This document describes a study evaluating the impact of a pharmacist-managed culture review process in an emergency department (ED). The study found that of 819 ED patients discharged with positive cultures in 2013, 21.2% required follow-up due to inappropriate antibiotic coverage. An ED pharmacist intervened in all of these cases, resulting in antibiotic changes for 56% of patients. The pharmacist-managed culture review process improved antimicrobial therapy and care escalation for 69.5% of ED patients with positive cultures. The study illustrates the value of pharmacists in providing antimicrobial recommendations to optimize therapy for ED patients.

1. 1138 Correspondence / American Journal of Emergency Medicine 32 (2014) 1125–1147
[11] iCPR – iPhone App for CPR training. D-Sign S.r.l. 2009, URL: http://www.icpr.it/
[accessed 13.01.11]. Archived at http://www.webcitation.org/5viPE6JUZ.
[12] PocketCPR - Your CPR Coach: PocketCPR for iPhone. Bio-Detek, Inc. 2013, URL:
http://www.pocketcpr.com/iphone.html [accessed 13.01.11]. Archived at http://
www.webcitation.org/5viPRP5yU.
[13] iSkin - pulse. iSkin Inc. 2011, URL: http://www.iskin.com/pulse/details.tpl
[accessed 13.01.11]. Archived at http://www.webcitation.org/5viQlT47f.
[14] Ivor Kovic. CPR PRO Cradle. Ivor Medical. 2010, URL: http://ivormedical.com/
products/cpr-pro-cradle/ [accessed 13.01.11]. Archived at http://www.webcitation.
org/5viQuLDUL.
[15] Rabiner LR, Rader CM. Digital signal processing. New York: IEEE Press; 1972.
[16] Takei Y, Nishi T, Matsubara H, Hashimoto M, Inaba H. Factors associated with
quality of bystander CPR: the presence of multiple rescuers andbystander-
initiated CPR without instruction. Resuscitation 2014;85(4):492–8.
Optimizing antimicrobial therapy through a
pharmacist-managed culture review process in
the ED☆,☆☆
To the Editor,
The establishment of clinical pharmacists in the emergency
department (ED) is an innovative practice implemented by a growing
number of health systems within the past decade. Various studies
have been published on the value of clinical pharmacy services in the
ED. Pharmacists practicing in the ED setting have been shown to
improve drug therapy, decrease medication costs, prevent adverse
drug events, promote medication safety, and provide for overall
continuity of care [1-5]. However, despite the evidence, a 2005 survey
by the American Society of Health System Pharmacists found that only
3.5% of hospitals surveyed have pharmacists assigned to the ED for
any period [6]. Emergency department pharmacists were established
at our institution in July 2007 for the purpose of optimizing patient
care through pharmacist participation in resuscitation efforts, intu-
bations, sedation procedures, medication reconciliation, prospective
order review, facilitation of medication distribution, and drug
information services.
The Legacy Good Samaritan Medical Center ED of our 247-bed
tertiary care hospital provides services to more than 26000 patients
each year. Composed of 22 beds, our ED sees a wide demographic base
of patients from diverse socioeconomic backgrounds with varying
degrees of morbidity. A large percentage of our patient population are
underserved populations (eg, homeless and indigent), presenting
with advanced comorbidities due to lack of funds and access to
medical care. Because of the complexity and acuity of the patients
seen in our ED, approximately 40% of all our ED patients are directly
admitted to the hospital. Currently, a unit-based clinical pharmacist is
stationed in the ED 10 hours per day, 7 days per week. Pharmacy shifts
cover the hours of projected peak patient volume—between 12:30
and 11 PM.
Before extending pharmacy services into the ED, ED providers
were unaware of the significant contributions clinical pharmacists can
make as part of the health care team. After implementing this service,
the ED pharmacists became intimately involved in antimicrobial
stewardship activities by providing antibiotic choice and dose
recommendations. Recognizing pharmacists’ contributions in this
area, our ED providers requested that the ED pharmacist undertake
the review of returned positive culture data for patients discharged
from the ED, which the providers had inconsistently done previously.
