Pharm World Sci (2010) 32:90–96 DOI 10.1007/s11096-009-9347-3
RESEARCH ARTICLE
Pharmacy services to UK Emergency Departments: a descriptive study Ursula Collignon • C. Alice Oborne Andrzej Kostrzewski
•
Received: 7 August 2008 / Accepted: 26 October 2009 / Published online: 8 November 2009 Springer Science+Business Media B.V. 2009
Abstract Objective To describe current hospital pharmacy services and facilities provided to United Kingdom Emergency Departments (EDs), identify potential roles for pharmacy technicians and possible benefits pharmacists may bring to the ED. Setting Emergency care specialist interest group workshop at an UK Clinical Pharmacy Association (UKCPA) conference in 2004. Workshop attendance was open to pharmacists and technicians. Method A descriptive study using a voluntary self-completed questionnaire covering ED services, pharmacy services and facilities to the ED and potential roles and benefits. Results Of 40 questionnaires distributed, 31/40 (78%) were returned representing 25 NHS hospitals. Most (72%) EDs received some level of pharmacy service. Emergency Department skill-mix, ED service models and pharmacy services varied. Pharmacists’ current roles were similar across EDs, with input into guideline development and review 12/25 (48%), patient group directions 11/25 (44%), provision of training 11/25 (44%), provision of advice (general and clinical)/liaison 10/25 (40%) and drug history taking 11/25 (40%). Potential roles identified for pharmacy technicians included assessment of patients’ own drugs, support for drug history taking, stock management and drug storage. Further benefits pharmacists could bring
to EDs included rationalisation of medicines on admission, identification of ADRs causing admission, support with complex medicine issues, new prescribing skills, supporting the maximum waiting time target and facilitating discharge. Conclusion Pharmacy services have developed to support service provision in EDs with similar roles to in-patient pharmacists. Pharmacy services in some EDs are now extensive with funded, full-time pharmacy posts but pharmacy service review is required to optimise ED patient care where there is limited or no current pharmacy input. New pharmacy services must fit with local ED service models and skill mix. Evaluation of these new services is vital to maximise benefit to patients and the NHS. Keywords Emergency service, hospital Medicines reconciliation Pharmacist Pharmacy service, hospital Prescriptions, drug Professional practice
Impact of findings on practice •
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Current pharmacy services in English emergency departments include pharmacists taking drug histories, medicine review, and guideline development. Although taking drug history and medicines review are of proven patient benefit to patients, under half of the organisations studied provided this in their emergency departments.
Introduction U. Collignon (&) C. A. Oborne A. Kostrzewski Pharmacy Department, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK e-mail:
[email protected]
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United Kingdom (UK) Emergency Department (ED) services have been radically redesigned following
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Government policy launched in 2000 which highlighted a clear need to reduce patient waiting time, improve the care delivered and transform patient experience. This policy—the NHS Plan—specified all patients should be seen and discharged, transferred or admitted within 4-h of presentation to the ED [1]. In the 1990s ED care was not a high government priority and increasing demand, coupled with under investment created growing patient and staff dissatisfaction, particularly with waiting times. A subsequent policy, Reforming Emergency Care, issued in 2001 [2] expanded key emergency care targets, outlined current problems, proposed solutions and provided a vision for the transformation of emergency care service delivery. Key points included nurse led minor injury services, quicker hospital discharge, freeing beds through investment in non-hospital care, i.e. intermediate care homes, improved tailoring of ED services to patient need, including discharge with self-care advice, and working in new ways across professions, practice and service boundaries. To support departments in achieving the challenging 4-h wait, the Emergency Services Collaborative (ESC) was established and run in England from 2002 to 2004 by the NHS Modernisation Agency [3]. This programme deliberately encompassed all staff groups and worked across a wide range of organisations including primary care (e.g. general practice, walk in centres in the community), secondary care (acute hospitals) and ambulance services and paramedics to challenge traditionally perceived attitudes and pathways of care. Clinical teams were brought together to focus on sharing good practice and broadening skill mix in emergency care. This highlighted possible roles for pharmacists including ward based dispensing for discharge