Working in urgent & emergency care

Community pharmacists are well placed to support with urgent requests for repeat medications as they have experience in providing emergency supplies at the request of patients.

Some areas in England have commissioned schemes such as Pharmacy Urgent Repeat Medicine Service (PURM) which include service level agreements for the supply of urgent repeat medication from community pharmacy. You can find further details of this in the Commissioning Standards for Integrated Urgent Care. NHS England has produced guidance on commissioning an emergency repeat medication supply service. 

NHS England has produced Urgent Repeat Medication Requests: Guide for NHS 111 Services How to refer directly to pharmacy and optimise use of GP out of hours services. There was announcement in October that there will be a national pilot for a community pharmacy Urgent Medicine Supply Service. Final details of this are yet to be announced, however the PSNC has current information on their website.

In Scotland, there is a National Patient Group Direction for the Urgent Supply of Repeat Medicines and Appliances. The Scottish Government has recommended that there should be an increased use of the National Patient Group Direction for the Urgent Supply of Repeat Medicines and Appliances. Further information on the national patient group direction can be found on the NHS Scotland website.

In Wales  a national enhanced service template for an emergency supply service has been developed, many health boards have commissioned this. Individual health boards should be contacted for further detail.

The Royal Pharmaceutical Society has produced professional guidance on emergency supply. Although this guidance does not cover the request of an emergency supply through a PGD, it does help individuals to identify the information you need to gather in order to decide whether an emergency supply requested by a prescriber or patient is appropriate or not. It also provides information on record keeping and labelling of medicines supplied.

We have also produced a professional judgment quick reference guide, to support you in the decision-making process.

Support for self-care forms part of the NHS community pharmacy contractual framework. You can find the service specification for England on the PSNC website. Details of the service in Scotland can be found on the NHS Scotland website. You can find out more about the pharmacy contract and services in Wales on the Community Pharmacy Wales website.

In England there are a variety of locally commissioned minor ailment services (MAS).
NHS Scotland website has details of the national minor ailments service in Scotland.
The Welsh Government website features details of the announcement for a national Choose Pharmacy Service.
 

Useful resources

• Self-care for minor ailments (RCGP, e-learning programme)
• Responding to minor ailments (CPPE, NES, WCPPE, pack).
• Responding to minor ailments (NES, distance learning pack)
• Self-management to help healthcare workers develop knowledge and understanding to support self-management (NES, learning resource)
• Minor ailments service within community pharmacy specification (PSNC).
• MAS core service in Scotland (Community Pharmacy Scotland).

For patients

• NHS Scotland  has produced Medicines Sick Day Rules Card. A useful resource for patients, carers and health professionals.
• NHS Choices is a useful website, providing health information in the form of articles, videos and tools for patients, pharmacists may choose to signpost patients to this.
• NHS Inform  is a health and care information service for people in Scotland.

A Patient Group Direction (PGD) is a written direction that allows the supply and/or administration of a specified medicine or medicines, by named authorised health professionals, to a well-defined group of patients requiring treatment for a specific condition. PGDs have been used in community pharmacy to enable pharmacists to supply or administer certain medicines.

Various Scottish health boards have PGDs in place for common clinical conditions, for example NHS Forth Valley have one for place for Supply of Prednisolone by Community pharmacists to patients with an exacerbation of COPD.

NHS Education for Scotland (NES) has produced a resource on common clinical conditions and minor ailments. The resource includes an overview of the most common clinical conditions (including signs, symptoms and alarm symptoms), and advice on how to respond to these conditions, be that through provision of advice or medication, or to refer to another profession or service.

The NHS England Quick Guide: Extending the role of community pharmacy in urgent care identified that dental pain is the second most common reason for calls to NHS 111. Community pharmacists are able to support patients with dental pain, and the Quick Guide states that:

"Early referral to community pharmacy to provide support for dental pain is critical. Analgesics available from community pharmacy can be effective if started early."

UK Medicines Information has produced dental pain guidance.

NHS England has produced a flowchart for the management of dental pain.

