ASHP Report

ASHP Guidelines on Emergency Medicine Pharmacist

Services
Am J Health-Syst Pharm. 2021;78:261-275
Melinda J. Ortmann, PharmD, BCPS,
T he American Society of Health-
System Pharmacists (ASHP) pub-
lished its first Statement on Pharmacy
documents provides one overarching
resource for recommendations on how
to establish, maintain, and optimize
Department of Pharmacy, The Johns
Hopkins Hospital, Baltimore, MD Services to the Emergency Department EM pharmacy services in alignment
Elizabeth Giesler Johnson, PharmD, (ED) in 2008.1 Best practices continue to with ASHP’s goals. The second goal is
BCPS, Department of Pharmacy, John evolve since then with numerous publi- to provide an updated roadmap for the
Peter Smith Hospital, Fort Worth, TX
cations demonstrating that emergency functions that are vital to quality EM
Daniel H. Jarrell, PharmD, BCPS,
BCCCP, Department of Pharmacy,
medicine pharmacist (EMP) participa- pharmacy services. One noteworthy
Banner – University Medical Center tion in patient care improves its safety difference in this edition is the removal
Tucson, Tucson, AZ, and Department and efficacy. In 2011, ASHP aimed to of the concepts “essential” and “desir-
of Pharmacy Practice and Science, The
University of Arizona, Tucson, AZ establish both a consistent approach able.” 2 All of the services and responsi-
and ideal practice model for emer- bilities identified in this document are
Matt Bilhimer, PharmD, BCPS,
Department of Pharmacy, Olathe Medical gency medicine (EM) pharmacy with considered essential, or vital, to EMPs’
Center, Olathe, KS its publication of the ASHP Guidelines ability to provide patient-focused phar-
Bryan D. Hayes, PharmD, DABAT, on Emergency Medicine Pharmacist macy services in the ED. Recognizing
FAACT, FASHP, Department of Services,2 developed by the ASHP Section that there will be limitations that may
Emergency Medicine, Harvard Medical
School, Boston, MA, and Department Advisory Group on Emergency Care. affect an institution’s ability to in-
of Pharmacy, Massachusetts General A group of EM clinical pharmacy corporate all of the recommendations
Hospital, Boston, MA
specialist content experts identified by stated, these updated guidelines are a
Aimee Mishler, PharmD, BCPS, ASHP developed these revised guide- framework for reference. Review of this
Department of Pharmacy, Valleywise
Health, Phoenix, AZ lines. The core writers group completed document in collaboration with ED and
a literature search for updated sup- pharmacy administrators and interdis-
Robert S. Pugliese, PharmD,
BCPS, Department of Pharmacy, porting evidence. A  modified Delphi ciplinary EM clinical staff, along with
Thomas Jefferson University Hospital, process was then applied to review the professional judgment of the EMP,
Philadelphia, PA, and Department of
Pharmacy, Thomas Jefferson University, recommendations and create a peer should be taken into consideration
Philadelphia, PA consensus in this document. The pur- when determining how to best imple-
Taylor A. Roberson, PharmD, BCPS, pose of these guidelines is to provide ment the recommendations in these
Department of Pharmacy, OhioHealth a framework reference to guide hos- guidelines at an individual institution.
Grant Medical Center, Columbus, OH
pitals, health systems, and, particu-
Giles Slocum, PharmD, BCCCP, larly, departments of pharmacy that Increased demand for
Department of Pharmacy and Department specialized emergency
of Emergency Medicine, Rush University are planning to initiate, expand, or
Medical Center, Chicago, IL optimize pharmacy services in the ED. medicine pharmacy services
Andrew P. Smith, PharmD, MBA, The recommendations in these guide- EM pharmacy practice continues to
BCPS, BCCCP, Department of lines represent a consensus of profes- expand, demonstrated not only by the
Pharmacy, Scripps Mercy Hospital, San
Diego, CA sional judgment, expert opinion, and number of EMP specialists working in
published evidence. They are written to hospitals, but also by the increase avail-
Katie Yabut, PharmD, BCPS,
Department of Pharmacy, Legacy Mount establish reasonable goals that are pro- ability of specialty residency training
Hood Medical Center, Portland, OR gressive and challenging yet attainable programs. The number of accredited
David E. Zimmerman, PharmD, BCPS, as best practices in applicable settings. training positions dedicated to EM
BCCCP, Department of Pharmacy, They do not represent minimum levels has risen from a mere 3 in 2007 to 70
Duquesne University School of Pharmacy,
Pittsburgh, PA, and Department of of practice, and readers are encouraged in 2020.3 This represents a more than
Pharmacy, UPMC-Mercy, Pittsburgh, PA to exercise their professional judgment 2,000% increase in specialty training
Address correspondence to Bruce
in assessing and adapting these recom- positions in just over a decade.
Hawkins (standards@[Link]). mendations to meet the specific needs In addition, national medical or-
of their healthcare organizations. ganizations, including the American
© American Society of Health-System This revision of the ASHP guide- College of Emergency Physicians
Pharmacists 2020. All rights reserved.
For permissions, please e-mail: journals. lines has a 2-fold aim. The first goal (ACEP) and the American College of
permissions@[Link]. is to combine the ASHP statement Medical Toxicology (ACMT), have pub-
DOI 10.1093/ajhp/zxaa378 and guidelines into a single docu- lished position statements endorsing
ment.1,2 Merging these 2 foundational the value of EMPs and formally

