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Archive for the ‘Pharmacy’ Category


Written by phil

November 1st, 2012 at 9:30 pm

Benzo Shortage

So for at least the foreseeable future, there is a shortage of IV ativan, please consider these alternatives

Sedation for Violent Behavior/Elopement Prevention
Please use droperidol/ versed (5/2) or either agent individually. This is a preferred choice over haldol/ativan even without the shortage. Get an ekg at some point in the patients course to document no prolonged QTc (this doesn’t need to precede the drugs)

Mild ETOH Withdrawal
Ativan 2mg PO Q6 or LIbrium 50 mg PO Q6

Severe ETOH Withdrawal/DTs
We may or may not have IV valium, if we do start with that just like always

If we run out, choose one of these course
Place patient on midazolam drip using standard drip sheet dosages, Patients may need a bolus of 2 mgs; repeated Q5 minutes until sedation achieved prior to the drip. Unintubated patients on midazolam drips must go to an ICU bed
Intubate the patient and place on midazolam, intubated pts on midazolam may go to A4/CCA
Intubate and place on a propofol drip. intubated patients on propofol may go to A4/CCA

Status Epilepticus
Hospital is conserving ativan specifically for these patients, so it should be available, if not:

use midazolam 2-4 mg (max 8mg) just as you would use ativan

Hospital is also adding IV Kepra and IV Valproate, consult neuro for dosing, timing, and usage

If and when we lose IV midazolam, furhter recs will follow

please write with questions


Scott Weingart, MD

Written by reuben

March 9th, 2012 at 3:12 am

Posted in Pharmacy,Shortage

Metoprolol Shortage

Our supply of metoprolol injection is now at a critical level. Based on our current utilization, we will exhaust our supplies by the weekend. We have been unable to obtain additional metoprolol, and it appears unlikely that we will get any in the foreseeable future. We have increased our supplies of propranolol injection, as well as labetalol and esmolol. We are also experiencing difficulty obtaining diltiazem injection and enalaprilat injection. Please use oral therapy or alternative agents when ever possible.

PS- please don’t kill the messenger

Gina Caliendo, BS, Pharm.D, BCPS

Written by reuben

January 31st, 2012 at 10:08 pm

Posted in Pharmacy,Shortage

Ketorolac Shortage

The country and therefore the hospital is running out of ketorolac.

For patients who can take PO, ibuprofen is equally effective. Also, it is not well known that the analgesic ceiling for ketorolac is probably around 10 mg IV. I personally use 15 mg, and the hospital still has a reasonable stock of 15 mg vials, so consider this in patients whom you think would benefit from a parenteral NSAID.


Ketorolac Shortage Announcement



Written by reuben

December 22nd, 2011 at 6:26 am

Posted in Shortage

Sux Shortage

EM Clinicians:

There is a manufacturer-side succinylcholine shortage and, for the indefinite future, when you call for succinylcholine, it may not be there.

The alternative agent for paralysis in RSI is rocuronium, which is dosed at 1.2 mg/kg. The onset is 45-60 seconds, and the duration is much longer than succinylcholine; at this dose generally 45-75 minutes. There are no contraindications (other than the contraindications to RSI itself). At Sinai, rocuronium is kept in the med room refrigerator in both the adult and pediatric zones.

Let me know if you have any questions.


Written by reuben

September 8th, 2010 at 1:51 am

Posted in Airway,Pharmacy

Prescription Refill Protocol

Prescription Refill Protocol

tags: chronic pain, narcotic

Written by reuben

December 2nd, 2009 at 8:52 am

Posted in Pharmacy,Toxicology

Emergency Department Pharmacist Hotline

with one comment

EMFaculty, EMResidents:

An ED pharmacist is in the department Monday through Friday, 1p-9p.  Their primary responsibility is to make sure that long-stay patients get their most important medications, but they are available to assist you in a variety of other ways including medication questions and helping out in codes/thrombolysis/hypothermia/etc. A single phone number has been created that will reach the ED pharmacist on duty:

(347) 637-8476, that’s (347) 6-DRUGS-6.

You can also leave a voicemail that will be returned by the EDP at the next available opportunity.

Let me know if you have any questions or concerns.


Written by reuben

October 13th, 2009 at 6:25 pm

Posted in Pharmacy

Antibiotic Restriction List

is here

Written by phil

August 26th, 2009 at 10:41 pm

Posted in Antibiotics,ID,Pharmacy

Emergency Department Pharmacists Protocol

1. Continuity of care

The Emergency Department Pharmacists’ primary mandate is to facilitate care of the long-stay ED patient, from the standpoint of medications. As such, they will assess patients, patient records, and orders put in by the admitting team–starting with the patients who have been in the department the longest, and working their way down by length of stay. They will identify important medications that the patient needs (anti-rejection meds, antiepileptics, antihypertensives, anticoagulants, etc) while awaiting inpatient beds. They will enter their recommendations into IBEX in accordance with the EDP medication policy (see appendix 1).

