Emergency Pharmaceutical Care in ED and ICU: Toxicology, Infectious Disease, Life Saving Drugs Management, Pharmacoeconomy as Synergic Knowledge Instrument to Reduce Mortality Rate and Healthcare Cost 2019

In this work we discuss about healthcare advantages related clinical pharmacist to take part in stabile way in medical team to improve clinical economical outcomes (and the role played by clinical pharmacist with medicine laboratory and imaging tools to monitoring therapy). The role played by hospital clinical pharmacist in emergency department or in ICU or in other relevant wards like infectious disease and other is a real fact with reduction in mortality rate and right cost containment as reported in biomedical literature. The high pharmacist specialization in field like toxicology, antidothes, antimicrobial agents, nuclear medicine, imaging and laboratory medicine contribute in every medical team to better Obtain efficacy clinical outcomes.


Introduction
Ward Clinical pharmacy, pharmaceutical care, and consultant pharmacist service can be considered interesting instruments in the world of cognitive service to improve global clinical/ economical results in multi-disciplinary medical team. This pharmacist field of working can be considered as an opportunity in this time in with a great number of new drugs molecules, medical -diagnostic procedure added to the more complexity of cure, politherapy and more necessity to containment cost for drugs and medical devices than past. Reduction of medication therapy errors is

Material and Methods
In this work we observed and analyze some relevant biomedical literature involved in clinical pharmacist presence in some medical team and the results obtained from an practical experience in order to produce a global conclusion.

Results
From Literature [1] in 2007clinical pharmacy service , pharmacy staffing , and hospital mortality rates. : " in 7 hospital, clinical pharmacy service reduces mortality rates." In a significant way [2] in "Pharmacist's effect as team members on patient care: A systematic review and meta-analyses": "Pharmacists provided direct patient care has favorable effects across various patient outcomes, health care settings, and disease states. (significant p<0,005)" [3]. This paper wants to improve the pharmaceutical care application in countries with advanced healthcare system in order to provide a more rational drug therapy to patients. When this is not possible, it would be a good idea using the pharmaceutical care, in determinate populations such as: severe disease, critically ill, patients with multiple illnesses, transplants, immunosuppression, oncology or other serious conditions, at least when the treatments are very expensive." And "In these studies, we observe a general positive influence of pharmacist's presence in the medical equips also in different clinical outcomes" [3].
The relevance of pharmaceutical care to diagnostic imaging can be considered from 2 approaches. Diagnostic imaging modalities either are based upon or employ drugs. radio-pharmaceuticals are the key to nuclear medicine procedures and radiopaque contrast agents are essential in many radiographic studies. The principles and practice functions touted for therapeutic medications and therapeutic patient-management apply to drugs employed in diagnostic imaging, as well. Diagnostic imaging modalities are also intimately involved in determining the disease state in many patients. diagnostic imaging is utilized to follow the course of therapy; i.e., determining therapeutic outcomes. Pharmacists, not only specialists, must be knowledgeable of the role diagnostic imaging plays in pharmaceutical care and be prepared to provide the pharm. care in diagnostic imaging [4][5]. The intent of this work is to provide pharmacists with an introduction to the clinical pathology laboratory discipline. As clinical pharmacy services expand, interactions between pharmacists and the laboratory will increase. Laboratory results are an essential tool for pharmacists involved in monitoring the drug therapy and adjusting dosing regimens. Laboratory medicine is a complex and rapidly changing field with new analytical techniques -instruments and continually being developed. methodologies vary greatly from one lab. to another and even within the same laboratory from time to time.
Quality control QC are necessary to ensure accurate and reliable results. The medical technologists who staff clinical laboratories are highly trained professionals. Pharmacists should utilize the medical technologist as a consultant on the interpretation / limitations of laboratory tests. there are many areas, such as therapeutic drug monitoring TDM , in which the pharmacist can serve as a consultant to the laboratory. Pharmacists involved in patient care will benefit from a greater understanding of the clinical laboratory and may also find new opportunities for the clinical pharmacy practice and interaction with other health care professionals [5]. To give a more rationale priority of actions and to select the patient to be seen in priority way we think a good solution to apply the principle of pharmaceutical care with the instrument of clinical pharmacy into a new management system [6].

