Pharmacists in the Emergency Department: Feasibility and Cost
In a pilot study at the Atlanta VAMC, pharmacists in the emergency department helped prevent adverse drug events, improved patient satisfaction, and demonstrated the potential for cost savings benefits.
For the remaining intervention, prescription refill, cost savings was determined by calculating the average times spent by the ED pharmacist on each intervention and then using the difference between hourly physician and pharmacist pay (about $50/h difference based on VA wage tables).
RESULTS
During the 30-hour total time in which a pharmacist was present in the ED, a total of 42 patients were assisted through 71 interventions (Table 1).
Pharmacists provided a diverse range of services to patients in the ED. The most common intervention was education and/or information inquiry. Tasks in this category included patient education about medication dosing, administration, AEs, interactions and warnings, as well as diabetes management. In several instances, education was provided to attending physicians or house staff, though it should be noted that this provider education was not counted as an intervention for this study unless it was associated with a patient (of which there were 3 total instances, eg, instruction on how to choose the proper insulin syringe).
Interventions, when a medication list was screened by the ED pharmacist for interactions or when drug choices were recommended to the physician or midlevel providers, were counted as prevention and management of ADEs. For example, the pharmacist noted a patient with a new diagnosis of gout who was prescribed hydrochlorothiazide; this was brought to the attention of the provider and alternative antihypertensives were suggested. In another instance, a patient was found to be on both ibuprofen and enoxaparin; the treating physician was alerted of this potential interaction. There were 15 such events in total.
Several other interventions arose from the screenings for ADEs, including adjusting dose or frequency of medication (11); therapeutic interchange (5); eliminating duplication of therapy (2); and prevention or management of allergies (1). Cases included hepatic and/or renal dose changes, substituting equivalent medications for better treatment outcome or adherence, or discontinuing 2 or more medications in a patient’s medication profile that were considered duplication.
During the pharmacist screening, one patient who had piperacillin/tazobactam ordered in the ED had a penicillin allergy. This intervention was categorized as prevention and management of an ADE as well as prevention and management of allergies. Interventions not accompanied by the “prevention of ADE” category included those in which the change did not provide a clear risk reduction. For example, one therapeutic interchange was from levofloxacin to moxifloxacin for a better-anticipated therapy. Another was a metformin dose increase, presumably for improved glycemic control.
Prescription refills occurred with the same frequency as prevention of ADEs.15 This intervention led in some cases to switching to pharmaceutical equivalents when a drug prescribed at another facility was not on the formulary. Other drugs that were not on the preferred list but available with nonformulary medication requests were ordered or approved with the assistance of the pharmacist. The pharmacist’s direct involvement significantly reduced the initial contact-to-approval time for these patients.
After tallying the total number of interventions, the potential financial cost savings to the ED were determined (Table 2). As mentioned previously, the Lee and Ling studies provided the categories for classification of 7 pharmacist interactions. The estimated cost avoidance for the 4 applicable groups from the Lee study had inflation-corrected values of $1,486 per adjusted dose or frequency of medication, $205 per elimination of duplication of therapy, $1,374 per prevention or management of ADEs, and $1,721 per prevention or management of allergies.30
The estimated cost avoidance for the 3 applicable groups from the Ling study had inflation-corrected values of $512.38 per education/information inquiry, $174.80 per formulary management, and $174.80 per therapeutic interchange.31 The eighth group, prescription refills, was valued at $12.50 each, using the difference between physician and pharmacist salary for an average of 15 minutes per interaction.
When multiplied by the number of interventions in each of these groups, the total potential cost avoidance in the study period was about $40,136.48. Extrapolated into a yearly amount, that is a $2,782,795.94 potential cost savings for the medical center.
Seventeen of the 42 (40.5%) postencounter surveys from the patients seen by the pharmacists were received. Of these veterans, 100% reported that they were “extremely satisfied” with the treatment they had received during their visit to the ED.
DISCUSSION
There is the potential for significant cost avoidance by adding a single full-time pharmacist to the ED: Annually, more than $2.7 million in potential savings for the medical center. Though surprising, this figure is actually in line with the much larger study by Lada and colleagues in which an estimated $3 million was avoided.15 At the same hospital 12 years earlier, Levy noted about $1 million in cost avoidance (not inflation-adjusted).33 The Ling study, however, did not have as high a figure, with annual cost avoidance estimated at $600,000.31 All these figures are based on estimates and, therefore, imprecise, but it is clear even using the most conservative model that the cost to employ a clinical pharmacist is justified.
