Hospital Pharmacy Volume 39, Number 2, pp 121124 2004 Wolters Kluwer Health, Inc.

Pediatric Therapeutics
Clinical Pharmacy Services in a Pediatric Emergency Room
Paula J. Mialon, BS, PharmD,* Penny Williams, RN MS, and Robert A. Wiebe, MD This continuing feature will focus on recent advancements in the areas of pediatrics and neonatal pharmacology and on methods for reducing medication error risk in this patient population. Most pharmacological agents are designed with the adult in mind, and there is little literature-based data from which to derive dosing schedules and proper drug administration techniques for the pediatric and neonatal patient. Moreover, pharmacological response in this group is not well understood. We hope that this feature will help you provide pharmaceutical care to this high-risk population. Direct questions or comments to hospitalpharmacy@ drugfacts.com.

hildrens Medical Center (Childrens) in Dallas, Texas, which has one of the busiest Pediatric Emergency Departments (ED) in the country, currently provides the first and only full service clinical pediatric emergency pharmacy program. Childrens serves as the trauma center for several counties and the ED triages over 120,000 patients annually. In December 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) performed its annual survey of the facility. JCAHO noted that not all medications administered in emergency room settings are truly emergent, and as such must be subject to the same standard of care as all other medications dispensed to patients in the hospital. This standard includes pharmacist review of

all medications characterized as nonemergent prior to administration. As a result of this information, a senior clinical pharmacist was assigned to the ED to evaluate activities, define the pharmacists role and scope of practice, establish a training program, and perform pilot studies to determine the necessary resources to support a pharmacy program of this nature. As part of this process, a task force composed of emergency department administration, staff, and pharmacy personnel was formed to further evaluate and define the scope of the program. A training manual was developed that covered the clinical pharmacotherapy of most of the common presentations to the pediatric ED. In addition, an experiential program was developed for the

*Senior Clinical Pharmacist, Emergency Medicine; Clinical Program Manager, Emergency Center; Medical Director, Emergency Center: Childrens Medical Center, 1935 Motor Street, Dallas, TX 75234. E-mail: paula.mialon@childrens.com.

pediatric emergency pharmacists that modeled the type of training that a Pediatric ED Fellow receives in the first year. Recruitment for the first four positions was initiated and a four-phase rollout occurred; all four positions were quickly filled. The team completed training in October, 2002 and began providing coverage from 8 am to midnight 7 days per week. Additional staff were hired and full 24-hour coverage commenced July 1, 2003. Designed from the ground up to improve patient care and safety, this program now uses the advanced specialized training and skills of eight clinical pharmacists and one senior clinical pharmacist to decrease the potential for medication errors, optimize workflow, and increase training program activities. This approach allows nursing staff to concentrate on patient care, while the pharmacist manages medication needs. Table 1 presents a list of the current activities of the pharmacy team, which provides coverage to the ED 24 hours per day, 7 days per week. Both medications classified as nonemergent and those considered emergent are reviewed by a pharmacist prior to dispensing or administration. This has resulted in a greater than 80% decrease in the number of medication errors reaching patients in the ED. The pharmacy team optimizes care by streamlining therapy and helping physicians choose the most appro-

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priate medications on a patientspecific and evidence-based-medicine basis. The pharmacists actively contribute to the hospitals overall goal of improving patient safety. A clinical pharmacist interviews every incoming patient or parent to obtain information about the patients history and home medication regimen. Additionally, the pharmacist verifies the patients weight and documents allergies in the patients chart and in Cerner Millennium, the hospitals electronic medical record. This ensures that patient information is always available to any practitioner who might need it, throughout the continuum of the patients stay at Childrens. The pharmacist also reviews the charts that accompany a patient transferred from any outside institution and documents any medications received prior to arrival in the chart. This ensures the documentation of all doses received and helps prevent unnecessary redosing, which can be harmful and result in poor patient outcomes. A member of the pharmacy team responds immediately to all incoming trauma victims and to all code blue situations within the ED. In these emergency situations, the ED pharmacist assists with correct dosing, prepares the medications for administration, and, in extreme situations, administers the medications required to treat these complicated and extremely critical patients. An ED pharmacist also participates in the treatment of all acutely ill patients, including those who present with diabetic ketoacidosis, severe respiratory distress or failure, cardiac complaints or congenital heart disease, any hematological or oncologic diagnosis, as well as patients who are less than