Since 2008, the culture and susceptibility reports at our facility have
been reviewed by an ED pharmacist 7 days a week.
To measure the impact of a pharmacist-driven antimicrobial optimi-
zation service in the ED, a retrospective chart review was performed for all
patients with positive cultures from specimens obtained in the ED during
a 1-year period from January to December 2013.
In 2013, 819 patients were discharged from our ED with ensuing
positive cultures. Of these patients, 174 (21.2%) required additional
intervention/follow-up due to inappropriate antimicrobial coverage.
An ED pharmacist intervened in all of these cases. Of the 174 patients
requiring follow-up, 97 patients (56%) required an antibiotic change
or addition, 24 patients (14%) were referred to their primary care
provider or another specialist, 28 patients (16%) were doing fine on
current therapy, and 25 patients (14%) were lost to follow-up, as our
facility serves a large percentage of homeless and indigent patients
who do not have permanent addresses and are not easily contacted
once they leave our care. Of the patient interventions requiring
additional follow-up, 120 patients (69%) were women, and 54
patients (31%) were men. The average patient age was 48.2 ± 23.7
years, and the median age was 45.5 years with a range of 5 to 101
years. Most positive cultures requiring outpatient follow-up were
urine specimens (50%), followed by wound/abscesses (12%), sexually
transmitted disease tests (9.2%), and throat cultures (8.6%).
Pharmacists at our institution have made a significant impact on
patient care through the implementation of a pharmacist-managed
culture review process in the ED, which resulted in antimicrobial
therapy modification and/or escalation of care in 121 (69.5%) ED
patients with ensuing positive cultures within the past year. Our study
illustrates the value of pharmacists as drug information experts to
provide effective antimicrobial therapeutic recommendations for ED
patients with positive cultures who otherwise might not receive
consistent follow-up. We strongly encourage all hospitals to use a
pharmacist-managed culture review process in the ED for both
ensuring continuity of care between the hospital and outpatient
setting as well as achieving optimal patient outcomes.
Elva A. Van Devender, PhD, PharmD
Legacy Good Samaritan Medical Center,
1015 NW 22nd Ave, Portland, OR 97210
Corresponding author. Tel.: +1-503-413-7145
E-mail address: evandeve@lhs.org
http://dx.doi.org/10.1016/j.ajem.2014.05.037
References
[1] Wymore ES, Casanova TJ, Broekemeier RL, et al. Clinical pharmacist’s daily role in
the emergency department of a community hospital. Am J Health Syst Pharm
2008;65(395–6):398–9.
[2] Fairbanks RJ, Hays DP, Webster DF, et al. Clinical pharmacy services in an
emergency department. Am J Health Syst Pharm 2004;61:934–7.
[3] Cohen V, Jellinek SP, Hatch A, Motov S. Effect of clinical pharmacists on care in the
emergency department: a systematic review. Am J Health Syst Pharm
2009;66:1353–61.
[4] Randolph TC. Expansion of pharmacists’ responsibilities in an emergency
department. Am J Health Syst Pharm 2009;66:1484–7.
[5] Weant KA, Humphries RL, Hite KM, et al. Effect of emergency medicine pharmacists
on medication-error reporting in an emergency department. Am J Health Syst
Pharm 2010;67:1851–5.
[6] American Society of Health-System Pharmacists. ASHP statement on pharmacy
services to the emergency department. http://www.ashp.org/s_ashp/docs/files/
BP07/New_ED.pdf . [accessed 2013 Dec 29].
☆ There are no conflicts of interest to disclose.
☆☆ EAV compiled all the data, performed analysis on the data, and drafted the
manuscript. No other parties contributed to this work. This work has not been
presented at any other meetings and was done without grant funding.