Editorial: The 21st-Century Emergency Department

Last month’s editorial “Pre” Prehospital Care described a new era of making very potent lifesaving medications (epinephrine, naloxone) and devices (AEDs) available to the public without prescription, to be used on anyone in dire need of such lifesaving treatment.

So, if we are making some of our most potent tools available to the public, how are we repurposing the 21^st-century ED to treat other conditions and patients? As noted in the 2013 Rand Report on the Evolving Role of EDs in the United States (http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf), for many people, the ED has become the place to go—or be sent—for CT scans, MRIs, additional blood work, observation and treatment, or admission to the hospital. Increased patient volume, prolonged stays, and newer, complex patient needs are making the large, urban ED a more difficult environment in which to ensure that each patient receives the correct dose of the correct medication, at the correct time. This is especially true for pain meds. The 21^st-century ED is also increasingly the place where the emergent diagnostic and therapeutic needs specific to an aging population are appropriately addressed.   

In this issue of EM, Michael Stern, MD, and Mary Mulcare, MD, consider the advantages of treating elderly patients with emergencies in a purpose-built geriatric emergency department (GED), utilizing specific bedside clinical protocols designed to rapidly diagnose and treat the elderly without causing iatrogenic problems and prolonged hospital stays. Also in this issue, Peter Byers, MD, and Associate Editor in Chief, Francis Counselman, MD, take EM readers through a grand tour of modern pain management for the most common painful conditions typically presenting to an ED, while avoiding both undertreatment and the overprescribing that leads to dependency and abuse.

Prescribing the correct medications and doses for older adults and younger children, and choosing and correctly dosing pain meds—along with a myriad of other prescribing needs required of multitasking, overworked, EPs—all can be substantially aided by a pharmacist stationed in the ED 24/7. An ED pharmacist can help guide the choices and doses of meds administered in the ED, and also provide help with outpatient prescriptions. Alerting the EP to possibly dangerous drug interactions and helping with medication reconciliation are but two of the many important patient care and patient safety services ED pharmacists can provide.

A recent story about ED pharmacists on National Public Radio (NPR) noted that at Children’s Medical Center in Dallas, 10 full-time ED pharmacists are assigned to the pediatric ED where they provide 24-hour review of every one of the almost 20,000 weekly prescriptions and medication orders in real time (http://www.npr.org/blogs/health/2014/06/09/318567633/hospitals-put-pharmacists-in-the-er-to-cut-medication-errors. June 9, 2014.). Also noted in the NPR story was a February 2013 Annals of Emergency Medicine study by Cesarz et al (2013;61[2]:209-214) finding that EM pharmacists intervened in 8.5% of adult prescriptions and 23.6% of pediatric prescriptions.

The issues related to pain meds alone could probably keep an ED pharmacist busy for an entire shift, and hospitals are now beginning to pilot pain-management teams in the ED. Though some may bemoan the evolution toward specialty teams à la football instead of baseball, a team consisting of as few as one NP or PA, working together with EPs to assess, reassess, and manage their ED patients’ pain, will not only improve an ED’s record of compliance with the CMS ED core measure of “door-to-pain treatment time,” but will help address the concerns raised by Drs Byers and Counselman, and Drs Stern and Mulcare about the under- and overtreatment of pain.

In the 21st century, EPs can look forward to a very different ED than the one in which we worked in the 1970s and 1980s. The large urban 21st-century ED will have discrete areas for pediatric, adult, elderly, and psychiatric patients, while ED pharmacists and pain management providers will aid EPs, NPs, PAs, and RNs in delivering state-of-the-art care for our patients.

Last month’s editorial “Pre” Prehospital Care described a new era of making very potent lifesaving medications (epinephrine, naloxone) and devices (AEDs) available to the public without prescription, to be used on anyone in dire need of such lifesaving treatment.

So, if we are making some of our most potent tools available to the public, how are we repurposing the 21^st-century ED to treat other conditions and patients? As noted in the 2013 Rand Report on the Evolving Role of EDs in the United States (http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf), for many people, the ED has become the place to go—or be sent—for CT scans, MRIs, additional blood work, observation and treatment, or admission to the hospital. Increased patient volume, prolonged stays, and newer, complex patient needs are making the large, urban ED a more difficult environment in which to ensure that each patient receives the correct dose of the correct medication, at the correct time. This is especially true for pain meds. The 21^st-century ED is also increasingly the place where the emergent diagnostic and therapeutic needs specific to an aging population are appropriately addressed.   

In this issue of EM, Michael Stern, MD, and Mary Mulcare, MD, consider the advantages of treating elderly patients with emergencies in a purpose-built geriatric emergency department (GED), utilizing specific bedside clinical protocols designed to rapidly diagnose and treat the elderly without causing iatrogenic problems and prolonged hospital stays. Also in this issue, Peter Byers, MD, and Associate Editor in Chief, Francis Counselman, MD, take EM readers through a grand tour of modern pain management for the most common painful conditions typically presenting to an ED, while avoiding both undertreatment and the overprescribing that leads to dependency and abuse.

Prescribing the correct medications and doses for older adults and younger children, and choosing and correctly dosing pain meds—along with a myriad of other prescribing needs required of multitasking, overworked, EPs—all can be substantially aided by a pharmacist stationed in the ED 24/7. An ED pharmacist can help guide the choices and doses of meds administered in the ED, and also provide help with outpatient prescriptions. Alerting the EP to possibly dangerous drug interactions and helping with medication reconciliation are but two of the many important patient care and patient safety services ED pharmacists can provide.

