Clinical Pharmacy Services in Canadian Emergency Departments: A 2022 National Survey

Abstract

Background

Support for the role of an emergency department (ED) clinical pharmacy team is evidence-based and recognized in numerous professional guidelines, yet previous literature suggests a low prevalence of ED clinical pharmacy services in Canadian hospitals.

Objectives

To update (from a survey conducted in 2013) the description and quantification of clinical pharmacy services in Canadian EDs.

Methods

All Canadian hospitals with an ED and at least 50 acute care beds were contacted to identify the presence of dedicated ED pharmacy services (defined as at least 0.5 full-time equivalent [FTE] position). Three separate electronic surveys were distributed by email to ED pharmacy team members (if available), pharmacy managers (at hospitals without an ED pharmacy team), and ED managers (all hospitals). The surveys were completed between November 2021 and January 2022.

Results

Of the 254 hospitals identified, 117 (46%) had at least 0.5 FTE clinical pharmacy services in the ED (based on initial telephone screening). Of the 51 (44%) of 115 ED pharmacy team survey responses included in the analysis, 94% (48/51) had pharmacists and 55% (28/51) had pharmacy technicians. The majority of pharmacy managers and ED managers identified the need for ED pharmacy services where such services did not exist. Inadequate funding, competing priorities, and lack of training remain the most commonly reported barriers to providing this service. Personal safety concerns were reported by 20% (10/51) of respondents.

Conclusions

Although the establishment of clinical pharmacy services in Canadian EDs has grown over the past 8 years, lack of funding and ED-specific training continue to limit this evidence-supported role in Canadian hospitals.

INTRODUCTION

Clinical pharmacists play a critical and valued role in the emergency department (ED) health care team, one that is recognized in position statements from multiple organizations, including the American Society of Health-System Pharmacists (ASHP), the American College of Emergency Physicians, and the American College of Medical Toxicology.^1–4 The ASHP’s guidelines for the provision of ED pharmacist services mention direct involvement in resuscitation, patient and provider education, and other direct patient care activities.⁴ In 2020, the Board of Pharmacy Specialties recognized emergency medicine as a pharmacy specialty, in recognition of the importance of this area of practice.

Clinical pharmacy in the ED has led to a variety of beneficial outcomes, including reduction in medication errors, greater recognition of adverse drug events (ADEs), and cost savings.^5–9 In the management of acutely ill patients, pharmacist involvement has been associated with reduced time to antibiotic administration in sepsis, faster administration of analgesia for trauma patients, faster sedation and analgesia following rapid-sequence intubation, and reduced mortality in cases of team-based resuscitation in cardiac arrest.^10–15

A previous survey, conducted in 2013, found that 39% (95/243) of Canadian hospitals with 50 or more acute care beds had dedicated pharmacy services in the ED.¹⁶ Pharmacy managers reported that the primary barriers to implementing ED pharmacy services were funding and appropriately trained staff, and 98% of ED managers valued ED pharmacist services in their department.¹⁶

This repeat survey study sought to describe and quantify current ED clinical pharmacy services in Canada and describe their evolution since 2013. Several important events have occurred since the previous study, which might lead to the previous results being outdated: recognition of ED pharmacy as a specialty practice, growing evidence of the benefit of ED clinical pharmacy services, and the COVID-19 pandemic.

METHODS

Study approval was obtained from the Island Health Research Ethics Board. The methods for this cross-sectional survey study were largely unchanged from the 2013 survey, which was reported in 2 previous articles.^16,17 The inclusion criteria (Canadian hospitals with minimum of 50 acute care beds and an ED) remained the same, although the total number of Canadian hospitals had increased since 2013, according to the Canadian Institute for Health Information.¹⁸ No exclusion criteria were applied.

In a primary telephone survey, pharmacy summer students (including A.C.) contacted ED charge nurses and pharmacy staff to inquire about the presence of an ED pharmacist or pharmacy technician of at least 0.5 FTE.