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 ASHP Report GUIDELINES ON EM PHARMACIST SERVICES

recognized the impact of EMPs on the the ED is provided can have a significant Direct patient care activities.
evaluation and management of EM and impact on EMP resource allocation and The majority of medication errors occur
toxicology patients.4,5 varying roles and responsibilities. It is in the prescribing and administration
important to recognize that EDs may phases of the medication-use process;
Factors affecting emergency function very differently, despite the therefore, it is critical for EMPs to be in-
medicine pharmacy practice universal goal of safe, optimized medi- volved in direct patient care activities,
Although EM pharmacy services cation therapy–related patient care. including medication selection and the
are now considered standard of care in prescribing process.8-12 EMPs are most
many US institutions, operational and Patient care effective in doing this when physically
clinical variables make a one-size-fits- The Institute of Medicine report present in the ED. EMPs, in collaboration
all approach to EM pharmacy practice Hospital-Based Emergency Care: At the with other EM providers, should be ac-
challenging. Ideally, all EDs would have Breaking Point6 recommends including countable for ensuring optimized medi-
access to EMPs with specialized training clinical pharmacists on the EM care cation therapy regimens and therapeutic
in direct patient care roles 24 hours per team to ensure patients’ medication outcomes based on emerging literature,
day, 7 days per week, and there would needs are appropriately met, to lead treatment guidelines, and quality meas-
be sufficient EMP staffing to allow time system changes to reduce or eliminate ures established by accrediting bodies.
for both dedicated direct and indirect medication errors, and to evaluate EMPs should create a triage system to
patient care activities. However, this is the cost-effectiveness of medication focus their patient care efforts on those
often not feasible, based on the staffing therapy for the patient and hospital.6 with critical illnesses or urgent needs, on
capabilities of departments of phar- As part of the interdisciplinary EM care high-risk patient populations, or on spe-
macy. Furthermore, organizations have team, pharmacists provide care to pa- cific classes of medications most associ-
different clinical and operational pri- tients through a variety of direct bed- ated with medication errors.
orities based on practice site–specific side clinical activities as well as indirect Medication information. The
variables. Examples of variables that patient care initiatives to ensure safe most common cause of medication
impact the operational aspects of EM and effective medication therapy man- errors is a lack of information related
pharmacy practice may include, but are agement in the ED setting. to medication therapy.13 Provision of
not limited to, type and setting of the In the past 10 years there has been medication information is therefore a
institution (eg, academic vs community a culture shift in which pharmacists in vital role in the practice of all pharma-
setting, urban vs rural, critical access this practice setting focus more of their cists, including EMPs. ED-based studies
hospital), size of the ED and number time performing clinical activities, demonstrate that the dissemination of
of annual visits, patient population as evidenced by a survey published medication information to providers,
served, and specialty services available in 2016. Thomas and colleagues7 re- nurses, and other hospital staff is an
(eg, pediatrics, geriatrics, trauma, burn, ported that of the 187 survey respond- important service provided by EMPs,
stroke, interventional medicine). Other ents, greater than 90% were engaged though only half of pharmacy depart-
factors that can impact the operations in routine clinical activities in the ED, ments reported performing this func-
of EMPs also include the number of which is in contrast to a similar 2009 tion.14-17 In addition, EM healthcare
full-time equivalents (FTEs) dedicated study where only 50% of respondents clinicians report that they are more
to EM patient care, hours of service were. Conversely, in 2009 the majority likely to utilize the resources of a
provided, whether an ED pharmacy of respondents were spending their pharmacist when that pharmacist is lo-
satellite is available for medication time on operational efforts. While cated in the ED rather than the central
preparation and dispensing, EMPs’ role clinical activities are a continuously pharmacy department.16
in medication order verification prior growing primary focus of EMPs, add- The medication information needs
to dispensing, and pharmacy techni- itional job functions are a necessary of the ED cover a broad spectrum of
cian support dedicated to the ED. and vital component of EMP respon- clinical scenarios and may include
In addition to operations, factors sibilities. Given this information and questions related to medication selec-
that may impact the scope of clinical the expanded training opportunities tion, dose, and administration; adverse
services provided by EMPs also vary for this specialty practice, the activ- medication reactions; intravenous (IV)
widely and can include, but are not ities in these guidelines are listed in compatibility; medication interactions;
limited to, both direct patient care (ie, order of how much time pharmacists and identification of unknown medi-
bedside presence) and indirect patient across the nation on average report cations.18 EMPs should ensure that
care services such quality and safety being involved in them. This approach access to appropriate primary, sec-
and other administrative responsibil- may help guide new practitioners ondary, and tertiary references is avail-
ities. The number of indirect care re- while still leaving space for individu- able to respond to both emergent and
sponsibilities and whether dedicated alizing practice to each EMP’s unique nonemergent medication information
time away from direct patient care in environment. requests. EMPs must be able to retrieve

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 GUIDELINES ON EM PHARMACIST SERVICES ASHP Report

the answers to medication informa- supply of necessary emergency medi- effectiveness and safety. These services
tion questions quickly and accurately cations in the ED. Multiple studies should be provided in collaboration
using readily available resources, such support the positive impact of EMPs with clinical and medical toxicolo-
as computer workstations, mobile ap- on specific outcomes in resuscitation. gists, when available, and local or re-
plications, textbooks, and other agile Examples in a variety of acute patient gional poison control centers. Finally,
resources. A  dedicated EMP computer presentations include: EMPs should serve as a resource to the
workstation in close proximity to the pharmacy department in ensuring that
clinical patient care area and provider • increased compliance with ad- an adequate inventory of toxicologic
care teams, with full internet connect- vanced cardiac life support (ACLS) antidotes and supportive therapies are
ivity, can help to ensure the EMP has guidelines24; available in the institution.40,41
fast access to both patient information • reduced time to administration of In preparing to become a member
and online resources needed to answer antibiotics for patients presenting of the resuscitation team, EMPs should
the wide breadth of questions encoun- with sepsis26,27; seek out training and certification in the
tered in the ED. • reduced time to analgesia for trauma conditions applicable to their practice
Resuscitation. EMPs should be patients28; settings. Several training opportunities
present during all critical and acute • reduced time to sedation and and certification programs are avail-
resuscitative efforts in the ED. Initial analgesia after rapid sequence able and include but are not limited to
studies of the role of EMPs in the re- intubation29-32; the following:
suscitation of trauma patients found • reduced time to thrombolysis for
improved safety from decreased pre- acute ischemic stroke33,34; and • American Stroke Association
ventable adverse medication events • improved door-to-balloon time for National Institutes of Health Stroke
and expedited time to medication ad- MI.22 Scale;
ministration.19-22 In addition to trauma • American Heart Association (AHA)
EMPs have also demonstrated im- Basic Life Support (BLS);
resuscitation, EMPs provide value in a provement in antibiotic selection and
number of clinical emergencies, such • AHA ACLS and AHA Pediatric
timeliness for patients with open frac- Advanced Life Support (PALS);
as stroke, myocardial infarction, car- tures when responding to traumas.35
diac and respiratory arrest, airway • American College of Surgeons
Pharmacist involvement in toxi­ Advanced Trauma Life Support
compromise requiring rapid sequence cologic emergencies was first described
intubation and postintubation care, and (ATLS);
in the literature more than 30  years • American Academy of Clinical
other medical emergencies. The role of ago.36,37 EMPs should be familiar with
EMPs in resuscitation may include a Toxicology Advanced HAZMAT Life
the recognition and treatment of pa- Support (AHLS);
variety of responsibilities including, but tients experiencing a toxicologic
not limited to: • Emergency Neurological Life Support
emergency. Their role should include (ENLS); and
• assisting clinicians with differential recognition of characteristic physical • Board certification as a Diplomate
diagnosis, particularly when related to signs and symptoms noted in the phys- of the American Board of Applied
a potential medication-related cause; ical examination, laboratory param- Toxicology (DABAT).
• ensuring appropriate medication eters, and other diagnostic evaluations
selection and dose; answering medi- (eg, toxidromes) that can result from At a minimum, all EMPs should
cation information questions; a wide range of substances, including achieve and maintain up-to-date cer-
• making recommendations for alter- prescription and over-the-counter tification in BLS, ACLS, and PALS as
native routes of administration when medications, illicit drugs, naturally appropriate, based on the patient
appropriate; preparing medications occurr­ ing poisons (eg, those from populations they serve. Board cer-
for immediate administration23; plants, mushrooms, or envenomations), tification is strongly encouraged to
• ensuring appropriate administration and various chemicals.38,39 When ensure ongoing expertise in a wide
of or administering medications pur- a patient with a suspected toxicologic variety of disease states and patient
suant to local scope of practice; emergency presents to the ED, EMPs populations.
• obtaining medications that are not should assist in obtaining a thorough High-alert medications and
readily available in the ED; and and accurate medication history and a procedures. EMPs should be present
• completing resuscitation history of present illness, as well as in at the bedside to facilitate the delivery of
documentation.24,25 identifying potential causative agents; patient care involving high-alert medi-
assist in the selection and preparation cations or procedures. Participation
In addition, EMPs should ensure that of specific antidotes and other sup- should include assisting in the appro-
processes are in place to maintain portive therapies; and provide recom- priate selection of medications and
an appropriate and readily available mendations for monitoring antidote corresponding doses, preparation of

