Pharmacists to the (Early) Rescue

One of the 12 interventions in the Institute for Healthcare Improvement’s 5 Million Lives Campaign is the Rapid Response Team, a small team of critical care experts available to rush to the bedside of any patient who shows early signs of deteriorating health. Working with the patient’s nurse, these teams — typically composed of a critical care nurse, a respiratory therapist, and sometimes a physician or physician assistant — can often prevent serious incidents such as cardiac arrest by intervening at the very first sign of trouble.

 
Now, some hospitals are discovering that the Rapid Response Team that has a pharmacist attached to it is even more effective, ensuring that medications are available and, where appropriate, helping determine the cause of a patient’s decline and offering expert clinical advice.
 
“Putting pharmacists on Rapid Response Teams brings a level of expertise that can be invaluable in an urgent situation,” says Frank Federico, RPh, an Institute for Healthcare Improvement Director. “Having a pharmacist on the scene can save time and expedite appropriate treatment.” This is an example of the way in which pharmacists’ roles are changing, says Federico, evolving from professionals “merely” responsible for dispensing medication to important members of clinical teams with valuable therapeutic expertise. This shift reflects a greater focus by regulatory and accreditation agencies, as well as organizations such as IHI, on reducing preventable complications and harm to patients, much of which involves medication safety.
 
At Long Beach Memorial Medical Center in Long Beach, California, pharmacists have always been integrated into the clinical team, says Carl Kildoo, PharmD, Clinical Director of Pharmacy. Long Beach Memorial and the Miller Children’s Hospital, which shares its campus, have a combined 768 beds; both facilities are part of the California-based MemorialCare integrated health system.
 
“We’ve had a clinical pharmacy program and a Pharmacy Residency Program for more than 30 years,” Kildoo says. Activities have long included involvement in CPR response, including documentation of the event. Therefore, “it was natural for us to include pharmacists on the Rapid Response Team.” Indeed, whenever the Rapid Response Team is called at Long Beach Memorial, the pharmacist is called too. “The pharmacist on the team reviews the patient’s medications to identify any potential medication-related problems, and facilitates obtaining medications quickly as needed.”
 
This can be especially important when the medication required is one to which nurses do not have direct and quick access through the hospital’s automated medication dispensing cabinets located in patient care areas. “If the patient is experiencing worrisome low blood pressure, for example, the pharmacist can facilitate obtaining a vasoactive infusion such as dopamine for a patient being transferred to the ICU,” says Kildoo. Having a pharmacist on the scene saves precious minutes that this process might otherwise take.
 
Once the patient’s medication needs are met, the pharmacist can leave unless the patient’s problem is heavily medication-related, says Kildoo. And in some cases the pharmacist can quickly determine that he or she is not needed at all. “Some calls don’t require a pharmacist’s expertise,” says Kildoo. “With limited staff, you have to use the pharmacist’s time efficiently.”
 
For this reason, Long Beach Memorial uses different procedures on the night shift when there are only two pharmacists working. “At night, pharmacists don’t automatically go on Rapid Response Team calls, but nurses know they can call for one if needed,” says Kildoo.
 
Danielle Philipson, MHA, CPHQ, Senior Quality Improvement Coordinator for Long Beach Memorial and Miller Children’s Hospital, says that having pharmacists work together with other clinicians in direct patient-care situations helps to solidify already strong relationships among staff. She gets very positive feedback from Rapid Response Team members about the pharmacist’s involvement. “They rely on the pharmacists’ familiarity with dosing and medications, especially for patients with hypertension or arrhythmias, and for identifying reversal agents when patients have respiratory depression due to oversedation.”
 
Kildoo concurs. “The nurses say they really like having the pharmacists on the scene,” he says.
 
At Johns Hopkins Children’s Center in Baltimore, Maryland, the Rapid Response Team and the Code Team (deployed when a patient suffers cardiac or respiratory arrest) are one and the same. Elizabeth Hunt, MD, MPH, says that pharmacists play an invaluable role on the team, and not just in the way that was expected. Hunt is Attending Pediatric Intensivist in the Johns Hopkins Pediatric Intensive Care Unit, and also directs Hopkins’ Simulation Center, which promotes patient safety by training staff using simulated patient situations.
 