Both English and French versions of 3 different electronic secondary surveys were developed by a panel of 11 Canadian hospital pharmacists with ED experience and were distributed to each of the following groups (with surveys open to participants from November 18, 2021, to January 28, 2022):

• ED clinical pharmacy teams (ED pharmacists or, in hospitals without an ED pharmacist, ED pharmacy technicians) working at least 0.5 FTE in the ED. This survey took approximately 15 minutes to complete (5 minutes if no ED pharmacist), with survey questions assessing the delivery of ED clinical pharmacy services.

• Pharmacy managers, clinical coordinators, or directors (hereafter referred to collectively as “pharmacy managers”) in hospitals with less than 0.5 FTE on the ED pharmacy team). This survey took about 5 minutes to complete, with survey questions assessing potential barriers to initiating ED pharmacist services.

• ED managers of all hospitals. This survey took approximately 5 minutes to complete, with survey questions assessing the perceived value of ED clinical pharmacy services.

The survey questions were largely unchanged from 2013, although some new questions were added, including questions about effects of COVID-19, modern training opportunities, and perception of safety (survey details are available by request to the corresponding author). One survey invitation and 2 reminders were sent by email to each potential participant. The survey software prevented duplicate survey responses from a single survey invitation link. Consent was implied by responding to the survey. Survey responses were voluntary; however, a response to each question was mandatory for each participant. Compensation was not provided.

The electronic surveys were built using Research Electronic Data Capture Systems (REDCap) software. The data were password-protected and stored electronically on a secure server within Canada. Access was limited to a research assistant and 3 of the authors (R.W., L.M., T.S.L.). Aggregate descriptive statistics provided by REDCap were used to analyze the data.

RESULTS

Primary Telephone Survey of Hospital Sites

This study identified 254 hospitals in Canada with at least 50 acute care beds and an ED. Most sites were located in Ontario (31%, 79/254), Quebec (26%, 66/254), British Columbia (13%, 33/254), and Alberta (7%, 18/254). ED pharmacy services were identified in 46% (117/254) of Canadian hospitals, including 73% (43/59) of those with 350 or more acute care beds and 17% (11/66) of smaller hospitals (50–100 acute care beds). In total, 94% (110/117) of sites with ED clinical pharmacy services had ED pharmacists (with or without pharmacy technicians), whereas 6% (7/117) had only ED pharmacy technicians. Only Nova Scotia (82%, 9/11), Manitoba (67%, 8/12), Quebec (65%, 43/66), and New Brunswick (64%, 7/11) had ED pharmacists in more than 50% of the provincial sites.

Figure 1 illustrates the distribution of primary and secondary surveys for all sites and the associated response rates.

FIGURE 1.

The distribution and response rates for a telephone survey and 3 electronic surveys targeting emergency department (ED) pharmacy teams, pharmacy managers, and ED managers. FTE = full-time equivalent.

Secondary Survey of ED Pharmacy Teams (ED Pharmacists or ED Pharmacy Technicians; n = 51)

The ED pharmacy team survey was distributed to 117 sites identified in the primary survey. Of the 53 sites that submitted responses, 2 sites reported less than 0.5 FTE ED pharmacy services and were not included in the secondary survey analysis. Therefore, the survey responses confirmed and described 44% (51/115) of remaining hospitals with at least 0.5 FTE ED pharmacy teams, with 94% (48/51) of surveys completed by ED pharmacists and 6% (3/51) by ED pharmacy technicians.

Secondary Survey of ED Pharmacists (n = 48)

The geographic distribution and hospital descriptors for the 48 responses from ED pharmacists are presented in Table 1.

TABLE 1.

Distribution of ED Pharmacist Responses and Description of Hospitals Surveyed

Characteristic	No. (%) of Responses (n = 48)
Preferred language
English	37 (77)
French	11 (23)
Province or territory
Alberta	3 (6)
British Columbia	6 (13)
Manitoba	5 (10)
New Brunswick	0 (0)
Newfoundland and Labrador	1 (2)
Nova Scotia	5 (10)
Ontario	8 (17)
Prince Edward Island	0 (0)
Quebec	18 (38)
Saskatchewan	2 (4)
Northwest Territories	0 (0)
Nunavut	0 (0)
Yukon	0 (0)
No. of ED visits/day
0–49	1 (2)
50–99	11 (23)
100–149	8 (17)
150–199	11 (23)
≥ 200	12 (25)
Not specified	5 (10)
No. of ED admissions/day
0–9	6 (13)
10–19	15 (31)
20–29	11 (23)
≥ 30	13 (27)
Not specified	3 (6)

ED = emergency department.

