Although pharmacy services have been present in EDs for more than 40 years,¹ the past two decades have seen the role of the emergency medicine (EM) pharmacist grow significantly in both academic and community hospital settings within the United States and across the globe in countries such as the United Kingdom, Japan, and Australia.

The fast-paced, chaotic nature of the ED combined with a multitude of patients requiring immediate management of their conditions make it logical to employ a dedicated health care provider, who is an expert in all aspects of the medication-use process, in this critical environment. Traditional elements of the medication-use process often are bypassed in the ED. Physicians frequently communicate verbally to nurses regarding medications prior to documenting drug orders in computerized prescriber order entry (CPOE) systems and without a pharmacist verifying the safety and efficacy of such therapies. Clearly, the ED setting poses significant potential for medication-related errors.

Research demonstrates that the presence of dedicated pharmacists in the ED reduces the incidence of errors and adverse events secondary to the medication-use process. Avoiding and/or preventing adverse drug events and drug-drug interactions averts needless hospital admissions and lengthened hospital stays. In addition, having pharmacists available to recommend optimal antimicrobial therapy for patients based on risk factors and source of infection reduces the number of patients who receive broad-spectrum coverage. All of this ultimately improves patient safety^2-5 and reduces costs. In fact, the cost savings associated with the presence of pharmacy services in the ED can total millions of dollars per year.^6-8

The Role of the EM Pharmacist
EM pharmacists play an invaluable part in optimizing pharmacotherapy for patients who present in critical disease states and require life-saving interventions at the bedside. A list of the various services that pharmacists provide in the ED can be found in TABLE 1.⁹ The principal responsibility of the EM pharmacist is to ensure that medications are appropriate and administered to patients in a timely and effective fashion with the necessary monitoring and follow up.^10-17

In addition, EM pharmacists engage in collaborative practice agreements. Although the extent of involvement varies with institutional and state regulations, such activities may include antimicrobial stewardship in the ED, including follow-up of cultures for patients discharged from the ED,^18-20 and facilitating initiation of anticoagulant therapy following events of deep vein thrombosis.²¹

Education and Training
Such value is not possible without an investment in education and training. Although not a requirement, many EM pharmacists possess postgraduate residency training experience. Some may complete a general first-year postgraduate pharmacy practice residency (PGY1) upon completion of their PharmD degree. Others may pursue further training by completing a specialized second-year postgraduate residency (PGY2) in EM pharmacy. Although the number of these programs is increasing, only about 30 PGY2 EM pharmacy residency programs exist currently in the US. As such, it is not uncommon for pharmacists who practice in the ED to have PGY2 residency training in other specialties, such as critical care, ambulatory care, or clinical toxicology.

In addition, EM pharmacists may receive certifications in basic life support, advanced cardiovascular life support, and pediatric advanced life support. Other certifications that EM pharmacists may attain include advanced hazmat life support, advanced trauma life support, emergency neurological life support, and board certification in pharmacotherapy or applied toxicology. With this level of training, pharmacists are well equipped to provide drug information in the emergency setting, particularly in typical ED situations wherein minimal information is known about the patient at the time of presentation. Such expertise and training makes these pharmacists ideally suited to educate attending physicians, medical residents, and nurses, as well as pharmacy students and residents, on pharmacology and pharmacotherapy of common disease states in the ED.

The value that EM pharmacists bring to the multidisciplinary team in the ED has not gone unnoticed. In October 2014, the American College of Emergency Physicians (ACEP) approved a policy statement in full support of the various services that EM pharmacists provide in the ED.²² See SIDEBAR 2 for an excerpt.