and prescription transcription. The collaborative process made it clear that all staff must be fully involved across an organisation to achieve effective service redesign. As ED services have changed and developed, new roles have emerged, creating opportunities for staff to develop and extend their skills and practice to directly benefit patient care. For example, GPs working within EDs seeing patients with primary care health needs [4]. Alongside these changes, short-stay in-patient care areas have been reconfigured to include Clinical Decision Units (CDUs) led by ED consultants and Medical Admission Units (MAUs) run by in-patient consultants. Historically, UK pharmacy services to EDs consisted of stock drug supply and prescription dispensing, but some organisations have established new pharmacy services to support the 4-h target and optimise medicines use and pharmaceutical care for patients in EDs. Several additional reasons necessitate review of pharmacy input to the ED: extensive use of Patient Group Directions
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(PGDs1), new non-medical prescribers, National Patient Safety Agency (NPSA) alerts including Safer use of Injectable Medicines [5], the National Institute for Clinical Excellent (NICE) requirement to implement medicines reconciliation [6], out of hours access to medicines [7], staff vacancy rates and increasing use of pharmacy technicians in in-patient ward areas to assess patients own drugs and manage drug stocks. In the UK the first clinically orientated ED pharmacist post was created in Nottingham in 2002 where a full time pharmacist is based directly in the ED [8]. This was followed by Northern Ireland in 2004 with specifically designated funding for ten full-time pharmacists, one in each ED. These pharmacists work as a formal network to implement PGDs, co-ordinate antidote availability, facilitate good dispensing practice by non-pharmacy ED staff and audit medicines use [9]. Clinical pharmacy is an established component of ED services in Australia [10] with accepted standards of service and staffing [11] and is developing in the United States of America [12–14]. The benefits of clinical pharmacists on in-patient length of stay, cost, prescribing quality and readmissions have already been demonstrated [15–17] but further work is required to assess the impact and benefits of a clinical pharmacy service in an ED environment. Although new ED pharmacy services are being developed in the UK, there is no published overview of ED pharmacy services or of EDs themselves to inform future practice and service design. This survey was conducted to establish current baseline pharmacy service provision in UK EDs.
Aim To describe current hospital pharmacy services and facilities provided to UK EDs, identify potential roles for pharmacy technicians and possible benefits pharmacists may bring to the ED.
Method A voluntary self-completion questionnaire was designed, using open and closed items to explore workplace arrangements and participant’s views. The questionnaire was piloted on clinical pharmacists in a large teaching 1
Patient Group Directions are used to supply or administer prescription medicines directly to patients by non-prescribers, in nurse led services. These directions are an UK legal framework that allow defined healthcare professionals to supply and/or administer medicines to groups of patients that fit the criteria laid out in the PGD, without the need for a prescription.
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hospital to ensure face validity. After minor modifications, fifteen items were included. Ten closed items asked about the work place, current service provision to EDs, services to the admission wards (short-stay wards were approximated as in-patient stay less than 24 h, medical admission wards as 24–48 h) and ED staffing models. Three open items explored pharmacy facilities and services to the ED and current pharmacist role(s). Two further open items assessed new roles: benefits of pharmacists and pharmacy technician roles in the ED. The study was conducted at an UK Clinical Pharmacy Association (UKCPA) conference in November 2004 within an emergency care pharmacists’ workshop entitled ‘The pharmacist’s role in the Emergency Department’. A purposive sample of all workshop attendees was used and the questionnaire was distributed to all workshop participants. Voluntary informed consent was obtained from all participants as outlined in the revised ethical guidelines for educational research [18]. Service structure and staffing data were analysed using Microsoft Office Excel 2003. Prior to analysis, duplicate responses from the same organisation were compared. For closed items, agreement between respondents was evaluated. Where ‘don’t know’ was indicated but another respondent from the same organisation provided an answer, the latter was used. No other responses were combined and all qualitative responses were included. Responses to open items were grouped into themes by the main investigator using content analysis.