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 ASHP Report GUIDELINES ON EM PHARMACIST SERVICES

medications, patient monitoring, and inpatient centralized pharmacy de- Medication shortages are common-
medication administration as accept- partment, or from a satellite pharmacy place, and EMPs may spend significant
able per state laws and hospital pol- within the ED. EMPs should be in- amounts of time monitoring for medi-
icies. EMPs should participate in efforts volved in the decision-making process cation availability and providing up-to-
to improve the safety of procedures that regarding which medications will be date alerts and recommendations
utilize high-risk medications. These ef- made available immediately within the to EM clinicians. EMPs should work
forts should include evaluation of cur- ED.45,46 Medications identified as ap- closely with pharmacy supply chain
rent processes and the development of propriate and necessary for frequent staff and their institution’s formulary
new or improved processes and systems use in the ED should be stored in auto- management committee to help plan
that prevent or reduce potential harm mated dispensing devices or another for alternative therapy recommenda-
and errors. The EMP’s role may include location designated safe by the institu- tions as soon as relevant medication
aiding in the development of policies and tion, with appropriate alerts to prevent shortages are identified.
protocols, with a focus on appropriate medication errors.46 EMPs may assist Medication order  review. The
medication selection, use, monitoring, in the evaluation and management of Joint Commission standards state
and management. Recommendations these medications, including moni- that all medication orders should
for reducing errors associated with high- toring for appropriate usage, inventory undergo prospective order review by a
alert medications and procedures are levels, override list optimization, and pharmacist prior to administration of
available.11,42-44 For example, use of medi- medication storage per both hospital the medication to the patient, with 2
cation infusion systems with smart infu- and regulatory body requirements. exceptions:
sion technology software and double Optimization of available medications
1. If a delay in administration would
checks on high-alert medications may should occur at regular intervals based
harm the patient; and
be considered.42,43 In addition, EMPs on changes in prescribing practices,
2. If a licensed independent practitioner
should provide education and training guideline or protocol recommenda-
is present to oversee the ordering,
related to high-alert medications to ED tions, medication availability, and for-
preparation, and administration of the
healthcare providers. mulary changes. Inventory and storage
medication.47
Medication procurement and replacement should be maintained
preparation. Medication procure- by pharmacy technician support and Although many medication orders
ment in the ED presents challenges that should not be the direct responsibility in the ED fall under the above excep-
differ significantly from those in other of EMPs. tions, the level of assessment during
areas of the hospital. Because of the ur- EMPs should be involved with the medication order review should be
gent treatment needs of patients in the institution’s formulary review and consistent with that provided for pa-
ED, several critical medications must process-improvement committees tients elsewhere in the hospital. The ED
be readily available. EMPs should be an to assist with medication reviews of medication order review process will
integral part of the medication procure- new formulary agents and for revi- vary between EDs and should be deter-
ment and preparation process for medi- sions to the current formulary re- mined by each institution based on its
cations used in the ED, as dispensing garding medications used in the ED. identified needs, staffing structure, and
medications is one of the 5 stages of Furthermore, data from medication- embedded medication-use systems,
the medication-use process that EMPs use evaluations (MUEs), safety moni- as well as site-specific interpretation
can influence to prevent medication toring, and monitoring for adherence of requirements by regulatory and ac-
errors.11 EMPs may serve as liaisons be- to national quality indicators should crediting organizations.
tween the pharmacy department and be used to assist in evaluating medi- The specific role of an EMP may not
ED regarding the development or revi- cation procurement and preparation focus on the ED medication order re-
sion of processes associated with medi- processes. view process alone but rather should
cation procurement, or they may play a The burden of extended inpatient parallel the role of other pharmacy
more active role in medication procure- boarding in the ED, in addition to specialists providing direct patient
ment and preparation based on oper- ongoing high ED patient volumes, re- care services within the institution.48-51
ational workflows. quires EMPs to consider the differing A workflow should be developed to en-
The options available for medi- medication distribution needs of both sure that there is adequate pharmacist
cation procurement vary widely and outpatient and inpatient populations support for timely review of medica-
should be based on both physical co-located in the ED. Similarly, the tion orders that are not verified by an
layout (ie, proximity of the ED to cen- EMP should be prepared to recog- EMP.52,53
tralized pharmacy areas) and oper- nize seasonal fluctuations in medi- Most medication orders in the ED
ational workflows. Medications may cation usage, communicating with are one-time orders, so an EMP’s inter-
be available in automated dispensing purchasers and adjusting stocks vention is most valuable if performed
devices, in emergency kits, from the accordingly. prior to medication administration.

