Dispensing Medications at the Hospital Upon Discharge from an Emergency Department Abstract

TECHNICAL REPORT Dispensing Medications at the Hospital Upon Discharge From an Emergency Department

Loren G. Yamamoto, MD, MPH, MBA, Shannon Manzi, abstract PharmD, and THE COMMITTEE ON PEDIATRIC EMERGENCY Although most health care services can and should be provided by their MEDICINE medical home, children will be referred or require visits to the emer- KEY WORDS emergency department, medication, pharmacy, hospital, gency department (ED) for emergent clinical conditions or injuries. Con- discharge tinuation of medical care after discharge from an ED is dependent on ABBREVIATIONS parents or caregivers’ understanding of and compliance with follow-up ED—emergency department instructions and on adherence to medication recommendations. ED This document is copyrighted and is property of the American visits often occur at times when the majority of pharmacies are not Academy of Pediatrics and its Board of Directors. All authors open and caregivers are concerned with getting their ill or injured have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through child directly home. Approximately one-third of patients fail to obtain a process approved by the Board of Directors. The American priority medications from a pharmacy after discharge from an ED. The Academy of Pediatrics has neither solicited nor accepted any option of judiciously dispensing ED discharge medications from the ED’s commercial involvement in the development of the content of outpatient pharmacy within the facility is a major convenience that this publication. overcomes this obstacle, improving the likelihood of medication ad- The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. herence. Emergency care encounters should be routinely followed up Variations, taking into account individual circumstances, may be with primary care provider medical homes to ensure complete and appropriate. comprehensive care. Pediatrics 2012;129:e562–e566 All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, INTRODUCTION revised, or retired at or before that time. The purpose of this report is provide information to support judicious dispensing of medications to improve compliance with discharge instructions and adherence to medication recommendations after a visit to the emergency department (ED). Unlike scheduled or sick visits to the medical home, most ED visits are unplanned and occur during “off hours.” Families may be limited in their ability to get prescriptions filled immediately for treatment of these acute conditions. Although the primary site of health care should be in the medical home, the ED plays an important role as a safety net for – children requiring emergent medical care.1 4 Medical care provided www.pediatrics.org/cgi/doi/10.1542/peds.2011-3444 in EDs often requires the treatment of acute clinical conditions, with doi:10.1542/peds.2011-3444 a high priority placed on the timely administration of medications PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). such as analgesics, antibiotics, bronchodilators, and corticosteroids. Copyright © 2012 by the American Academy of Pediatrics Prompt initiation and maintenance of therapy are important factors in achieving an optimal therapeutic effect. Relapses or exacerbations of chronic conditions (eg, epilepsy, diabetes) are often attributable to medication nonavailability or nonadherence. Because emergency care is provided around the clock, the lack of available pharmacy services to dispense outpatient medications can be a significant therapeutic barrier. Community-based pharmacies that are open 24 hours a day are valuable community resources in providing these medications at all hours. However, the nearest 24-hour pharmacy may be quite far