Results From 40 workshop attendees, 31/40 (78%) completed questionnaires were returned, representing 25 UK organisations. For quantitative questions, no discrepancies were found between respondents from the same organisation. All 25 (100%) were NHS secondary care hospitals. Seven (28%) were from Northern Ireland, no organisations from Wales or Scotland were represented. Emergency Department services All respondents stated there was an ED within their organisation. Seven (28%) gave approximate patient attendances to their ED ranging from 100/week to 125,000/year, eighteen (72%) did not know this information. Alongside the main ED, the most common additional service model represented was minor injury units (Table 1). Dedicated acute in-patient beds in short stay ward/areas were present in 22 (88%) organisations, 16 (73%) of which were run as part of the ED. Nineteen (86%) of these areas received a pharmacy service. Medical admission ward(s) that accept
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Pharm World Sci (2010) 32:90–96 Table 1 Emergency Department service models Service present
Unknown
Main Emergency Department
25 (100%)
0 (0%)
Minor injuries unit (secondary care, not in-patient stay)
15 (60%)
1 (4%)
Walk-in centre (primary care led)
4 (16%)
0 (0%)
Primary care facility
6 (24%)
2 (8%)
GP Practice on same site (primary care led)
0 (0%)
0 (0%)
new patients at the start of their hospital stay were present in 22 (88%) organisations. Range of staffing in Emergency Departments A range of staff other than hospital doctors, nurses and allied healthcare professionals worked in the EDs: eighteen departments (72%) had emergency nurse practitioners (ENPS)—speciality trained nurses who manage minor illnesses and minor injuries, nine (36%) had general practitioners (working directly for the hospital) and fourteen (56%) had pharmacists in the department. Pharmacy facilities Nineteen (76%) organisations surveyed had ED pharmacy facilities. These included: access to an outpatient pharmacy department (dispensing medicines directly to patients), access to the main hospital dispensary, referral to primary care (not based on site) and prepacks (medicines pre-labelled with directions for use, ready to be issued to patients) and training. One respondent did not know whether there were any available pharmacy facilities for their ED. Pharmacy services A range of pharmacy services provided to EDs were reported by respondents: supply of stock drugs and parenteral fluids, pharmacy technician support, prepacks, outof-hours pharmacist residence service and regular checks of controlled drug stocks and records. Out patient medicines Take-home medicines for patients attending the ED during pharmacy opening hours were supplied solely from pharmacy in 13 (52%) organisations. Outside pharmacy opening hours, no organisations supplied medicines solely from pharmacy (i.e. via a resident pharmacist or on-call pharmacy service), 19 (76%) supplied only from ED and 3 (12%) from both.
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Pharmacist services
Table 3 New roles: possible benefits of pharmacists in the Emergency Department
Fourteen organisations (56%) had pharmacists working in the ED and of those that did not, four (16%) provided pharmacist support via telephone. The median grade of pharmacist providing services to the ED was NHS Whitley pay scale D [range C (mid grade pharmacist) to E (senior pharmacist)], with one pharmacist on the new NHS pay scale (Agenda for Change) at Band 8a. Pharmacists on this new scale are graded at bands 6 (newly qualified) to 9 (chief pharmacist). The allocated time for pharmacist service delivery to EDs varied: some provided regular visits or support, while others were dedicated full-time to provide clinical pharmacy services to their ED.
Drug history taking
Pharmacy roles and benefits
Supporting targets (discharge and 4-h wait) Improved quality of care including accuracy of prescribing
Current pharmacist role(s) were described for 20/25 (80%) organisations, 71% (63/89) of stated roles fell into six categories the commonest of which was guideline development and review (Table 2). Possible new benefits from pharmacists were also identified (Table 3).
Management of minor illness
Possible technician roles
Rationalisation of medicines from admission Risk management including safer prescribing and improved communication with primary care Identification of adverse drug reactions (ADRs) and drug related admissions Provision of medicines advice to staff Development of protocols and PGDs Provision of patient advice and compliance assessment Assessment and use of patients own drugs, reducing medicine wastage Identification of patients with complex medicines/medication needs (including non admitted patients)
Utilisation of pharmacist prescribing Reduction of missed doses
Table 4 Participants’ proposed pharmacy technician roles Assessment of patients’ own drugs Stock management and drug storage (including major incident stock)
Participants proposed technician roles identified ranged from medicines storage and supply to supporting guideline development and information provision directly to patients (Table 4). One respondent stated they were ‘‘yet to be
Supporting medicine history taking Dispensing support Patient education Staff education and training Transcription of drug charts Pharmacist support for developing and auditing guidelines
Table 2 Current roles for pharmacists in Emergency Departments Role undertaken (n = 25) Guideline development and review
12
48%
Drug history taking
11
44%
Writing and reviewing PGDs
11
44%
Education and training for medical and nursing staff
11
44%
Advice (general and clinical) and liaison
10
40%
Medicine supply including discharge prescriptions
8
32%
Financial support e.g. drug expenditure/budget
5
20%
Patient education
3
12%
Attend ward round
3
12%
Patients own drugs e.g. reviewing, ensuring transfer Risk management
3
12%
2
8%
Writing drug charts
2
8%
Other roles e.g. responding to patients requesting medicines, urgent dispensing, staff induction training
8
32%
convinced’’ of the benefits of a pharmacist or of potential technician roles in the ED setting.