Evolution of Clinical Pharmacist Services in the ED

According to survey respondents, 52% (25/48) of ED pharmacist services had been established for 10 years or more, with 8% (4/48) initiated within 4 years before the survey. Although pharmacy departments funded the majority of ED clinical pharmacist positions, EDs provided full or partial funding for ED pharmacists at 6% (3/48) and 4% (2/48) of sites, respectively. About a quarter (23%, 11/48) of sites with an ED pharmacist had funding for an additional ED pharmacist position that remained vacant.

ED Pharmacist Staffing and Hours of Service

About three-quarters (73%, 35/48) of sites had 1 FTE ED pharmacist, 13% (6/48) had 2 FTEs, 4% (2/48) had more than 2 FTEs, and 10% (5/48) had less than 1 FTE. Nearly all (94%, 45/48) reported no change to ED pharmacist staffing as a result of the COVID-19 pandemic. Most respondents (96%, 46/48) reported daytime coverage, and 8% (4/48) had evening coverage; no overnight ED pharmacist services were reported. Most respondents (85%, 41/48) reported provision of Monday through Friday coverage, and 8% (4/48) reported provision of weekend coverage. At three-quarters of the hospitals (75%, 36/48), different pharmacists rotated through the ED, with 33% (12/36) of these reporting varied ED pharmacist service provision because of different training or expertise among the pharmacists. Just over half (56%, 27/48) of the ED pharmacists reported covering additional clinical areas outside of the ED, and 10% (5/48) covered more than 1 ED.

Services

Direct patient care activities performed by ED pharmacists are listed in Table 2, along with the 2013 data¹⁶ for comparison.

TABLE 2.

Frequency of Direct Patient Care Activities^a Performed by ED Pharmacists

Activity	Frequency; Survey Yearb; % of Responses
	> Once per Day		Daily		Weekly		Infrequent		Never		No Response
	2013	2022	2013	2022	2013	2022	2013	2022	2013c	2022	2013	2022
Order verification	50	56	7	13	5	8	23	13	11	10	4	0
Order clarification	82	81	14	13	0	4	2	2	0	0	2	0
Troubleshooting	79	81	18	13	2	6	0	0	0	0	2	0
BPMH or medication reconciliation	77	63	11	13	4	10	5	10	2	4	2	0
Renal assessment	75	75	14	19	2	4	7	2	0	0	2	0
Allergy assessment	64	58	21	25	7	13	4	4	0	0	4	0
Interaction assessment	59	63	29	19	4	17	7	2	0	0	2	0
Drug information	59	44	23	29	7	19	7	6	2	2	2	0
Screening for ADEs on admission	50	56	25	25	4	10	9	4	9	4	4	0
Reporting of medication error or ADE	5	23	23	17	30	29	34	29	4	2	4	0
ED rounds	0	2	25	8	5	6	9	15	59	69	2	0
Therapeutic monitoring	43	38	38	42	11	10	7	10	0	0	2	0
Full pharmaceutical care work-ups	38	40	27	31	16	10	18	15	0	4	2	0
Patient education	NA	13	NA	13	NA	29	NA	42	NA	4	NA	0
Medication preparation	5	15	11	15	11	8	27	25	45	38	2	0
Administration of nonparenteral medication	0	0	2	2	5	2	11	15	80	81	2	0
Administration of parenteral medication	2	0	2	0	5	2	7	8	82	90	2	0
Trauma or “code blue”	5	13	14	15	14	25	27	21	38	27	2	0
Procedural sedation or rapid-sequence intubation	5	6	7	13	7	23	23	10	54	48	4	0
Toxicology review	4	4	14	17	38	29	32	33	11	17	2	0
Outpatient antibiotic assessment	5	6	7	8	4	6	23	0	59	79	2	0
Postdischarge culture and sensitivity assessment	5	10	5	2	5	8	16	13	66	67	2	0

ADE = adverse drug event, BPMH = best possible medication history, ED = emergency department, NA = not applicable.

