Section 33.4: Emergency & Critical Care Sets

33.4.1 The “Why”: A Paradigm Shift from Accuracy to Accurate Urgency

In every preceding section, the focus has been on methodical, systematic, and meticulous verification. For the vast majority of your work, this diligent, sequential process is the hallmark of a safe pharmacist. Emergency and Critical Care Order Sets, however, demand a fundamental paradigm shift. The core principle is no longer just accuracy; it is accurate urgency. In these scenarios—sepsis, stroke, heart attack—the irreversible death of tissue (brain, myocardium, etc.) begins within minutes. The entire structure and logic of these order sets are engineered to combat the tyranny of the clock. They are not checklists; they are launch sequences.

These order sets are designed to facilitate parallel processing. Unlike a standard admission order set where you might work through orders from top to bottom, an emergency set is designed to have multiple, independent teams spring into action simultaneously. The moment a “Code Stroke” or “STEMI Alert” is activated, a cascade of events is triggered. The CT scanner is cleared. The cath lab team is paged. The ICU bed is reserved. And in the pharmacy, the most time-sensitive medications are prepared. Your role shifts from a linear verifier to a dynamic, real-time clinical hub, processing information and delivering life-saving therapies under extreme pressure. You must learn to triage not just patients, but individual orders within a single patient’s profile, identifying the few that are truly “rate-limiting steps” and executing them with flawless precision.

Mastering these order sets is the pinnacle of the hospital pharmacist’s operational skill. It requires a calm head, an encyclopedic knowledge of inclusion/exclusion criteria, and an intimate understanding of your pharmacy’s own logistical capabilities. How fast can you get a tPA dose to the ED? How quickly can you compound a heparin drip? Your efficiency directly impacts patient outcomes. In this world, there is no “I’ll get to it in a few minutes.” There is only now. This section is designed to forge the mindset and provide the clinical knowledge necessary to function as an elite-level pharmacist in the hospital’s most critical moments.

33.4.2 Masterclass: The Sepsis “Bundle” Order Set – The Race Against Shock

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. In plain terms, it’s the body’s over-the-top, catastrophic inflammatory response to an infection that begins to shut down vital organs. The progression from sepsis to septic shock can be terrifyingly rapid. To combat this, modern sepsis care is built around the concept of “bundles”—groups of evidence-based interventions that, when performed together within a specific, short timeframe, have been shown to dramatically reduce mortality.

The Sepsis Order Set is a direct translation of the “Surviving Sepsis Campaign 1-Hour Bundle” into actionable orders. It is designed to ensure that every patient with suspected sepsis receives the five core, life-saving interventions as close to Time Zero (the time of triage and recognition) as possible. Your role is to function as the bundle’s quarterback for all medication-related components, ensuring they are not just ordered, but administered within that critical first hour.

The Pharmacist’s Minute-by-Minute Sepsis Response

Time from Alert	Action	Rationale & Clinical Focus
T=0 minutes	Sepsis Alert Order Set Received. Open the patient’s profile immediately.	The clock has started. Your goal is to have the first dose of antibiotics verified and on its way to the patient’s room within 15-20 minutes.
T=0 to 2 minutes	Scan for “Hard Stops.” Perform an ultra-fast review for the two things that can kill the patient: a severe, anaphylactic allergy to the ordered antibiotic, or a massively incorrect weight leading to a dangerous fluid bolus or drug dose.	This is your triaged verification. You’re not worried about minor interactions yet. You’re looking for the single, fatal flaw in the plan. If the patient has a documented anaphylactic allergy to penicillin and the order set has piperacillin-tazobactam selected, you must call the provider *immediately* to change the antibiotic.
T=2 to 5 minutes	Verify the Fluid Bolus. Find the patient’s weight in the chart. Quickly calculate the 30 mL/kg crystalloid bolus. (e.g., 90 kg patient = 2700 mL). Verify the order.	Fluid resuscitation is as important as antibiotics. An error in the weight can lead to massive under- or over-resuscitation. A 2.7 liter bolus is a large volume; ensure the pharmacy can supply this rapidly (e.g., three 1L bags of NS or LR).
T=5 to 15 minutes	Dose and Verify Antibiotics. The STAT lab results (especially serum creatinine) should be resulting now. Calculate the CrCl. Determine the optimal, guideline-recommended broad-spectrum antibiotic regimen based on suspected source (e.g., community-acquired pneumonia vs. urosepsis). Calculate the correct, renally-adjusted dose. Critically, calculate the correct weight-based loading dose for vancomycin. Verify these orders.	This is the most important medication-related step. Do not just blindly approve what was clicked. Use your clinical judgment. Did the provider choose the right antibiotic for the suspected source? Is the dose optimized for the patient’s renal function? Giving a standard vancomycin dose to a patient in septic shock with acute kidney injury is a major error.
T=15 to 30 minutes	Expedite Dispensing and Communicate. Physically ensure the verified antibiotics are prepared immediately. If you have a satellite pharmacy, call them to alert them. If working centrally, you may need to walk the first dose to the tube station yourself. Call the patient’s nurse. “Hi, this is the pharmacist. I’ve just verified the vancomycin and cefepime for your septic patient in room 201. They are tubed now. Please remember to draw blood cultures before you hang them.”	Your job extends beyond the computer screen. You are the final link in the chain to ensure the medication gets to the patient. Clear, closed-loop communication with nursing is essential to ensure the timing and sequencing (cultures first) are correct.
T=30 to 60 minutes	Anticipate the Next Step. The patient has received fluids and antibiotics. What’s next? If their blood pressure is not responding, they will need vasopressors. Review the vasopressor section of the order set (e.g., norepinephrine). Does your pharmacy have a standard concentration drip ready to dispense? Alert the ICU/ED satellite. Be prepared to verify and dispense this with the same urgency as the antibiotics.	An elite pharmacist doesn’t just react; they anticipate. By preparing for the next likely step, you can shave precious minutes off the time to starting vasopressors, which can directly impact a patient’s survival from septic shock.

