Emergency Department
Loren Bonner
Much has been said about the importance of having pharmacists in an emergency department (ED), but little is out there about what pharmacists are capable of in a freestanding ED.
In an American Journal of Health-System Pharmacy (AJHP) report from August 22, 2024, pharmacists who work in a freestanding ED in Rochester, NY, described their experience developing and putting pharmacy services into place within a freestanding ED, which was located in a rural community roughly 20 miles from the main medical center.
The freestanding ED opened in 2014 following a hospital closure and allowed the community continued access to health care.
“Pharmacists are an integral part of the [emergency medicine] team, even in a small rural ED, we can and do make a difference by being onsite,” said Darlene DeBona, PharmD, one of the authors of the report.
She said they felt it was important to share their experiences as the literature surrounding pharmacists in freestanding EDs is limited.
Duties
The official definition of a freestanding ED from the American College of Emergency Physicians says it is a licensed facility that is structurally separate and distinct from a hospital and provides emergency care. Since their inception in the 1970s as a way for remote areas to have hospital access, freestanding EDs have expanded with over 500 sites in 45 states, according to a Medicare Payment Advisory Commission report from 2017.
In the freestanding ED described in the AJHP report, a small team of full-time pharmacists and full-time pharmacy technicians provide coverage 7 days per week, including holidays. After hours (from 6:01 pm to 9:29 am), a pharmacist was on call and all pharmacy orders were auto verified.
Emergency medicine experience was preferred, noted the report authors, but was not required for pharmacists who were hired to staff the freestanding ED. A comprehensive list of the services provided by pharmacy team members is included in the table on the next page.
DeBona said some emergencies, such as cardiac or respiratory resuscitations and pulmonary embolisms, which they see routinely, are easy to care for. But others that are less frequent, such as neonatal resuscitation and metformin-associated lactic acidosis, can be a challenge.
Education can help pharmacists overcome this, said DeBona.
“Sometimes the education comes in the form of a debrief. Sometimes it is a formal presentation. Other times it occurs during skills day,” she said. The freestanding ED pharmacy team works with several teams from the pharmacy departments of the larger medical center with which they are affiliated.
To tackle other challenges, such as a lack of insulin drips, pantoprazole drips, vasopressin drips, or controlled substance drips, DeBona said they provide alternative—and equally effective therapies—using bolus doses.
“For treatment of diabetic ketoacidosis, we were able to find literature to support the use of sub-Q doses of insulin lispro,” she said.
With the help of pharmacy technicians, pharmacists in the freestanding ED also perform inventory management.
DeBona said not only do pharmacists affect patient care being stationed in the ED, but they can make a difference through cost savings, too.
Regulations
There are no states that require emergency medicine pharmacists in the ED, but it is heavily encouraged by multiple physician and pharmacist organizations, including the American Society of Health-System Pharmacists.
For freestanding EDs, regulations vary across the nation. A study published in 2016 in Health Affairs found that 21 states had policies addressing freestanding EDs, 29 states had no regulations, two states regulated them on a case-by-case basis, and one state essentially barred them.
Authors noted in the AJHP report that to maintain crucial access to emergency care in rural areas and halt rapid expansion of freestanding EDs in urban areas, CMS will reimburse emergency services differently based on location. CMS recommendations do not apply to independent freestanding EDs, although state regulations may, the agency said. ■