Effect on door‐to‐needle recombinant tissue plasminogen activator administration times for acute ischemic stroke with and without an emergency department pharmacist

Impact of pharmacists during in-hospital resuscitation or medical emergency response events: A systematic review

BACKGROUND

We sought to determine the impact of the presence of a pharmacist on medication and patient related outcomes during the emergency management of critically ill patients requiring resuscitation or medical emergency response team care in a hospital setting.

METHODS

We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search of databases from January 1995 to April 2023 was conducted to identify studies of contemporary pharmacist practice. Results were extracted and analysed for included studies, those evaluating the impact of the presence of a pharmacist on medication and patient related outcomes during the emergency management of critically ill hospitalised patients requiring resuscitation or medical emergency response team care. To determine risk of bias, the Newcastle-Ottowa Quality Assessment scale was used for non-randomised studies and the Revised Cochrane risk-of-bias tool for randomised trials.

RESULTS

Of 1345 studies identified, 54 were selected for full text review, and 30 were included in the final analysis. There were 29 cohort studies and one randomised controlled trial. The studies reported the impact of a pharmacist for a variety of patient presentations. The study team assigned each study to one of eight patient cohorts: acute stroke, cardiac arrest, rapid response calls, S-T segment elevation myocardial infarction, acute haemorrhage, major trauma resuscitation, sepsis and status epilepticus. The most frequently reported outcome, associated with a statistically significant benefit in 23 studies, was time to medication administration. Few studies reported a significant difference in patient outcome measures such as mortality. Only 8 of the 30 studies were assessed to have a low risk of bias.

CONCLUSIONS

The results of this systematic review provide support for a beneficial impact of a pharmacist presence and intervention during resuscitation or medical emergency response team care, with significant improvements in outcomes such as time to initiation of time-critical medications, medication appropriateness and guideline compliance. However, studies were predominantly small and retrospective and were not powered to detect differences in patient related measures such as length of stay and mortality. Future research should investigate the clinical impacts of the pharmacist in ED resuscitation settings in controlled, prospective studies with robust sampling methods.

Impact of an emergency medicine pharmacist on door to needle alteplase time and patient outcomes in acute ischemic stroke

PURPOSE

Time is a critical metric in the emergency department (ED) for acute ischemic stroke and thrombolytic therapy. National guidelines have emphasized tracking time from stroke onset to treatment and decreasing door to needle (DTN) time [1, 2]. Multidisciplinary teamwork is encouraged but, there is limited evidence demonstrating the value of the pharmacist on the stroke response team. The goal of this study is to compare DTN times in the ED with or without a pharmacist at bedside and examine the impact on subsequent patient outcomes.

METHODS

This was a single-center retrospective cohort study. Investigators identified patients who presented to the ED between August 2016 - May 2020 with signs of ischemic stroke and subsequently received intravenous alteplase. Patients were excluded if they refused alteplase or received alteplase off-campus before being transferred. Pharmacist documentation of clinical interventions was used to identify participation on the stroke response team. The primary outcome was median DTN time. Secondary outcomes included severity of deficits measured by the National Institutes of Health Stroke Scale (NIHSS), hospital length of stay (LOS), 90-day Modified Rankin Scale (mRS), incidence of intracranial hemorrhage (ICH), and inpatient all-cause mortality.

RESULTS

Of the 164 patients included, 31 had an emergency medicine pharmacist at bedside (EMP group) and 133 did not (No EMP group). The median DTN time was significantly shorter at 35 min EMP [interquartile range (IQR) 29-44] vs 42 min No EMP [IQR 34-55]; p = 0.003. The number of cases achieving a DTN time of 30 min or less was significantly higher when a pharmacist was involved (35.5% vs.16.5%; p = 0.018) as well as the number of patients receiving alteplase within 45 min (80.7% vs. 57.1%; p = 0.015). NIHSS scores at discharge were lower in the EMP group (2 [IQR 0-5] vs. 4 [IQR 0-8.25]; p = 0.049). In patients with magnetic resonance imaging (MRI) confirmed stroke, a difference was not observed in the secondary outcomes.

CONCLUSION

Patients with an emergency medicine pharmacist as part of their stroke response team had significantly lower DTN times. A higher proportion of these cases met benchmark DTN times less than 45 min and 30 min. An emergency medicine pharmacist on a stroke response team has the potential to improve patient care.