33.4.3 Masterclass: The Acute Ischemic Stroke & Alteplase (tPA) Order Set

In no other area of medicine is the phrase “Time is Brain” more literally true than in the treatment of acute ischemic stroke. Each minute that a cerebral artery is occluded by a clot, millions of neurons die. The goal of the Acute Stroke Order Set is to mobilize a multidisciplinary team to perform a rapid-fire series of diagnostic steps to determine if a patient is a candidate for the only FDA-approved pharmacologic intervention for dissolving such clots: Alteplase (tPA).

The order set is a rigid, unforgiving algorithm. It is designed to move a patient from the hospital door to a head CT scan to a decision on tPA in well under 60 minutes. The pharmacist’s role in this process is arguably the most high-stakes in the entire hospital. You are the absolute, final guardian of the gate for alteplase administration. While the neurology team assesses the patient, your job is to run a parallel, independent verification of every single one of the numerous and complex inclusion and exclusion criteria. Giving tPA to a patient who is not a candidate (e.g., one with an intracranial hemorrhage or a recent major surgery) can be fatal. Your systematic review is the patient’s most critical safety net.

The Stroke Order Set in Action: The tPA Pathway

The order set is a branching algorithm. The first branch contains the initial STAT orders for everyone with stroke symptoms. The second, conditional branch contains the orders for tPA itself.

Order Set Component	Example Orders	Clinical Logic & Pharmacist’s Focus
Initial STAT Orders (For All Patients)	[X] STAT Head CT without contrast [X] STAT Fingerstick Glucose [X] STAT CBC, PT/INR, aPTT [X] Place 2 peripheral IVs	Logic: This is a race to get the data needed to make the tPA decision. The CT rules out a hemorrhagic stroke. The glucose rules out hypoglycemia mimicking a stroke. The labs screen for bleeding diatheses. Pharmacist’s Focus: You will be monitoring the lab results in real-time. The moment the INR and platelet count result, you are comparing them to the exclusion criteria. You must also proactively look at the patient’s medication history for any recent anticoagulant use.
Blood Pressure Management	[X] IF SBP > 185 or DBP > 110:    [ ] Labetalol 10-20mg IV push, may repeat x 1    [ ] Nicardipine infusion, titrate to goal BP…	Logic: Severe hypertension is an absolute contraindication to tPA due to the increased risk of hemorrhagic conversion. These orders provide the tools to attempt to lower the BP to a safe range to make the patient eligible. Pharmacist’s Focus: You need to have these medications available in the ED immediately. Ensure your automated dispensing cabinets are stocked. Be prepared to verify the nicardipine infusion order and guide the nurse on the standard concentration and titration parameters.
Alteplase (tPA) Dosing & Administration	[X] IF patient meets criteria: Alteplase 0.9 mg/kg IV. Max dose 90 mg.    Patient Weight: [___] kg (MUST be an actual weight)    Give 10% of total dose as an IV bolus over 1 minute.    Infuse remaining 90% over 60 minutes.	Logic: This is the standardized, evidence-based dosing regimen for tPA in stroke. Pharmacist’s Focus: This is your moment. You must obtain an accurate patient weight. A stated weight is unacceptable. Re-calculate the dose yourself. Dosing errors are a major source of harm. Once you have calculated the total dose (e.g., 70kg patient = 63mg total), you will calculate the bolus (6.3mg) and the infusion (56.7mg). You will oversee the preparation, which often involves wasting a portion of the vial. Many institutions require an independent double check by a second pharmacist for all tPA calculations.
Post-tPA Care	[X] Admit to ICU or Stroke Unit [X] Neurologic checks q15min x 2h, then q30min… [X] Maintain BP < 180/105 mmHg for 24 hours. [X] HOLD all antithrombotic (anticoagulant/antiplatelet) agents for 24 hours.	Logic: The 24 hours after tPA are a period of high risk for intracranial hemorrhage. The patient requires intensive neurologic and blood pressure monitoring. Holding all other blood thinners is mandatory to minimize this risk. Pharmacist’s Focus: You must be vigilant in ensuring no antiplatelet or anticoagulant is inadvertently resumed or ordered during this 24-hour window. This is a common and dangerous error. You are the final safety net to enforce this “no-fly zone.”