28 days old or weigh less than 5 kg, have active seizures, or have ingested a poisonous substance. The ED Pharmacy Program at Childrens is also unique in that the pharmacists do not use a local satellite for medication preparation. Ready-to-administer (RTA) medications are delivered quickly to the bedside from the central pharmacy after chart and order review is complete. In addition, the ED pharmacist is available to provide medication teaching and patient counseling at discharge. The lack of a satellite encourages pharmacists to remain at the bedside as active and integral members of the health care team. Because the emergency pharmacy program is a new and unique practice, research and publication of findings is a high priority. The department has collected and published data related to increased medication safety and the comprehensive teaching tool used to train new pharmacists in ED practice. Additionally, since Childrens is a teaching hospital, the ED pharmacists participate in various teaching activities with new medical residents, interns, fellows, new graduate nurses, and interns. The teams senior pharmacist has lectured throughout the country about the progress and success of this program. The successes in the ED have been most evident in the area of medication error reduction. Preliminary data show that pharmacist presence in the ED decreases incidence of medication errors by more than 80%, and the department has not noticed an increase in length of stay attributable to this process change. Children's has seen a marked decrease in the number of dosing errors, particularly errors that might have reached the patient without phar-

macist intervention. The use of an automated drug dispensing device (Omnicell) has decreased, because most medications are ordered through the central pharmacy after review by an ED pharmacist. Early pilot studies assessing cost estimated that more than $800,000 per year would be saved with this program. In addition, nurses in the ED now may focus solely on patient care, while the pharmacists provide the medications and handle all order issues and clarifications. ED pharmacists intervene daily in situations ranging from answering relatively routine dosing questions to recommending different drugs or doses, with potentially significant impact on patient outcomes. The team routinely recommends focused antibiotic therapy and makes dosing recommendations for improved antibiotic use. Because all orders are processed through a centralized team, tighter control is maintained over medication ordering. The potential for overdosing or incompatible medication orders is greatly reduced in a busy ED, where many different practitioners may see the same patient during his or her hospital stay. The fast pace of any ED can result in less than optimal charting; consequently, tracking duetimes for repeat medications can be a challenge to nursing staff in the best of circumstances. If the pharmacist is responsible for keeping track of repeat doses and providing them to the nurse in a timely fashion, the nurse can focus on assessment and procedures. The pharmacist also ensures that repeat doses are not given inappropriately, such as when the medication was already given at an outside hospital or by Emergency Medical Services (EMS) personnel. This is critical when the medication (eg,

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Table 1. ED Pharmacist Activities

Continuously seek out interventions by making rounds in the medical, trauma, and observation units. Clinical Pharmacist offers suggestions and assists in preventing medication errors from occurring. Suggest appropriate medication and/or dose recommendations when necessary. Assist in drip calculations, medication dosing, and drip compatibility, particularly in code/trauma situations. Perform pharmacokinetic dose checks and make recommendations on dose adjustments for antiepileptic medications, phenytoin, theophylline, digoxin, and aminoglycoside orders, and therapeutic drug monitoring of other meds as necessary. Serve on medical and trauma code response teams. Attend all incoming transport patients until deemed stable or transferred to another area. Aid in the management of the poisoning/toxicology patient, including review of toxin and its appropriate treatment. Aid with recommendation and use of appropriate antidotes to common poisons. Inform on adverse medication events/reactions; document occurrence. With other members of the ED team, design and implement plans for elimination or minimization of errors. Inform on medication side effects, interactions, and incompatibilities. Answer drug information questions from ED staff and patients. Enter physician orders after review. Facilitate rapid turnaround time from pharmacy. Inform on drugdrug or drugdisease interactions. Fill emergency room outpatient prescriptions for difficult-to-find after-hours emergent prescriptions Document clinical and cost-saving activities/interventions and the routine provision of information. Educate medical staff on costs of comparable medications (eg, outpatient formulary concerns) and assist prescribing habits (review of individual patient's insurance formulary to provide best possible discharge care). May include assistance in acquisition of medications from drug companies for indigent patients. Responsible for all pharmacy distribution issues in the ED. Serve as liaison between pharmacy and ED to improve medication delivery and turnaround time. Facilitate transfer of patient to floor/ICU by notifying floor/ICU pharmacist of situation and immediate medication needs after arrival. Recommend alternate drug entities during drug shortages as needed. Perform formal/informal consultations as needed to ED staff as requested. Identify unknown medications (by name or medication itself). Provide and attend physician, nursing, and pharmacy inservices on emergency medicine-related topics. Recruit, maintain, and educate ED pharmacy staff. Recommend alternate routes of administration when appropriate. Inservice physician and nursing staff as requested. Serve as preceptor to pharmacy students, interns, fellows and residents. Recommend judicious use of laboratory draws for medications (phenobarbital, phenytoin, etc) Obtain current, accurate medication and allergy histories, notify caregivers and document on chart as needed. Verify severity of any allergic reaction and document on chart. For new allergies occurring in ED, document and inform caregivers including parents and ED staff. Place allergy wristband on patient if RN staff has not. Serve as investigational drug study liaison. Project work as deemed necessary or requested by attending physician staff. May include DUE/MUE or DI papers. Participate in a variety of ongoing research projects (eg, initiate drug studies, quality assurance, and MUE/DUE). Discharge counseling for all newly diagnosed asthmatics, epileptics, and diabetics, and patients with other disease states when appropriate or requested. Provide a link to information for patients after discharge home. Use laboratory data to evaluate the efficacy of drug therapy selected may include follow-up after admission with the floor/ICU pharmacist. Discuss compliance and compliance-related issues with patients and medical staff. Review nursing/pharmacy interaction and process for medication acquisition and improve when necessary (eg, premade medications, local stock changes). Evaluate and study outcomes of pharmacist presence in the ED for review, position justification, and publication.

