EMPOWER Podcast Episode 1 – The Next Step In Upstairs Care, Downstairs

The link to the podcast in iTunes is here.

Episode 1: The Next Step in Upstairs Care, Downstairs

Show Notes:

The research and evidence for emergency medicine pharmacists is out there in mass quantity. The ASHP Emergency Care section has done the most complete collection of the existing data and links to the manuscripts.

Selected citations:
  • Medication errors occur in up to 60% of ED patients – Patanwala AE, Warholak TL, Sanders AB, et al. A prospective observational study of medication errors in a tertiary care emergency department. Ann Emerg Med. 2010;55:522-526
  • EM pharmacists’ care reduces medication errors – PI is an MD – Rothschild JM, Churchill W, Erickson A, et al. Medication errors recovered by emergency department pharmacists. Ann Emerg Med. 2010;55:513-521.
  • “The pharmacists’ nominally assigned activity—reviewing medication orders—was less important in preventing medication errors than their general availability for discussion and consultation.” – 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;59:369-373
Emergencypharmacist.org was a great site run by one of the icons of EM pharmacy – Dan Hays. Unfortunately I do not think it is updated anymore. However, all the resources are still there, and worthwhile checking out.
While this data is plentiful, I do have to admit, from a purely skeptical view of things, each paper is written largely (if not exclusively) by pharmacists.  Clearly, we have a vested interest in finding positive results, and there may be some publication bias with respect for other trials where no benefit of an EMP was found (I can already hear the “they took our jobs” in Southpark dialect). But with that said, there is ample opportunity for fair and balanced investigation.
The Institute for Safe Medication Practices (ISMP)  http://www.ismp.org
Defining a medication error: “A medication error is “any error occurring in the medication use process”
Defining the medication use process: “Medication use is a complex process that comprises the sub-processes of medication prescribing, order processing, dispensing, administration, and effects monitoring.”
Here is the an excerpt from the ACEP website discussing the Joint Commission mandate: (http://www.acep.org/Clinical—Practice-Management/The-Joint-Commission-(TJC)/)

The Joint Commission has once again changed its standard requiring first dose, prospective pharmacy review — a move that should provide some relief to emergency departments nationwide.
The revised standard now allows for an exception to the rule “in urgent situations,” and frees the emergency physician from actually being required to order, prepare and administer the medication by allowing a registered nurse to process and administer the medication if a physician is in the proximity of the patient.
The revisions came after several months of ACEP representatives working with the Joint Commission to find a solution to the concerns facing emergency departments with the standard. ACEP joined forces with AAEM and ENA, and wrote several letters to the Joint Commission since the standard begin Jan. 1. A Joint Commission task force that includes ACEP members will continue to monitor the standard.

“We are pleased that the Joint Commission heard the concerns of the emergency physicians,” said Marilyn Bromley, RN, ACEP’s Director of EM Practice. “We believe these changes still keep the standard’s intent of providing patient safety, but allow for a process in the ED that still manages patient throughput and minimizes treatment delays.”

Perhaps it’s time to address this argument once again, but with a different approach to what and how pharmacists can contribute to emergency medicine.

2 thoughts on “EMPOWER Podcast Episode 1 – The Next Step In Upstairs Care, Downstairs

  1. Craig-First off, there is nowhere near enough profanity in your writing or podcast for them to be inspired by Bourdain. Secondly, I have always found it very interesting that as the gatekeepers of the medication use process via “the principles of EBM” (I'll get into my use of quotes on that some other time), pharmacists generally like to play fast and loose when considering the evidence for practice issues, especially as it relates to expansion of services. We bring “intangibles”, and “invisible services” that cannot be measured. We do things because they seem like the right thing to do, even if they aren't proven to improve hard outcomes. I think this is why practice research is so important, even if I find it incredibly dry. As you astutely point out, administrators generally don't care for unmeasurable outcomes. Our institution is so “fortunate” to have a large consulting group “streamlining” our processes right now. We are benchmarked to number of patient beds served, number of doses, and orders processed per hour. I would love to ask them how they take into account patient/family counseling, my frequent jaunts down to the ED bringing alteplase, or KCentra, doing drip rounds twice a day, rounding with the medical team, going to the micro or hematology lab to get early results, etc. Luckily, they don't have to take it into account because these are unmeasurable, so they do not care.We tend to be reactive to problems in US healthcare vice proactive. Studying for the MPJE was easy: Somebody messed up, people died, we passed a law. Rinse and repeat. We have fought for an ED presence for many years, most recently using many of the articles you reference. We were told that “peer reviewed literature is great, but find us some anecdotal stories at our institution.” Awesome…Anyway, I think this podcast is a great idea, and I hope you continue to find this venture fruitful. Any thought to having this outside iTunes as well? Something embedded in the post?


  2. Thanks for reading and listening Steve – and you wouldn't believe the amount of effort it takes to refrain from using Bourdain-esque language.I'd love to hear more about your air quotes of EBM, drop me a line via email (craig.cocchio@gmail.com).


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