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 GUIDELINES ON EM PHARMACIST SERVICES ASHP Report

Ideally, all orders for high-risk medica- selected was safe and effective, was documentation for cost justification
tions would receive prospective review, suboptimal, or failed and changes to purposes and patient care notes in the
but optimal medication use in the ED the regimen are needed. Pharmacist electronic medical record for handoff
requires a balance between ensuring participation in monitoring medication to other medical professionals. Allergy
patient safety and preventing delays in therapy improves clinical outcomes in a documentation, therapy plans, and pa-
patient care. EMPs should incorporate variety of settings, including treatment tient education are some examples of
a triage system into the medication- selection, adjustment, and monitoring activities that can be documented in the
order review process to help prioritize of therapies used in chronic disease medical record. They should regularly
evaluation of high-risk medications, states, such as diabetes mellitus, hyper- review intervention documentation
high-risk patient populations, and tension, and hyperlipidemia, and to identify trends, which may indi-
emergent or urgent situations, followed from therapeutic medication moni- cate a need to educate ED healthcare
by more routine medication orders. toring of antimicrobial and anticoagu- providers or change medication-use
When evaluating medication orders, lant therapy in the hospital setting.56-59 procedures. Finally, cost-avoidance
EMPs should focus on key factors such These clinical outcomes include re- documentation may provide the justifi-
as appropriateness of the medication duced medication errors, lower ad- cation needed for further expansion of
and doses, potential medication inter- verse event rates, increased medication EMP services.
actions, and patient-specific factors.47 adherence, and increased medication Healthcare institutions should sup-
Prospective order review by an EMP appropriateness, and these outcomes port EMPs by providing the means
can significantly decrease medication can be translated to the ED setting with to document interventions. Different
error rates.8 Approximately one-third of EMP services.59 media are used to document interven-
the total medication error interceptions To help address chronic therapy tions, including personal digital assist-
by an EMP occur during medication issues, EMPs should, as appropriate, ants, software programs on institutional
order review, but the majority occur assess home medications of ED pa- intranets, and manual paper sys-
during consultative activities, often tients and quickly identify any labora- tems.73-78 Electronic systems offer more
during bedside care; therefore, with tory tests needed to ensure the ED visit complete, readily retrievable docu-
limited time or resources, medication is not related to medication effects. mentation and shorter entry times than
order review should not be the highest Protocols can be implemented for manual systems, without the risk of
priority for EMPs.54 Irrespective of the pharmacists to order drug level tests as loss associated with paper records.79,80
strategy used to identify medication appropriate as well as any laboratory In addition, electronic documentation
errors, a high proportion intercepted tests that may be associated with that systems offer the benefit of associating
by EMPs are considered significant or medication’s assessment; such proto- cost avoidance with the documented
serious.55 cols are instrumental in both the critic- intervention and making it readily
Medication therapy monitoring. ally ill and general ED population. available for data capture.70 Although
EMPs should provide recommenda- Documentation. Pharmacist inter- determining true cost avoidance can be
tions for monitoring parameters for ventions in the inpatient setting improve difficult, there is some guidance avail-
both effectiveness and safety of medi- patient outcomes through optimized able for quantifying this metric with
cations administered in the ED. Given pharmacotherapy regimens, monitoring pharmacist interventions.15,60,61,81-84 In
the number of patients in the ED and of medication therapy, and avoidance addition to these benefits, electronic
competing interests for an EMP’s time, of adverse medication events.58 In add- documentation of EMP interventions
focusing on high-risk medications ition, pharmacist participation in pa- may improve communication with
should be prioritized (eg, vasopressors, tient care significantly reduces the costs other healthcare providers caring for
IV antihypertensives, insulins, analgesic associated with medication therapy.60,61 the patient after transitioning to ad-
and sedative agents, antithrombotics In the ED specifically, EMPs improve mitted status. The EMP can enhance
and hemostatic agents). EMPs should the medication-use process and patient transitions of care (TOC) by documen-
work closely with nursing staff and re- care by providing recommendations tation of medication therapy issues or
assess patients on these medications about medication therapy, serving as a monitoring needs for the next pharma-
to ensure proper response, safety, and medication information resource, and cist or healthcare team member as-
monitoring is completed. When appro- improving patient safety.8,14,62-67 Cost suming care to follow up and ensure
priate, EMPs should follow up with pro- avoidance has also been documented in appropriate therapy is continued.
viders to escalate and de-escalate care. several studies.68-72 EMPs also increase the rate of medi-
The identification and assessment EMPs should be diligent in cation error reporting, which, in turn,
of monitoring parameters related to documenting interventions provided supports an institution’s ability to iden-
medication therapy are essential steps during patient care and other activ- tify issues contributing to errors and
in the medication-use process. They ities (eg, education). Documentation implement measures to prevent future
will determine whether the therapy can include both internal pharmacy errors.66 Because up to 90% of adverse

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 ASHP Report GUIDELINES ON EM PHARMACIST SERVICES