e562 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 23, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS from the ED, and then the patient or potentially risky not to provide addi- administration of antibiotic suspen- parent must wait for the medication tional doses on discharge from the ED sions requires that unit doses be to be dispensed. Most patients and for home use. Even families who adhere created. Pharmacies at larger hospi- families have already spent a con- to medication regimens might have tals can efficiently dispense multiple siderable amount of time in the ED difficulty getting such prescriptions fil- unit doses, but smaller hospitals are receiving diagnostic tests and treat- ledintimeforthepatient’s next dose. more likely to use fewer doses, re- ment, and some families do not have During epidemics when there may be sulting in more wastage of the remain- the resources to easily travel to an off- medication shortages, EDs can be ing reconstituted antibiotic suspension. site pharmacy. These factors may im- prepared to dispense medication to First-dose administration practice can pede adherence to essential discharge those most a risk. Parents frequently at least guarantee that the first dose is medications and instructions. request that medications be dispensed given, and if the patient is observed fl Several studies have demonstrated low from the ED, because it is perceived to brie y, it improves the likelihood that medication adherence rates after ED be faster, more convenient, and a logi- an immediate adverse reaction can be visits.5–14 In one of the more recent cal patient expectation. Many families recognized and addressed. This prac- studies, one-third of insured pediatric may be unfamiliar with the location of tice can also reduce the need for ini- patients who were prescribed “priority local pharmacies, especially a particu- tial parenteral antibiotic dosing, although medications” (defined as new medi- lar pharmacy providing late night ser- long-duration parenteral antibiotics cations for an acute condition that ex- vice. Dispensing medications for the have some advantages over oral cluded over-the-counter medications, acute illness or injury from the ED is a antibiotics. Administering a single oral refills, and continuation of therapy that means to both improve service to the dose in the ED does not necessarily was previously initiated) did not pick patient and provide better care. The ensure adherence, because the re- fi them up.5 In examining the Medicaid medical home should be noti ed of mainder of the medication course subgroup separately, half did not pick the ED visit and medications prescribed. must be obtained from an outpatient fi up their “priority medications,”5 de- Renewal of medications or re lls of pharmacy, but it does permit the ’ spite the absence of financial barriers. these medications after the acute ill- patients family to return home to get The resources spent on emergency ness or injury should be done by the some rest so that they can obtain the care will not result in optimal out- primary physician in the medical home. remainder of the medication course at a more convenient time. Although comes unless prompt medication ad- administering the first antibiotic dose herence is achieved. Knowing that PRACTICES THAT HAVE BEEN in the ED has significant advantages, medication adherence rates are likely PROPOSED AS POTENTIAL dispensing the entire course from the to be low, many emergency physicians SOLUTIONS ED is more convenient and is more in choose to err on the side of caution Prescriptions May Be Called In, line with patient expectations. Factors and administer more medications (eg, Faxed, or Submitted Electronically that improve full adherence are less corticosteroids, long-acting intramus- to the Community Pharmacy likely to result in complications from cular antibiotics) before discharging Although this has the potential to save treatment failure and induction of anti- patients from the ED, further increasing time, pharmacists will typically give biotic resistance. cost and lengthening ED stays, or they priority to patients who are physically may choose to hospitalize the patient to present and waiting over a patient who A Few Days’ Supply of Medication avoid the risks associated with non- may or may not show up. Some anti- Can Be Dispensed to Allow the adherence, adding additional cost. biotic suspensions are expensive, and Patient Enough Time to Get to Although pharmacy access is not the if the patient does not pick it up, the a Neighborhood Pharmacy only factor determining medication pharmacy might have to discard the This solution also works better for adherence, it has been demonstrated medication. Thus, suspensions are fre- medications in pill or capsule formula- 9 to be a significant one. Most studies quently not reconstituted until the tions but not as well for suspensions. A of medication adherence have been patient is physically present. potential pitfall of this method is the conducted in adult populations, but failure of the caregiver to fill the re- pediatric studies have demonstrated The First Antibiotic Dose Can Be mainder of the prescription because 5,11,12 similar nonadherence rates. Administered in the ED the child appears to be feeling better. The short duration of action of some This works well for patients who are This would also require a second medications (eg, albuterol) makes it able to take pills. For children, first-dose prescription to be written for the