A recent story about ED pharmacists on National Public Radio (NPR) noted that at Children’s Medical Center in Dallas, 10 full-time ED pharmacists are assigned to the pediatric ED where they provide 24-hour review of every one of the almost 20,000 weekly prescriptions and medication orders in real time (http://www.npr.org/blogs/health/2014/06/09/318567633/hospitals-put-pharmacists-in-the-er-to-cut-medication-errors. June 9, 2014.). Also noted in the NPR story was a February 2013 Annals of Emergency Medicine study by Cesarz et al (2013;61[2]:209-214) finding that EM pharmacists intervened in 8.5% of adult prescriptions and 23.6% of pediatric prescriptions.

The issues related to pain meds alone could probably keep an ED pharmacist busy for an entire shift, and hospitals are now beginning to pilot pain-management teams in the ED. Though some may bemoan the evolution toward specialty teams à la football instead of baseball, a team consisting of as few as one NP or PA, working together with EPs to assess, reassess, and manage their ED patients’ pain, will not only improve an ED’s record of compliance with the CMS ED core measure of “door-to-pain treatment time,” but will help address the concerns raised by Drs Byers and Counselman, and Drs Stern and Mulcare about the under- and overtreatment of pain.

In the 21st century, EPs can look forward to a very different ED than the one in which we worked in the 1970s and 1980s. The large urban 21st-century ED will have discrete areas for pediatric, adult, elderly, and psychiatric patients, while ED pharmacists and pain management providers will aid EPs, NPs, PAs, and RNs in delivering state-of-the-art care for our patients.

Last month’s editorial “Pre” Prehospital Care described a new era of making very potent lifesaving medications (epinephrine, naloxone) and devices (AEDs) available to the public without prescription, to be used on anyone in dire need of such lifesaving treatment.

So, if we are making some of our most potent tools available to the public, how are we repurposing the 21^st-century ED to treat other conditions and patients? As noted in the 2013 Rand Report on the Evolving Role of EDs in the United States (http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf), for many people, the ED has become the place to go—or be sent—for CT scans, MRIs, additional blood work, observation and treatment, or admission to the hospital. Increased patient volume, prolonged stays, and newer, complex patient needs are making the large, urban ED a more difficult environment in which to ensure that each patient receives the correct dose of the correct medication, at the correct time. This is especially true for pain meds. The 21^st-century ED is also increasingly the place where the emergent diagnostic and therapeutic needs specific to an aging population are appropriately addressed.   

In this issue of EM, Michael Stern, MD, and Mary Mulcare, MD, consider the advantages of treating elderly patients with emergencies in a purpose-built geriatric emergency department (GED), utilizing specific bedside clinical protocols designed to rapidly diagnose and treat the elderly without causing iatrogenic problems and prolonged hospital stays. Also in this issue, Peter Byers, MD, and Associate Editor in Chief, Francis Counselman, MD, take EM readers through a grand tour of modern pain management for the most common painful conditions typically presenting to an ED, while avoiding both undertreatment and the overprescribing that leads to dependency and abuse.

Prescribing the correct medications and doses for older adults and younger children, and choosing and correctly dosing pain meds—along with a myriad of other prescribing needs required of multitasking, overworked, EPs—all can be substantially aided by a pharmacist stationed in the ED 24/7. An ED pharmacist can help guide the choices and doses of meds administered in the ED, and also provide help with outpatient prescriptions. Alerting the EP to possibly dangerous drug interactions and helping with medication reconciliation are but two of the many important patient care and patient safety services ED pharmacists can provide.

A recent story about ED pharmacists on National Public Radio (NPR) noted that at Children’s Medical Center in Dallas, 10 full-time ED pharmacists are assigned to the pediatric ED where they provide 24-hour review of every one of the almost 20,000 weekly prescriptions and medication orders in real time (http://www.npr.org/blogs/health/2014/06/09/318567633/hospitals-put-pharmacists-in-the-er-to-cut-medication-errors. June 9, 2014.). Also noted in the NPR story was a February 2013 Annals of Emergency Medicine study by Cesarz et al (2013;61[2]:209-214) finding that EM pharmacists intervened in 8.5% of adult prescriptions and 23.6% of pediatric prescriptions.

The issues related to pain meds alone could probably keep an ED pharmacist busy for an entire shift, and hospitals are now beginning to pilot pain-management teams in the ED. Though some may bemoan the evolution toward specialty teams à la football instead of baseball, a team consisting of as few as one NP or PA, working together with EPs to assess, reassess, and manage their ED patients’ pain, will not only improve an ED’s record of compliance with the CMS ED core measure of “door-to-pain treatment time,” but will help address the concerns raised by Drs Byers and Counselman, and Drs Stern and Mulcare about the under- and overtreatment of pain.

In the 21st century, EPs can look forward to a very different ED than the one in which we worked in the 1970s and 1980s. The large urban 21st-century ED will have discrete areas for pediatric, adult, elderly, and psychiatric patients, while ED pharmacists and pain management providers will aid EPs, NPs, PAs, and RNs in delivering state-of-the-art care for our patients.