The Royal Pharmaceutical Society’s Innovator’s Forum has produced a new free online toolkit and handbook, Hospital Referral to Community Pharmacy, endorsed by the Royal College of Physicians, on how you can set up an electronic referral system in your area.  It provides the business case for investment in an e-referral system and gives practical advice on how to implement it, along with helpful case studies.

We have stated in our urgent and emergency care campaign that we believe pharmacists in the community could play a greater role in urgent care requests from people with common self-limiting ailments, both as a triage and referral service but also as an end point for self-limiting common ailments.
 

Triage + Treat Service (Wales)

Selected pharmacies in Wales are offering this service to help patients who have a low level injury, such as minor abrasions, superficial cuts and wounds. Further detail can be found on the NHS Wales website.
 

Red flag Identification

Community pharmacists are ideally placed to identify red flag symptoms and provide support and onward referral where appropriate.

RCGP has produced an e-learning programme for the self-care for minor ailments. You can find this on the CPPE website.  A learning objective of this programme is: “identify red flag symptoms, or signs that indicate a potentially dangerous condition in minor ailments” 

You will be taking an increasingly patient-facing role as you support medicines optimisation and the public health agenda. The Royal Pharmaceutical Society report, Now or never: shaping pharmacy for the future, outlines the need for pharmacy to be proactive in patient care.

The Consultation Skills for Pharmacy Practice website has been developed to support when speaking and consulting with patients and people about their medicines and lifestyle choices. The practice standards for consultation skills set out the knowledge, skills, behaviours and attitudes you need when communicating and consulting with patients.

WCPPE (Wales) has also produced a learning programme to support development of consultation skills.

Information on the current status of Electronic Health Records (EHR) for England, Scotland and Wales can be found on our Electronic Health Record resource page.
We have published guidance to support pharmacists accessing patient record: ‘Electronic Health Records (EHR): Guidance for Community Pharmacists and Pharmacy Technicians’. The guidance informs pharmacy professionals on key principles concerning the maintenance and use of EHRs of all types, including pharmacy Patient Medication Records, GP systems or national NHS electronic record services. It describes some of the issues associated with using EHRs in pharmacy professional practice and makes recommendations to pharmacy professionals concerning best practice use of EHRs to support high quality practice and patient care.

NHS Digital (formerly known as HSCIC) has produced a factsheet for pharmacy professionals  which includes the benefits for community pharmacy, training, consent, pharmacy use of summary care records, and insurance and liability. NHS Digital has also produced information on how access to summary care records can help with emergency supply.

The NHS England Commissioning Standards  – Integrated Urgent Care has further information on access to records which can be found on page 25-26. Across urgent care settings there are a number of locally held patient records for “Special Patient Notes” and to support end of life care.

In Scotland  currently emergency care summary access is limited to A&E units, the Ambulance Service, some hospital wards and NHS24. Community pharmacists can contact NHS24 to receive this information unless part of pilot roll-out testing. NHS Scotland has produced information about how community pharmacists, with the patient’s consent, can contact NHS 24 if they require further information within the patient’s Emergency Care Summary (ECS).

The Welsh GP Record  is available to doctors and nurses routinely in out of hours services, and is being rolled out for unscheduled care services. Further development of a web-based application called Choose Pharmacy will enable community pharmacists in Wales to access the Welsh GP Record when required, to provide emergency supplies of medicines.

Community pharmacists can support in the delivery of advanced care for patients through the development of their ability to assess, diagnose and manage patients.

The following CPPE learning programmes can be useful for pharmacists interested in advanced practice:

• Urgent care - A focus for pharmacy (distance learning)
• Advanced training in assessment and management of urgent cases (two day residential course for pharmacists in NW England)
• Urgent care - playing your part (e-learning)
• Urgent care in pharmacy practice (distance learning)

The British Medication Association (BMA) has published information and guides on the NHS complaints procedure in England, Scotland and Wales.

A PGD is a written direction that allows the supply and/or administration of a specified medicine or medicines, by named authorised health professionals, to a well-defined group of patients requiring treatment for a specific condition.

