Escolar Documentos
Profissional Documentos
Cultura Documentos
Education. The role of EMPs in education can be variable Research and Scholarly Activity. The Institute of Medicine
and broad, and it has been mentioned in conjunction with has described three aspects of emergency care research.95
other responsibilities throughout these guidelines. It is desir- These aspects include EM research, defined as research con-
able for EMPs to participate in the education of other health ducted in either the prehospital or ED setting by EM spe-
care providers, including pharmacists and pharmacy staff, cialists; trauma and injury control research, defined as the
pharmacy students, pharmacy residents, physicians, medi- research of the acute management of traumatic injury; and
cal residents, midlevel practitioners, nurses, and emergency research contributions that affect the ED but are attributed
medical support personnel. The types and levels of educa- to other practice specialties. EM research can be further
tion will vary with patient care and administrative workload. subdivided into basic science, clinical, and health services
Provision of education to ED health care staff should, research. A number of research priorities in the prehospital
at a minimum, include information on the appropriate use of and ED settings have been described.96100
340Medication Therapy and Patient Care: Specific Practice AreasGuidelines
There is also an urgent need for research in EM phar- 7. Patanwala AE, Hays D. Pharmacists activities on a
macy, both for pharmacotherapy and pharmacy practice. trauma response team in the emergency department.
Such research would be facilitated by the development of a Am J Health-Syst Pharm. 2010; 67:15368.
practice-based research network, which is a group of practi- 8. Fairbanks RJ, Hays DP, Webster DF, et al. Clinical
tioners located locally, regionally, or nationally that collabo- pharmacy services in an emergency department. Am J
rates on pursuits of scholarly activity.101 Practice research Health-Syst Pharm. 2004; 61:9347.
networks can be effective, as a larger group of researchers 9. Wymore ES, Casanova TJ, Broekemeier RL, et al.
represents a larger patient population that is more diverse Clinical pharmacists daily role in the emergency de-
than a single medical center. Practice-based research net- partment of a community hospital. Am J Health-Syst
works have been successful in other areas of practice and Pharm. 2008; 65:3956, 3989.
among a wide variety of health care practitioners, including 10. Whalen FJ. Cost justification of decentralized pharma-
interdisciplinary health care teams. ceutical services for the emergency room. Am J Hosp
The role of the pharmacist in research has been de- Pharm. 1981; 38:6847.
scribed and can be applied to the ED setting.102,103 EMPs 11. Culbertson V, Anderson RJ. Pharmacist involvement
may participate in ongoing clinical and practice-based re- in emergency room services. Contemp Pharm Pract.
search being conducted in the institution, including identi- 1981; 4:16776.
fying a research question, providing assistance with patient 12. Powell MF, Solomon DK, McEachen RA. Twenty-
recruitment and randomization, assisting with research med- four hour emergency pharmaceutical services. Am J
ications, and completing data collection and analysis. EMPs Hosp Pharm. 1985; 42:8315.
could also assist in securing funding for conducting research 13. Kasuya A, Bauman JL, Curtis RA, et al. Clinical phar-
in the ED, and, after the completion of research projects, macy on-call program in the emergency department.
EMPs could participate in the scholarly activities related to Am J Emerg Med. 1986; 4:4647.
research efforts. 14. Schauben JL. Comprehensive emergency pharmacy
services. Top Hosp Pharm Manage. 1988; 8:208.
Conclusion 15. Laivenieks N, McCaul K, OBrodovich M. Clinical
pharmacy services provided to an emergency depart-
EMPs provide many vital services within the ED. The cen- ment. Can J Hosp Pharm. 1992; 45:1135.
tral role of the EMP is to improve patient outcomes by im- 16. Berry NS, Folstad JE, Bauman JL, et al. Clinical phar-
proving patient safety, preventing medication errors, and macy services provided to an emergency department.
providing optimized pharmacotherapy regimens and thera- Ann Pharmacother. 1992; 26:47680.
peutic outcomes through participation in direct patient care 17. Levy DB. Documentation of clinical and cost-saving
activities and quality-improvement initiatives in the ED. In pharmacy interventions in the emergency room. Hosp
addition, EMPs can provide education to members of the Pharm. 1993; 28:6304, 653.
pharmacy department and other health care providers, as 18. Mialon PJ, Williams P, Wiebe RA. Clinical pharmacy
well as patients and their caregivers, and EMPs may partici- services in a pediatric emergency department. Hosp
pate in research and scholarly activities in the ED. Pharm. 2004; 39:1214.
