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.
The final value of cost savings is likely significantly underestimated relative to non-VA hospitals due to the decision to correct for inflation, using the total market inflation rate rather than the medical sector inflation rate over the same time period. The Lee study values were increased by 25.0% and the Ling study values by 15.2%, to bring them to 2011 amounts. Using the medical inflation rate instead (42.3% and 25.2%, respectively), an additional $378,000 in annual savings would have been realized. The lower CPI inflation rate rather than the higher rate in the medical sector was chosen to make the cost avoidance outcomes more conservative.
The true value of a clinical pharmacist comes from the services they provide to patients. In this pilot, as well as in several others, it has been shown that education is a commonly performed and highly valued task. Education was a service lacking in this ED prior to this intervention due to financial and logistical constraints. It is unclear how much instruction patients receive at the outpatient pharmacy while picking up medications after leaving the ED, but it is likely limited, given the large volumes and long lines often found at the in-house pharmacy. Education has a demonstrated effect on prevention and management of ADEs and was the most interactive of the interventions the pharmacist provided during this study. This type of intervention was most likely the source of increased patient satisfaction that was noted in the postencounter surveys.17,24
Prevention of ADEs, which was a frequent intervention in this pilot, has been noted by many sources to be the single most beneficial task performed by a clinical pharmacist both from financial and risk reduction standpoints.13,21-23 Although not able to assess patient outcomes after this limited pilot, the authors anticipate such an evaluation when a full-time ED pharmacist joins the department.
The Joint Commission recommends that a pharmacist review all medication orders before administration, though there is an exception for the emergency setting.34 The Joint Commission also recommends medication reconciliation at every visit, including those in the ED setting. The addition of a clinical pharmacist would increase compliance with this and other standards and bring ED operations up to the same benchmark as other practice settings.
LIMITATIONS
The most significant limitation of this study was sample size. The volunteered time of the pharmacists in the ED totaled only 30 hours over 2 weeks. In that limited time, however, the pharmacists had more patient interactions than were anticipated. Had the pilot been conducted over a longer period, it is unclear whether this would have been sustained or whether this was a coincidental overestimate of the effect that a full-time pharmacist would have on the department. Likely, it is an underestimate of their potential, as the availability of the pharmacist was novel and likely underused by other providers. Given more time with the ED staff, pharmacists would be more frequently called on for their expertise, because their skills and knowledge set would be better understood. During this pilot, the pharmacist was located in a separate room in the ED where not all ED staff knew they were available for consultation.
The other major limitation of the pilot was the inherent imprecision of cost avoidance estimates. The dollar amounts attributed to the duties fulfilled by the pharmacists relied on 2 studies. The first, by Lee and colleagues, provided cost avoidance estimates of certain pharmacist actions based on a combination of 4 to 5 clinicians’ estimates of risk reduction, combined with their individual location’s costs for hospitalization, laboratory tests, diagnostic procedures, medications, telephone care, clinic visits, and emergency department visits.30 The numbers are based not only on a small number of individual estimations of risk, but also on facility costs that are highly variable. Despite this, the authors believe the estimates are actually on the conservative side, since they do not account for costs of lost productivity and/or litigation.
The current pilot was performed in a different type of setting than the one by Lee. That study was conducted in a similar VAMC setting, but their study data were obtained from other areas of the medical center. Of 600 pharmacist interventions, 250 were in an outpatient clinic, 250 were in an inpatient setting, and 100 were in a nursing home.30 Despite this, the estimates are likely still relevant to this study, given that drugs used in the ED are often a mix of inpatient and outpatient ones, with the same risks to an individual regardless of where they are initiated, changed, or discontinued.