It is important that pharmacists involved with PGDs understand the scope and limitations of PGDs as well as the wider context into which they fit to ensure safe, effective services for patients.

The supply and administration of medicines under a PGD should only be reserved for those limited situations where this offers an advantage for patient care, without compromising patient safety. A PGD should only be developed after careful consideration of all the potential methods of supply and/or administration of medicines, including prescribing, by medical or non-medical prescribers.

The following useful resources relating to patient group directions: 

• Online resources are available at the Specialist Pharmacy Services website
• Patient group directions (NHS Education for Scotland)
• Patient group directions: who can use them (MHRA, Decemeber 2014)

It is a regulatory requirement for all registered pharmacists to "make sure that all your work, or work that you are responsible for, is covered by appropriate professional indemnity insurance".

The RPS is not regulated by the Financial Conduct Authority and cannot recommend professional indemnity insurance providers, however NHS Employers has published guidance and a series of questions and answers regarding professional indemnity insurance.

The GPhC website contains information on Professional indemnity requirements.

Record keeping is an integral component of clinical governance and safe practice. The GPhC standards for registered pharmacies state that “all necessary records for the safe provision of pharmacy services are kept and maintained” and that you must “keep full and accurate records of the professional services you provide in a clear and legible form”.

NHS East & South East England Specialist Pharmacy Services has produced a document about the retention of pharmacy records. It includes guidance for all pharmacy settings as well as some sector specific information.

The need to protect patient confidentiality and obtain patient consent is layered through legislation, regulation and contractual frameworks.

Useful resources include:

• The NHS code of practice for confidentiality
• The NHS constitution
• Information commissioner's office guide to data protection

Registered pharmacists also need to be aware of GPhC regulatory guidance for consent and confidentiality:

• GPhC guidance on consent
• GPhC guidance on confidentiality

 

Covert administration

UKMI has published comprehensive information on What legal and pharmaceutical issues should be considered when administering medicines covertly?

NICE has produced Quality Statement 6: Covert medicines administration.

CPPE run a workshop on The Mental Capacity Act 2005 and covert administration of medicines. 

The Mental Welfare Commission for Scotland has published the Good Practice Guide Covert Medication which applies to situations in which an individual lacks capacity to make a decision regarding medical treatment and refuses treatment.

Betsi Cadwaladr University Local Health Board (East) has published NEWT Guidelines for the administration of medication to patients with enteral feeding tubes or swallowing difficulties. (Please have a look at the guidance on the NEWT Guideline website on how to use the information obtained on each drug in practice).

The  Handbook of Drug Administration via Enteral Feeding Tubes, 3^rd Edition (March 2015) Rebecca White and Vicky Bradnam, Pharmaceutical Press , covers the technical, practical and legal aspects that you should consider before prescribing or administering drugs via enteral feeding tubes. 

The Royal College of Paediatrics and Child Health has worked with 19 different bodies to produce Safeguarding children and young people: roles and competencies for health care staff; a framework for healthcare staff, which describes the level of competency and training required for different roles.

Other sources of information include:

• Protecting vulnerable adults quick reference guide (RPS)
• Protecting children and young people quick reference guide (RPS)
• Safeguarding training - Level 1 and 2 (CPPE)
• Safeguarding training - Level 1 and 2 (wCPPE - Wales)

Evidence-based clinical guidelines support community pharmacists in the decision making process and when undertaking clinical checks of prescriptions.

NICE guidelines are evidence-based recommendations for managing specific conditions.
SIGN produce similar guidelines for use in Scotland.

NICE clinical pathways are clinical flow decision trees designed to help clinicians to make decisions.

Medicines Complete (subscription required) is a platform that provides online access to a range of drug and healthcare reference sources.

NICE has published a range of guidance and clinical pathways to help with the care of older people.

The United Kingdom Clinical Pharmacy Association (UKCPA), a partnership group of the Royal Pharmaceutical Society and a member association for clinical pharmacy practitioners, have a special interest group for care of the elderly.