According article Infectious Disease Pharmaceutical Care:
Analyzing the article reported in this work we can see a relevant role of clinical pharmacist in field of the infectious disease [7]. Infectious clinical pharmacist provides direct patient care in different inpatient settings (internal medicine a, critical care hemology/ oncology, solid organ transplant with other, as well as outpatient settings such as HIV clinics). Antibiotic stewardship/surveillance programs can be considered efficacy instruments available today as well as a guideline of protocols, procedure, EBM criteria and many others. Clinical pharmacokinetic consultant service, microbiologic and laboratory assay and assessment, scientific drug information, toxicity management, ADR, interactions, medicinal chemistry competences are the core curriculum of clinical pharmacist course and for this reason the permanent presence of clinical pharmacists results in general positive outcome in many clinical equip" [7,8].
To review the effects of pharmaceutical care on hospitalizations, 54 RCTs were included in the present review. 46 of these studies ranked high-quality according to the Jadad scoring system.
Studies were categorized into their general condition groups.
Interventions in patients with diabetes, depression, respiratory disorders, cardiovascular disorders, epilepsy, osteoporosis, and interventions in older adults were identified. In the majority of studies pharmaceutical care was found to lead to significant improvements in clinical outcomes and/or hospitalizations when RCTs conducted to evaluate pharm. care appear to be effective in improving patient short-term outcomes for a number of conditions including diabetes and CV conditions, other conditions such as depression are less well researched" [8,9]. "Pharmacists were consulted by the physicians to correct any drug-related issues that they suspected may cause or contribute to a fatal outcome in the cardiology ward. A total of 1,541 interventions were suggested by the clinical pharmacist in the study group; 1,416 (92.0%) of them were accepted by the cardiology team, and violation of incompatibilities had the highest percentage of acceptance by the cardiology team. All-cause mortality was 1.5% during Phase I (pre-intervention) and was reduced to 0.9% during Phase II (post-intervention), and the difference was statistically significant (P=0.0005). After PS matching, all-cause mortality changed from 1.7% during Phase I down to 1.0% during Phase II, and the difference was also statistically significant (P=0.0074)" [9,10].
Clinical pharmacists did not perform any interventions during the phase 1 (pre-intervention) and consulted with physicians to address drug related problems (DRPs) during phase 2 (postintervention). The main outcome was a decrease in mortality from AMI. The 2 phases were compared using propensity score matching (PSM). pharmacists' interventions could result in a significant decrease in mortality" [10,11]. "This research -study was conducted with 13 health-system pharmacists and 5 local health managers that were involved in the CPS implementation. The pharmacists who consented to participate were those who agreed to implement CPS in their respective workplaces. In order to get a comprehensive understanding of the facilitators that influenced the CPS implementation process, the health-system pharmacists were divided into 2 groups: The clinical profile was cited as facilitator. We defined this profile as a set of intrinsic characteristics of a professional who

Facilitators Related to Implementation Process of CPS
Participants reported that assistance provided by supporters

I do not think [local health-management] giving us a glucometer
in December is a support. Support is to be together, to attend. (Nonaccredited Pharmacist C).

Strategies Related to the Pharmacists
Pharmacists proposed strategies they themselves should

Strategies Related to the CPS Implementation Process
Some accredited pharmacists suggested some strategies that could be adopted in future implementation processes in local healthcare networks. According to them, it would be interesting to adapt the CPS according to social demands where the service will be offered and select the pharmacists according to their clinical profiles this could ensure better medication adherence and reduce the dropout rate during the process. "There was a lack of selection on the professionals' profile there were many professionals who actually started doing this because they were involved, but they had no "clinical profile", no capacity, or no help, either they had no infrastructure or, due to any other difficulty, they gave up the project and this was discouraging for other professionals site infections and length of stay. In hospitals that did not offer pharmacist-managed antimicrobial prophylaxis, annual death rates were 52% higher, with 105 excess deaths (OR, 1.54; 95% CI, 1.46-1.63; P < , .0001); length of hospital stay was 10.2% longer, with 167,941 excess patient days ( P < , .0001); and infection complications were 34.3% higher (OR, 1.52; 95% CI, 1.40-1.66; P < .0001) than in those with pharmacist involvement [12].

