Original Article

Drug utilization patterns in the emergency department:

A retrospective study
Abstract

Objectives: The aim of this study was to assess the prescribing trends and costs of drugs in the emergency
department (ED) at Sultan Qaboos University Hospital (SQUH), a tertiary care hospital, in Muscat, the Sultanate
of Oman.
Materials and Methods: This was a retrospective cross‑sectional study of all patients (n = 300) who attended
the ED at SQUH in May 2012. Analyses were performed using descriptive and univariate statistics.
Results: The average age of patients was 34 ± 19 years. The average number of drugs prescribed per patients
was 3.2 ± 1.9 and the majority of the patients (n = 78; 26%) received two drugs. The most common route of
drug administration was the oral route (n = 481; 51%) followed by parenterally (n = 357; 38%). Non‑steroidal
anti‑inflammatory drugs (NSAIDs) were the most commonly prescribed class of drugs (38%) followed by the
gastro‑intestinal tract drugs (19%) and central nervous system drugs (13%). The average cost per prescription
was 242 ± 632 US$. Morphine had the highest cost (1885 US$) followed by cefuroxime (1404 US$) and
filgrastim (939 US$) over the 1‑month period. There was a significant positive correlation between hospital cost
and age (P < 0.001), duration of stay at the ED (P = 0.008) and emergency types (P < 0.001).
Conclusion: NSAIDs were the most frequent class of drugs administered to patients. Highest number of drugs
was prescribed for cardiovascular diseases followed by respiratory and gastrointestinal diseases. Anti‑infective
drugs cost was the highest among all other classes. The results of the present study are attempts to highlight the
importance of strategies that have to be implemented to optimize medication use at the ED.

Key words:
Drug, emergency, pattern, utilization

Introduction adverse drug events ranging from 3% to 12%.[2] These studies

indicate that 1.5‑3% of all adverse drug events occur in the
Problems associated with drug prescriptions are not uncommon emergency department (ED). However, the EDs had the highest
world‑wide. These include mainly medications errors and proportion of prevalence of preventable (70‑82%) errors.[2]
adverse drug events.[1] A meta‑analysis of 35 studies between
1990 and 2005 indicated that medication errors occurred in a Patients come to the ED for evaluation of emergent or urgent
mean of 5.7% of all drug administration episodes while adverse conditions for after‑hours medical care, or by referral from
drug events affected 6.1 patients per 100 hospitalized.[1] Many their primary physician. In the ED, doctors face urgent and
factors are involved in drug prescription errors including
sever cases that need to be treated quickly with high quality.
polypharmacy, lack of sufficient pharmacological knowledge,
This creates a challenge for physicians to initiate and select
errors in patients’ charts or documentation by nurses,
appropriate drugs for the patient. Furthermore, the unique
inadequate pharmacy service, being a female, age >65 years,
renal excretion of drugs, drugs with narrow therapeutic index operating characteristics of ED make the ED vulnerable to
and the use of anticoagulants or diuretics.[1] Furthermore, medical errors including medication errors and adverse drug
several studies in the United States have consistently reported
K. A. Al Balushi1, S. Al‑Shibli1, I. Al‑Zakwani1,2
Access this article online 1
Department of Pharmacology and Clinical Pharmacy, College of Medicine
Quick Response Code and Health Sciences, Sultan Qaboos University, Al‑Khod,
Website: 2
Gulf Health Research, Muscat, Oman
www.jbclinpharm.org
Address for correspondence:
Dr.  K. A. Al Balushi,
Department of Pharmacology and Clinical Pharmacy, College of Medicine
DOI:
and Health Sciences, Sultan Qaboos University,
10.4103/0976-0105.128226 P. O. Box 35, Postal Code 123, Al‑Khod, Sultanate of Oman.
E‑mail: [email protected]

Vol. 5 | Issue 1 | December-February 2014 1 Journal of Basic and Clinical Pharmacy
 Al Balushi, et al.: Drug use in emergency department