events in hospitals go undetected and prescribers by ensuring thorough medi- patients understand any changes made
occur in up to one-third of all hospital cation therapy management for complex to their medication regimen and helping
admissions, error prevention is vital.85 boarded patients while continuing to to identify at-risk patients for the team to
Patient and caregiver educa- focus efforts on the urgent or emergent ensure proper follow-up with their pri-
tion. EMPs are uniquely qualified to needs of newly arrived ED patients. mary care physicians or postdischarge
provide medication education and in- Processes should be developed, clinics. For example, discharge educa-
formation to patients and their care- based on institutional resources, to ad- tion for anticoagulation provided by an
givers and should play a key role in the dress the needs of boarded patients. EMP for ED patients resulted in greater
delivery of medication information.68,86 Pharmacists and pharmacy depart- patient understanding and decreased
EMPs should develop a system of triage ments should evaluate all available re- return visits.91 Pharmacist-run TOC
for patient education so that coun- sources to support the ongoing level programs for patients presenting to the
seling is focused on patients who will of care needed for inpatients who re- ED with a chief complaint of chronic
be discharged from the ED with a new main located in the ED (eg, an EMP or obstructive pulmonary disease, chronic
or high-risk medication or whose visit the pharmacist assigned to the area to heart failure, or an asthma exacerbation
to the ED was the result of a medication which the patient will be admitted, or can provide useful interventions and re-
adverse event or error. EMPs may also a combination of both, may assume re- ferral follow-up in an ambulatory care
rely on other EM healthcare providers to sponsibility for the medication-related clinic or home-based medication man-
identify patients in need of medication needs of boarded patients). By sup- agement program.92
education. The medication education porting this patient influx with add- EMPs have demonstrated to ED staff
provided to patients and caregivers in itional pharmacist resources, EMPs that EMP review of ED discharge pre-
the ED is diverse and may include infor- can maintain their primary role in en- scriptions can improve patient safety,
mation related to the use of a new device suring the safety and effectiveness of optimize medication regimens, and im-
or new medication, the importance of the medication-use process for ED prove patient satisfaction.93 If EMPs are
medication adherence in disease state patients. When staffing levels are in- unable to provide this resource, they
management, or prevention and man- sufficient (eg, when only a single can serve as liaisons for physicians and
agement of adverse medication events. EMP is present in the ED) or when triage calls from outpatient pharma-
Education should include oral or written the boarding area is physically separ- cies. EMPs can field the call and iden-
materials and should be documented ated from the ED, the responsibility of tify the options to fix the issue with the
in the patient’s medical record. EMPs caring for boarded patients could be discharge prescription, discuss with a
should confirm patient and caregiver assigned to the inpatient pharmacist. physician, and communicate the deci-
understanding of the medication educa- Ideally, to ensure continuity of care, the sion to the outpatient pharmacy. Such
tion provided. inpatient pharmacist providing care to a process could more efficiently pro-
Care of boarded patients. ED the boarded patient would be the same vide corrective actions to prescription
overcrowding is common.87,88 There are pharmacist responsible for providing issues and lead to faster patient care by
many obstacles and processes that factor care after admission. The services pro- reducing the amount of physician time
into the timely transfer of admitted pa- vided to boarded patients by EMPs will spent on these issues.
tients from the ED to an inpatient bed.89 depend on the level of services offered EMPs can also take an active role in
Overcrowding in the ED often results in by the institution. At a minimum, EMPs discharge culture review. Many EDs are
ED staff providing care to patients for should review the medication profile of responsible for managing positive cul-
long periods of time while patients await boarded patients, with a focus on high- ture results from patients discharged
admission or physical transfer to an in- risk medications, medication dosing without hospital admission. EMP in-
patient bed or to another institution for and procurement, and monitoring, volvement in ED culture follow-up
a different level of care (ie, boarding). 90 as necessary. When it is necessary to can decrease time to positive culture
The needs of a boarded patient can vary initiate a standing medication order review and time to patient or primary
from simple requests for as-needed for a boarded patient, the responsible care provider notification,94 lead to a re-
medications to complex needs such as pharmacist should review medications duction in ED revisits,95,96 and result in
critical care management. In addition, administered in the ED and those taken improved appropriateness of changes
EM clinicians may be tasked with the re- prior to arrival at the ED to prevent du- in therapy.97 Institutional support for
sponsibility of initiating and maintaining plications in therapy. pharmacist-led innovative programs
inpatient levels of care, including rou- Transitions of  care. EMPs can targeting reduced return visits and ad-
tine medications and chronic disease provide a variety of TOC services. missions is important. Pharmacist in-
state management. EM clinicians are Responsibility for follow-up may be left tegration into home-hospital services
not specifically trained to provide in- solely to patients, who often face barriers that facilitate continued treatment at
patient care for extended lengths of stay. to receiving ongoing primary care. EMPs home has demonstrated potential.98,99
EMPs are challenged in trying to support should help bridge this gap by ensuring One group targeted ED discharge

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 GUIDELINES ON EM PHARMACIST SERVICES ASHP Report

