital admissions. Associated with many EDs are short-stay units, the specific names of which vary and include ‘Emergency Medical Unit’, ‘Medical Admission Planning Unit’ and ‘ShortStay Observation Unit’. Typically, patients in such units are admitted for up to 24 or 48 h. The pharmacist responsible for the overall EM service is referred to as the EM pharmacist. OBJECTIVES

Partnered medication review and charting between the pharmacist and medical officer in the Emergency Short Stay and General Medicine Unit.

OBJECTIVE A partnered medication review and charting model involving a pharmacist and medical officer was implemented in the Emergency Short Stay Unit and General Medicine Unit of a major tertiary hospital. The aim of the study was to describe the safety and effectiveness of partnered medication charting in this setting. METHODS A partnered medication review and charting model was developed. Credentialed pharmacists charted pre-admission medications and venous thromboembolism prophylaxis in collaboration with the admitting medical officer. The pharmacist subsequently had a clinical discussion with the treating nurse regarding the medication management plan for the patient. A prospective audit was undertaken of all patients from the initiation of the service. RESULTS A total of 549 patients had medications charted by a pharmacist from the 14th of November 2012 to the 30th of April 2013. A total of 4765 medications were charted by pharmacists with 7 identified errors, corresponding to an error rate of 1.47 per 1000 medications charted. CONCLUSIONS Partnered medication review and charting by a pharmacist in the Emergency Short Stay and General Medicine unit is achievable, safe and effective. Benefits from the model extend beyond the pharmacist charting the medications, with clinical value added to the admission process through early collaboration with the medical officer. Further research is required to provide evidence to further support this collaborative model.

Reducing medication errors in hospital discharge summaries: a randomised controlled trial.

Objectives: To evaluate whether pharmacists completing the medication management plan in the medical discharge summary reduced the rate of medication errors in these summaries.

Partnered pharmacist charting on admission in the General Medical and Emergency Short‐stay Unit – a cluster‐randomised controlled trial in patients with complex medication regimens

Patients admitted to general medical units and emergency short‐stay units are often complex with multiple comorbidities, polypharmacy and at risk for drug‐related problems associated with increased morbidity and mortality. The aim of this study was to evaluate the effectiveness of a partnered pharmacist charting model completed at the time of admission to prevent medication errors.

Implementation of hospital‐wide reform at improving access and flow: Impact on time to antibiotics in the emergency department

ED overcrowding has been associated with increased mortality, morbidity and delays to essential treatment. It was hypothesised that hospital‐wide reforms designed to improve patient access and flow, in addition to improving ED overcrowding, would impact on clinically important processes within the ED, such as timely delivery of antibiotics.

A ‘time and motion’ evaluation of automated dispensing machines in the emergency department

BACKGROUND There has been limited assessment of the impact that automated medication dispensing machines have on the medication administration process, particularly in Australian emergency departments. The aim of this study is to examine the change in medication retrieval times, number of medications retrieved and staff perceptions before and after the installation of automated dispensing machines in an Australian emergency and trauma centre. METHODS A time and motion method recorded the time taken and number of medications retrieved from the medication room by emergency department staff, before and after the installation of two automated dispensing machines. Surveys were administered to staff members to elicit the perceived impact on clinical practice, utilising 5-point Likert scales. RESULTS A total of 954 medication retrievals (1030 medications) were recorded in the pre-implementation period and 842 (991 medications) in the post-implementation period. The mean time taken to retrieve any medication was significantly longer in the post-implementation period (+5.7s; p<0.01). For schedules 2, 3, 4 or unscheduled medications, the mean time increased by 26.9s (p<0.01), but decreased by 36.1s (p<0.01) for schedule 8 or 11 medications. The mean number of medications per retrieval increased slightly in the post implementation period (+0.10; p<0.01). Staff perceptions were that automated dispensing machines improve knowledge of medications on imprest (p=0.03) and reduced medication retrieval time (p<0.01). CONCLUSIONS This study found that the medication retrieval process was slower with automated dispensing machines for Schedules 2, 3, 4 and unscheduled medications, but quicker for Schedule 8 and 11 medications in an Australian emergency and trauma centre. Although retrieving medications took slightly longer overall, staff believed automated dispensing machines save time.

Use of Idarucizumab for dabigatran reversal: Emergency department experience in two cases with subdural haematoma