CPPE has published an older people learning programme to highlight health and medicines use and polypharmacy in older people. The consulting with older people workshop is part of the consultations skills for pharmacy practice programme and helps you support the older person in making decisions about their medicines.

WCPPE (Wales) has published Older people: managing medicines (Level 1) an online course which will provide you with the key issues affecting medicines management and older people.

You might also find useful the Decision aid for diagnosis and management of suspected urinary tract infection (UTI) in older people, produced by the Scottish Antimicrobial Prescribing Group.

NICE has produced a summary of the evidence-base on wound care products.

WCPPE (Wales) has produced a learning programme on wound management.

CPPE has produced a distance learning programme on wound management.

NHS Education for Scotland has produced the following learning resource:

• Your dermatology pocket guide: common skin conditions explained

1. X-ray request and interpretation
2. Body examination (e.g. external body)
3. Clinical examination and assessment 
4. Clinical skills
5. Neurological assessment
6. Paediatrics
7. Chest examination
8. Respiratory assessment or examination
9. Eye examination
10. Observations

Physical examination skills

Pharmacists working in urgent and emergency care settings could be involved in the assessment of patients, including physical examination.
  

Support with venous thromboembolism assessments for patients that have been admitted

1. ECG
2. Bloods
3. Urine testing
4. Arterial blood gas interpretation
5. Differential diagnosis
6. Troponin T
7. D-dimer test request
8. CT Scan interpretation
9. Blood pressure
10. Doppler

Understanding pathology results – monitoring 

 

Subtheme (top 10)

1. Trauma and injury management
2. Wound care
3. Analgesia
4. Paediatric
5. Fracture management
6. Minor illnesses
7. Pain management
8. Nosebleeds
9. Respiratory treatment
10. Skin conditions
     

Case management of appropriate presentations

King's Fund has produced a paper on Case management - What it is and how it can best be implemented.
 

Trauma

NICE has produced guidelines for Major trauma: assessment and initial management.
 

Sepsis

NHS England has produced a report, Improving outcomes for patients with sepsis – a cross-system action plan.
 

Patient management plans

Pharmacists may be involved in developing patient management plans as well as working with other members of the emergency department multidisciplinary team to draft treatment protocols for the management of patients in the emergency department.
 

Providing self-care and minor ailments advice 

• Self-care for minor ailments (RCGP, e-learning programme)

For patients

• NHS Scotland  has produced Medicines Sick Day Rules Card. A useful resource for patients, carers and health professionals.
• NHS Choices is a useful website, providing health information in the form of articles, videos and tools for patients, pharmacists may choose to signpost patients to this.
• NHS Inform  is a health and care information service for people in Scotland.
   

Wound/injury management

NICE has produced a summary of the evidence-base on wound care products.

WCPPE has produced a learning programme on wound management.

CPPE has produced a distance learning programme on wound management.

NHS Education for Scotland  has produced the following learning resource:

• Your dermatology pocket guide: common skin conditions explained

Respiratory 

NICE has produced guidelines for respiratory conditions. 
CPPE has produced a distance learning programme on Respiratory disease: evidence-based management of.

WCPPE has created the following resources:

• Respiratory disease: Asthma
• Respiratory disease: COPD
• Respiratory disease: Inhaler devices
• Respiratory disease: Nebulisers
• Respiratory disease: Oxygen

NHS Education for Scotland has produced the following resources:

• Asthma resource
• Chronic obstructive pulmonary disease (COPD) resource
• Nebulisers resource

Responding to medicines related questions in practice

Pharmacists will need to respond to requests for information on medicines from colleagues and patients.

CPPE, NES and WCPPE, together with UKMI, have produced learning programmes to support pharmacists responding to medicines-related questions.