patients at high risk for not filling anti- emergency care team, there are still op- system level to assist in implementing
microbial prescriptions, provided a full portunities for growth and utilization. safeguards at the point of prescribing
course at no charge to the patient, and Thomas and colleagues7 reported that and administration, reducing the risk
demonstrated a 50% reduction in re- 69% of survey respondents provide an of medication errors and optimizing
turn visits within the subsequent 7 days EMP for more than 8 hours per day, but medication-use practices.122
compared to standard of care.100 35% of respondents do not provide an Medication  safety. EMPs play an
Medication histories and medi- EMP on weekends. One editorial advo- important role in monitoring and en-
cation reconciliation. Medication cated for expansion of clinical pharma­ suring patient and medication safety
reconciliation research has identified cists to EDs and argued the current in the ED. By its nature, the ED envir-
several barriers to obtaining an accurate volume of the EMP workforce is inad- onment is at high risk for patient and
medication history in the ED.101-107 In equate for high-risk patient popula- medication near misses and adverse
many cases, ED staff are required to con- tions.116 These inadequacies continue, as events.123 EMPs should encourage and
tact multiple sources, including primary there are many challenges to implemen- assist in maintaining a safe environment
care physician offices, pharmacies, and tation of a dedicated EMP or expansion for medication and patient safety, and
family members to obtain a medication of current EMP services. Because EMPs establish an ongoing continuous review
history, and even these burdensome ef- do not generate a direct source of rev- cycle for potential process improve-
forts may not result in an accurate home enue, it may be difficult for administra- ments. Such a review could include
medication list. tors to realize the added value and cost proactive and continuous monitoring
Although pharmacy personnel are savings an EMP may provide. However, of medication practices; identification
the health professionals who obtain the quality and efficiency benefits of of errors and high-risk medications for
the most accurate home medication EMPs, in addition to their contribution monitoring; addressing hazardous con-
list,108-111 dedicating a pharmacist solely to patient safety, may more than offset ditions with potential for harm; and
to medication history collection is not the costs.117 documentation and review of medica-
the best allocation of pharmacist re- tion errors, adverse medication events,
sources in the ED. EMPs should assist and near misses.19,80,124
in the development and implemen- Administrative Medication errors and adverse drug
tation of a risk-stratification protocol responsibilities reactions that occur in the ED should
for identifying and determining which As a practitioner in the ED setting, be reviewed by EMPs, in an interdis-
ED patients need a medication his- an EMP should help identify and lead ciplinary collaboration with other
tory. In general, medication histories quality improvement initiatives re- healthcare providers and hospital ex-
should be obtained for patients with lating to direct patient care, medication ecutives, to identify potential sources
known or suspected toxicologic emer- safety, compliance with hospital and of error, contributing factors related to
gencies, with known or suspected ad- regulatory policies, and adherence to the error, and potential solutions for
verse events from home medications, national practice recommendations preventing similar errors. Performance
or with complicated medication his- and guidelines.118-120 EMPs, or other of a root cause analysis (RCA) could
tories that will influence ED clinical pharmacy representatives, should be identify potential error trends or
decision-making. extensively involved with quality im- system failures and contribute to the
Auxiliary pharmacy staff (phar- provement initiatives in the ED and development of safe medication prac-
macy students hired through work/ prehospital setting.121 Participation in tices and processes for prevention of
study programs or pharmacy techni- interdisciplinary committees with EM future events. RCAs can lead to MUEs
cians) can also be effective in obtaining healthcare providers and hospital ad- of commonly used medications in the
accurate home medication histories; ministrators (eg, pharmacy and thera- ED, as well as those associated with
when possible, they should be incorp- peutics, infection control, or disaster errors.125,126 Completion of RCAs and
orated into medication reconciliation preparedness committees) will provide MUEs should result in education and
procedures.112-115 Quality reviews of EMPs with an avenue for improving future policy or guidelines develop-
medication histories completed by patient care processes in the ED. In ment. EMPs should be responsible for
auxiliary pharmacy staff should be addition, EMPs have a unique under- the development and provision of edu-
conducted to assess accuracy and to standing of formulary management, cation to EM healthcare providers on
provide guidance for further training operational issues, and ED workflow potential sources of errors, the risks
opportunities. EMPs may take an ac- that may impact therapeutic decision- associated with errors, and ways to pre-
tive role in providing oversight of such making. Treatment pathways and vent similar errors in the future.
programs in the ED setting. medication-use policy should be con- Performance and quality im-
Opportunities for growth in gruent with nationally accepted prac- provement. EMPs have the oppor-
EMP patient  care. Despite improved tice guidelines and quality indicators. tunity and responsibility to collaborate
integration of pharmacists into the Finally, EMPs can contribute at the with interdisciplinary teams throughout

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 ASHP Report GUIDELINES ON EM PHARMACIST SERVICES

the health system to ensure best prac- preparedness plans, programs, and sup- EMPs should play a pivotal role not
tices throughout the entire institution. port systems, such as mass prophylaxis only in the development of emergency
By participating or taking on a leader- plans, antidote stocking policies, and operations plans but also in the provi-
ship role in institutional committees and the Strategic National Stockpile and the sion of clinical services during a disaster
performance improvement initiatives, CHEMPACK program, is paramount in or emergency.132 Ensuring the efficacy
EMPs can have a significant impact in the development and successful imple- and safety of the medication-use pro-
advancing the role of clinical pharma- mentation of institution-specific emer- cess is a natural role for pharma­cists,
cists in patient care. EMPs demonstrate gency preparedness plans.131 EMPs because treatment of disaster victims
value in several administrative or indirect can also participate in evaluating con- invariably involves the use of pharma-
care activities, including regulatory com- tingency planning needs for mass dis- cologic agents.128,133
pliance, adherence to core measures for charge of inpatients with “take-home As appropriate, EMPs should seek
maintenance of hospital certifications pack”–style medications (eg, what medi- out training and certification in emer-
(such as stroke, MI, trauma, and sepsis), cations are included, how many days’ gency preparedness, such as certifica-
and the creation of medication-use supply, dispensation plan). Planning tion for Advanced Hazmat Life Support
policy and disease state management for care of employees and their fam- (AHLS), Basic Disaster Life Support,
pathways. In addition, EMPs should ilies with prophylaxis and treatment Advanced Disaster Life Support, and
focus a significant portion of their time to allow them to continue caring for the Federal Emergency Management
on developing and enhancing medica- patients during disasters may also be Agency (FEMA) National Incident
tion ordering and order set development part of the institution’s emergency Management System training program.
in electronic health records. preparedness plan. In addition, local training programs
When the ED is evaluating various Furthermore, hospitals should funded by FEMA exist and are a great re-
technologies as part of the medication- maintain their own supply of anti- source for hospitals to initiate hospital
use process, the EMP should assist in dotes congruent with national con- emergency response teams trained to
selection, development, implementa- sensus guidelines for lesser exposures. respond to MCIs or disasters that may
tion, and assessment of the technology. ASHP advises that emergency response occur inside or outside the institution.
EMP involvement may include, but is planners at the federal, regional, state, Connecting with the institution’s emer-
not limited to, automated dispensing and local levels call on pharmacists to gency preparedness coordinator as well
devices location and inventory opti- participate in the full range of plan- as the local healthcare incident liaison
mization, infusion pump selection, ning issues related to pharmaceuticals, can also create opportunities for EMP
implementation of smart pump tech- including development of a disaster involvement in local training programs
nology and medication library updates, formulary and inventory management; and drills. FEMA’s Center for Disaster
communicating ongoing issues with medication procurement, distribution, Preparedness in Anniston, AL, offers
technology updates, crash cart stocking and use; and stockpile maintenance courses year-round, with many, such
recommendations, and implementa- and acquisition.41,127,129 EMPs can take as “Healthcare Leadership for Mass
tion of medication kits for management a leadership role in ensuring the pre- Casualty Incidents,” that are directly
of emergencies such as anaphylaxis paredness level of their institution(s) applicable to EMPs. These training
and rapid sequence intubation. with respect to medication assessment programs help to build and strengthen
Emergency preparedness. With and needs. the EMP’s knowledge and ability to not
expertise in pharmacology and toxi- Actively participating in emergency only respond to but also take a leader-
cology, EMPs are well suited to prepare preparedness events, such as disaster ship role in coordinating necessary re-
for and respond to emergencies such or MCI drills, strengthens the ability sponse efforts by pharmacy staff.
as natural disasters; disease outbreaks; of EMPs to effectively identify oppor- Interdisciplinary education. The
biological, radiological, or chemical ex- tunities for improvement within the role of EMPs in education can be
posures; mass casualty incidents (MCIs); disaster plan. Another valuable oppor- variable and broad, and it has been
and acts of terrorism. It is essential that tunity for EMPs is participation within menti­ oned in conjunction with other
EMPs, in conjunction with the depart- institutional hospital emergency pre- responsibilities throughout these guide-
ment of pharmacy and institutional paredness response teams. EMPs and lines. As appropriate for the specific in-
leadership, participate in emergency leadership in the pharmacy depart- stitutional setting, EMPs should play
preparedness planning.127-130 Planning ment should work together in the de- an active role in the education of phar-
and involvement should occur at a min- velopment of pharmacy-specific plans macy staff, including pharmacists, stu-
imum at the institutional level, with par- that parallel institution-specific plans. dents, and residents, in addition to
ticipation ideally expanding to include Education of ED and pharmacy staff other healthcare professionals, such
community emergency preparedness related to emergency preparedness as physicians, medical residents, ad-
efforts and beyond. Knowledge of local, should be among the responsibilities vanced practice providers, nurses, and
state, regional, and national emergency of EMPs. emergency medical services personnel.

