Journal of Pharmacy Practice

Emergency medicine (EM) pharmacy practice has existed for over 30 years. In recent years, however, the specialty has grown significantly. A large number of health care systems have either a dedicated EM pharmacist or other clinical pharmacist presence in the Emergency department (ED). Over the past decade, the role of the EM pharmacist as a critical member of the health care team has expanded significantly and many innovative practices have evolved throughout the country. There is also some heterogeneity between different EM pharmacy practice sites. This article reviews the history and general concepts of EM pharmacy practice as well as illustrate some of the established benefits of an EM pharmacist.

The clinical pharmacist in the emergency department is now commonly incorporated as a member of the emergency department trauma team. As such, the emergency pharmacist needs to have detailed knowledge of the pharmacotherapy of resuscitation and be able to apply the skills needed to function as a valuable member of this team. In addition to the traditional skills of the discipline of clinical pharmacy, the emergency pharmacist must be familiar with the intricacies of treating life-threatening injuries in an emergent setting and be able to anticipate the direction of the patient’s care. The ability to provide valuable pharmacological interventions throughout the resuscitation and stabilization process requires familiarity with the process of resuscitation, including rapid sequence induction, analgesia and sedation, seizure prophylaxis, appropriate antibiotic and tetanus prophylaxis, intracranial pressure control, hemodynamic stabilization, and any other specific drug therapy that the clinical situation demands. This article discusses the aforementioned pharmacotherapeutic topics and describes the role of the Emergency Pharmacist on the ED trauma team.

Stroke continues to be one of the leading causes of death and adult disability. Increasing public awareness of stroke has led to a rise in the number of patients presenting to emergency departments (EDs) who qualify for emergent and time-sensitive treatments such as t-PA, clot extraction, and surgery. Timely treatment and supportive care of the stroke patient in the ED is crucial for patient outcomes. Emergency medicine (EM) pharmacists are the medication experts and can have a significant impact on the care of a stroke patient. Thus, it is essential for EM pharmacists to have a solid knowledge of the current guidelines and evidence-based literature or lack there of. In this article, we describe the epidemiology of stroke, review the classifications of stroke, and discuss the present treatment strategies for emergent and supportive care.

Clinicians are frequently confronted with toxicological emergencies and challenged with the task of correctly identifying the possible agents involved and providing appropriate treatments. In this review article, we describe the epidemiology of overdoses, provide a practical approach to the recognition and diagnosis of classic toxidromes, and discuss the initial management strategies that should be considered in all overdoses. In addition, we evaluate some of the most common agents involved in poisonings and present their respective treatments. Recognition of toxidromes with knowledge of indications for antidotes and their limitations for treating overdoses is crucial for the acute care of poisoned patients.

Patients present to the emergency department (ED) for a variety of reasons and some require diagnostic and therapeutic procedures for their conditions. In order for some of these procedures to be carried out successfully, the patient must be at a suppressed level of consciousness in order to tolerate the associated pain and anxiety. Medications administered to achieve these goals include analgesics and sedatives as they decrease the patient’s discomfort and awareness while allowing the patient to maintain their airway. However, medication selection and dosing is critical and should be tailored to each patient and procedure. Pharmacists have an opportunity to reduce medication errors during procedural sedation and analgesia (PSAA) as the majority of medication errors leading to adverse events occur during the ordering and administration steps of the medication use process. Common errors include drug-dosing, potential drug interactions, and administration of the wrong pharmacologic agent. Pharmacists in the ED can provide drug information and assist with drug selection and dosing; medication preparation; and monitoring of the patient and of the time intervals since medication administration relative to the duration of the procedure. Having a pharmacist present provides an extra layer of protection and reduces the likelihood for potential medication errors.

The practice of antimicrobial stewardship can be defined as optimizing clinical outcomes while minimizing the consequences of antimicrobial therapy such as resistance and superinfection. Antimicrobial stewardship can be difficult to transition to the emergency department (ED) since the traditional activities include the evaluation of broad-spectrum antimicrobial regimens at 72 and 96 hours and intravenous to oral medication conversion. The emergency medicine clinical pharmacist (EPh) has the knowledge and clinical assessment skills to manage an antimicrobial stewardship program focused on culture follow-up for patients discharged from the ED. This paper summarizes the experiences of developing an EPh-managed antimicrobial stewardship and culture follow-up program in the ED from 2 separate institutions. Specifically, the focus is on the steps for establishing an EPh-managed antimicrobial stewardship program, a description of the culture follow-up process, managing the culture data and cultures that require emergent notification and review, medical/legal concerns, and barriers to implementation. Outcomes data available from institutions with similar ED based antimicrobial stewardship programs are also discussed.

