Dispensing Medications at the Hospital Upon Discharge From an Emergency Department

The purpose of this report is to present and discuss the evidence regarding dispensing of medications in the emergency department (ED). Unlike scheduled or sick visits to the medical home, many ED visits are unplanned and occur when community pharmacies are not open. 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 is the medical home, the ED plays an important role as a safety net for children requiring emergent medical care.^1–6  Medical care provided in EDs often requires the treatment of acute clinical conditions, with a high priority placed on the timely administration of medications such as analgesics, antibiotics, bronchodilators, and corticosteroids. Prompt initiation and maintenance of therapy are important factors in achieving an optimal therapeutic effect. Relapses or exacerbations of chronic conditions (eg, asthma, epilepsy, diabetes) are often attributable to lack of medication or nonadherence. Because emergency care is provided around the clock, inadequately 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 services at all hours. However, the nearest 24-hour pharmacy may be quite far from the ED, and then the patient or parent must wait for the medication to be dispensed at the time of arrival to the pharmacy if not electronically prescribed. Patients and families may have already spent a considerable amount of time in the ED receiving diagnostic tests and treatment, and some families do not have the resources to easily travel to an off-site pharmacy, potentially exacerbating disparities in care and outcomes.^7–9  These factors may impede timely access to essential discharge medications.

Several studies have demonstrated low medication adherence rates after ED visits.^10–17  In one study, one-third of insured pediatric patients who were prescribed “priority medications” (defined as new medications for an acute condition that excluded over-the-counter medications, refills, and continuation of therapy that was previously initiated) did not pick them up.¹⁰  In examining the Medicaid subgroup separately, half did not pick up their “priority medications,”¹⁸  despite the absence of financial barriers. Reasons for lower medication pick-up rates include lack of transportation, language barriers, health literacy, cultural barriers or discordance with providers, patient understanding of treatment plans, and agreement with treatment plan. The resources spent on emergency care will not result in optimal outcomes unless prompt medication availability is achieved. A recent study demonstrated a pick-up rate of less than 60% for medications prescribed for adolescents with sexually transmitted infections.^19,20 

Knowing that medication adherence rates are likely to be low, many emergency physicians may administer additional doses of medications (eg, corticosteroids, long-acting intramuscular antibiotics) before discharging patients from the ED, indirectly increasing cost and lengthening ED stays. Emergency physicians may also lean toward hospitalizing the patient when issues related to nonadherence or lack of access to outpatient medications are identified.

Although pharmacy access is not the only factor determining medication adherence, it has been demonstrated to be a significant one.¹⁴  Most studies of medication adherence have been conducted in adult populations, but pediatric studies have demonstrated similar nonadherence rates.^10,16,17 

A compelling argument can also be made that it is difficult to predict which families will fill prescriptions after discharge from the ED.^21,22  The short duration of action of some medications (eg, albuterol) makes it potentially risky not to provide additional doses at the time of discharge from the ED for home use. Families might have difficulty getting such prescriptions filled in time for the patient’s next dose. During times when there may be medication shortages, EDs can be prepared to dispense medication to those most at risk. Parents frequently request that medications be dispensed at time of discharge from the ED, because it is perceived to be faster, more convenient, and a logical patient expectation. Families may be unfamiliar with the location of local pharmacies, especially pharmacies providing late-night service. There are portions of the country with limited to no retail pharmacy resources and many other areas with no access to 24/7 pharmacy services.²³  Dispensing medications for the acute illness or injury from the ED is a means to both improve service to the patient and provide better care.^24,25  A recent adult study by Farris and colleagues demonstrated an 88.5% adherence rate when patients had access to a 24/7 retail pharmacy collocated in the ED.²⁶  Optimal coordination between the ED and the medical home includes notification of the ED visit and medications prescribed and dispensed by the ED. In some cases, electronic prescribing by the ED to the hospital outpatient pharmacy can facilitate access by medical homes to prescription details via the electronic health record. If medications are dispensed to patients by the prescriber, documentation must occur in the electronic health record, including drug name, dosage form, prescribed dose, and quantity. If controlled substances are dispensed, those must be reported to the appropriate state prescription drug monitoring program, where applicable, and usually within 24 hours.

