The role of the hospital pharmacist has evolved into one that involves active prevention of medication errors, in part by screening provider orders for accuracy in dose, drug interactions, contraindications, and allergies. Multiple studies have shown the positive impact a clinical pharmacist has on patient care in the critical care setting (18
). A study evaluating the effects of pharmacist participation on intensive care unit rounds found a 66% reduction in preventable adverse drug events (18
). Brent et al. documented the services that a clinical pharmacist can provide as a member of the trauma team, in both the acute and follow-up phases of care (5
). Several studies have described the value of a dedicated clinical pharmacist in the ED through survey data and documentation of interventions, but few studies have addressed outcomes data in regards to the EPh (10
In 1999, the time required to perform direct coronary angioplasty and its relationship with mortality was evaluated in a prospective substudy of the GUSTO-IIb trial (14
). The 30-day mortality rate of patients who underwent balloon angioplasty ≤ 60 minutes, 61 to 75 minutes, 76 to 90 minutes, and ≥ 91 minutes from randomization was 1%, 3.7%, 4.0%, and 6.4%, respectively. Further analysis revealed that the risk of death increased 1.6 times (p = 0.008) for a movement from each time interval to the next (14
). Rathore et al. report a 4.6% overall in-hospital mortality in a recent prospective cohort study of 43,801 patients presenting with STEMI that subsequently underwent primary PCI (16
). Patients who died were found to have a median 14 minute longer door-to-balloon time than those who survived, 96 vs. 82 minutes, p<0.001. Furthermore, multivariate regression models indicate longer door-to-balloon times were associated with a higher adjusted in-hospital mortality, 30 minutes = 3%, 60 minutes = 3.5%, 90 minutes = 4.3%, 120 minutes = 5.6%, 150 minutes = 7%, 180 minutes = 8.4%, p<0.001 for the trend (16
). Additionally, prolonged door-to-balloon time was an independent predictor for both in-hospital and late-mortality in a 2,322 consecutive patient study (23
). These findings further illustrate the need to minimize door-to-balloon time to the greatest extent beyond the accepted 90 minute endpoint.
In our study, we assumed that the EPh has the most impact from the time the patient either entered the ED with a pre-hospital diagnostic ECG or received a diagnosis of an STEMI in the ED based on ECG (door/diagnosis) to the time the patient arrived in the CCL. The EPh is not able to effect the time from arrival to the CCL to balloon angioplasty. The role of the EPh during STEMI presentation to the ED and AMI team evaluation has not been previously described in the literature, however it is similar to emergency resuscitation in that the pharmacist facilitates medication administration, evaluates the appropriate medication use and medication dose, supports adherence to the hospital protocols, and prevents medication related adverse events.
We were able to show that EPh presence was independently associated with a mean 13.1 minute decrease in door/diagnosis-to-CCL time and a mean 11.5 minute decrease in door-to-balloon time after controlling for confounders such as CCL on-call status and means of arrival to the ED. Furthermore, the EPh was independently associated with achieving both a door/diagnosis-to-CCL time ≤ 30 and ≤ 45 minutes. At our institution, arrival at the CCL to the time for balloon angioplasty averages 35 minutes, therefore spending ≤ 45 minutes in the ED would increase the likelihood of door-to-balloon times ≤ 90 minutes.
To our knowledge medication administration has not been evaluated to determine if it presents a limitation in achieving a faster door-to-balloon time. However, at our institution we felt that the decreased time intervals are likely due to the fact that EPh presence helps expedite medication administration. Specifically, the EPh can anticipate the need for AMI related medications and can obtain them from the automated medication dispensing cabinets and program the medication infusion pump while the nurses are starting intravenous lines, drawing blood, repeating the ECG, and placing the patient on a portable monitor. This has been the practice at our institution over the past several years, regardless of nursing staffing patterns.
There are limitations to this study that should be recognized. Based on the retrospective design of the study it is difficult to ensure that all variables that may have affected our results were identified. Although our ED has consistent staffing patterns, evening and weekend shifts are generally considered to be more demanding for all ED staff. Since the CCL staff is on-call during the evening and weekend hours, these variables are highly correlated and the inclusion of this CCL staff variable into the multivariate analysis was able to take this into consideration. Additionally, the impact of specific nursing and physician staff in the ED and for the Cardiology service were not evaluated to determine the impact on these results.
The study was designed to evaluate the presence or absence of an emergency medicine clinical pharmacist as a member of the interdisciplinary team and what effect that has on the time outcome variables. We did not evaluate the activities of the pharmacist and how these specific activities may have contributed to the time dependent endpoints. Our results may be due to having an extra person as part of the team during patient care and not necessarily the importance of it being a pharmacist, however this study was not designed to determine the specific roles of each person in the interdisciplinary team and how each affected the time endpoints