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phenytoin or morphine) has a narrow therapeutic index. The Senior Clinical Pharmacist reviews all medication-related incidents in the ED and assists pharmacy and ED management to affect process changes to decrease or eliminate recurrence. Issues at Childrens Medical Center of Dallas that have resulted in such changes include the following: Patients arrive on the floor or in the ICU with lengthy admission orders. Medications from home may be overlooked and medications given in the ED may be repeated. By implementing a written medication history taken by the ED pharmacist that is placed in the chart for admission, the inpatient staff have a complete medication record. A patients weight may be documented incorrectly upon arrival in the ED, especially with trauma patients who are transported without a parent or other informant. Since medication dosing in pediatrics is frequently based on weight, it is imperative to have accurate information. The ED pharmacist reviews the weight as documented, using prior medical records, an interview with the family, and/or by using the Broselow Tape. The pharmacist then ensures that the correct

weight is documented on all appropriate pages of the chart and in the patients electronic medical record. Pediatric practitioners generally dose medications by weight, but most medications have maximum adult single doses that should not be exceeded. A common example of this type of medication error involves ceftriaxone, an antibiotic used frequently in the ED. It can be dosed at 100 mg/kg, but the maximum single dose is 2000 mg. There is the potential for dosing mistakes in patients weighing more than 20 kg, if the physician does not realize that there is an upper limit. The pharmacists are attuned to maximum single or adult dosing, and as a result, these errors are corrected before reaching the patient. Additionally, the pharmacist uses this type of opportunity to educate the physician staff, helping to prevent this type of error from being repeated in other areas of the hospital and at institutions where the physician may eventually practice. Sometimes it can be difficult to obtain a full report from EMS staff when they arrive so that the ED staff have the information they need to provide optimal care. A clinical example of

this problem was seen when a patient with a behavior disorder fell, was separated from his family during the ambulance ride to the hospital, and became combative. EMS personnel administered haloperidol to the patient in the ambulance, resulting in an acute change in mental status. Upon arrival, the EMS crew failed to inform the physician about the use of haloperidol, but the pharmacist noticed it during chart review and related it to the physician. As a result, several unnecessary procedures (eg, possible endotracheal intubation) were avoided. The next steps for the program include the publication of more data pertaining to decreased costs and improved drug use, as well as continuous improvement of the systems used within the practice. Research aimed at the publication of medication error reduction data is ongoing. Emergency pharmacy is a rapidly growing practice area, and pediatric and adult EDs will continue to demand this high level of service. We believe that pharmacists must be involved in the review, preparation, and administration of emergent as well as nonemergent drugs in the pediatric setting; the risk of error is highest and the tolerability of error is the lowest with this subset of patients.

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