• Answering medicines-related questions in practice (CPPE, England)
• Answering medicines-related questions in practice (NES, Scotland)
• Answering medicines-related questions in practice (WCPPE, Wales)

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Identifying and responding to adverse drug reactions

The Medicines and Healthcare Products Regulatory Agency (MHRA) has produced guidance on adverse drugs reactions, which includes a classification of adverse drug reactions. Pharmacists play a significant role in the identification and reporting of adverse drug reactions and as a result can help prevent hospital admissions caused by adverse events. 

The RPS has produced Professional standards for the reporting, learning, sharing, taking action and review of incidents

NHS Digital (formerly known as HSCIC) has produced information on how access to summary care records can help reduce adverse reactions.

Welsh Medicines Resource Centre has published a bulletin on medicines-related admissions. The bulletin states that medicines-related admissions could be caused by the following ways:

• Unwanted side-effects
• Errors or incidents
• Poor adherence

Yellow Card Centre Scotland and NHS Education for Scotland have developed a learning resource about adverse drug reactions, including "their incidence and public health implications". It explains the different classifications of ADRs and drug allergies, how to identify if a patient is experiencing an ADR and subsequent management.”

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Medicines reconciliation on admission

NICE describes medicines reconciliation as accurately listing the all of a person’s medicines including prescribed, over-the-counter, and complementary medicines. Pharmacists working in emergency departments can help recognise admissions that have been caused by issues relating to medicines.

You might find our Medication history quick reference guide helpful when conducting a medicines reconciliation. Download our medicines reconciliation checklist.

Medicines Use and Safety Team Specialist Pharmacy Service has produced Medicines Reconciliation: Best Practice Resource and Toolkit.

Medicines Use and Safety Team Results of a Collaborative Audit of Pharmacy-led Medicines Reconciliation (MR) in 56 trusts across E & SE England.

NHS Education Yorkshire and the Humber Pharmacy Development Unit have produced a document to assist in the training and development in Medicines History Taking.

Pharmacists working in urgent and emergency care settings may be involved in taking a patient medical history. This is an important opportunity to gather vital information about the patient and their presenting complaint.

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Medicine discharge optimisation

NICE has produced guidelines on Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes

NICE guidelines describe medicines optimisation as “the safe and effective use of medicines to enable the best possible outcomes.

We have created a wide range of resources on medicines optimisation; including good practice guidance, a patient leaflet, and briefings on optimising medicines for a number of conditions.

NICE has also developed a medicines optimisation pathway, covering the decision making processes used to help optimise a person’s medicines; including medicines reconciliation and medication review.

NHS England has developed a Medicines Optimisation Dashboard England, which is designed to further understanding of how patients are being supported with medicines use locally. NHS England has stated that: “Reducing unwarranted variation and increasing value through medicines optimisation is a crucial element of NHS RightCare’s innovation work.” You can find more information on the Right Care programme here. Tools and products to optimise the use of medicines can be found on the NHS England website, these have been brought together by NHS RightCare and partner organisations, including NICE and CQC.

CPPE has produced the following e-learning programmes relating to medicine optimisation:

• Medicines optimisation: essential skills
• Medicines optimisation: getting ready to make a difference

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Pharmaceutical Care (Scotland)

NHS Education for Scotland has produced a learning resource for the pharmaceutical care of people with dementia.

The Scottish Neonatal and Paediatric Pharmacists Group, in conjunction with NHS Education for Scotland have produced a distance learning pack on An Introduction to Paediatric Pharmaceutical Care.

NHS Education for Scotland has produced a learning resource for the pharmaceutical care of the eye.

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Pharmaceutical Care and Prudent Pharmacy Wales

Your Care, Your Medicines: Pharmacy at the heart of patient-centred care presents a vision for pharmacy in Wales.

Further information on the prudent agenda can be found at www.prudenthealthcare.org.uk. 

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Medicines safety

Pharmacists working in emergency departments can support with the safe use of medicines through:

• Preventing omitted doses
• Ensuring doses are administered correctly
• Engaging with GP/Community Pharmacy/Care Homes

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Polypharmacy

Pharmacists have a role in supporting the reduction of inappropriate polypharmacy.

PrescQIPP has produced a Polppharmacy & Deprescribing Webkit which includes a range of information and resources. 