19. Ling JM, Mike LA, Rubin J, et al. Documentation
of pharmacist interventions in the emergency depart-
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Medication Therapy and Patient Care: Specific Practice AreasGuidelines343
97. Maio RF, Garrison HG, Spaite DW, et al. Emergency fective by designing monitoring plans for medications ad-
medical services outcomes project I (EMSOP I): pri- ministered both in the ED and prior to arrival. EMPs should
oritizing conditions for outcomes research. Ann Emerg subsequently provide recommendations for modifications to
Med. 1999; 33:42332. medication regimens based on the results of monitoring pa-
98. Seidel JS, Henderson D, Tittle S, et al. Priorities for rameters and established goals for therapy.
research in emergency medical services for children:
results of a consensus conference. Ann Emerg Med. Patient care involving high-risk medications and proce-
1999; 33:20610. dures: Whenever possible, EMPs should be present at the
99. Becker LB, Weisfeldt ML, Weil MH, et al. The patients bedside to assist in the delivery of patient care that
PULSE initiative: scientific priorities and strategic utilizes high-risk medications or procedures. EMPs should
planning for resuscitation research and life saving review the use of high-risk medications in the ED and should
therapies. Circulation. 2002; 105:256270. assist in the development of processes and procedures to
100. Hoyt DB, Holcomb J, Abraham E, et al. Working improve patient safety and avoid errors. In addition, EMPs
group on trauma research program summary re- should provide education to ED health care providers related
port: National Heart Lung Blood Institute (NHLBI), to the use of high-risk medications.
National Institute of General Medical Sciences
(NIGMS), and National Institute of Neurological Resuscitation: EMPs should be present during all resuscita-
Disorders and Stroke (NINDS) of the National tions in the ED, including trauma, cardiopulmonary arrest,
Institutes of Health (NIH), and the Department of and toxicologic emergencies. In the resuscitation setting,
Defense (DOD). J Trauma. 2004; 57:4105. EMPs should prepare medications for immediate adminis-
101. Lipowsi EE. Pharmacy practice-based networks:
tration, ensure the appropriate administration and dose of
Why, what, who, and how. J Am Pharm Assoc. 2008; medications, obtain medications that are not readily avail-
48:14252. able in the ED, make recommendations for alternative routes
102. American Society of Hospital Pharmacists. ASHP
of medication administration, answer medication informa-
statement on pharmaceutical research in organized tion questions, assist with differential diagnosis, and com-
health-care settings. Am J Hosp Pharm. 1991; plete resuscitation documentation. EMPs should be familiar
48:1781. with the recognition and treatment of toxicologic emergen-
103. Fagan SC, Touchette D, Smith JA, et al. The state cies and should assist in identifying causative agents, with
of science and research in clinical pharmacy. the selection and administration of antidotes and other sup-
Pharmacotherapy. 2006; 26:102740. portive therapies, and with recommendations for monitor-
ing antidote therapy in conjunction with toxicologists and
Appendix ASummary of poison control centers. EMPs should seek training programs
relevant to the conditions treated in their EDs.
Recommendations
Medication procurement and preparation: Although the role
Essential Direct Patient Care Roles of EMPs
of EMPs will vary, depending on the needs and resources
Direct patient care rounds: It is critical for EMPs to be ac-
of the institution, EMPs should be an integral part of the
countable for and involved in direct patient care activities,
medication procurement and preparation process in the ED.
including medication selection and the prescribing process.