^aOther activities identified within free-text responses were prescribing, order entry, consultations (geriatrics, preoperative, medication coverage), drug distribution support.

^bResults of 2013 survey (data collected July to September 2013) were previously published by Wanbon and others.¹⁶

^cFor the purpose of comparison with 2022 results, the 2013 responses of “Not applicable or N/A” and “Never” were interpreted as equivalent and were therefore merged as “Never”.

In the current survey, ED pharmacists most commonly assessed 11–15 patients per day, with priority typically given to admitted patients and consultations. Other aspects of prioritization included specific diagnoses, specific age groups, target drugs, and therapeutic drug monitoring. Only a few (6%, 3/48) of the ED pharmacists reported using a triage tool to prioritize patients.

Indirect patient care activities performed by ED pharmacists are listed in Table 3, with 2013 data¹⁶ provided for comparison. Most (90%, 43/48) of the ED pharmacists reported spending less than 25% of their time performing indirect patient care activities. The same proportion (90%, 43/48) reported providing experiential education rotations. Table 4 summarizes the number and distribution of these rotations.

TABLE 3.

Frequency of Indirect Patient Care Activities Performed by ED Pharmacists

Activity	Frequency; Survey Yeara; % of Responses
	> Once per Day		Daily		Weekly		Infrequent		Never		No Response
	2013	2022	2013	2022	2013	2022	2013	2022	2013c	2022	2013	2022
Administration or management	9	4	0	4	21	21	39	44	25	27	5	0
Research	7	6	7	2	13	15	34	35	34	42	5	0
Education or in-service sessions	5	2	5	8	30	19	50	58	5	13	4	0
Formulary review	5	2	0	0	5	8	68	46	18	44	4	0
Drug utilization and drug shortages	4	2	9	2	20	19	50	42	14	35	4	0
Quality improvementb	4	6	4	8	32	17	50	50	7	19	4	0
Committee work	4	2	2	2	50	29	39	50	2	17	4	0
Policy	2	4	4	2	38	17	48	65	5	13	4	0
Disaster preparedness	2	2	0	0	2	2	66	44	27	52	4	0

ED = emergency department.

^aResults of 2013 survey (data collected July to September 2013) previously published by Wanbon and others.¹⁶

^bReferred to as “quality assurance” in the article by Wanbon and others.¹⁶

TABLE 4.

Clinical Pharmacy Experiential Rotations in Emergency Medicine in Canadian Hospitals

Variable	No. (%) of Hospitals (n = 48)
Type of rotationa
Undergraduate	37 (77)
Military	3 (6)
Hospital residency	31 (65)
Postgraduate PharmD	6 (13)
PGY2 / residency year 2	2 (4)
Emergency-related fellowship	0 (0)
None	5 (10)
No. of rotations offered/year
0	5 (10)
1	7 (15)
2	10 (21)
3	7 (15)
4	5 (10)
≥ 5	14 (29)
Regional distribution of rotations
Residencyb	34
Alberta	2 (6)
British Columbia	6 (18)
Manitoba	1 (3)
New Brunswick	2 (6)
Nova Scotia	1 (3)
Ontario	3 (9)
Quebec	17 (50)
Saskatchewan	2 (6)
Postgraduate PharmDb	6
Alberta	1 (17)
British Columbia	4 (67)
Nova Scotia	1 (17)
Critical care PGY2 (ED rotation)	2
British Columbia	2 (100)

ED = emergency department, PGY2 = postgraduate year 2.

^aSome institutions had more than 1 type of experiential rotation.

^bPercentages for this variable do not sum to exactly 100% because of rounding.

Almost half (44%, 21/48) of the ED pharmacists reported involvement with mitigation strategies for opioid use disorder (e.g., implementation of protocols and patient care pathways), and 17% (8/48) were actively involved with relevant direct patient care activities (e.g., naloxone kit dispensing and counselling).

The COVID-19 pandemic affected the ED pharmacist role at 23% (11/48) of sites, with 45% (5/11) of these reporting they were no longer able to participate in the resuscitation room.

