Day in the life of an Emergency Medicine Pharmacist

Meet Christopher Hidayat! Chris has written a great article below about his role as an emergency medicine pharmacist and gives some great tips for nurses!

Specialist Pharmacist – Emergency Medicine, Westmead Hospital
Clinical Fellow – Graduate School of Health, University of Technology Sydney

Tell us about yourself! And what is your favourite medication and why!

Hello everyone! My name is Chris and I am an Emergency Medicine Pharmacist at Westmead Hospital in Western Sydney. I love the outdoors and am an avid beach goer and hiker. My favourite drug right now has to be the COVID-19 vaccine because it demonstrates the amazing efforts and hard work of our scientific community and healthcare workers in such a short span of time.

Provide a brief overview of your career path to date.

I started off my pharmacy career in Western NSW where I completed my internship at Dubbo Base Hospital. During this time, I gained a lot of insight into some of the challenges of working in a rural area. Post internship, I decided to move to a tertiary teaching hospital to deepen my clinical knowledge and skills and this led me to Westmead Hospital in Sydney. I worked as a rotational clinical pharmacist in a variety of clinical areas before settling into Emergency Medicine.

What made you choose pharmacy as a career?

I have always had a passion for science and humanitarian aid and pharmacy was my first offer after completing the HSC and I took it! I graduated with a Bachelor of Pharmacy and anyone aspiring to become a pharmacist will need to complete this or a Master of Pharmacy through an accredited Australian university.

There are no formal qualifications to become an ED pharmacist but they must have a broad range of clinical knowledge, supported by several years of clinical experience in the hospital setting, particularly in the areas of critical care, cardiology, toxicology, general medicine, infectious diseases, surgery and pain management.

What is an Emergency Medicine Pharmacist?

An ED pharmacist is a pharmacist who is based within the ED, providing a clinical pharmacy service to patients presenting to the ED, as well as supporting the ED with anything and everything medication-related. No day is ever the same and it can range from:

• Conducting medication histories and medication reviews for high-risk patients or patients on multiple medications (with a particular focus on ruling out medication-related problems that may have contributed to their ED presentation)
• Ensuring timely supply of medications particularly those that are time-critical
• Identifying medicine-use problems within the ED and developing solutions to address them (quality improvement)
• Reviewing drug-related guidelines/protocols/procedures to ensure they reflect current best practice (e.g. complicated regimens for IV drugs, antidotes, antivenoms)
• Providing continuing education for medical and nursing staff
• Adverse drug reaction documentation and reporting
• Reviewing and evaluating drug use within the ED particularly high-cost medicine use
• Participating in resuscitation situations to assist with the acutely deteriorating patient
• Participating in the development and implementation of pre-hospital medication protocols e.g. for the medical teams going out to music festivals
• Participating in local disaster and pandemic planning e.g. with the COVID-19 testing clinic

What’re the most rewarding and challenging parts of working as an Emergency Medicine Pharmacist in ED?

For me personally, the most rewarding thing working as an ED pharmacist is the team spirit within the department. EDs are highly stressful, fast-paced, demanding and unpredictable environments and the team you work with make a big difference in terms of your ability to provide high-quality patient care and I am fortunate to have a great team here at Westmead. One of the big challenges of my job is accepting that it is not possible to see every patient presenting to the ED at Westmead and this is where prioritisation becomes really important. It would be a dream come true if we achieved a 1 to 10 pharmacist to patient ratio in our Australian EDs.

What kind of education do you find that nurses need or want?

I do a lot of teaching and education to doctors and nurses and this can be around clinical therapeutics, medication incidents, clinical pearls, drug administration, medication safety and drug updates to name a few. Drug administration is obviously a big part of the nursing role and education around this goes a really long way and is greatly appreciated, particularly when you have IV drugs with complex administration or patients who cannot swallow oral medications and you need to figure out an alternative solution.

In what ways can nurses utilise pharmacists as a resource in a hospital and vice versa?

I think if you’re ever unsure of anything, why the patient was prescribed a certain drug or you’re worried about the dose or you don’t know how to give the drug, don’t be afraid to ask your ward pharmacist or ring down to the pharmacy. It is our job as pharmacists to make sure that patients get the most out of their medicines with minimal adverse effects, keeping them safe at the end of the day.

I think for pharmacists, sometimes it is our nursing staff who know our patients best, they are often the eyes and ears for a lot of hospital staff and the patient’s advocate, so utilise them to find out more about the patient for example their clinical status.

How can nurses and pharmacists work more effectively together?

I already see nurses and pharmacists working collaboratively in a range of clinical settings and it’s really great to see this. All I can say is keep up the great work! Each profession has its own unique body of knowledge and skills to provide and we should harness and combine these to improve patient care.

What are the most common issues that you find nurses struggle with regarding pharmacy?

One common issue I find nurses struggle a lot with is knowing which medications are time-critical. Time-critical medications are defined as medications where early or delayed administration may cause harm to the patient or compromise the therapeutic effect resulting in suboptimal therapy. Some hospitals and health services will have their own locally developed list of time-critical medications but some of these medications include (not an exhaustive list):

• Anticoagulants
• Antimicrobials (particularly in sepsis)
• Antiepileptics
• Antidotes
• Hypoglycaemic agents
• Immunosuppressive agents (e.g. for solid organ transplants and myasthenia gravis)
• Antiparkinsonian medications

Nurses should become familiar with their local health facility’s policy around the management of time-critical medications.