events. Many factors, either intrinsic or extrinsic, influence the from all age groups. The hospital information system was
quality of health care in the ED. These include: High levels of used to extract relevant patients’ information.
activity, high cognitive load, high decision density, high levels
of diagnostic uncertainty, inexperience of physicians and WHO core drug prescribing indicators
nurses, distractions, narrow time window and shift work.[2] The WHO prescribing indicators mentioned above were
measured retrospectively from the hospital’s medical records.
The World Health Organization (WHO) compiled a set of No information was collected about the signs and symptoms
core drug use indicators that are useful for studying patterns of diseases as this is not a requirement as per the WHO
of drug prescribing in health care facilities.[1] The WHO also guidelines in this type of study.[4]
stated that: “Rational use of drugs requires that patients receive
medications appropriate to their clinical needs, in doses that Statistical analysis
meet their own individual requirements for an adequate period Descriptive statistics were used to describe the data. For
of time and at the lowest cost to them and their community.”[3] categorical variables, frequencies and percentages were reported.
The WHO core indicators for drug utilization include: Average For continuous variables, means and standard deviations (±SD)
number of drugs per encounter, percentage of drugs prescribed were reported. The cost of medications was tested for normal
by generic name, percentage of encounters with an antibiotic, distribution using one‑sample Kolmogorov‑Smirnov test.
percentage of encounters with an injection, percentage of drugs The association between drugs cost and patient’s gender was
prescribed from the essential drug list.[4] Another tool used to conducted by Mann‑Whitney Test and between the drug cost
control and contrast the rational use of drugs is the hospital’s and type of emergency and patient’s outcome. However, the
pharmaco‑therapeutic guide, which is used and studied by the correlation between drug cost and duration of stay at the ED
pharmaceutical and therapeutics commission of any hospital. and patient’s age was performed using Spearman’s correlation
coefficient. An a priori two‑tailed level of significance was set at
In contrast, irrational use of drugs refers to the distribution the 0.05 level. Statistical analyses were conducted using STATA
or consumption of drugs in ways that negate or reduce their version 12.1 (STATA Corporation, College Station, TX, USA).
efficacy or in situations where they are unlikely to have the
desire effect.[5] Irrational prescription of drugs leads to Ethical approval
unproductive and risky treatment and poses a major risk Ethical approval for the study was obtained through the
of present day medical practice. The problem of irrational Medical research and Ethics Committee at the College of
drug prescription is not restricted to developing countries Medicine and Health Sciences.
as there is evidence from many developed countries on the
inappropriate use of drugs.[6] Appropriate medication use is of Results
both clinical and economic significance to any health system
and should be given adequate attention.[7] General characteristics of the patients
Among the recruited patients, 155 (52%) were males and
Drug utilization research is a component of medical audit that 145 (48%) were females. The average age of the patients was
plays an important role in pharmaco‑epidemiological studies. 34 ± 19 years. Only 15% (n = 45) of patients were referred to
This is because it reports the extent, quality, determinants and other departments for further management. The characteristic
outcome of drug exposure. In addition, it helps in assessing of the patients are shown in Table 1.
rational usage and cost control of various medications
used in the hospital. Pharmaco‑epidemiological studies Drug utilization pattern among patients
detailing prescribing patterns of physicians are very few from The total number of prescriptions for the 300 patients over
developing countries.[8] Currently, there is limited local data the month was 939. The average number of drugs prescribed
on the prescribing habits of doctors at the ED. The aim of this
study was to assess drug prescribing trends, average number
Table 1: Summary of the characteristics of the
of drugs per prescription, the WHO core indicators for drug
utilization and prescription cost during patients’ visits at the
300 patients in the ED at Sultan Qaboos University
ED at Sultan Qaboos University Hospital (SQUH). Hospital
Total number of patients (N) 300
Materials and Methods Age, mean±SD, (years) 34±19
Sex (n, %)
Study setting Female 145 (48)
This study was conducted at the ED of SQUH, a tertiary care Male 155 (52)
hospital, in Muscat, the Sultanate of Oman. The SQUH has a Weight, mean±SD, (kg) 51±28
total of 557 beds while the ED has 28 beds. The ED is visited Duration of stay at ED, hours (median, IQR) 3.38 (1.5-4.5)
by approximately 60,000 patients annually. Number of drugs prescribed per patient (mean±SD) 3.16±1.89
Patient’s outcome %
Study design and subjects Discharged 85
This was a retrospective cross‑sectional study of all Referred to other departments 15
patients (n = 300) who attended the ED at SQUH in May of ED: Emergency department, IQR: Interquartile range, SD: Standard
2012. The subjects included both Omanis and non‑Omanis deviation