Training

More than half (65%, 31/48) of the ED pharmacists had completed a hospital residency, 21% (10/48) had completed a postgraduate PharmD, and 4% (2/48) had completed an ED-specific residency or fellowship. A small proportion (13%, 6/48) had completed the Pharmacotherapy certification of the Board of Pharmacy Specialties, but 31% (15/48) had no additional training beyond an entry-level pharmacist degree. Just over half (52%, 25/48) of respondents had basic cardiopulmonary resuscitation (CPR) training. Of the ED pharmacists who reported performing resuscitation care, 54% (19/35) were certified for Advanced Cardiac Life Support (ACLS), and 6% (2/35) had Pediatric Advanced Life Support certification. Advanced Hazmat Life Support certification, which relates to toxicology training, had been completed by only 6% (3/48).

Communication

Just over three-quarters (77%, 37/48) of ED pharmacists had a designated workspace in the ED. The ED pharmacists were primarily contacted by cell phone (96%, 46/48), in person (81%, 39/48), and/or by pager (46%, 22/48). Almost a third (31%, 15/48) of respondents reported using the relevant Pharmacy Specialty Network of the Canadian Society of Hospital Pharmacists or the Association des pharmaciens des établissements de santé du Québec equivalent to network with other ED pharmacists. Most (69%, 33/48) of the ED pharmacists reported that networking and communications occurred through known contacts; only 6% (3/48) used social media.

Secondary Survey of ED Pharmacy Team (n = 51)

Of the 51 ED pharmacy teams that completed the survey, 48 teams included at least 1 pharmacist, and 28 teams included technicians.

Pharmacy Technicians

At least 28 hospitals in Canada were offering ED pharmacy technician services (Figure 1), and 43% (12/28) of these had at least 2.0 FTE ED pharmacy technicians. All of the hospitals with ED pharmacy technician services provided daytime coverage, and 43% (12/28) provided evening service; no overnight ED pharmacy technician services were reported. The reported roles of ED pharmacy technicians included maintaining ward stock (54%, 15/28), entering medication orders (43%, 12/28), and delivering “stat” medications (39%, 11/28).

Best Possible Medication History and Medication Reconciliation

Nearly all (96%, 46/48) of the ED pharmacists reported conducting best possible medication histories (BPMHs) or medication reconciliation, with 63% (30/48) completing these tasks multiple times a day. The BPMHs were obtained by technicians at 75% (21/28) of the sites with ED pharmacy technicians. One-fifth (20%, 10/51) of the ED pharmacy teams reported completion of BPMH work by nonpharmacy staff, with 70% (7/10) of these EDs using a standard BPMH process. A large proportion (80%, 41/51) stated that ED staffing was inadequate to obtain BPMHs for all admitted patients.

Quantification of BPMHs by ED pharmacy teams varied greatly, with only 16% (8/51) obtaining more than 15 BPMHs per day. BPMHs were prioritized for admitted patients (82%, 42/51) and for patients with a pharmacy consult (53%, 27/51). The BPMH form also functioned as an order form at 67% (34/51) of the hospitals, but only 16% (8/51) of the hospitals had BPMHs documented before admission orders were prepared.

Perception of Personal Safety

A notable proportion (20%, 10/51) of ED pharmacy respondents reported not feeling safe in the ED because of impacts on their own mental health (60%, 6/10), COVID-19 (30%, 3/10), and physical risks (10%, 1/10). Anecdotally, numerous respondents commented on the emotional stress and reduced levels of compassion because of the ED environment and workload. Overall, 53% (27/51) of respondents felt “less safe” because of COVID-19.

Secondary Survey of Pharmacy Managers (n = 31)

The overall response rate for the survey of pharmacy managers was 33% (48/144); however, 17 responses were excluded from the analysis because the pharmacy manager reported an ED pharmacist or technician at the site, despite the primary telephone survey suggesting absence of an ED pharmacy team. The remaining 31 survey responses from pharmacy managers at institutions without ED pharmacists were received primarily from British Columbia (29%, 9/31), Quebec (26%, 8/31), and Ontario (16%, 5/31). The need for an ED pharmacist service was expressed by 77% (24/31). More than half of respondents (61%, 19/31) reported having received a request for an ED pharmacist from the ED. A small proportion (6%, 2/31) reported having a vacant ED pharmacist position, and 23% (7/31) were actively seeking funding for an ED pharmacist position. A few sites (6%, 2/31) reported removal of an ED clinical pharmacist from the ED because of COVID-19. Pharmacy managers perceived the need for clinical pharmacy services in the ED as having either equal (61%, 19/31) or higher (29%, 9/31) priority relative to other care areas.