Discussion Provision of pharmacy services to Emergency Departments This survey demonstrates similar pharmacist roles have emerged in different organisations despite independent development of ED pharmacy services and variation in ED characteristics. In EDs with greater pharmacy input, pharmacy activities reported here are very similar to pharmacy services to in-patient wards including medication review, clinical advice and guideline development. For EDs with a pharmacist in the department versus pharmacy support via telephone (as a bleep) the only trend in service provision by the former was a more comprehensive service including services at an individual
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patient level. Drug history taking [19–21] or medicines reconciliation [6, 22] was undertaken and is of proven benefit to patients. Pharmacists’ drug histories are more complete than those taken by other healthcare professionals [23–25] but under half of organisations represented stated they provided drug history taking in the ED, and a similar proportion had no physical pharmacist presence in the department. New UK guidance on medicines reconciliation highlights a role for accredited pharmacy technicians to support drug history taking [6]. Pharmacy support to short stay Emergency Department inpatients Of the organisations surveyed, more than a quarter admit short-stay ED patients. These patients may be just as likely to have medical problems as traditional medical inpatients but until recently received very little pharmacy input. Their pharmaceutical care is challenging with limited time to identify and manage the patients’ medicine issues: accessing information on patients medicines is difficult with poor patient recall, lack of patients own medicines and GPs and community pharmacies closed, yet incomplete drug histories may result in drug-induced admissions being overlooked [26]. Therapy may be unintentionally duplicated and patients using medicines compliance aids who require changes to medicines may be overlooked. Liaison between hospital staff, community healthcare professionals and relatives or carers is required for ED patients as well as inpatients if changes to medicines are to be communicated and effected. Our data suggest these short stay ED patients still receive very little pharmacy input in some organisations. The finding that some short-stay ward/areas had no pharmacist input warrants review of pharmacy services around quality of care and medicine risks [24, 27].
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Patient prioritisation The majority of patients attending the ED are not admitted and are discharged home. Patients are currently not reviewed by a pharmacist unless they receive medicines to take home that are dispensed from pharmacy or are referred to or seen by the ED pharmacist (where one exists). Guidelines are needed to assist other healthcare staff to identify ED patients requiring pharmacy input. Further work is required to identify specific groups; patients discharged directly from the ED and ED admitted patients who would benefit from pharmacy input. Pharmacists working in EDs will have to work flexibly, only some hospitals provide an out-of-hours pharmacy service and work is also required to assess the medicine-related needs of out-of-hours ED patients. Patient Group Directions, guideline development and teaching Some conditions are commonly treated in EDs. Pharmacists can input to guideline development for common treatments e.g. antibiotics and analgesia. Through these guidelines, evidence-based care can be introduced, promoted and audited for large numbers of patients. To effectively implement such guidelines across all ED staff, a significant role reported by respondents was provision of training, as re-enforcing guidelines with teaching enhances application in practice [28]. As legally required signatories for PGDs, pharmacists must also assist in writing, reviewing, teaching and audit of PGDs. Further amendments to UK prescribing legislation have now enabled nursing staff to gain supplementary or independent prescriber status and these staff require formularies, audit and practice support. Managing medicine risks
Specific pharmacist roles for ED patients The open question regarding current pharmacist roles produced very consistent responses with 71% (63/89) of stated roles falling into six categories. Many ED pharmacist roles identified are similar to those already undertaken by clinical pharmacists within in-patient areas. Respondents also described individual, responsive patient services such as emergency supply of medicines or ED staff education. Several of the current and new roles identified by respondents overlap (Tables 2, 3), reflecting current variation in service provision. Interestingly, less than a quarter of respondents stated a role in drug supply, including discharge medicines. This may be because respondents view medicines supply as a core pharmacy service.