Electronic delivery of prescriptions (e-prescribing) has been shown to improve quality and reduce harm in pediatric health care and to decrease patient wait times and improve patient satisfaction at the pharmacy; however, e-prescribing has not been shown to increase medication adherence.²⁷  E-prescribing, with drug-dosing support tools, has the additional advantage of decreasing prescription errors, although a significant number of errors on e-prescriptions continue to occur, including choosing the wrong patient, wrong quantity, wrong drug, wrong indication, and wrong pharmacy selection.^28–30  Although e-prescribing does have the potential to save time, some pharmacists may still give priority to patients who are physically present and waiting over a patient who may or may not present.²⁹  E-prescriptions may be sent to a community pharmacy that does not have the medication in stock, requiring the transfer of the prescription to another community pharmacy and, thus, delaying medication availability and administration.²⁹  E-prescribing from the ED to the outpatient hospital pharmacy, if available, is a way to potentially know quickly whether the medication is available.

Administration of the first antibiotic dose in the ED works well for patients who are able to take pills. For children, first-dose administration of antibiotic suspensions requires that unit doses be created. Pharmacies at larger hospitals can efficiently dispense multiple unit doses, but smaller hospitals or those that primarily see adults are more likely to use fewer doses, resulting in more wastage of the remaining reconstituted antibiotic suspension. The practice of administering the first dose can at least guarantee that the patient receives one dose. In addition, if the patient is observed briefly, it improves the likelihood that an immediate adverse reaction can be recognized and addressed. This practice can also reduce the need for initial parenteral antibiotic dosing, although long-duration parenteral antibiotics have some advantages over oral antibiotics. Administering a single oral dose in the ED does not necessarily ensure adherence, because the remainder of the medication course must still be obtained from an outpatient pharmacy, but it does permit the patient’s family to return home before obtaining the remainder of the medication course at a more convenient time. Although administering the first antibiotic dose in the ED has advantages, dispensing the entire course from the ED is more convenient for the patient and is more in line with patient expectations. Dispensing the entire antibiotic course also obviates any concerns about inability to afford medication or inability to obtain transportation to a community pharmacy. Factors that improve full adherence mean the patient is less likely to develop complications from treatment failure and induction of antibiotic resistance.^31,32  In addition, first-dose administration in the ED affords the ED staff an opportunity to counsel the patient on use of the proper dispensing device and techniques for administering the medication, which might not be available at the neighborhood pharmacy. Limited English proficiency has been shown to adversely affect medication adherence because of communication barriers³³ ; however, with the use of interpreters, health systems have been able to decrease this disparity.³⁴ 

Dispensing a few days’ supply of medication can give the patient’s family enough time to fill the prescription at a neighborhood pharmacy. This solution works better for medications in pill or capsule formulations but not as well for suspensions. A potential pitfall of this method is the failure of the caregiver to fill the remainder of the prescription because the child appears to be feeling better. This would also require a second prescription to be written for the outpatient pharmacy and a second pharmacist to be involved in dispensing a single course of therapy. Extra steps in the medication use process introduce additional potential for error. In addition, the family may have to pay 2 separate copayments for 2 separate prescriptions. There is increased risk, because there may be no pharmacy education available, as well as dispensing and labeling errors if a pharmacist is not involved in medication dispensing. Medications to be administered at schools may have additional labeling or container requirements.

Transferring all prescriptions written from the ED to the inpatient hospital pharmacist(s) increases their workload substantially, such that it might compromise the other duties of the pharmacist(s) and create the potential for medication errors.³⁵  Conversely, the need for prescriptions to be dispensed at the time of discharge from the ED could justify the need for additional staff pharmacists. Staffing of additional pharmacists may be difficult to achieve because they are in short supply in many areas or the expense may not be offset by the revenue gained from filling home medication prescriptions. Many patient care improvements are not cost-neutral, but the overall systematic improvement in patient care and outcomes may justify these expenses. Prescription kiosks have been successfully installed in community-based pharmacy settings and a limited number of adult hospitals. However, these kiosks are challenged with pediatric dose formulations requiring refrigeration or reconstitution, as well as reimbursement issues.^36,37  Competing demands for pharmacist resources would need to be addressed in most health systems.³⁸  In this case, patient and staff satisfaction and medication adherence can both potentially improve.³⁹ 