No funding (90%, 28/31), competing priorities (48%, 15/31), and a lack of trained staff (48%, 15/31) were identified as barriers to initiating ED pharmacist services. The majority of pharmacy managers considered an entry-level pharmacy degree (48%, 15/31) or a hospital residency (42%, 13/31) to be adequate training for an ED pharmacist. A smaller proportion (10%, 3/31) required a postgraduate Doctor of Pharmacy degree or year-2 residency.

Well over half (68%, 21/31) of pharmacy manager respondents stated that they would support an appropriately trained ED pharmacist to select, prepare, and administer parenteral medications to patients with trauma, sepsis, cardiac arrest, acute stroke, or toxic syndrome or for procedural sedation or intubation; 26% (8/31) were unsure about doing so.

Secondary Survey of ED Managers (n = 57)

Survey responses were received from 22% (57/254) of ED managers, with broad representation across Canada. Almost half (46%, 26/57) of these respondents reported having dedicated ED pharmacy services. All of the respondents valued traditional clinical pharmacist services (i.e., medication reconciliation, identifying and resolving drug-related problems, rapid medication delivery, drug information, providing in-service sessions, and counselling patients). Almost all respondents (96%, 55/57) valued an ED pharmacist to assist with high-acuity or critical care patients, including preparing and/or administering medications in cases of trauma, sepsis, cardiac arrest, acute stroke, and toxic syndrome, as well as for procedural sedation or intubation.

Best Possible Medication History

The ED managers reported completion of BPMHs by nurses (47%, 27/57), physicians (47%, 27/57), and paramedics (2%, 1/57), and 74% (42/57) noted that their hospitals had a standardized BPMH process. Almost three-quarters (72%, 41/57) of ED managers expressed the need for additional staffing resources to support BPMH processes in the ED.

The ED managers reported the following factors used to prioritize BPMH work: admitted patients (82%, 47/57), non-admitted patients (30%, 17/57), specific diagnoses (7%, 4/57), and severity of illness according to the Canadian Triage and Acuity Scale (12%, 7/57); a small group (5%, 3/57) reported not having a BPMH prioritization process.

DISCUSSION

Since the 2013 survey, 12 new hospitals were identified and 1 hospital was temporarily closed. The primary survey, which consisted of a telephone call to each site, suggested that ED pharmacy services had increased from 39% (95/243 sites) in 2013 to 45% (115/254 sites) in 2022; however, responses to the secondary electronic surveys were not received from all sites to allow us to confirm these findings.

For all groups, the response rates to the secondary surveys were lower in 2022 than in 2013: ED pharmacy team, 45% vs 67%; pharmacy managers, 33% vs 51%; and ED managers, 22% vs 53%. Conducting the later survey over the December holiday season, during a period with ongoing COVID-19 workload and staffing impacts, may have reduced survey response rates relative to 2013. An increase in the daily number of ED visits may also have been a workload barrier to completing the survey. Lastly, a proportionately large reduction in survey responses from ED pharmacy teams was observed in Ontario, indicating that regional factors may have also contributed. Given the lower response rate and the absence of correction for nonresponses, some results of this study may not entirely represent clinical pharmacy in Canadian EDs at the time of the survey; however, the results may still identify areas for growth.