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 Al Balushi, et al.: Drug use in emergency department

per patients was 3.16 ± 1.89. The distribution of drugs among Correlation of drug utilization pattern and cost with
patients included in this study was: 55 (18%) patients received different patients’
one drug; 78 (26%) patients received two drugs; 60 (20%) Parameters
patients received three drugs; 47 (16%) patients received There was no significant association between the hospital
four drugs; 30 (18%) patients received five drugs; and the cost and patient’s gender (P = 0.730) and clinical
rest received more than five drugs (10%). There were no outcome (P = 0.958). However, there was a significant
patients who did not receive no drug. The majority of drugs correlation between the hospital cost and age (older patients
were administered by the oral route (n = 481; 51%) followed had higher medication cost; P < 0.001), duration of stay at
by the parenteral route (n = 357; 38%) and then topical the ED (as the hospital stay increases so too was the cost;
route (n = 54; 6%). P = 0.008) and emergency types (higher cost was associated
with infection; P < 0.001).
A total of 103 drugs, belonging to seven categories, were
prescribed. Figure 1 shows the most frequently administered Discussion
classes of drugs. The non‑steroidal anti‑inflammatory
drugs (NSAIDs) were the most commonly prescribed Studying drug utilization pattern in the ED provides a
class of drugs (38%) followed by the gastro‑intestinal means of assessing drug prescribing trends, efficiency and
tract (GIT) drugs (19%) and central‑nervous system (CNS) cost‑effectiveness of hospital formularies. To the best of
drugs (13%). Table 2 outlines the top 10 drugs prescribed to our knowledge, this is the first study in Sultanate of Oman
all patients. Paracetamol was the most commonly prescribed to analyze drug utilization patterns in the ED. The mean
drug (n = 195; 21%) followed by morphine (n = 67; 7%) and age of the patients was 34 ± 19 years and 155 (52%) were
diclofenac (n = 62; 7%). males. The average number of drugs per prescription, which

Table 3 shows the distribution of drug classes across various

emergency types, indicating that NSAIDs and CNS drugs Table 2: The top 10 drugs prescribed to 300 patients
were mostly prescribed for hematological patients (56 and in the ED at Sultan Qaboos University Hospital in
54 cases, respectively), whereas asthma drugs and steroids Muscat, Oman
were mostly prescribed for respiratory patients (21 and
6 cases, respectively).
Name of drug N Percentage
Paracetamol 195 21
WHO core indicators of drug utilization pattern Morphine 70 7
The WHO core prescribing indicators are shown in Table 4. Diclofenac 62 7
Co‑codamol (paracetamol and codeine) 29 3
Drug prescribing cost at the ED at SQUH Ranitidine 49 5
As shown in Table 5, the average cost per prescription was Augmentin (amoxicillin and clavulanate potassium) 45 5
242 ± 631 US$. Table 6 shows the top 10 drugs that account for Ibuprofen 39 4
the highest cost among all drugs prescribed. Morphine had the Metoclopramide 36 4
highest cost (1884 US$) followed by cefuroxime (1404 US$) Ipratropium 19 2
and filgrastim (940 US$). Figure 2 represents the percentage Salbutamol 18 2
of the cost of different drug classes showing that anti‑infective Others 377 40
drugs incurred the highest cost (2810 US$) followed by CNS Total 939 100
drugs (2004 US$). ED: Emergency department

Table 3: Distribution of drug classes across various emergency types among 300 patients in the ED at Sultan
Qaboos University Hospital in Muscat, Oman
Drugs (n) Anti‑infective Asthma drugs CNS drugs CVS drugs GIT drugs NSAID Steroid Others
Hematological ‑ ‑ 54 ‑ 1 56 ‑ 10
Musculoskeletal 2 1 15 1 5 46 ‑ 15
Infection 62 2 5 ‑ 12 50 2 13
Trauma 4 ‑ 12 1 1 32 ‑ 12
CVS 1 ‑ 2 21 6 11 ‑ 1
CNS ‑ ‑ 12 1 2 16 1 1
Metabolic ‑ ‑ ‑ 1 4 5 1 3
Respiratory 7 21 ‑ 1 2 16 6 10
Renal 9 ‑ 6 ‑ 8 26 ‑ 7
Gastrointestinal 12 4 13 1 125 55 1 16
Others 4 2 4 4 15 44 6 11
Total 101 30 123 31 181 357 17 99
CVS: Cardiovascular system, CNS: Central nervous system, NSAID: Non‑steroidal anti‑inflammatory drug, ED: Emergency department,
GIT: Gastro‑intestinal tract