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 GUIDELINES ON EM PHARMACIST SERVICES ASHP Report

The types and levels of education will for students.135 With the expansion of Research and professional de-
vary when balancing patient care and EM pharmacy services among health velopment. EMPs should also assume
administrative workload. Provision of systems, expanding coverage hours, roles in EM-based research and schol-
education to EM healthcare staff should, and the increasing role of EMPs in ad- arly activity; in professional develop-
at a minimum, include information on ministrative activities, the need for ment, service, and leadership; and in
the appropriate use of medications, im- additional qualified pharmacists in- defining future roles for EMPs.
provement in quality and effective medi- creases. New EMPs should focus on EM-based research and schol-
cation use, and patient and medication developing current services, with plans arly activity. The Institute of Medicine
safety. Education may include, but is not to develop advanced residency training provides a framework for EM research
limited to, formal sessions (eg, in-service programs after the service model is es- that further delineates specific areas of
or didactic presentation at a confer- tablished and the practice experience focus.139 Those areas have been identi-
ence) or participation in courses such is significant. Expansion of PGY2 EM fied as EM research (ie, research con-
as BLS, ACLS, or PALS; emergency pre- pharmacy residency programs will as- ducted in the prehospital or ED setting
paredness; disaster management; poi- sist in filling the demand gap of highly by EM specialists); trauma/injury con-
soning prevention and treatment5; and trained EMPs providing 24-hour clin- trol research (ie, research of the acute
immunizations. Participation in formal ical pharmacy services. Such residency management of trauma injury), and re-
education sessions may strengthen the programs should meet ASHP residency search contributions that are not spe-
relationship with other EM healthcare quality standards.136 These programs cific to but nevertheless impact the care
providers and serves as a method of con- should prepare future EMPs for board of patients in the ED setting. As a spe-
tinuous learning for EMPs. Given the certification in the specialty most appro- cialty, EM has already helped to define
nature of the ED environment, EMPs priate for their practice.137 Achievement a scope of research priorities over the
have a unique opportunity to provide of the goals, objectives, and expected years.140-144 What is less clearly defined is
continuous, on-the-spot education via outcomes of such training can result in how EMPs can support research efforts
daily interdisciplinary interaction in the a greater ability to provide around-the- through interdisciplinary participation
ED, particularly at the bedside, which is clock or on-call EM clinical pharmacist in ongoing EM research or identifying
an efficient, effective tool for education services.138 opportunities to lead research in medi-
of staff. Pharmacy resident and student cation therapy and pharmacy specialty
Training the pharmacist work- precepting is a typical part of the job care outcomes in the ED setting.
force. Participation in the didactic for many EMPs; however, faculty ap- The EM-based pharmacy research
and experiential education of doctor pointments at schools of pharmacy or compendium continues to grow, ex-
of pharmacy students is a strongly en- medicine present unique possibilities ploring the impact of various clinical
couraged, routine part of practice that to educate students, residents, and fac- activities, including anticoagulation
also supports the development of the ulty in a more formal setting. reversal, toxicology, naloxone distri-
profession.134 Precepting pharmacy resi- In addition, EMPs should identify bution programs, emergency response
dents in EM learning experiences sup- opportunities to provide education team participation, and pain manage-
ports the overall development of direct and training for currently practicing ment.28,145-148 Other studies describe
patient care practitioners and provides pharmacists not specialized in EM. To progress in the medication-use process
exposure to the practice of EM phar- train pharmacists not specialized in and EM-based pharmacy activities.7,117
macy. To support the growth of EM EM, institutions should create a check- Although these studies contribute new
pharmacy services, the continued de- list and minimum competency stand- knowledge that addresses the varied
velopment and expansion of EM phar- ards to prepare their staff for the ED scope and range of EM pharmacy
macy residency programs is necessary. environment and ensure they are set services, additional information and
EMPs must be leaders in this endeavor, up for success in this challenging arena. analysis are still necessary. As a profes-
using their unique skills and expertise Training should at a minimum consist sion and specialty practitioner group,
in this practice setting to train the next of knowledge of pharmacist roles in EMPs must continue to provide the
generation. Although the number of resuscitations and direct patient care necessary evidence that demonstrates
postgraduate year 2 (PGY2) residency activities, appropriate certifications the benefit EMPs provide to care in the
programs in EM has increased signifi- (eg, ACLS, BLS, PALS), knowledge of emergent environment. In addition,
cantly in recent years, ASHP advocates common EM medications and anti- EMPs must challenge themselves to
for continued emphasis on the expan- dotes, how to triage and prioritize incorporate the research priorities de-
sion of the number of EM-based training direct patient care in the ED, and other scribed by the Institute of Medicine
opportunities for pharmacists, phar- institution-specific practices in the ED into their scholarly work, which would
macy students, and residents. Colleges setting. Such training may help fill clin- require EMPs to think on a broader
of pharmacy are encouraged to provide ical practice gaps and allow for addi­ scope, not only about research topics
EM-based educational opportunities tional support in ED coverage models. but also about how to best carry out