Although the number of Canadian hospitals with dedicated ED clinical pharmacy services has grown, the overall proportion remains low, including for larger hospitals (those with more than 350 beds). All ED manager respondents described an ED clinical pharmacist service as valuable to their departments, whether or not they currently had this service. With a smaller response rate, selection bias may have occurred, with those interested in ED clinical pharmacy services perhaps being more likely to respond. Most pharmacy managers at sites without an ED clinical pharmacy service suggested that an ED clinical pharmacy service was needed; however, most did not place a higher priority on the ED relative to other care areas, and active funding requests for this service were not common. Lack of funding was identified as a barrier at almost all sites. Given the increase in ED visits and admissions, along with the known roles and benefits of an ED clinical pharmacist service, alternative business cases and funding model strategies should be explored. One example might be the ActionADE program, which funded pharmacists to address ADEs in the ED at several British Columbia hospitals.^19–21

A lack of trained staff was also an identified barrier. Hospital residency programs have limited capacity, and emergency medicine rotations are also limited. There are no specific emergency medicine year-2 residency programs (PGY2) in Canada, and traditional postgraduate PharmD programs are now unavailable. However, half of pharmacy managers would only require an undergraduate degree for an ED pharmacist, with only 3 pharmacy managers requiring a postgraduate PharmD or PGY2 degree. Aside from a greater overall proportion of respondents with ACLS certification, ED pharmacists reported a similar level of training relative to 2013.

Hours of service for ED clinical pharmacy teams and the role of the ED clinical pharmacist were largely unchanged since 2013, but more ED pharmacists were covering additional clinical areas outside the ED. Small trends toward higher-acuity roles (e.g., medication preparation, participation in traumas or “code blue” activities, assisting with procedural sedation and rapid-sequence intubation) and less involvement in indirect patient care roles (e.g., committee work, quality improvement, formulary review) were observed. These observations were not tested statistically, and selection bias may also have been more prominent with the lower response rate; however, 23% of ED pharmacists reported changes in service due to COVID-19.

This survey identified a number of areas for improvement in ED clinical pharmacy services in Canada based on current guidelines and other evidence-based literature, as described in the following paragraphs.

Patient Education

Two of the 8 Canadian consensus-based clinical pharmacy key performance indicators (cpKPIs) involve patient education.²² Patient education by a pharmacist has been associated with a reduction in patient mortality and is recommended in the ASHP guidelines,^4,10,22 yet only 1 in 4 ED pharmacists in the current survey reported performing this activity at least once daily.

Support for Resuscitation, Trauma, Rapid-Sequence Intubation, and Procedural Sedation

ED pharmacist support with resuscitations, a role associated with a reduction in patient mortality (and also recommended in ASHP guidelines), ^4,10,12–16 was reported by over half of hospitals. These activities may be less commonly required at some hospitals. Almost all ED managers and two-thirds of pharmacy managers reported support for the preparation and administration of medications by a pharmacist in cases of resuscitation and other high-acuity events, yet very few ED pharmacists reported providing such services. Further training programs, additional certifications (including CPR and ACLS), and more advocacy within the pharmacy profession are likely needed to support these important ED pharmacist services.

Disaster Preparedness

Disaster preparedness remains an uncommon, yet important, ED pharmacist service. Further literature is now available to guide ED pharmacists with clinical and distributional preparations for disaster events.²³

BPMH by Pharmacy Technicians

The majority of ED managers and ED pharmacy teams reported needing more resources for completing BPMHs, with only a minority of hospitals using pharmacy technicians to obtain BPMHs in the ED. Pharmacy technicians obtain BPMHs as accurately as and more cost-effectively than other health care professionals.¹⁷ Pharmacy technician support for BPMHs in the ED may enable ED pharmacists to prioritize other evidence-based tasks.

Personal Safety

Workplace safety in EDs is a known concern in the nursing literature, with mental and emotional safety perhaps overlooked more than physical safety.^24,25 The current study identified a similar risk among ED pharmacy team members, with 1 in 5 respondents reporting that they did not feel safe in their ED. Although half of ED pharmacy team respondents reported feeling less safe because of COVID-19, only 3 respondents said they felt unsafe because of COVID-19. It is unclear if these responses reflected perceptions in the early COVID-19 (prevaccine) period. Additional staff resources, research, and quality improvement are needed to support staff safety in EDs.

CONCLUSION

Pharmacy services in the ED have continued to grow over the past 8 years, yet a lack of funding and a lack of training opportunities remain significant barriers to the further expansion of these services. Shifting BPMH tasks to pharmacy technicians may assist ED pharmacists in the provision of other guideline- and literature-supported priorities. Mental and emotional safety in the ED was identified as a challenge requiring more support and research.