Introduction Idarucizumab is the first effective humanized monoclonal antibody fragment developed specifically as a reversal agent for dabigatran, a Direct Oral Anticoagulant. Despite recent trials demonstrating reversal of clinically relevant bleeding, there is a paucity of data on use outside the trial setting. This manuscript describes the use of Idarucizumab to reverse dabigatran in two patients presenting to the emergency department of a major tertiary hospital with acute traumatic subdural haematomas (SDH). Methods Patients were identified through retrospective review of medication dispensing systems and electronic medical records. Results Two cases of Idarucizumab use were identified. Case 1 was of a 63-year-old male who presented following a motorcycle crash. Case 2 was of a 77-year-old male who presented with a 3-week history of ataxia and recurrent falls. Both patients were taking dabigatran for atrial fibrillation (AF). CT Brain revealed acute SDH with clinical indications for urgent surgical evacuation. Serum dabigatran levels were obtained on arrival in the emergency department with levels of 155 ng/ml and 110 ng/ml (reference range 117–275 ng/ml). Idarucizumab for dabigatran reversal was commenced; Case 1 received 5 g Idarucizumab as an intravenous bolus dose, while Case 2 received 5 g Idarucizumab as two 2.5 g intravenous infusions. Serum dabigatran levels for Cases 1 and 2 were 0 ng/ml at 75 min and 340 min post Idarucizumab administration respectively. Both patients proceeded to craniotomy with evacuation of the SDH. There was no extension of the SDH in either case. Anticoagulation was withheld until outpatient clinic review, and both patients transferred for rehabilitation prior to discharge home. Conclusion Idarucizumab was clinically effective for reversing dabigatran, resulting in undetectable serum levels, and should be considered in patients presenting to hospital with clinically significant bleeding associated with dabigatran therapy.

Improving influenza vaccination among hospitalised patients in General Medicine and Emergency Short Stay units - a pharmacist-led approach

Patients admitted to General Medical Units (GMU) and Emergency Short Stay Units (ESSU) are often elderly with multiple comorbidities and the majority are considered to be at high risk of complications from influenza. The aim of this study was to assess the practice of including a pharmacist assessment of appropriateness and charting of influenza vaccination in a partnered pharmacist charting model in a GMU and ESSU.

Early involvement of the emergency department pharmacist in severe trauma: LETTER TO THE EDITOR

Dear Editor, Miller et al. recently identified that one-fifth of severely injured patients did not have a medication history on admission in one Australian level one trauma centre. Although the absence of a medication history was not associated with morbidity and mortality, the authors concluded that a more complex relationship might exist between patients, their mechanism of injury and medication history. Engagement of a clinical pharmacist was a proposed option to improve admission medication histories in severe trauma. This conclusion is supported by a recent systematic review identifying involvement in severe trauma and resuscitation as a key emerging area of practice for Emergency Medicine (EM) clinical pharmacists. A number of US studies have found EM pharmacists improved time to medication administration such as analgesia in severe trauma and reduced medication errors in the hectic stages of resuscitation. Supported by this evidence, North American practice routinely includes early involvement of the EM pharmacist during trauma resuscitation. In this environment, the EM pharmacist is perfectly positioned to also be able to improve early medication history and support the trauma team. In addition to the observational evidence, there is strong physiological rationale for the benefit of pharmacist involvement among severely injured patients. For example, anticoagulants and antiplatelets are associated with higher mortality after trauma that may be mitigated by early identification and treatment. This is particularly relevant in the high acuity setting where assessment and diagnosis remains the focus of clinical practice and little consideration may be afforded to identification of medications taken on admission. Assigning the EM pharmacist to this crucial role is a logical next step given the well established literature in favour of accurate medication history taking and extensive knowledge on appropriate anticoagulant reversal. Despite emerging international evidence in this area, routine involvement of the EM pharmacist in severe trauma presentations in Australia is rare. Clinical pharmacists undertaking routine medication history in the ED is recommended and occurs frequently in many centres; however, the focus is on patients being discharged home from the ED with polypharmacy and stable medical admissions. But as clinical pharmacy services continue to expand in Australian EDs pharmacists are increasingly being involved in acutely unwell patients. The benefits of early and accurate medication history in acute trauma should be given a greater priority. There is significant potential to establish this new model as a standard of care during resuscitation in Australia. However, a key barrier that remains is the availability of clinical pharmacists and cost. Early involvement of the EM pharmacist in trauma may be difficult to justify based on drug cost savings alone, particularly to hospital administrators who may not understand the benefit to patients and in settings that receive relatively low volumes of such patients. Further research is required in this area of practice, particularly in high volume Australian trauma centres. Competing interests

Roles of the emergency medicine pharmacist: A systematic review

Purpose Results of a systematic literature review to identify roles for emergency medicine (EM) pharmacists beyond traditionally reported activities and to quantify the benefits of these roles in terms of patient outcomes are reported. Summary Emergency department (ED)–based clinical pharmacy is a rapidly growing practice area that has gained support in a number of countries globally, particularly over the last 5–10 years. A systematic literature search covering the period 1995–2016 was conducted to characterize emerging EM pharmacist roles and the impact on patient outcomes. Six databases were searched for research publications on pharmacist participation in patient care in a general ED or trauma center that documented interventions by ED‐based pharmacists; 15 results satisfied the inclusion criteria. Six reported studies evaluated EM pharmacist involvement in the care of critically ill patients, 5 studies evaluated antimicrobial stewardship (AMS) activities via pharmacist review of positive cultures, 2 studies assessed pharmacist involvement in generating orders for nurse‐administered home medications and 2 reviewed publications focused on EM pharmacist involvement in management of healthcare‐associated pneumonia and dosing of phenytoin. A diverse range of positive patient outcomes was identified. The included studies were assessed to be of low quality. Conclusion A systematic review of the literature revealed 3 key emerging areas of practice for the EM pharmacist that are associated with positive patient outcomes. These included involvement in management of critically ill patients, AMS roles, and ordering of home medications in the ED.