The Scottish Government  has created polypharmacy guidance for the safe and effective use of multiple medicines to manage long term conditions.

SIGN Polypharmacy guidance.

The King’s Fund published a report on medicines optimisation and polypharmacy. Exploring systems for managing polypharmacy and offering recommendations for improving care for older people and those who have two or more chronic medical conditions.

CPPE has produced a learning programme to help develop your knowledge and skills in working with patients and other health and social care professionals to enable patients to get the best possible outcomes when they are taking multiple medicines.

WCPPE  has produced a learning programme to help pharmacy professionals understand the physiological changes that occur in the elderly and the impact of polypharmacy and reducing medicines wastage.

All Wales Medicines Strategy Group  has produced Polypharmacy Guidance for Prescribing.

NHS Wales has developed guidance on Polypharmacy: Guidance for Prescribing in Frail Adults.

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Preparing and implementing pharmaceutical care plans

Pharmacists may work with patients to help identify individual pharmaceutical care needs and develop a care plan to support this.

The Your Care, Your Medicines Report  describes how pharmacists can support with pre-screening and unscheduled care through the development of a pharmaceutical care plan. You can find more information about this in the report.

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Medicines adherence

Poor medicines adherence can lead to hospital admissions and difficulty in managing conditions.

Further information can be found in the RPS quick reference guide Medicines Adherence and NICE clinical guidelines on Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence.  

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Antimicrobial stewardship

Pharmacists have an important public health role to play in educating people about antibiotic resistance.

We have worked with University College London to create an online resource, www.AMSportal.org, which signposts to resources and information to promote learning about microbiology and antimicrobial stewardship.

RCGP is offering a free e-learning course about antibiotic resistance for all primary care health professionals in the UK.

The TARGET (Treat Antibiotics Responsibly, Guidance, Education, Tools Antibiotics Toolkit) aims to help influence prescribers’ and patients’ personal attitudes, social norms and perceived barriers to optimal antibiotic prescribing. It includes a range of resources that can each be used to support prescribers’ and patients’ responsible antibiotic use, helping to fulfil CPD and revalidation requirements. Using the resources in the TARGET Antibiotics Toolkit will enable organisations to demonstrate compliance with the Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance. The Toolkit also supports recommendations made in the recent NICE guideline: Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use (August 2015) and is linked within the guideline.

NICE guideline [NG15] Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use (August 2015) covers the effective use of antimicrobials (including antibiotics) in children, young people and adults. It aims to change prescribing practice to help slow the emergence of antimicrobial resistance and ensure that antimicrobials remain an effective treatment for infection.

Scottish Antimicrobial Prescribing Group: Antibiotics – an information leaflet for staff in care homes and community hospitals

CPPE  has produced an e-learning programme on Antimicrobials and infection management and a reducing antimicrobial resistance.

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Therapeutic drug monitoring

Pharmacists may be involved in therapeutic drug monitoring and also advising others involved in this.

The BNF contains information around drug monitoring.

"The Monitoring section specifies any special monitoring requirements, including information on monitoring the plasma concentration of drugs with a narrow therapeutic index (e.g. theophylline, p. 238). Monitoring may, in certain cases, be affected by the impact of a drug on laboratory tests (e.g. hydroxocobalamin, p. 837), and this information is included in Effects on laboratory tests."
In some cases, when a drug is withdrawn, further monitoring or precautions may be advised (e.g. clonidine, p. 137): these are covered under Treatment cessation.”

(How to use BNF, BNF 72)

There are often local guidelines for therapeutic drug monitoring which you can refer to, we have highlighted an example below. London and South East Medicine Information Service, South West Medicine Information Service and Croydon Clinical Commissioning Group has produced suggestions for Drug Monitoring in Adults in Primary Care.

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High risk medicines

High risk medicines can often be the cause of admission to urgent and emergency care settings. Pharmacists can support with the safe use of high risk medicines and help prevent admissions as a result of their use. When patients are admitted to urgent and emergency care settings, pharmacists may identify high risk medicines when conducting medicines reconciliation, and make appropriate recommendations.  