Future Expansion
With such endorsement, the field of EM pharmacy likely will continue its expansion. Opportunities for future growth and development include:

• The initiation of services in institutions where EM pharmacy currently does not exist, as well as expansion of pharmacy services in those institutions where they do exist to provide 24/7 coverage
• The development and launch of additional postgraduate residency training programs in EM pharmacy to supply EDs in institutions across the country with the expertise to establish or expand ED pharmacy services programs
• The provision of hands-on training to EM medical residents so that they understand and gain a better appreciation for the medication-use process in the ED
• The expansion of multidisciplinary research activities related to the provision of pharmacotherapy to patients in the ED and their impact on meaningful patient-oriented outcomes

Although the provision of pharmacy services in the ED may seem innovative, it is founded on a wealth of evidence and simple logic. Research shows that the presence of a dedicated pharmacist in the ED reduces medication-related errors, increases patient safety, and reduces costs. Expanding educational programs and research opportunities will help fuel the growth of the profession and ensure that EDs, and, in turn, patients, reap the benefits.

Nadia Awad, PharmD, BCPS, is an emergency medicine pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey. After obtaining her BA in biological sciences from Rutgers College in 2007, and a PharmD from the Ernest Mario School of Pharmacy at Rutgers University in 2011, she completed 2 years of postgraduate residency training at Robert Wood Johnson University Hospital, specializing in emergency medicine pharmacy. Nadia serves as associate editor and staff blogger on the blog, Emergency Medicine PharmD. She is actively involved in research in areas that include emergency medicine, toxicology, disaster preparedness, acute neurocritical care, and social media in pharmacy education.

References

1. Elenbaas RM, Waeckerle JF, McNabney WK. The clinical pharmacist in emergency medicine. Am J Hosp Pharm. 1977;34(8):843-846.
2. Brown JN, Barnes CL, Beasley B, et al. Effect of pharmacists on medication errors in an emergency department. Am J Health Syst Pharm. 2008;65(4):330-333.
3. Ernst AA, Weiss SJ, Sullivan A 4th, et al. On-site pharmacists in the ED improve medical errors. Am J Emerg Med. 2012;30(5):717-725.
4. Rothschild JM, Churchill MS, Erickson A, et al. Medication errors recovered by emergency department pharmacists. Ann Emerg Med. 2010;55(6):513-521.
5. Patanwala AE, Sanders AB, Thomas MC, et al. A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department. Ann Emerg Med. 2012;59(5):369-373.
6. Ling JM, Mike LA, Rubin J, et al. Documentation of pharmacist interventions in the emergency department. Am J Health Syst Pharm. 2005;62(17):1793-1797.
7. Aldridge VE, Park HK, Bounthavong M, Morreale AP. Implementing a comprehensive, 24-hour emergency department pharmacy program. Am J Health Syst Pharm. 2009;66(21):1943-1947.
8. Lada P, Delgado G Jr. Documentation of pharmacists’ interventions in an emergency department and associated cost avoidance. Am J Health Syst Pharm. 2007;64(1):63-68.
9. Eppert HD, Reznek AJ; American Society of Health-System Pharmacists. ASHP guidelines on emergency medicine pharmacist services. Am J Health Syst Pharm. 2011;68(23):e81-95.
10. Brent RJ, Poltorak I. The pharmacist as a trauma team member. Hosp Pharm. 1987;22(2):152-155.
11. Scarponcini TR, Edwards CJ, Rudis MI, et al. The role of the emergency pharmacist in trauma resuscitation. J Pharm Pract. 2011;24(2):146-159.
12. Patanwala AE, Thomas MC, Casanova TJ, Thomas R. Pharmacists’ role in procedural sedation and analgesia in the emergency department. Am J Health Syst Pharm. 2012; 69(15):1336-1342.
13. Baker SN, Weant KA. Procedural sedation and analgesia in the emergency department. J Pharm Pract. 2011;24(2):189-195.
14. Hampton JP. Rapid-sequence intubation and the role of the emergency department pharmacist. Am J Health Syst Pharm. 2011;68(14):1320-1330.
15. Weant KA, Baker SN. Emergency medicine pharmacists and sepsis management. J Pharm Pract. 2013;26(4):401-405.
16. Woloszyn AV, Schwarz MA. Early management of stroke patients in the emergency department. J Pharm Pract. 2011;24(2):160-173.
17. Acquisto NM, Hays DP, Fairbanks RJ, et al. The outcomes of emergency pharmacist participation during acute myocardial infarction. J Emerg Med. 2012;42(4):371-378.
18. May L, Cosgrove S, L’Archeveque M, et al. A call to action for antimicrobial stewardship in the emergency department: approaches and strategies. Ann Emerg Med. 2013;62(1):69-77.e2.
19. Baker SN, Acquisto NM, Ashley ED, et al. Pharmacist-managed antimicrobial stewardship program for patients discharged from the emergency department. J Pharm Pract. 2012;25(2):190-194.
20. Acquisto NM, Baker SN. Antimicrobial stewardship in the emergency department. J Pharm Pract. 2011;24(2):196-202.
21. Falconieri L, Thomson L, Oettinger G, et al. Facilitating anticoagulation for safer transitions: preliminary outcomes from an emergency department deep vein thrombosis discharge program. Hosp Pract. 2014;42(4):16-45.
22. Clinical Pharmacist Services in the Emergency Department. Clinical Policy Statement. American College of Emergency Physicians. https://www.acep.org/Clinical---Practice-Management/Clinical-Pharmacist-Services-in-the-Emergency-Department. Accessed September 10, 2015.