Some states have regulations limiting outpatient dispensing by an inpatient facility. For example, the state of Massachusetts allows hospital inpatient pharmacies to dispense up to 14 days of medication, whereas the state of Washington only allows hospital inpatient pharmacies to dispense medications in extraordinary circumstances, and even then, typically only a 48-hour supply.^40,41  Many hospital pharmacies have created programs to dispense medications to uninsured patients, those with extraordinary circumstances such as need for postexposure prophylaxis, or medications that cannot be obtained in the community. Regulations cited typically apply to medications dispensed by the ED providers (not a pharmacy), medications dispensed by the hospital inpatient pharmacy, medications dispensed by the hospital, or a limited subset of medications (eg, controlled substances). Note that these special regulations apply to hospital units or inpatient pharmacies but not to outpatient pharmacies; therefore, the most efficient solution with the fewest regulatory obstacles is to have a 24-hour outpatient pharmacy available to service the needs of the ED.

Insurance companies might deny payment for outpatient medications dispensed by an inpatient pharmacy. In addition, pediatricians who enter into value-based contracts may be impacted if the medication costs are dependent on where the medication is dispensed. These possibilities are difficult to confirm or refute, because insurance company reimbursement practices may vary within a given state or region or health plan. In theory, if the hospital had the appropriate insurance adjudication software, there is no reason why an insurance company should pay a community outpatient pharmacy but not a hospital pharmacy, as long as the cost agreements and the regulatory requirements are met. If this practice becomes more common, then insurance company payment practices are likely to become more consistent. Having a 24-hour outpatient pharmacy available to serve the needs of the ED would address this concern, as well. ED administrators can monitor payer practices, such as identifying an ED or hospital outpatient pharmacy as out of network or charging a copay for both the acute need and the maintenance prescription, to ensure these practices are not deleterious to families. Lack of transparency with the patient/family regarding the final cost of the prescription at time of dispensing from the hospital inpatient or outpatient pharmacy, with insurance coverage or denial of payment, can be detrimental and cause significant financial harm to patients and families.

Hospitals might have an economic advantage over small community pharmacies because of size and/or nonprofit status, as well as the ability to purchase medications in larger bulk and under different contract agreements. This may be true relative to smaller community pharmacies; however, it is less common that a 24-hour pharmacy is a small community pharmacy. The current 24-hour pharmacies are generally part of larger pharmacy chains that have similar or more robust purchasing strength. Federal case law has been established in this issue. In Abbott Laboratories versus Portland Retail Druggists (425 US 1 [1976]), the US Supreme Court ruled that hospitals acquiring drugs under their nonprofit contracting status for ED and inpatient discharge prescriptions does not violate antitrust laws, and the only restriction is that hospital-based pharmacies are limited in the total day supply that can be dispensed.⁴² 

Enhancing the convenience of obtaining medications may encourage potentially avoidable visits to the ED (versus the medical home) for minor acute care. The medical home is the preferred site for children to receive care for acute but nonurgent health concerns. Children with a medical home have lower rates of ED visits. Some families may use acute care services, such as the ED, outside of the medical home with a perceived or true benefit of accessibility, because of convenience, or because they do not have a primary care physician. Most EDs will triage patients with minor acute conditions to lower-priority categories, resulting in longer waiting times in most cases. Reasonable access to care would be a concern if a family would need to wait hours in an ED just for the convenience of also getting their discharge medications. Providing medications from the ED under these circumstances helps patients receive necessary treatment, providing the beneficial safety net of emergency care. When medications are dispensed from the ED, it is important to communicate with the medical home in a timely and complete manner. Patients treated in the ED without an established primary care provider can be linked to a medical home in their community.⁴³ 

Obligating hospital pharmacies to dispense medications to uninsured patients increases hospital financial expenses. Community pharmacies are unlikely to dispense medications at no charge if the patient lacks financial resources to cover the expense of the medications. Dispensing the medications at no charge from a hospital pharmacy represents an expense, but in some situations this expense may be less than the overall health care costs of not treating the condition or a return ED visit if the condition persists. Small rural hospital EDs may not have the same resources as larger hospitals, limiting options for patients to receive their medications.