This study researches the efficacy and safety of pegylated interferon alpha-2a (pegIFNα-2a) in Egyptian children and adolescents diagnosed with hepatitis C virus. Thirty patients were enrolled to receive pegIFN once a week with ribavirin twice daily for 12 weeks; viral load and experienced adverse effects were then assessed. Of the 30 patients, 16 (53.33%) were cleared from the virus, showing early virologic response (EVR). Three patients (10%) showed a 2-log reduction by week 12, with an overall early response rate of 63.33%. Three patients who showed EVR after 4 weeks relapsed by week 12. Levels of serum alanine aminotransferase (ALT) normalized at week 12. Adverse events included fever, myalgia, headache, flu-like symptoms, fatigue, anemia, and leucopenia; 63.33% of the patients showed significant reduction in their body weight. Although the patients showed a reduction in average body mass index, this reduction was not significant. Hemoglobin values decreased within the first 2 weeks and then stabilized but not back to baseline. A significant reduction in the level of absolute neutrophil count (ANC) was observed by the 4th week and started to improve by the 12th week. Of the recruited patients, 29.4% were subjected to IFN dose reduction. None of the patients with neutropenia developed serious infection or sepsis. The authors concluded that pegIFN plus ribavirin therapy is promising when tested on Egyptian children.

Aims: To examine practices and complications among Arab Americans observing fasting during Ramadan. Methods: Adults with type 2 diabetes mellitus, of native Arab ancestry, and observing fasting were invited to complete an interview. Changes made to behavioral characteristics or diabetes management during Ramadan and consequences of fasting were assessed. Results: Twenty-seven patients (60.1 ± 9.8 years, 51.9% male) participated. Majority reported exercising less frequently during Ramadan. Modifications in home blood glucose monitoring (HBGM) were observed in 48% of patients, of these 25% and 17% decreased frequency or had not tested at all, respectively. Consultation with providers prior to Ramadan was reported by 67%. Education regarding medications, risks of fasting, indications to break fasting, meal plans, and exercise were not provided in the majority. Therapeutic changes were made in 50% and 46% of insulin and oral medication users, respectively. Excessive thirst was the most commonly reported symptom. The overall frequency of hypoglycemia and hyperglycemia was low. One patient stopped fasting during Ramadan due to uncontrolled hyperglycemia. Hospitalization or emergency room visits were not reported. Conclusions: Lack of patient education prior to Ramadan may contribute to the suboptimal practices reported. Pharmacists may be able to ensure safe fasting practices among Arab Americans by providing patient-specific education.

Objective: Protease inhibitors (PIs) exhibit considerable interpatient pharmacokinetic variability in plasma trough concentrations. Therapeutic drug monitoring (TDM) is occasionally used to guide chronic dosing to achieve target trough concentrations, but its clinical success assumes minimal intrasubject variability. Therefore, our primary objective was to evaluate intrapatient variability in atazanavir (ATV) plasma trough concentrations in HIV-1-infected patients. Design/Methods: In a single-site, prospective, cohort study, patients on atazanavir with or without ritonavir (ATV/r or ATV) for 2 clinic visits were enrolled. Adherence and time since last dose (TSLD) were verified at each visit. ATV was assayed with high-performance liquid chromatography. Intra- and interpatient variation was evaluated using the median intraindividual percentage coefficient of variation (ICV). Results: The mean 24-hour ATV trough concentrations for the first and second visit for the ATV/r group (n = 10) was 598 (CV 84%) and 525 ng/mL (CV 66%), respectively (P = .511), and 300 (CV 81%) and 434 ng/mL (CV 106%) for the ATV group (n = 4), respectively (P = .369). Median ICV was 43.1% for all patients (range: 0.6%-107.6%), 38.1% (0.6%-107.6%) for the ATV/r group, and 33.1% (2.3%-87.6%) for the ATV group. Conclusions: Potential intrapatient variability in ATV troughs suggests that repeated measurements may be required to ensure that target values are maintained.

The objective of this research was to assess the knowledge levels and attitudes of all students enrolled in 1 biomedical university regarding the human papillomavirus quadrivalent (types 6, 11, 16, and 18) recombinant vaccine (Gardasil-Merck; the HPV vaccine). A survey of students from all 7 programs at the University was conducted in January 2009. A total of 1120 useable questionnaires were obtained. These programs included pharmacy, osteopathic medicine, physician assistant, physical therapy, occupational therapy, doctor of psychology, and master of biomedical sciences. Mean percentage correct on the HPV vaccine knowledge test was 73. Subjects scored highest on the question that asks whether the vaccine helps prevent cervical cancer (97% correct) and lowest on the one asking whether it helps prevent genital warts (41% correct). Eighty-eight percent thought that patients 18 years and older should be able to receive the HPV vaccine without parental consent. Only about 5% think that the vaccine would cause patients to become sexually active, or that it would cause patients to have unprotected sex. The results suggest that these students have reasonable but limited knowledge of the vaccine. Their positive attitudes suggest that they will likely recommend or provide the vaccine to their patients.

In 2010 many of the health disciplines in Australia will be involved in national registration and accreditation, to ensure a more sustainable and flexible health workforce for the future. To this end, in each of the health professions, there is an increasing emphasis on reflective practice and lifelong learning to maintain practice competency. This research focuses on academic teaching and learning in the Pharmacy undergraduate curriculum to develop an indicator tool of graduate practice skills before the student enters the practice internship year. The Graduated Descriptors Competency Tool was developed by means of state, territory, and national stakeholder collaboration. The aim of the project was to assist the scaffolding processes around undergraduate practice teaching and learning. Students on experiential placements have used the tool to demonstrate their current practice skills and the learning required to attain competency during their internship year. Students are guided to develop critical reflection skills for deep understanding and insight into the continued learning and professional development required to maintain long-term health care expertise.