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 ASHP Report GUIDELINES ON EM PHARMACIST SERVICES

this work on a larger scale with limited can help by providing larger and more with medical providers, residents, and
resources. Studies that generate data diverse patient populations in which students. Such collaboration has re-
on therapeutic, safety, humanistic, and to conduct research. The ability to cently yielded the recognition and en-
economic outcomes of EMP-mediated collaborate with other EMPs from dif- dorsement of EM pharmacy services
process changes are needed. Although ferent practice settings may also help by ACEP and ACMT, as demonstrated
not an exhaustive list, specific areas of to strengthen the depth and breadth by statements of support from both
needed research expansion include of research being conducted, resulting organizations.1,2 By engaging at a
the following: in studies that have the potential to national organization level with
impact change in EM practice. In add- other disciplines in emergency care,
• Alternative strategies for providing
ition, EMPs should collaborate with EMPs continue to build the backbone
24/7 access to EMP services:
EM clinicians, nursing staff, clinical of support needed to encourage
◦ Leveraging non-EMP staff to as-
staff, and relevant others in research funding and resources for expanded
sist with EMP services
activities. EMP practice at the institutional
◦ Pharmacy resident resources and
Professional development, ser­ level.
patient outcomes
vice, and leadership  duties. Hos­ Future efforts. EMPs have dem-
• Clinical and operational out-
pitals and health systems are encouraged onstrated their value in providing
comes of electronic medical record
to support EM-based educational well-rounded clinical and operational
interventions:
programs that produce experts in the medication therapy–related services in
◦ Impact of EMP electronic medical
field. Postgraduate training of pharma- the ED setting. Their unique training
record development and main-
cists will provide a pipeline of clinicians, and expertise ensures improved pa-
tenance on patient safety
educators, leaders, and scientists who tient safety and optimized patient out-
◦ Impact of order set or clinical
are experts in and committed to quality comes in direct patient care. As the
pathway development on patient
emergency care as well as the expansion future of pharmacy evolves, so too must
outcomes
of this specialty service. The leadership the EMP. Expanding both the scope of
• Clinical outcomes of ED-specific,
role of EMPs should include responsibil- practice and the role within the patient
medication-related interventions:
ities to both the pharmacy department care continuum is important to sus-
◦ Evaluating clinical programs for
and ED. Involvement in administrative taining and maximizing the benefits
economic outcomes
processes of both departments allows of this clinical specialty. In the next
◦ Exploration of tangible cost sav-
EMPs to serve as a liaison between the decade, EMPs should engage in acti­
ings or revenue generation
groups to support joint endeavors. vities that serve both the needs of the
◦ Impact of antimicrobial
Furthermore, participation in healthcare team and public health ef-
stewardship
professional organizations at the forts at large. Although some of these
◦ Impact of opioid stewardship
local, state, and national levels is es- efforts are already underway, it will
and substance use disorder
sential for the continued growth of be incumbent upon EMPs to help ad-
treatments
the practice of EM pharmacy. At the vance the goals of provider status and
◦ Impact of medication use on
local level, EMPs may collaborate to collaborative practice agreements, al-
disposition and ED throughput
develop a local support network for lowing practice at the highest level of
metrics
training and research and can pro- licensure.
◦ Medication efficacy and safety
vide new practitioners with avenues
outcomes of high-risk medica- In addition, public health is an
for learning. At the state level, legis-
tions in the ED with EMP bedside area in which EMPs can contribute.
lative and professional advocacy may
monitoring Examples include the following:
help educate government officials and
◦ Patient outcomes of ED-specific
other healthcare professionals about • Providing structure to opioid crisis
medication therapy management
EM pharmacy practice. At the national services, such as naloxone distri-
in TOC.
level, collaboration among EMPs in- bution and counseling147,150 and
• Disaster response:
creases their strength as a group; pharmacist-initiated medication
◦ Pharmacist-specific impact in
serves to challenge existing programs assisted therapy;
disaster response
to improve; assists new programs in • Reducing antimicrobial resistance
• Public and population health initia-
their development; and allows collab- and reducing sepsis mortality with
tives and outcomes.
oration as a group to affect the stature, improved ED-specific antimicro-
Development of a collaborative, inter- practice, and further development of bial stewardship interventions and
disciplinary research network among EM pharmacy practice. In addition to monitoring; 151
EMPs would facilitate enhanced evalu- promotion from ASHP, pharmacy pro- • Improving stroke management and
ation of clinical and professional ques- fessionals are encouraged to create meeting core metrics for better pa-
tions of interest.149 Research networks strong interdisciplinary partnerships tient outcomes;

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 GUIDELINES ON EM PHARMACIST SERVICES ASHP Report

• Establishing ED-based pharma- Burkins, PharmD, BCPS; J Campbell, PharmD, [Link]

cist medication therapy monitoring BCPS, BCCCP; Michael Dejos, PharmD, BCPS, tory/#/program/residency. Accessed
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BCPS; Amanda Eger, PharmD; Madeline 4. American College of Emergency
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BCCCP, BCPS; Michael C.  Thomas, PharmD, 10. Flynn EA, Barker K, Barker B.
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pharmacy profession, and, most im- Disclosures
12. DeFrates SR, Weant KA, Seamon JP,
portantly, patient care. Where possible, The authors have declared no potential con- et al. Emergency pharmacist impact
flicts of interest.
we encourage pharmacy and hospital on health care-associated pneu-
leaderships to use these guidelines as a monia empiric therapy. J Pharm Pract.
tool to help provide the necessary sup- Additional information 2013;26:125-130.
Approved by the ASHP Board of Directors 13. Leape LL, Bates DW, Cullen DJ, et al.
port for development and expansion of Systems analysis of adverse drug events.
on August 21, 2020. Developed through the
EMP services. ASHP Section of Clinical Specialists and ADE prevention study group. JAMA.
Scientists. These guidelines supersede the 1995;274:35-43.
ASHP Guidelines on Emergency Medicine 14. Wymore ES, Casanova TJ,
Acknowledgments Broekemeier RL, et al. Clinical
Pharmacist Services dated July 8, 2011, and
ASHP gratefully acknowledges the following pharmacist’s daily role in the emer-
the ASHP Statement on Pharmacist Services
organizations and individuals for reviewing gency department of a community
to the Emergency Department dated June 10,
these guidelines (review does not imply en- hospital. Am J Health-Syst Pharm.
2008.
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