(Management Case Study) Implementation of 24-Hour Emergency Department Clinical Pharmacy Services in a Community Hospital

Purpose: Development of very robust clinical pharmacy services in a 350-bed, non-teaching, community hospital led to clinical pharmacy practice gaps on night shift. This case describes the justification, approval, and implementation of additional clinical pharmacist full time equivalents (FTEs) working night shift in the emergency department (ED). With this FTE addition, ED clinical pharmacy coverage expanded from 15 hours per day to 24 hours per day.

Methods: In 2016, a pharmacy resident completed a review of the impact of pharmacist-led medication history documentation overnight. Results of that project indicated that pharmacists obtained a more complete medication history than non-pharmacy personnel. While impactful, there was not enough evidence to justify overnight clinical pharmacist positions in the ED. Five years later, another resident completed two weeks of overnights providing clinical pharmacy support in our ED and throughout the hospital. After completing a needs assessment to demonstrate practice gaps in clinical pharmacist coverage, a business plan was developed and presented to hospital administration. This resulted in approval for an additional unbudgeted 2.4 FTE, expanding clinical pharmacy services in the ED to 24 hours per day. The program was fully operational in September 2022.

Results: With the addition of ED overnight clinical services, Severe Sepsis and Septic Shock Management Bundle (SEP-1) compliance improved from 66.5% to 80.2%. Total night shift pharmacist clinical interventions in the first seven months after go-live were 4563, a 31% increase over baseline. Of these interventions, 2646 were medication histories completed by the night shift clinical pharmacist, easing the burden for day shift pharmacists while decreasing the risk of medication errors. The clinical pharmacist presence on night shift allowed for an additional 525 clinical interventions for direct, bedside patient care for code response in the ED and throughout the hospital, including ST elevation myocardial infarction (STEMI), rapid sequence intubation (RSI), and thrombolytic preparation for stroke response. Additional pharmacist coverage allowed for the transition to pharmacist prospective medication review for all medications ordered in the ED, eliminating the risk associated with auto-verify order functionality.

Conclusion: Expansion of ED clinical pharmacy services allowed for growth in clinical and distributive services, in addition to an improvement in quality metrics.