“The hospital had included a pharmacist on the adult team for quite a while, but at first we weren’t sure whether we needed one on the pediatric team,” recalls Hunt. But data gathered from mock pediatric code drills convinced them that it would be a good idea. “At mock cardiac arrests or medical emergencies, the nurses were overburdened with a number of things they were asked to do,” explains Hunt. “Their first responsibility should be to do the ABCs [checking airway, breathing, and circulation], but they also felt they needed to draw meds and get equipment in the room for the code team.”
 
So Hunt says they decided to help nurses carry out their roles as first responders more effectively by adding a pharmacist to the team; they also created a first responder curriculum that trains staff on everyone’s specific role in an emergency. Now, it’s the pharmacist who prepares medications in an emergency. “This significantly eases the burden of the first responder nurses and the PICU [pediatric intensive care unit] nurses,” says Hunt. “Now the team keeps functioning while the drug is prepared, instead of a key player turning away from the patient.”
 
The surprise in the two-and-a-half years since pharmacists were added to the pediatric team, says Hunt, has been how valuable pharmacists have been on calls for patients not experiencing cardiac arrest, which are, in fact, most of the calls. “Most calls are hypotension, seizures, or neurological changes, and pharmacists are particularly good at drawing up meds quickly, and they have a direct link to the pharmacy and can get meds we don’t keep in our med boxes on the floors.” They are also attentive to checking for drug allergies, she says, and occasionally identify medications that are inappropriate for the patient.
 
For children who need to be intubated in an emergency, pharmacists are key, says Hunt. “Suddenly you need to sedate and paralyze a child, but we don’t keep narcotics or paralytics readily available,” she says. The solution was to create a bag of certain medications the pharmacist can grab in a hurry. In addition to narcotics and paralytics, the bag includes a pre-loaded epi-pen for anaphylactic reactions, as well as anti-seizure and anti-hypertension medications; the pharmacist also grabs some insulin from the nearby refrigerator.
 
Hunt recalls one memorable time the pharmacist and the bag made all the difference to a child in danger. “We had a child who arrived in the outpatient clinic not breathing. The outpatient code team responded immediately, but they were having difficulty with intubation because the child was waking up. When the Rapid Response Team arrived, the pharmacist had the appropriate drugs right there and was able to administer them quickly. We intubated the child in the outpatient clinic.”
 
Having a pharmacist available for pediatric Rapid Response Team calls or emergencies can be especially important because children’s medication needs are harder to anticipate than those of adults. “In adults, you can pre-prepare some meds for cardiac arrest,” says Hunt. “But because children come in so many sizes, you have to draw up the right dose for each child.”
 
Hunt says that one of the lessons this model has revealed in her hospital is that the majority of the drugs used on pediatric Rapid Response Team calls are not kept in the floors’ emergency drug boxes. “The pharmacist helps us get them quickly by bringing their bag or calling the pharmacy,” she says. And while she recognizes there may be a need to rethink what is stocked in the drug boxes, “the system we’ve developed is working.”
 
Nurses and pharmacists now have a stronger relationship, says Hunt, because of the Rapid Response Teams. “Nurses appreciate that pharmacists make all sorts of interventions go more smoothly. And pharmacists have a better understanding of issues that arise at the bedside, instead of just being on the receiving end of an urgent demand for a drug. It’s been a great model for us, for both clinical and staff-related reasons.”
 
Despite the benefits of this improved collaboration, the industry faces some significant challenges. There aren’t enough hospital pharmacists available to meet current demand, and those working are often stretched thin. Yet as evidence mounts that patients are safer when pharmacists are an active part of care teams — beyond their involvement in medication reconciliation and preventing harm from high-alert medications — hospitals, notes IHI’s Frank Federico, will need to be responsive and inventive. “Each hospital has to define the role of the pharmacist on the team in ways that make the best use of this resource.”
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