PHARMACY SERVICES IN SCGH EMERGENCY DEPARTMENTDanny Soo (ED Pharmacist)

Current service• Monday to Friday from 0724 to 1600• No extended hours service or weekends• Current FTE is 1.0• Daily admission ~ 200 patient per day• On average can see between 12-20 patients per day

depending on complexity or involvement

Current role of ED pharmacist• Medication history taking and reconciliation

• What is medication reconciliation?• Medication review and identifying medication related problems

• Facilitating patient discharge by reviewing prescriptions and dispensing by pharmacy or liaison with community pharmacy or health care provider

• Counselling patient on medications• Supply of medications to patients in a timely manner and

in accordance to best practice• Providing education • Involvement and update of drug guidelines

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Current role of ED pharmacist• Governance of medicine use in accordance with Drug and

Therapeutics Committee, hospital policies, hospital formulary, infectious diseases and PBS

• Orientation of new nurses to the department• Providing advice on medicines to nurses, prescribers –

administration, use, dosing, interactions, researching information

• Making therapeutic recommendations• Identifying medication misadventures • Promoting quality use of medicines – standard 4

Medication safety standards• Involvement with projects

Some examples of identified problems• Inappropriate use of broad spectrum antibiotics as empiric

therapy – Tazocin, ceftriaxone, • Prescribing of antibiotic despite patient allergy • Patient allergy not documented or incorrect• Incomplete prescription order• Incorrect drug, dose, form, frequency, • Incorrect medication charted due to inaccurate medication

history – old discharge summary• Prescriptions PBS non compliance – quantities, authority, • S8s and S4s legal requirements

Community Program for Opiod Pharmacotherapy (CPOP)_

• Patients who are on Community Program for Opiod Pharmacotherapy (CPOP) like methadone liquid, buprenorphine/naloxone (Suboxone®) wafers require their current dose VERIFIED either by your Clinical Pharmacist or Drug and Alcohol nurse

• Dose must be current and script must be valid. Do not copy from previous discharge summary or trust patient

• If unable to verify, DO NOT prescribe dose• OK to skip dose until next day when dose can be

verified

Medication Management Pathway

Common Pitfalls in Medication History Taking

• Not asking the patient –how they take their medications, assessing their compliance, which pharmacy they attend

• Not questioning the patient on allergies or updating it• Referring to an old discharge summary (3 months

maximum)• Referring to a GP letter without checking details• Using only one source• Transcribing incorrectly• Webster pack patients – not asking about non-packed

medications such as inhalers, insulin,warfarin

Type and frequency of medication prescribing errors on admission resulting from inaccurate medication history

Results:• 100 consecutive patients• 247 errors• 165 ‘significant’ / 82 ‘insignificant’• 69% omission• 21% incorrect dose• 3% medications no longer taken• Remainder: incorrect

formulation/medication/route/timing

Type and frequency of medication prescribing errors on admission resulting from inaccurate medication history

• Own medications• 78% patients with own medications had errors• 67% patients without own medications had errors

• Dose Administration Aids (excluding Nursing home)• Of the 27 patients using DAA, 21 had errors (78%)

• Nursing Home or residential care facilities• Of the 18 N/H patients, 12 had errors (67%)

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Tier 3 prescribing errors

Incorrect dose

Incorrect formulation

Incorrect medication/fluid

Incorrect route

Incorrect timing of dose

Medication omitted

Medication charted no longertaken by patient

ED Environment• ED is a high risk area for medication misadventure

• High risk medicines use - APINCH• High turnover of patients and diversity of patients• High stress and urgent situations, fast paced environment• Constant interruption and distraction to workflow• Lack of continuity• Pressure of the 4 hour rule, bed pressures,

Referring patients to your Pharmacist• All of this is AVOIDABLE !• Refer patients to ED pharmacist when:

• There is difficulty obtaining medication history• Patient requires medication review• Patient has difficulty managing medicines, accessing medicines,

assessment for DAA• Review of discharge medications, EpiPen counselling, NOAC or

warfarin counselling, etc•

Referring patients to your Pharmacist• A referral is made via EDIS by selecting ‘Pharmacy’ under

consultations, similar to when a patient is referred to a specialty like respiratory or neurology, CCT.

• The ED pharmacist will check the screen periodically to see any new referrals that are added onto the system.

• Your ED pharmacist can also be reached on DECT phone: 6731.

Pharmacy online resources• WA Drug Formulary Service (DFS)• Medication management guidelines• National Prescribing Services (NPS)

Drug Formulary System (DFS)

Drug Formulary System (DFS)

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Comparison of pharmacy services here and over East

Hospital State FTE Operation Hours Weekend Extended services Satellite pharmacyRoyal Perth Hospital

WA 1 0800 to 1630 No No No

Fiona Stanley Hospital

WA 1.5 0730 to 1800 Yes (8-5pm pager cover)

Yes until 6pm (covered by Crit Care team)

No

Joondalup Hospital

WA NIL

NoAustin Hospital Victoria 2 0800-2000 Yes (8-5pm) Yes until 8pm

weekdaysYes

Alfred Hospital Victoria 3 0700-2100 2 pharmacists from 7-4pm and 1 pharmacist from 12-9pm Mon to Friday

0700-2100 1 pharmacist 7-12pm, 1 pharmacist 7-4pm and 1 pharmacist 12-9pm

Yes No

Sir Charles Gairdner Hospital

WA 1 0724 to 1600 No No No

Where to from here? • How much do you value pharmacy services in ED?• What do you want your service to look like?• Benefit of satellite pharmacy in ED• Advocacy to Exec for more FTE – patient safety,

medication safety, patient flow

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Questions?