PEDIATRICS Volume 129, Number 2, February 2012 e563 Downloaded from www.aappublications.org/news by guest on September 23, 2021 outpatient pharmacy and a second supported by the revenue gained from Insurance Companies Might pharmacist to be involved in dispen- filling home medication prescriptions. Choose to Deny Payment for singasinglecourseoftherapy.Both Many patient care improvements are Outpatient Medications Dispensed are potential sources of error. Elec- not cost-neutral, but the overall sys- by an Inpatient Pharmacy tronic health record and order entry tematic improvement in patient care This is difficult to confirm or refute, systems would need to generate 2 may justify these expenses. Competing because insurance company reim- “prescriptions” with coordinated start demands for pharmacist resources bursement practices may vary within and stop dates, making the process wouldneedtobeaddressedinmost a given state or region or health plan. of ordering a single course of ther- health systems. Expecting that patient In theory, there should be no reason apy twice as complicated and time- satisfaction improvements will be why an insurance company would re- consuming. without cost is unreasonable. In this imburse a community outpatient phar- case, patient satisfaction and medi- macy but not a hospital pharmacy, as Drug Company Samples cation adherence can both potentially long as the costs and the regulatory Can Be Used improve. requirements are the same. If this Samples dispensed in a private office practice becomes more common, then setting are severely restricted in insurance company reimbursement There Is Concern That This hospital-based EDs, essentially making practices for this are likely to become Prescribing Practice Might Be them infeasible. All medications dis- Illegal more consistent. Having a 24-hour out- pensed within a hospital (including patient pharmacy available to service samples) must be managed and reg- Some states have regulations limiting the needs of the ED would address this ulated by the pharmacy. Additionally, outpatient dispensing by an inpatient concern as well. samples are only available for a small facility. For example, the state of proportion of medications used in Massachusetts allows hospital inpa- Hospitals Might Have an Economic children, and the appropriate formu- tient pharmacies to dispense up to 14 Advantage (Because of Size and/or lation is often not available, making days of medication, whereas the state Nonprofit Status) Over Small this option difficult to manage and of Washington only allows hospital Community Pharmacies, Because unreliable. Electronic health records inpatient pharmacies to dispense a 24- Hospitals Purchase Medications in that maintain a patient’s medication hour supply, except in extraordinary Larger Bulk and Under Different record would have difficulty keeping circumstances. Many hospital phar- Contract Agreements track of medication samples, because macies have created programs to This may be true relative to smaller it is possible that no prescription dispense to outpatients when con- community pharmacies; however, it is would be generated, resulting in a fronted with extraordinary circum- less common that a 24-hour pharmacy lack of records in the patient’s pre- stances, such as free-care patients or is a small community pharmacy. The scription history. medications that cannot be obtained current 24-hour pharmacies are gen- in the community. Regulations cited erally part of larger pharmacy chains BARRIERS TO DISPENSING HOME typically apply to medications dis- that have similar purchasing strength. MEDICATIONS FROM THE ED pensed by the ED (not a pharmacy), Federal case law has been established medications dispensed by the hospi- in this issue, and the only restriction is Staffing of a 24-Hour Outpatient tal inpatient pharmacy, medications that hospital-based pharmacies are Pharmacy Is Not Likely to Be Cost- dispensed by the hospital, or a limited Effective limited in the total day supply that can subset of medications (eg, controlled be dispensed.14 Transferring all the home prescrip- substances or “dangerous” medications from the ED to the pharmacist(s) tions). Note that these special regu- POTENTIAL ADVERSE EFFECTS OF increases their workload substantially, lations apply to hospital units or DISPENSING MEDICATIONS FROM such that it might compromise the inpatient pharmacies but not to THE ED OR HOSPITAL PHARMACY other duties of the pharmacist(s) and outpatient pharmacies, therefore create the potential for medication the most efficient solution with the Dispensing Home Medications errors. Staffing of additional pharma- fewest regulatory obstacles is to From the ED or Hospital Pharmacy cists may be difficult to achieve, be- have a 24-hour outpatient phar- Simplifies and Increases the cause they are in short supply in many macy available to service the needs Convenience of Obtaining areas or the expense may not be of the ED. Medications, Which Might Further