Turnaround time, or “throughput,” is a critical focus in most EDs. By providing medications for discharge, a system must be established so that dispensing medications does not impede patient flow. Such systems can be accomplished through a predetermined list of high-use medications that can be dispensed, which would facilitate the availability of templated paper orders or computerized order sets, preprinted labels, and appropriate stock and supplies. These preparations can significantly improve turnaround time for prescription dispensing in the ED environment.^3,44  Additionally, when dispensing medications, the pharmacist must make an “offer to counsel,” which is a requirement in most states. This offer includes counseling on medication administration. Counseling can be a time-consuming process, which may take the pharmacist away from other responsibilities in the department.

Clinical outcomes for many acute conditions are highly dependent on timely access to medications. Optimal care is compromised if it is accompanied by lack of access to such medications. When unanticipated and off-hour visits to an ED for an acute illness or injury occur, access to quality emergency care, the essential components of “after care” after an ED visit, including follow-up, and ensuring the medical home is informed about the visit are important. It is important to consider involving care coordination and social work at the time of discharge to help patients and families, particularly those who are uninsured and with patients who do not have a medical home.

Failing to provide access to appropriate medications to treat conditions identified by emergency care encounters compromises the emergency care safety net. Some parents may not disclose inability to pay at the time of the ED encounter, especially if not specifically asked. By dispensing medications at the site of service, inability to pay can be identified promptly so that a no-charge compassionate care provision can be used to dispense the medications under a predetermined protocol.

Dispensing important and necessary medications from the ED outpatient pharmacy in selected instances, if logistically, legally, and financially possible, allows medication to be provided more conveniently, reliably, and in a manner more proximate to the encounter. This practice gives providers additional opportunities to reinforce medication instructions and their importance, including the use of materials for caregivers with low literacy, to ensure the family understands what they should do to safely administer medications to children once they get home. This therapeutic approach, in conjunction with primary care follow-up and communication, maximizes the likelihood of an optimal outcome.

• Suzan S. Mazor, MD, FAAP

• Michelle C. Barrett, PharmD, BCPS, BCPPS

• Corinne Shubin, MD, FAAP

• Shannon Manzi, PhD, PharmD, BCPPS, NHDP-BC, FPPAG

• Gregory P. Conners, MD, MPH, MBA, FAAP, FACEP, chairperson

• James Callahan, MD, FAAP

• Toni Gross, MD, MPH, FAAP

• Madeline Joseph, MD, FAAP

• Lois Lee, MD, MPH, FAAP

• Elizabeth Mack, MD, MS, FAAP

• Jennifer Marin, MD, MSc, FAAP

• Suzan Mazor, MD, FAAP

• Ronald Paul, MD, FAAP

• Nathan Timm, MD, FAAP

• Mark Cicero, MD, FAAP, National Association of EMS Physicians

• Ann Dietrich, MD, FACEP, American College of Emergency Physicians

• Andrew Eisenberg, MD, MHA, American Academy of Family Physicians

• Mary Fallat, MD, FAAP, AAP Section on Surgery/American College of Surgeons

• Cynthia Wright Johnson, MSN, RN, National Association of State EMS Officials

• Cynthiana Lightfoot, BFA, NRP, AAP Family Partnerships Network

• Charles Macias, MD, MPH, FAAP, EMSC Innovation and Improvement Center

• Diane Pilkey, RN, MPH, Maternal and Child Health Bureau

• Katherine Remick, MD, FAAP, FEMS, National Association of Emergency Medical Technicians

• Elizabeth Stone, RN, PhD, RN, CPEN, Emergency Nurses Association

• Javier Gonzalez del Rey, MD, MEd, FAAP

• Joseph L. Wright, MD, MPH, FAAP, chairperson (2016–2020)

Sue Tellez

ED

emergency department