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 Al Balushi, et al.: Drug use in emergency department

is an important index of the standard of prescribing, was This study demonstrated a high use of NSAIDs in the ED
3.16 ± 1.89, with a significant number of the patients in and this could be explained by the large therapeutic range
this study (26%) receiving at least two drugs per episode. as shown in Table 3 of this class, especially their usage as
Cardiovascular diseases had the highest average number of analgesics. Furthermore, the reason for high indication of
drugs per prescription (3.70 ± 1.49). The average number of morphine use could be explained by the fact that most patients
drugs per prescription is higher than the WHO recommended that visited the ED during the study period were hematological
average number of drugs per prescription of 2.0.[9] cases (18%; n = 54) having mainly sickle cell disease crisis
which required morphine to manage their crisis [Table 3]. This
Two studies conducted in India (n = 200 and n = 259) showed study also showed GIT drugs as the second most commonly
an average number of drugs per prescription of 4.2 and 3.3, prescribed medications (19%) with ranitidine being the
respectively.[8‑10] In these two studies, cardiovascular disease most commonly prescribed drug of this class (5%) [Table 2].
and alcoholic liver disease had the highest average number This could be reflected by the fact that GIT cases represent
of drugs per prescription (5.4 and 3.9, respectively). Another 17% (n = 51) of all drug indications in the study [Table 5].
study conducted in Spain (n = 669) showed an average
number of drugs per prescription of 1.7.[11] In addition, a A study evaluated the use of drugs across the different indications
study on elderly patients (n = 124) presented to the ED in the ED in India (n = 200 patients; 629 prescriptions) and
in the USA found an average number per prescriptions of found that antibiotics were the most commonly prescribed
8.6 (range 0‑21).[12] One reason for the higher average number drugs (22%) followed by NSAIDs (12%) and a class of GIT drugs
of drugs per prescription in USA compared with the WHO called proton pump inhibitors (12%).[12] In contrast to our study,
standards is that physicians tend to administer polypharmacy the most common indication for drug prescription in the Indian
during the initial contact with patient while the diagnosis is study was infection (19%), while infection was the third most
not yet confirmed and waiting for laboratory results. Despite common indication for drug prescription in our study (15%).
this, keeping the mean number of drugs per prescription to Paracetamol was also the most commonly prescribed drug (10%)
as low as possible is always preferable to reduce the risk of in a study conducted at the ED in Spain,[11] which is similar
drug‑drug interactions, development of drugs resistance and to our study results, followed by ibuprofen-an NSAID-(9%)
adverse drug events. and omeprazole (7%). However, in the Spanish study,[11] the
most common indication for drug prescribing was the GIT
and metabolism (22%) followed by blood and hematopoietic
Table 4: WHO core drug prescribing indicators in the system (2%), which is almost similar to our data.
study population (n=300) at the ED at Sultan Qaboos
University Hospital in Muscat, Oman In our study, the highest average number of drugs per
prescription was for cardiovascular disease (3.70 ± 1.49)
Indicator value
followed by respiratory disease (3.41 ± 2.45) and
Average number of drugs per encounter 3.16±1.89 gastrointestinal disease (3.39 ± 2.32). In the Indian
Percentage of encounters with an antibiotic 10% study,[10] the average number of drugs per prescription was
Percentage of encounters with an injection 38% highest in the cardiovascular disease (5.4 ± 1.2) followed
Percentage of drugs prescribed from the essential drug list 58% by the central nervous system (4.5 ± 1.0) and renal
ED: Emergency department, WHO: World Health Organization disease (4.2 ± 0.9).

Figure 1: Percentage of different classes of drugs prescribed to 300 Figure 2: The Percentage of the cost of different drug classes
patients (N = 939 prescriptions) in the Emergency Department at of 300 patients in the Emergency department at Sultan Qaboos
Sultan Qaboos University Hospital in Muscat, Oman, NSAID: Non- University Hospital in Muscat, Oman, NSAID: Non-steroidal anti-
steroidal anti-inflammatory drugs, GIT: Gastrointestinal tract, CNS: inflammatory drugs, GIT: Gastrointestinal tract, CNS: Central
Central nervous system, CVS: Cardiovascular system nervous system, CVS: Cardiovascular system

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 Al Balushi, et al.: Drug use in emergency department