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Encourage the Inappropriate Use Need for the Medication Is a to an ED for an acute illness or injury of the ED (Versus the Medical High Priority occur. Access to quality emergency care Home) for Minor Acute Care For example, refilling a prescription should be available to all, including The medical home is the preferred site that will run out in 1 week is not the access to the essential components of of care for most common illnesses and role of an ED pharmacy. A standardized “after care” following an ED visit. minor injuries. Most EDs will triage set of indications for dispensing dis- Failing to provide access to appropri- patients with minor acute conditions to charge medications from the ED out- ate medications to treat conditions lower-priority categories, resulting in patient pharmacy (including a no-charge identified by emergency care encoun- longer waiting times in most cases. It is compassionate care provision) can be ters compromises the emergency a rare family that would wait hours in agreed on in advance to facilitate this care safety net. Children and families an ED just for the convenience of also process. Creation of such a system with no insurance and no ability to pay getting their discharge medications. also permits physicians to appreciate for medications at a retail pharmacy are Perceived abuse of the emergency care cost and efficacy factors that are not likely to be given medications at no system is more likely to be a symptom assessed to a lesser degree during charge. Some parents will not disclose of community primary care availability conventional medication prescribing inability to pay at the time of the ED rather than the desire to get a conve- decisions. Special circumstances that encounter. By dispensing medications nient medication. Not dispensing med- cannot be anticipated in advance can at the site of service, inability to pay ications from the ED does not fixthis be considered on a case-by-case basis can be identified promptly so that less problem. On the contrary, providing with the ED physician and the phar- costly therapeutic options can be of- medications from the ED under these macist on duty. fered or a no-charge compassionate circumstances helps patients receive care provision can be used to dispense necessary treatment, providing the Dispensing Medications May the medications under a predetermined beneficial safety net of emergency Further Slow ED Throughput protocol. Federal regulations require care. Turnaround time, or “throughput,” is that that emergency care be provided a critical focus in most EDs. By pro- regardless of ability to pay. The benefit fi Obligating Hospital Pharmacies to viding medications for discharge, a of this rst step is not fully realized until Dispense Medications to system must be set up so that dispen- treatment is initiated and completed. Uninsured Patients Increases sing of these medications does not Providing important and necessary Financial Expenses impede patient flow. Such systems medications from the ED outpatient Community pharmacies are unlikely can be accomplished through a pre- pharmacy in selected instances re- to dispense medications at no charge determined list of high-use medi- duces the risk of nonadherence by if the patient lacks financial resources cations that can be dispensed, providing the medications more con- to cover the expense of the medica- which would facilitate the availabil- veniently, reliably, and in a manner tions. Dispensing the medications at ity of templated paper orders or more proximate to the encounter, giving no charge from a hospital pharmacy computerized order sets, preprinted providers additional opportunities to represents an expense, but this ex- labels, and appropriate stock and reinforce medication instructions and pense is often less than the overall supplies. These preparations can their importance. This results in a more fi health care costs of not treating the signi cantly improve turnaround optimal therapeutic approach in con- condition. Small rural hospital EDs time for prescription dispensing in junction with primary care follow-up should not be expected to have the the ED environment. and communication to maximize the same resources as larger hospitals; likelihood of a good outcome. however, there should be an available SUMMARY option for patients to obtain their LEAD AUTHORS Clinical outcomes for many acute Shannon Manzi, PharmD medications. conditions are highly dependent on Loren Yamamoto, MD, MPH, MBA timely access to medications. Optimal Both of These Potential Adverse care is compromised if it is accom- COMMITTEE ON PEDIATRIC – Effects of Dispensing Medications panied by lack of ready access to such EMERGENCY MEDICINE, 2011 2012 medications. Although most health Kathy N. Shaw, MD, MSCE, Chairperson on Discharge From the ED Can Be Alice D. Ackerman, MD, MBA Reduced by Requiring the care should be sought from the medical Thomas H. Chun, MD, MPH Physician to Confirm That the home, unanticipated and off-hour visits Gregory P. Conners, MD, MPH, MBA

PEDIATRICS Volume 129, Number 2, February 2012 e565 Downloaded from www.aappublications.org/news by guest on September 23, 2021 Nanette C. Dudley, MD Kim Bullock, MD – American Academy of Family Cynthia Wright Johnson, MSN, RNC – National Joel A. Fein, MD, MPH Physicians Association of State EMS Ofﬁcials Susan M. Fuchs, MD Toni K. Gross, MD, MPH – National Association of Lou E. Romig, MD – National Association of Brian R. Moore, MD EMS Physicians Emergency Medical Technicians Steven M. Selbst, MD Elizabeth Edgerton, MD, MPH – Maternal and Sally K. Snow, RN, BSN – Emergency Nurses Joseph L. Wright, MD, MPH Child Health Bureau Association Tamar Magarik Haro – American Academy of David W. Tuggle, MD – American College of LIAISONS Pediatrics Department of Federal Affairs Surgeons Isabel A. Barata, MD – American College of Jaclynn S. Haymon, MPA, RN – Emergency Emergency Physicians Medical Services for Children National Re- STAFF source Center Sue Tellez

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Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/129/2/e562 References This article cites 11 articles, 3 of which you can access for free at: http://pediatrics.aappublications.org/content/129/2/e562#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Current Policy http://www.aappublications.org/cgi/collection/current_policy Committee on Pediatric Emergency Medicine http://www.aappublications.org/cgi/collection/committee_on_pediatr ic_emergency_medicine Emergency Medicine http://www.aappublications.org/cgi/collection/emergency_medicine_ sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 23, 2021 Dispensing Medications at the Hospital Upon Discharge From an Emergency Department Loren G. Yamamoto, Shannon Manzi and THE COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE Pediatrics 2012;129;e562 DOI: 10.1542/peds.2011-3444 originally published online January 30, 2012;

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2012 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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