Scottish Patient Safety Programme in Primary Care aim to reduce events which could cause avoidable harm from healthcare delivered in any primary care setting and has developed a number of tools and resources to support this. The Safer Medicines workstream focuses on the prescribing and monitoring of high risk medicines.

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Falls due to medicines

Standard 6 of the National Service Framework for Older People is falls. Falls are a common cause of emergency department attendance and medicines can be a common cause of falls. Pharmacists can support with the prevention of falls.

CKS website contains guidance on sssessing risk of falling and managing people at high risk of falls.

NHS Doncaster – Community pharmacy falls prevention service. You can find further detail of this on the PSNC website . 

The British Geriatrics Society has produced Fit for Frailty guidance on the recognition and management of older patients with frailty in community and outpatient settings.

All Wales Medicines Strategy Group  has produced polypharmacy guidance for prescribing, this contains key considerations for prescribing in frail adults.

NICE has produced guidance on Falls in older people: Assessing risk and prevention.

The National Poisons Information Service (NPIS) "promotes, supports and develops best practice for the management of cases of poisoning in UK health facilities". NPIS provide a 24-hour telephone information line, 0344 892 0111 (UK only) which "provides clinical staff with case-specific advice on more complex cases".

Toxbase® service is the primary clinical toxicology database of the NPIS.
Toxbase® e-learning modules can be used by UK NHS staff who would like to learn more about the TOXBASE® database and the management of patients with poisoning.

The NHS England Commissioning Standards for Integrated Urgent Care contains recommendations on For Medicines and Poisons training on page 34.

Patient information leaflets may contain information for patients on what to do if they take too much of a medication.

College of Emergency Medicine and National Poisons Information Service have produced guidelines on antidote availability for emergency departments, together with an appendix.

Novel Psychoactive Treatment UK Network (NEPTUNE) has produced guidance on the clinical management of acute and chronic harms of club drugs and novel psychoactive substances.

In urgent and emergency care settings, triage is a useful process to determine the urgency of presenting patients.

The Royal College of Emergency Medicine has produced a position statement on triage, which defines “the activities of triage, initial assessment and streaming and indicate the added value of each to the patient pathway in the emergency/urgent care settings.” 

NHS Pathways  provides triage over the telephone for a variety of settings such as NHS 111 and GP out-of-hours. The NHS Digital website has further information. NHS Digital was formally known as HSCIC.

NHS England has produced an Urgent Repeat Medications Requests: Guide for NHS 111 Services.

Information on the national Patient Group Direction for the urgent supply of repeat medicines and appliances in Scotland, and on direct referrals to the out of hours services, can be found on the NHS Scotland website. 

Royal College of General Practitioners run a Enhance your telephone consultations and triage course, which pharmacists can attend. 

Employers may offer basic life support and advanced life support courses. The Resus Council has produced Quality standards for cardiopulmonary resuscitation (CPR) practice and training.

The Human Medicines Regulations allows the administration of listed parenteral medicines to human beings in an emergency for the purpose of saving life. The list of medicines for use by parenteral administration in an emergency can be found in Schedule 19 of The Human Medicines Regulations 2012 (www.legislation.gov.uk).

An example is administering adrenaline injection 1 in 1000 (1mg/ml) for the emergency treatment of anaphylaxis.

Adrenaline is a prescription only medicine and is given intramuscularly for the treatment of anaphylaxis. Brands of adrenaline intramuscular injections in your pharmacy may include Epipen®, Emerade® and Jext®.

Where a pharmacist is expected to recognise and treat an anaphylactic reaction as part of their usual clinical role (for example, if they are offering a vaccination service), they must have access to an anaphylaxis pack (as outlined in the Green Book) and have received the required training in the recognition of anaphylaxis and administration of adrenaline. The anaphylaxis pack will include ampoules of adrenaline and syringes and needles or prefilled syringes which should be used preference to auto injectors such as those listed above.