Table 5: Drug indications, prescribing trends and prescription cost in the ED at Sultan Qaboos University Hospital
in Muscat, Oman
Indication n Percentage Average no. of drugs (mean±SD) Average cost/patient (US$)
Hematological 54 18.00 3.13±2.02 3.80±2.17
Gastrointestinal 51 17.00 3.39±2.32 72.98±328.61
Infection 45 15.00 3.27±1.56 23.69±23.89
Musculoskeletal 30 10.00 3.27±1.66 20.46±61.72
Trauma 28 9.33 2.61±1.20 9.67±27.25
Respiratory 17 5.67 3.41±2.45 23.37±27.87
Renal 16 5.33 3.25±1.84 14.98±18.33
CNS 13 4.33 2.85±1.77 32.08±77.09
CVS 10 3.33 3.70±1.49 8.48±5.25
Metabolic 6 2.00 2.17±1.60 18.49±34.29
Others 30 10.00 3.00±2.08 13.55±22.00
Total 300 100 3.16±1.89 241.54±631.49
CVS: Cardiovascular system, CNS: Central nervous system, SD: Standard deviation, ED: Emergency department, US: United States

the WHO essential drug list [Table 4]. Several drug use studies

Table 6: The top 10 drugs’ cost of prescribing for
using these standard drug‑use indicators have been performed
300 patients in the ED at Sultan Qaboos University in many developing countries under the supervision of the WHO
Hospital in Muscat, Oman to provide ideal values for each indicator (more details can be
Drug name Cost (US$) found in Hogerzeil et al. 1993 and in the WHO manual[4,13]). The
Morphine 1886 average number of drugs per prescription ranged from 1.3 to
Cefuroxime 1404 3.8. In these studies, the percentage of antibiotics use ranged
Filgrastim 940 from 25% to 63% while the percentage of injectable drug use
Tazocin (piperacillin and tazobactam) 580 ranged from 0.2% to 48% respectively. Furthermore, some of
Paracetamol 396 these studies showed that about 85‑88% of drugs prescribed
Celecoxib capsule 356 were from the WHO essential drug list.[4]
Augmentin (amoxicillin and clavulanate potassium) 345
Lactulose solution 284 Our study showed that there was a significant association
Salbutamol 274 between the hospital cost and age. Older patients had higher
Ciprofloxacin 213 medication cost because as a person gets older he/she are more
ED: Emergency department prone to have variants of diseases as well as chronic diseases
with their complications that require further medication
management. Moreover, duration of stay in the ED had a
Cost analysis is an important part of drug utilization research.
In our study, anti‑infective drugs’ cost (2810 US$) was the significant association with the hospital cost. As the hospital
highest among all drug classes prescribed followed by CNS stay increases so too was the cost because long stays mean
drugs (2004 US$) and NSAIDs (878 US$) [Figure 2]. This further investigations and management that are required
high cost of these classes was due to the high frequency for the patient. Furthermore, there was also a significant
of drugs prescription of these classes as shown in Table 3. association between the hospital cost and emergency types.
Moreover, most patients came to the ED with hematological,
gastrointestinal and infectious diseases which require This study is not without limitations. No power analysis
prescription of these classes of drugs. The total cost of all was performed in this study and one could not be certain
drug classes was 8690 US$ over the 1‑month period and the that our sample size (n = 300) was a representative sample
average cost per prescription was 242 ± 631 US$. In a study of the general Omani population. However, the sample size
conducted in India,[10] the mean cost per prescriptions was was in accordance with WHO recommendation for practice
784 ± 134 INR (14 ± 2.4 US$). It should be kept in mind that in assessment in individual facilities which requires that a
order to have a realist view on the total cost of ED visits, other minimum of 100 samples per facility should be collected for
aspects of health care such as investigations, stay in hospital the purpose of evaluation.[9,13] This sample size will give a 95%
and other intangible costs should be calculated. These aspects confidence interval of within 10% for the individual result.[13]
were not part of the objectives of this study. Furthermore, since this study was performed in only 1 month,
it could not have captured seasonal variations, which could
The WHO core indicators of prescribing practices measure the have affected prescribing patterns.
performance of health care providers in several key dimensions
related to the appropriate use of drugs. In our study, the average Conclusion
number of drugs per prescription was 3.16 ± 1.89, the percentage
of antibiotics use was 10%, the percentage of injectable drug The average number of drugs prescribed per patients in the
use was 38% and about 58% of drugs were prescribed from ED over the 1 month period was 3.16 ± 1.89. NSAIDs were the

Vol. 5 | Issue 1 | December-February 2014 5 Journal of Basic and Clinical Pharmacy
 Al Balushi, et al.: Drug use in emergency department

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Source of Support: Nil, Conflict of Interest: None declared.
6. Siddiqi  S, Hamid  S, Rafique  G, Chaudhry  SA, Ali  N, Shahab  S,

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