Thank you so much for joining us today to discuss something that I'm very passionate about, which is making sure that our critically ill patients can and should get the care that they deserve when they're boarding in the emergency department. I have no disclosures, but I will say that this will be one big plug, shamelessly, for the use of pharmacists in the emergency department. So today we're going to discuss some special patient populations that we should all give special attention to because they can present with additional challenges, and I'll outline a care plan to make sure that they can get the care that they need and deserve while they're in the ED. So Dr. Ellie did a wonderful job outlining the crisis that we're in right now, wherein we have a higher percentage of critically ill patients presenting to the ED and issues with getting them out of the ED to their ICU beds. Critically ill visits are up over 80%, and depending on the studies that you look at, it is associated with worse outcomes. But I think we can outline a few strategies to mitigate these poor outcomes, increase medication safety, and the care for our patients. So complex patient needs and high volumes of these critically ill patients are leading to longer length of stay, mortality, longer intubation, and increased staff duress. Dr. Ellie, again, outlined that beautifully. However, the one thing that I think we can focus on from a pharmacy perspective is adherence to guideline therapy and prevention of medication errors when we're talking about these special populations. The patients that I'll specifically discuss today are those that are pregnant or pediatric age, pre- and post-transplant, as well as our immunocompromised hematology and oncology patients. Pediatric patients are at high risk for medication errors, and one in 12 ED visits are for a medication-related problem. So there are a few things that I think every pediatric patient needs in order to get optimal care. The first being an accurate weight in kilograms. The Institute of Safe Medication Practices recommends only reporting weights in kilograms, never using estimated or named weights, and to enter them into the electronic medical record at several points throughout the stay. At our institution, we do have standardized dosing guidelines, as well as order sets for pediatric patients. And then we also have a pediatric dosing guideline that we utilize, where you put in the patient's weight, and it gives you a range of doses that are safe for that patient's weight. And then the dose has to be double-checked by a second RN or a pharmacist prior to administration. The next special patient population I want to focus on are pregnant patients. The fetus is starting to be exposed to medications around the fifth week of gestation. However, I think we should treat all medications as if they do reach the fetus and can cause harm. So when I'm taking care of a pregnant patient in the emergency department, I always ask how far along is the mother, what is the risk of the medication to the fetus at that gestational age, and what is the benefit to the mother that we are weighing against the risk? And then finally, I always recommend using a resource to look at all of this information for the medication, and Briggs, Drugs and Pregnancy and Lactation is my favorite resource. It gives a great overview of the literature to support the use or against the use of these medications in pregnancy and breastfeeding. So some of the most critically ill patients we see in the emergency department, particularly at Mayo Clinic, are patients that are pre-transplant. They can easily come in for a decompensation of their original disease or for another reason. However, there are a lot of medication considerations to take into account. Always looking at their organ function, see if any medications need dose adjustments or if they are contraindicated, or how long are they going to last. So your typical dose of morphine in someone with normal renal function is going to last a lot less time than someone who has end-stage renal disease. Specifically looking at heart failure patients, I'm always looking at their home medications, assessing their volume status and seeing if we need to be more aggressive or less aggressive with diuresis. LVAD patients can be very complicated with anticoagulation issues. And then a lot of times these patients in heart failure with pulmonary hypertension have continuous infusion medications that can't be interrupted because if you stop someone's inotrope or their prostanoid, it could be life-threatening. So best practice is to have a hospital-supplied version of that medication to ensure accurate documentation and monitoring from the nurses. And then depending on your institution, you may see more cirrhotic patients or end-stage renal disease patients. And like I said, checking medications for interactions, for efficacy and safety is really important in these patients. They also have home medications that really can't be missed. So if you can think about a patient who takes lactulose four times a day to prevent hepatic encephalopathy and they're sporting in the ED for 12 hours and miss all of those doses, they could eventually become from a floor patient to an intubated ICU patient in a matter of 12 hours. So it's really important to make sure that we're not missing medications that we wouldn't necessarily consider as emergency or ICU medications, but they're still really important to the care of these patients. And then