In cases where orders have been entered into TDS by the inpatient team, the pharmacist shall transcribe the important medications into IBEX when appropriate. In this case no co-signature is needed, as a physician has already ordered the medication in a different system. Similarly, TPN orders entered by ED pharmacists do not require co-signature; the pharmacist will ensure that the original paper order has been scanned into the chart.

The pharmacist shall enter all TDS orders for long-stay patients into the pharmacy information system (WoRX).

ED pharmacists may find it clinically necessary to clarify certain patients’ allergies and/or home medications prior to reconciliation by the admitting team, on ED practitioner request or to ensure continuity of medical care as above. Clarifications to a patient’s current medication list in IBEX as entered by the triage nurse may be made as appropriate. The pharmacist may document the sources that informed the clarification, including patient/family interviews, medication bottle and content inspections, computer records and outpatient pharmacy contacts. The pharmacist’s role is to supplement the existing medication reconciliation process in the ED, not to replace it.

2. Symptom Relief

Unaddressed pain and other symptoms–one of the major effects of overcrowding–underlie much morbidity and many patient complaints. The ED pharmacists will inquire with patients regarding treatable symptoms and recommend key medications (for example: tylenol, morphine, zofran, reglan, pepcid, nicotine patch) as they perform their assessments. The role of the pharmacist is to supplement and not to substitute the role of the physician or nurse in monitoring patient symptoms.

3. Core Measures

Pharmacists can screen chest pain patients for aspirin and beta blocker orders and dyspneic or febrile patients for antibiotic orders. Where potential deficiencies exist, the pharmacist will make recommendations for the treating MD.

4. Participation in resuscitations

Pharmacists are ACLS certified and can anticipate and assist the team with the preparation and delivery of medications used in resuscitations and cardiac arrests–especially where more complicated drips are called for (amiodarone, tPA). Pharmacists may also be able to facilitate the preparation of RSI meds.

5. Drug Information

Pharmacists are available to address medication questions that arise and will usually be able to provide information regarding drug selection, dosing, indications, contraindications, interactions, monitoring and drip preparation in a clinically relevant time frame.

6. Error Reduction

The EDP will expedite medication order processing by screening for incorrect orders; for example, alerting novice (and veteran) IBEX users of faulty syntax in their orders, changing non-formulary medications to formulary (e.g. Novolin to Humulin), or adding a patient weight to LMWH orders. This will improve the accuracy of ED documentation and reduce turnaround times when medications have to be sent from pharmacy. Medication-targeted laboratory tests may also be recommended if not ordered, for example, partial thromboplastin time for a patient on a heparin drip, fingerstick for a patient on insulin, etc.

The EDP will change particular medication orders for the purposes of conforming to the ED and hospital formulary and resolving other problem orders (form-route mismatches, missing units, wrong units, etc) according to the order clarification and substitution protocols (see appendix 2). In these cases the original order will be cancelled by the EDP with a note that the order is changed per protocol, and a new order is entered by the EDP with the same ordering physician; co-signature is not necessary.

7. Patient counseling

EDPs can discuss with the patient any medication the patients receive in the ED or have been prescribed at discharge.

The role of the ED Pharmacist is in evolution and will be revised to best meet the needs of all concerned parties.

Appendix 1: Medication Policy

Policy for medication orders involving Emergency Department Pharmacists

1. The emergency department pharmacist (EDP) will enter his/her recommendations into Picis PulseCheck (IBEX) in the Med SVC section.

2. The EDP will approach a treating MD and review his/her recommendations.

3. The treating MD will sign the order using the Co-Sign function in the Med SVC section.

4. The RN will then pick up the order and administer the medication.

Appendix 2: EDP Order Clarification & Substitution Protocols

Written by reuben

July 1st, 2009 at 9:41 pm

Posted in Pharmacy

Multiple Updates from Kevin Baumlin

Multum update–  the end result of this means that your med service and rx quick lists may be a bit different… of note toradol and lasix have changed… sorry, these updates .. we are required to take…

bed request– “none” is no longer autopopulated in the isolation question…. UGGGH.. i know… but hopefully this will decrease the re-listing for isolation pts that seems to happen daily.

bedboard overview– now has an additionally column for mrsa/vre– this is pulled through from cerner– (meaning the pt has had a mrsa/vre positive cx in the past.  this should help decrease confusion as to who is and who isn’t iso, and for what reason.

current medications  please put this on your tool bar and check pts med lists!

Obs– for pts 8+ hours and overnight obs pts– fill out the new “hpi” template

Peds ROS– working on it

Studer– AIDET— bottom line is, its not enough to take great care of your pts.  you need to do it with a smile, introduce yourself, manage expectations and say thanks for coming….


Written by reuben

February 26th, 2009 at 9:50 pm

ED Pharmacists

The ED pharmacists let us know their phone numbers:
SB’s work phone is 646-438-5480
ER’s is 646-315-5347.

Written by phil

September 26th, 2008 at 4:05 pm

Posted in Pharmacy