According publication Sharing Economy and Healthcare Today
The aim of this work was to analyze the relationship between professional social-media use and the healthcare in sharingeconomy time when used in healthcare field and specifically in pharmaceutical hospital settings [13]. The innovation introduced with bio-medical databases has improved research works with rapid steps in all kind of scientific researches areas tools as interests, discipline with more rapid development, never seen in last two decades. We think that using sharing economy instruments we can reduce healthcare costs about 30-40%" [13,14]. "Pharmacists in Japan currently play a crucial role in patient hospital care. Their Our evaluation demonstrates the positive economic effects of pharmacists' interventions in hospital setting " [14].

According Pharm Care and Toxicology
"Poisoning often is a rare event , but in some cases whit critical consequences and so the right diagnosis and therapy is a golden endpoint. The toxicology medical tram-equip must be multi-   interventions. The information from these interventions was used to assess the safety components and to estimate the cost avoidance of their activities. A staff satisfaction survey was also created to assess the pharmacist's impact on providers and nurses, as well as its effect on workflow within the ED. Among the many benefits The median door-to-rtPA time when a pharmacist was present was statistically significantly shorter than when a pharmacist was absent (69.5 vs. 89.5 min; p = 0.0027). When a pharmacist was present, a door-to-rtPA time of < 60 min was achieved 29.9% of the time, as compared with 15.8% in the pharmacist-absent group (p = 0.1087).
Pharmacist involvement on stroke teams may have a beneficial effect on door-to-rtPA time and patient care in the ED" [24,25].  Each study was assessed for the quality using the Jadad scoring system. 54 RCTs were included in the present review. 46 of these studies ranked high quality according to the Jadad scoring system. Studies were categorized into their general condition groups.
Interventions in patients with diabetes, depression, respiratory disorders, cardiovascular disorders, epilepsy, osteoporosis, and interventions in older adults were identified. In majority of studies pharmaceutical care was found to lead to significant improvements

Discussions
In emergency field and in ICU settings ( cardiac, pediatric or other ) we notice that clinical pharmacist can improve clinical and economic outcomes using the medicine laboratory and imaging knowledge for the relationship of this discipline in therapy and it' s monitoring [4,5]. (In example microbiological data on antimicrobial resistance or sensibility and many other) From ASHP guideline :"EMERGENCY PHARMACIST provide many vital services within the Emergency dep . The central role of the EMP is to improve patient outcomes by improving patient safety, preventing medication errors, and providing optimized pharmacotherapy regimens and therapeutic outcomes through participation in direct patient care activities and quality-improvement initiatives in the ED. In addition, EMPs can provide education to members of the pharmacy department and other health care providers, as well as patients and their caregivers, and EMPs may participate in research and scholarly activities in the ED" According editorial the clinical pharmacist main focus is reprted : "We think that the main focus of the clinical pharmacist must be applied in priority way to the most critical patients in order to achieve the best results available . In this condition even benefit of 1 life achieved in mortality rate is a real golden endpoint (we can think for example to a paediatric poisoning, or severe infectious disease in pregnancy or the effect of inefficacy immunosuppressive therapy in transplanted et other) [10]. This can be considered in example as a reduction in NNT to improve a therapeutic strategy" [33].

Conclusion
Related the bibliography observed in this work we request a more involvement of clinical pharmacist in field as Emergency medicine, cardiac ICU, toxicology, infectious disease ,medicine laboratory and in imaging for clinical pharmaceutical care purpose.
If in emergency medicine time is universally considered "TIME IS