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Emergency Department Pharmacists Protocol

1. Continuity of care

The Emergency Department Pharmacists’ primary mandate is to facilitate care of the long-stay ED patient, from the standpoint of medications. As such, they will assess patients, patient records, and orders put in by the admitting team–starting with the patients who have been in the department the longest, and working their way down by length of stay. They will identify important medications that the patient needs (anti-rejection meds, antiepileptics, antihypertensives, anticoagulants, etc) while awaiting inpatient beds. They will enter their recommendations into IBEX in accordance with the EDP medication policy (see appendix 1).

In cases where orders have been entered into TDS by the inpatient team, the pharmacist shall transcribe the important medications into IBEX when appropriate. In this case no co-signature is needed, as a physician has already ordered the medication in a different system. Similarly, TPN orders entered by ED pharmacists do not require co-signature; the pharmacist will ensure that the original paper order has been scanned into the chart.

The pharmacist shall enter all TDS orders for long-stay patients into the pharmacy information system (WoRX).

ED pharmacists may find it clinically necessary to clarify certain patients’ allergies and/or home medications prior to reconciliation by the admitting team, on ED practitioner request or to ensure continuity of medical care as above. Clarifications to a patient’s current medication list in IBEX as entered by the triage nurse may be made as appropriate. The pharmacist may document the sources that informed the clarification, including patient/family interviews, medication bottle and content inspections, computer records and outpatient pharmacy contacts. The pharmacist’s role is to supplement the existing medication reconciliation process in the ED, not to replace it.

2. Symptom Relief

Unaddressed pain and other symptoms–one of the major effects of overcrowding–underlie much morbidity and many patient complaints. The ED pharmacists will inquire with patients regarding treatable symptoms and recommend key medications (for example: tylenol, morphine, zofran, reglan, pepcid, nicotine patch) as they perform their assessments. The role of the pharmacist is to supplement and not to substitute the role of the physician or nurse in monitoring patient symptoms.

3. Core Measures

Pharmacists can screen chest pain patients for aspirin and beta blocker orders and dyspneic or febrile patients for antibiotic orders. Where potential deficiencies exist, the pharmacist will make recommendations for the treating MD.

4. Participation in resuscitations

Pharmacists are ACLS certified and can anticipate and assist the team with the preparation and delivery of medications used in resuscitations and cardiac arrests–especially where more complicated drips are called for (amiodarone, tPA). Pharmacists may also be able to facilitate the preparation of RSI meds.

5. Drug Information

Pharmacists are available to address medication questions that arise and will usually be able to provide information regarding drug selection, dosing, indications, contraindications, interactions, monitoring and drip preparation in a clinically relevant time frame.

6. Error Reduction

The EDP will expedite medication order processing by screening for incorrect orders; for example, alerting novice (and veteran) IBEX users of faulty syntax in their orders, changing non-formulary medications to formulary (e.g. Novolin to Humulin), or adding a patient weight to LMWH orders. This will improve the accuracy of ED documentation and reduce turnaround times when medications have to be sent from pharmacy. Medication-targeted laboratory tests may also be recommended if not ordered, for example, partial thromboplastin time for a patient on a heparin drip, fingerstick for a patient on insulin, etc.

The EDP will change particular medication orders for the purposes of conforming to the ED and hospital formulary and resolving other problem orders (form-route mismatches, missing units, wrong units, etc) according to the order clarification and substitution protocols (see appendix 2). In these cases the original order will be cancelled by the EDP with a note that the order is changed per protocol, and a new order is entered by the EDP with the same ordering physician; co-signature is not necessary.

7. Patient counseling

EDPs can discuss with the patient any medication the patients receive in the ED or have been prescribed at discharge.

The role of the ED Pharmacist is in evolution and will be revised to best meet the needs of all concerned parties.

Appendix 1: Medication Policy

Policy for medication orders involving Emergency Department Pharmacists

1. The emergency department pharmacist (EDP) will enter his/her recommendations into Picis PulseCheck (IBEX) in the Med SVC section.

2. The EDP will approach a treating MD and review his/her recommendations.

3. The treating MD will sign the order using the Co-Sign function in the Med SVC section.

4. The RN will then pick up the order and administer the medication.

Appendix 2: EDP Order Clarification & Substitution Protocols

http://spreadsheets.google.com/pub?key=r2tbu4GCqzxZWAjeqm-3Rkg&output=html

Written by reuben

July 1st, 2009 at 9:41 pm

Posted in Pharmacy

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