33.4.4 Masterclass: The Acute Coronary Syndrome (STEMI) Order Set

An ST-Elevation Myocardial Infarction (STEMI) is a heart attack caused by the complete occlusion of a coronary artery. The guiding principle of care is “Time is Muscle.” The longer the artery remains blocked, the more heart muscle dies. The entire goal of the STEMI Order Set is to facilitate the fastest possible reperfusion of the blocked artery, most commonly via a procedure called percutaneous coronary intervention (PCI) in the cardiac catheterization lab. The national quality metric is “Door-to-Balloon” time—the time from the patient’s arrival at the hospital to the time the artery is opened with a balloon catheter—with a goal of less than 90 minutes.

The order set is a high-speed preparation checklist for the cath lab. It is designed to get critical, vessel-opening medications on board immediately while the cath lab team is being activated. As the pharmacist, you are the fuel master for this rocket launch. Your job is to ensure the potent combination of antiplatelet and anticoagulant medications is dosed correctly, checked for contraindications, and delivered to the ED STAT so it can be administered before the patient is transported to the cath lab.

The STEMI Order Set in Action: Paving the Way to the Cath Lab

Order Set Component	Example Orders	Clinical Logic & Pharmacist’s Focus
Immediate Actions (“MONA” Therapy)	[X] Oxygen, apply if O2 Sat < 90% [X] Aspirin 324 mg (4 x 81 mg chewable), give STAT [X] Nitroglycerin 0.4 mg SL q5min PRN chest pain (hold if SBP < 90) [X] Morphine 2-4 mg IV push PRN chest pain refractory to NTG	Logic: This is the classic “MONA” mnemonic, though its application is now more nuanced. Oxygen is only for hypoxia. Aspirin is the single most important, life-saving intervention and must be given immediately to start inhibiting platelet aggregation. Nitrates and morphine are for symptom relief (vasodilation and analgesia). Pharmacist’s Focus: Ensure the aspirin is ordered as chewable for fastest absorption. Verify the patient has no true, anaphylactic aspirin allergy. Check the patient’s blood pressure before verifying the nitroglycerin.
P2Y12 Inhibitor Loading Dose (Opt-in)	(Choose ONE) [ ] Ticagrelor (Brilinta) 180 mg PO x 1 STAT [ ] Prasugrel (Effient) 60 mg PO x 1 STAT [ ] Clopidogrel (Plavix) 600 mg PO x 1 STAT	Logic: This is the second, more potent antiplatelet agent that, combined with aspirin, forms Dual Antiplatelet Therapy (DAPT). This aggressive platelet inhibition is crucial to prevent the clot from propagating and to prevent the new stent from clotting off. The choice of agent depends on institutional preference and patient specifics. Pharmacist’s Focus: This is a major safety checkpoint. You must screen for contraindications. Ticagrelor can cause bradycardia and dyspnea. Prasugrel has an absolute contraindication in patients with a history of stroke or TIA. Clopidogrel is often reserved for patients who cannot take the others or are at high bleeding risk. You must verify this history before dispensing the loading dose.
Anticoagulation	[X] Heparin IV Bolus: 60 units/kg (max 4000 units) [X] Heparin Infusion: Start at 12 units/kg/hr (max 1000 units/hr)	Logic: While antiplatelets inhibit platelet aggregation, anticoagulation is needed to inhibit the fibrin-rich clotting cascade. A heparin bolus and infusion provide a rapid and titratable level of anticoagulation for the duration of the PCI procedure. Pharmacist’s Focus: Accurate weight is paramount. You must use an actual patient weight to calculate the bolus and initial infusion rate. You will be responsible for preparing the heparin drip and verifying all calculations. You must also check the patient’s baseline CBC for any signs of heparin-induced thrombocytopenia (HIT) from a previous exposure.
Adjunctive Medications	[X] Metoprolol 25-50mg PO x 1 (hold if HR < 60, SBP < 100, or signs of heart failure) [X] Atorvastatin 80mg PO x 1 STAT	Logic: Early oral beta-blockers can reduce infarct size and life-threatening arrhythmias, but must be used with caution. High-intensity statins, regardless of baseline cholesterol, have been shown to improve outcomes in ACS due to their pleiotropic anti-inflammatory effects. Pharmacist’s Focus: You must check the patient’s heart rate and blood pressure to ensure the beta-blocker is safe to give. You will also ensure the high-intensity statin is dispensed and administered promptly.