EMPs should be involved in selecting medications stocked
EMPs should focus on providing direct patient care and will
in the ED, should ensure safe storage and usage of these
be most effective in doing this when physically present in
medications, should ensure timely turnaround for medica-
the ED, working as visible and well-integrated members of
tions obtained from the central pharmacy, and may assist
the multidisciplinary ED team.
in the preparation of urgently needed medications. EMPs
should be involved with the institutions formulary review
Medication order review: Review of medication orders in
and process-improvement committees to assist with formu-
the ED should provide the same level of assessment provided
lation of policies regarding medications used in the ED.
to patients elsewhere in the hospital. The role of an EMP
in medication order review will vary, depending on site-
Medication information: Medication information is a vital
specific factors. The EMP should develop a triage system
role of EMPs. The medication information needs of the ED
to focus the medication order review process on high-risk
cover a broad spectrum of clinical scenarios and patient
medications, high-risk patient populations, and emergent
cases. EMPs should ensure access to appropriate primary,
situations. The EMP must not be the sole party responsible
secondary, and tertiary references as needed to respond to
for ensuring that medication order review occurs in the ED;
medication information requests and must be able to quickly
the pharmacy department should ensure that adequate pro-
and accurately retrieve the answers to medication informa-
cesses are in place to ensure that all medication orders are
tion questions using those resources.
reviewed in compliance with federal, state, and local regula-
tions and accreditation requirements. Each institution should
Documentation: EMPs should document interventions pro-
strive to identify the optimal balance between accountability
vided in the ED to allow measurement of improvement in
for prospective medication order review and direct patient
patient outcomes and potential cost avoidance. EMPs should
care activities in the ED.
regularly review intervention documentation to identify
trends, which may indicate a need to educate ED health care
Medication therapy monitoring: EMPs should ensure that
providers or change medication-use procedures. Health care
medication therapy administered in the ED is safe and ef-
344Medication Therapy and Patient Care: Specific Practice AreasGuidelines
institutions should support EMPs by providing means to Desirable Administrative Roles of EMPs
document those interventions. Education: It is desirable that EMPs provide education to
fellow pharmacists; other health care providers; pharmacy
Desirable Direct Patient Care Roles of EMPs students and residents; and ED patients, their families, and
Care of boarded patients: Based on institutional resources, caregivers.
processes should be developed to identify the pharmacist
accountable for providing care to boarded patients. These Research and scholarly activity: There is an urgent need for
processes should not compromise the EMPs primary role research in EM pharmacy, both for pharmacotherapy and
in ensuring safe and effective use of medications for new pharmacy practice. EMPs can be valuable researchers in the
patients presenting to the ED. When possible, responsibil- ED and should be encouraged to participate in the comple-
ity for the care of boarded patients should be assigned to tion of research projects and scholarly activities. The estab-
the pharmacist who will be responsible for providing care to lishment of pharmacy practice research networks to facili-
the patient after admission to ensure continuity of care. At tate the completion of pharmacy-based research projects in
a minimum, the responsible pharmacist should review the the ED setting should also be encouraged.
medication profile of critical patients, review any high-risk
medications, assist with medication dosing, assist with med- Appendix BRecommended Readings,
ication procurement, and provide monitoring as necessary.
References, and Resources
Medication histories and medication reconciliation: EMPs
The following list represents suggested readings that would
may assist in the development of a risk-stratification proto-
be useful to readers and should be considered in addition to
col for determining which medication histories will be ob-
those references and resources provided in the guidelines.
tained in the ED. In general, a focus on patients with known
The suggested readings are categorized into applicable cate-
or suspected toxicologic emergencies, with known or sus-
gories and are then listed in alphabetical order by the primary
pected adverse events from home medication regimens, or
author. For additional resources related to specific areas of
with complicated medication histories that will influence
emergency medicine pharmacist (EMP) service develop-
ED clinical decision-making should be considered.