What advice do you have for nurses to improve their pharmacology and medication administration skills?

I often see nurses using MIMS to look up drug information which is OK to find out the basic pharmacology and mechanism of action of the drug but it’s important to keep in mind that it may not have the most up-to-date information or reflect current best practice with regards to indication and doses. If you wanted to find information about indication and doses, the best place to go is the Australian Medicines Handbook or the Therapeutic Guidelines. In terms of drug administration, key resources to be very familiar with is the Australian Injectable Drugs Handbook and the Don’t Rush to Crush Handbook.

Polypharmacy is very common within the ageing population – what is a pharmacists role in managing this?

Australia’s ageing population means that individuals are often on multiple medications to treat a range of chronic diseases. Pharmacists both in the hospital and community setting have a key role in ensuring the safe and effective use of medicines by providing comprehensive medication reviews. This includes identifying actual or potential medication-related problems and making recommendations to prescribers to optimise medicines use. It can also include deprescribing i.e. the process of discontinuing drugs that are either potentially harmful or no longer required, addressing the harms associated with inappropriate polypharmacy.

In the hospital setting, older patients with complex medical backgrounds and on multiple medications are often given priority for pharmacist medication reviews. In the community setting, there are a variety of pharmacy initiatives to target polypharmacy including:

• Home Medicines Review (https://www.healthdirect.gov.au/home-medicines-review)
• MedsCheck and Diabetes MedsCheck (https://www.ppaonline.com.au/programs/medication-management-programs/medscheck-and-diabetes-medscheck)
• Residential Medication Management Review (https://www.ppaonline.com.au/programs/medication-management-programs/residential-medication-management-review-and-quality-use-of-medicines)

The number of pharmacists working in GP clinics are also growing and their positive impact on health outcomes is becoming increasingly recognised. A recent study by the University of Queensland showed that hospital readmissions, ED presentations and health costs dropped when general practice-based pharmacists conducted medication reviews for patients newly discharged from hospital.

What are some common myths about pharmacists that you’d like to debunk?

I think when people think of pharmacists they automatically think just drug supply and dispensing. Whilst that is one of our core activities we have very much shifted away from that to promoting health awareness and contributing to the betterment of the community. We are continually expanding our scope of practice to meet the growing needs of the community and particularly our ageing population. For example in the community setting, there are many professional services that community pharmacies provide that the general public may not be aware of including:

• General medicines advices
• Dose administration aids
• MedsChecks
• Diabetes MedsChecks
• Home Medicines Reviews/Residential Medication Management Reviews
• Mental health/crisis support and counselling
• Breastfeeding advice and support
• Vaccinations (flu, measles-mumps-rubella, meningococcal, whooping cough)
• Smoking cessation advice and support
• Baby progress recording
• Blood glucose monitoring
• Blood pressure measuring and monitoring
• Health, fitness and nutrition programs
• BMI/waist circumference monitoring
• COPD screening
• Inhaler technique checks
• INR and/or lipid monitoring
• Compounding
• Disposal of unwanted medicines
• Needle and syringe programs
• Hearing checks
• Sleep apnoea screening

How does working as an Emergency Medicine Pharmacist differ from working as a pharmacist in other areas of the hospital?

Working as an ED pharmacist, you are dealing with more acute, urgent and time-critical aspects of illness and injury presenting from the community and this is where having a critical care background is of benefit. You are also dealing with patients who present for a whole variety of reasons and you will often have to tap into your clinical knowledge spanning a range of specialities. As an ED pharmacist, you may also be involved in pre-hospital care, toxicology, disaster planning or pandemic management. A pharmacist working in a different area of the hospital for example in the renal unit, will not have the knowledge and skills for some of the ED specific activities described above but will have specialist knowledge and skills in renal medicine for example in kidney transplantation.

Can you provide a brief overview of the other career opportunities for pharmacists? 

There is a common misconception that the only two choices after studying pharmacy are hospital or community practice, however, there are many different careers pathways for pharmacy graduates (not an exhaustive list):

• Community pharmacy
• Hospital pharmacy
• Consultant pharmacist
• Pharmaceutical industry/clinical trials
• Researcher/academic pharmacist
• General practice pharmacist
• Locum pharmacist
• Aged care pharmacist
• Government or NGO roles
• Military or defence force roles

All pharmacy career pathways aim to improve patient care and influence health outcomes but if you are particularly interested in working with a range of health professions to help the acutely unwell patient then hospital pharmacy may be a career for you.

Which stakeholders do you collaborate with within your role and in what capacity?

Working as the ED pharmacist, you are working alongside all levels of medical and nursing staff not only within the ED but outside of the ED, and this can be related to guideline/policy/procedure development or education and training. I also have very good working relationships with the universities here in Sydney and their pharmacy schools where I do a lot of teaching especially experiential teaching. I also work closely with the NSW Agency for Clinical Innovation and Society of Hospital Pharmacists of Australia to share local knowledge and experience to improve clinical care on a wider level.

Tell us your best pharmacy joke!

Beta-blockers make me LOL… (apologies for the bad joke)

What are the key take away messages you would like those reading this to have?

Although pharmacy has a lot to do with medications, we have a breadth of knowledge and skills about therapeutics and healthcare which is underutilised and are very much broader advocates for improving healthcare on a more holistic level.

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