SIDEBAR 1
A Day in the Life of an Emergency Medicine Pharmacist
“Trauma code, by air, 10 minutes.”

As I hear the page, I immediately engage in a state of physical and mental readiness. At the physician station, I learn that the incoming case involves a male pedestrian who was struck by a vehicle. Although he briefly lost consciousness, he has vomited several times en route to the ED and is now awake. As a result, I prepare not only the pack of medications that I routinely carry to all trauma resuscitations, but also the kit required for rapid sequence intubation. I don my surgical gear—gown, shoe covers, gloves, and mask—and wait with the attending emergency medicine and trauma physicians, emergency medicine and surgical medical residents, nurses, and clinical care technicians for the patient to arrive in the trauma bay.

Minutes later, the flight medic team wheels the patient into the room and begins a detailed discourse about the patient and the circumstances of the accident. It becomes clear that the patient’s airway is compromised so I draw up individual doses of sedatives and paralytics into syringes and label the syringes with the medication names and respective doses as the team prepares for rapid sequence intubation. I hand off the syringes to one of the nurses for immediate administration. After the team evaluates the hemodynamic status of the patient, I prepare medications for postintubation sedation and analgesia so that they are primed and ready for infusion at the bedside. Once the patient is stabilized, the team quickly wheels the patient away to undergo a series of diagnostic examinations, including a computed tomography scan of the brain to determine the presence of neurological injury. At that point, I go about determining where else in the ED I may be needed.

During the remainder of my shift, I am involved with life-threatening cases of myocardial infarction, ischemic stroke, and cardiac arrest. I also participate in procedural sedation at the bedside for a patient with an elbow fracture, consult with our in-house toxicologist regarding antidote dosing recommendations for a pediatric patient who ingested a supratherapeutic amount of acetaminophen, and advise one of my emergency medicine residents on antimicrobial therapy for a lactating patient who has developed a urinary tract infection—a typical day in the life of an emergency medicine pharmacist.

SIDEBAR 2
American College of Emergency Physicians Policy Statement on Pharmacists in the ED²²
The American College of Emergency Physicians (ACEP) believes that pharmacists serve a critical role in ensuring efficient, safe, and effective medication use in the ED and advocates for health systems to support dedicated roles for pharmacists within the ED. The emergency medicine pharmacist should serve as a well-integrated member of the ED multidisciplinary team who actively participates in patient care decisions including resuscitations, transitions of care, and medication reconciliation to optimize pharmacotherapy for ED patients. The exact delivery method for these services can vary among institutions depending on size, financial resources, presence of academic programs, and other factors. ACEP encourages emergency medicine rotations for pharmacy residents and clinical research regarding pharmacist access in the ED.