ment, implementation, and best practices, please refer to the
ASHP Section of Clinical Specialists and Scientists Section
Essential Administrative Roles of EMPs
Advisory Group on Emergency Care Internet Resource Center
Medication and patient safety: In collaboration with physi-
(www.ashp.org/EmergencyCare.aspx). In addition to these
cians, nurses, and hospital executives, EMPs should assist in
resources and references, interested parties should seek out
reporting medication errors, reviewing reported medication
relevant resources and references related to local, regional,
errors, and identifying error trends. EMPs should further as-
state, and national regulatory and accrediting agencies.
sist in developing safe medication practices and processes
for prevention of errors, assist in implementing system im-
Internet Resources
provements, and provide staff education when needed.
1. American Society of Health-System Emergency Medi-
cine Pharmacist Practice Internet Resource Center.
Quality-improvement initiatives: EMPs or other pharmacy
www.ashp.org/EmergencyCare.aspx
representatives should be extensively involved with quality-
2. American Society of Health-System Pharmacy Medica-
improvement initiatives in the ED. EMPs should participate
tion Reconciliation Toolkit. www.ashp.org/Import/
in ongoing efforts to optimize pharmacotherapy regimens
PRACTICEANDPOLICY/PracticeResourceCenters/
through medication-use evaluation and development of
PatientSafety/ASHPMedicationReconciliationToolkit_1.
medication-use guidelines and pathways.
asp
3. Institute for Healthcare Improvement: Prevent Adverse
Leadership duties and professional service: The leadership
Drug Events (Medication Reconciliation). www.ihi.org/
duties and professional service of EMPs may include in-
IHI/Programs/Campaign/ADEsMedReconciliation.
volvement at the hospital level, which provides EMPs with
htm
an avenue for improving both patient care and medication
use. Involvement with local, state, and national professional
Primary Literature
pharmacy organizations, as well as with other professional
Initial descriptions of EMP services
health care organizations, will allow for collaboration, lead-
1. Berry NS, Folstad JE, Bauman JL, et al. Follow-up
ing to further development of EM pharmacy practice and
observations on 24-hour pharmacotherapy services in
the role of the EMP as an integral member of the ED health
the emergency department. Ann Pharmacother. 1992;
care team.
26:47680.
2. Culbertson V, Anderson RJ. Pharmacist involvement
Emergency preparedness: The role of EMPs in emergency
in emergency room services. Contemp Pharm Pract.
preparedness should include education, training, and certi-
1981; 4:16476.
fication; knowledge of federal, state, and local emergency
3. Elenbaas RM. Role of the pharmacist in providing
preparedness and response policies; involvement with in-
clinical pharmacy services in the emergency depart-
stitutional emergency preparedness policy development;
ment. Can J Hosp Pharm. 1978; 31:1235.
planning of and participation in planned disaster drills; and
4. Elenbaas RM, Waeckerle JF, McNabney WK. The
education of pharmacy and ED staff.
clinical pharmacist in emergency medicine. Am J
Hosp Pharm. 1977; 34:8436.
Medication Therapy and Patient Care: Specific Practice AreasGuidelines345
5. High JL, Gill AW, Silvernale DJ. Clinical pharmacy 24. Witsil JC, Aazami R, Murtaza UI, et al. Strategies for
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348Medication Therapy and Patient Care: Specific Practice AreasGuidelines
Heather Draper Eppert, Pharm.D., BCPS, and Alison Jennett Copyright 2011, American Society of Health-System Pharma-
Reznek, Pharm.D., BCPS, are gratefully acknowledged for author- cists, Inc. All rights reserved.
ing these guidelines. The authors and ASHP gratefully acknowledge
Roshanak (Roshy) Aazami, Pharm.D., BCPS, Emergency Medicine The bibliographic citation for this document is as follows: Ameri-
Pharmacist, Cedars-Sinai Medical Center, for her substantial contri- can Society of Health-System Pharmacists. ASHP guidelines on
bution and dedication to the completion of these guidelines. emergency medicine pharmacist services. Am J Health-Syst Pharm.
2011; 68:e8195.