thinking about our post-transplant patients, these immunocompromised patients can be just as complicated, but they get a lot of attention and for a reason. Always assess the graft function. So if they're a kidney transplant, are they having an AKI? Are they having hepatitis after a liver transplant? Is this a sign of rejection or something else? A good medication history is vital for all patients in the ED, but particularly those who are post-transplant and on immunosuppression. Their immunosuppression can be a big risk for medication errors because a lot of the drug formulations are not interchangeable, the routes are not interchangeable, and a lot of them require therapeutic drug monitoring to assess for safety and efficacy. And then a lot of these patients are at very high risk for opportunistic infections and require treatment or prophylaxis, so making sure that those get continued while they're inpatient and thinking about these opportunistic infections if they're presenting with infectious symptoms. I want to highlight one important drug interaction for a transplant patient just as an example. This is a patient who was initiated on Paxilovid for COVID and is a post-kidney transplant patient. Their dose was reduced because of his renal function and then on day two, they obtained a tacrolimus level. So Paxilovid is made up of ritonavir and another antiviral. Ritonavir inhibits the metabolism of tacrolimus so the levels go up. This patient went from a level of five, which was within their therapeutic range, all the way to a level of 30. And as a result, they had an AKI wherein it did not resolve for 20 days. So just think about any medication that you're starting in a patient, consult with your pharmacist, find out if there are any significant drug interactions, and make sure that we're not harming them by trying to do extra help. And then another immunocompromised patient population we should definitely consider are hematology and oncology patients. Most of the time, they present with chest pain, abdominal pain, electrolyte disturbances, pneumonia, or other infections. So they can present just like many of your other ED patients, however, there's an extra layer of complexity because they are immunosuppressed. Another thing to think about with these patients is pain management. Many are on chronic opioids outpatient, and if they're sitting in the ED for 12 hours at a time, and we've given them five milligrams of oxycodone, but they take 30 milligrams of oxy-extended release at home, we are under-treating their pain and putting them at risk for withdrawal syndrome. Infectious considerations are super important for this patient population, and particularly treating neutropenic fever in a timely manner, as well as assessing for anemia and things like that. Immune checkpoint inhibitors are a relatively new mode of therapy for patients with solid tumors or lymphomas, and they can come with a wide variety of side effects and toxicities, and they can affect any organ system that you can think of. So someone may come in with an AKI, or I've seen new onset diabetes because of pancreatic toxicity. So there is a lot to be said for these medications and in consulting an expert and treating them, but also knowing that it could be due to a toxicity of their immunotherapy that they're receiving. Treatment for this can be with steroids, immunosuppression, or just decreasing their dose, depending on the severity of the toxicity, and I would recommend involving the patient's primary team before treating with steroids or something like that. So for all boarding patients, there are a few things that we can do to ensure that they get optimal care, including getting an accurate weight, a thorough medication history, restarting any home medications that you think would be beneficial for them, or keep them from having adverse effects, thinking your beta blockers, your immunosuppression, your outpatient antibiotics, anticoagulation if it's safe. These are things that shouldn't be missed, and if they are, then they can cause severe consequences. And I'm just going to plug pharmacists in the ED, who are very good for drug information, medication therapy monitoring, medication reconciliation, transitions of care, and caring for our boarded patients. So if you don't have a pharmacist in your ED, I would highly recommend getting one, especially if you have a lot of boarders. There are a lot of studies showing that pharmacists in the ED can do a lot of great things. One of the most impressive is a decrease in medication errors by over 70%. And we can do all these great things. We can provide fast care, medication guideline-related therapies, but also we can help save money. This study from 2021 from the Pharm-EM group showed that there can be a savings of over $7 million from over 900 pharmacist EM shifts, an average savings of $8,000 per shift. And I just want to point out the individualization of care and adverse drug event prevention, because that could be something specifically for our special patient populations in the ED. So overall, all ICU patients boarding in the ED should receive a thorough medication history and reconciliation, restarting any medications that they would normally be taking if they were inpatient, and then consult your pharmacist for medication therapy management to optimize their care. Thank you, and I'll be happy to take questions at the end.

quality care

pharmacists

medication safety

special patient populations

medication management strategies