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Respondents clearly identified a role in managing and reducing risk in relation to medicines. The ED, particularly the resuscitation area is a known area of high risk medicine use [29–31]. With increasing healthcare and NHS regulator focus on medicine-related risks [6, 32] pharmacy must take an active lead on medicine safety including implementing national directives from the NPSA and NICE guidance. Forty percent of respondents reported providing advice to EDs and with an increasingly diverse workforce, differing pharmacy information requirements will exist. Communication of tailored information must be reliable: whatever communication systems are put in place they must reach all staff irrespective of the hours they work. Paper-based systems are increasingly outdated with information becoming computer or web-based.
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Out of hours medicine supply
2004, membership has grown steadily from 82 in 2006/ 2007, 98 in 2007/2008 to 129 in 2008/2009. As the group encompasses pharmacy staff working in non-ED areas, e.g. Ambulance Services and the Territorial Army, it is unclear if this increase in numbers represents increased pharmacy input into the ED since 2004.
Ensuring round the clock supply of medicines for patients in the ED is still a challenge. Although some respondents reported out-of-hours pharmacy services as part of pharmacy services to ED, none of these were the sole source of out-of-hours medicines. Such a service would require significantly more pharmacy staff resource than at present. The majority of respondents reported out-of-hours supply of medicines from ED alone using pre-labelled packs of medicines. Pharmacy staff have a role in reviewing availability and usage of pre-labelled medicines and ensuring non-pharmacy staff understand the legal requirements for supply of medicines under the Medicines Act and the different legal frameworks of PGDs versus independent prescribing. Potential pharmacy technician roles A variety of roles were proposed for pharmacy technicians including stock management and drug storage, co-ordinating drugs stocks for major incidents and providing dispensing support. In the UK, in other areas of in-patient care, accredited pharmacy technicians may record drug histories which are then clinically reviewed by a pharmacist. For the last 3 years a pharmacy medicines management technician has overseen pharmacy ED services at a large London hospital [33]. This role is now well established and cost savings have been achieved.
Conclusion Pharmacy services have developed to support UK EDs with similar pharmacist roles in different organisations despite little liaison between organisations. Although some EDs now receive extensive and well funded services which are similar to pharmacy services to inpatient wards, a significant proportion of ED and short-stay patients receive no direct pharmacy input, highlighting gaps in current pharmacy service delivery. Increasingly, designated pharmacist time for ED is recognised as essential if ED and short-stay patients are to receive the same standard of care as other inpatients. The variety of service models and staff mix in EDs reported here highlights future pharmacy developments should be tailored to local need. These new pharmacy services will then require evaluation to ensure they provide benefit to patients, individual organisations and the NHS. Acknowledgements Thanks are due to the UKCPA and the UKCPA emergency care group committee for allowing the survey to be conducted as part of the workshop.
Limitations and generalisability of findings
Funding
This work was conducted at a bi-annual national pharmacy conference which is widely advertised in journals received by all UK pharmacists. The conference was held in England and due to travel distance or geographical barriers the sample may not represent the variation of services within the UK. Further work may be required to gain a complete overview of UK practice. The purposive survey sample of a voluntary specialist workshop may have over represented EDs with higher pharmacy involvement but one respondent expressed reticence to pharmacy involvement in ED, suggesting a range of organisations were represented. Since the data were collected, national pharmacy policy has not included specific recommendations regarding ED pharmacy services but has emphasised medicines safety and managing risk [6, 32]. Thus the proportion of ED pharmacists now engaged in safety and risk activities is likely to be greater than the 8% reported here. Several respondents listed risk management as a future role. The number of UK pharmacists with an interest in emergency care is reflected in the membership of the UKCPA emergency care group. Launched in November
Conflicts of interest The authors are members of the UKCPA and Ursula Collignon is a committee member of the UKCPA emergency care group.
Unfunded study.
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