Anaphylaxis is a severe, life-threatening, systemic hypersensitivity reaction resulting in rapidly developing

airway and/or breathing difficulty and/or hypotension. Other features of an allergic reaction are often present, including skin and mucosal changes such as urticaria and angio-oedema of the face. Anaphylaxis is an emergency which should be treated immediately once identified.

Regulation 238 of the Human Medicines Regulations 2012 allows adrenaline to be administered by anyone for the purpose of saving life in an emergency.

Therefore pharmacists using their professional and clinical judgement can administer adrenaline in an emergency to persons presenting with symptoms of anaphylaxis.

If a pharmacist administers adrenaline they must also ensure that an ambulance is called by dialling 999 and reporting that there is a case of suspected anaphylaxis.

Pharmacists working in services such as NHS 111 and NHS 24 frequently support care homes through a variety of ways including:

• Medicines enquiries
• Advice on toxic ingestion
• Requests for urgent repeat medication
• Access to medicines
• Medicines advice for minor illness. 

Pharmacists may have a role in emergency planning.

Ursula Gotel has written an article which “covers changes that have brought emergency planning to the fore, practical guidance on where to start and lessons learnt in an acute hospital environment.”

Information on what the Governments are doing about emergency health planning can be found on the following pages:

• England
• Scotland
• Wales

NICE guidelines are evidence-based recommendations for managing specific conditions. 

SIGN produce similar guidelines for use in Scotland.

NICE clinical pathways are clinical flow decision trees designed to help clinicians to make decisions.

Medicines Complete (subscription required) is a platform that provides online access to a range of drug and healthcare reference sources.

BMJ Best Practice provides access to information when making diagnosis and treatment decisions. 

NICE has published a range of guidance and clinical pathways to help with the care of older people.

The United Kingdom Clinical Pharmacy Association (UKCPA), a partnership group of the Royal Pharmaceutical Society and a member association for clinical pharmacy practitioners, have a special interest group for care of the elderly.

CPPE has published an older people learning programme to highlight health and medicines use and polypharmacy in older people. The consulting with older people workshop is part of the consultations skills for pharmacy practice programme and helps you support the older person in making decisions about their medicines.

WCPPE (Wales) has published Older people: managing medicines (Level 1) an online course which will provide you with the key issues affecting medicines management and older people.

You might also find useful the Decision aid for diagnosis and management of suspected urinary tract infection (UTI) in older people, produced by the Scottish Antimicrobial Prescribing Group.

The Silver Book: Quality Care for Older People with Urgent and Emergency Care Needs gives an overview of some of the most pressing, clinical and social problems met by older people when they present in an emergency.

The Green Book (Immunisation against infectious disease) contains the latest information on vaccines and vaccination procedures in the UK.

NHS Education for Scotland has produced a learning resource on the storage and handling of vaccines.

NHS Pathways allows for a clinical-based triage of patient symptoms in order to assess the care needs of the patient. NHS Pathways has specific NHS 111, 999 and face to face versions of the clinical assessment algorithms. NHS Pathways is used by most Ambulance Trusts now to run their 999 service but they have a separate version of clinical content for their call handlers.

Evidence would suggest that up to 80% of calls could be managed by non-clinicians with clinical support and the remaining 20% of calls are cases that require additional assessment by clinical advisors.  Following the identification of a care need the NHS Pathways system matches patients with a service in their area who have:

a) The clinical skills required to treat the patient
b) Which services are open within the timeframe of the final disposition (as outlined by commissioners on the Directory of Services)
c) Who has the capacity to see the patient

• Data network of clinically based questions which support telephone triage to assess symptoms
• Used by specially trained call handlers, i.e. Health advisors  and clinical advisors
• Linked to the national Directory of Services (DoS) database, this is managed by local commissioners
• The NHS 111 service safely manages 1 - 1.3 million calls per month nationwide (NHS 111 Minimum Data Set 2015-16);
• NHS 111 is a single point of contact commissioned locally and nationally coordinated through telephony systems;
• All NHS 111 service providers use NHS Pathways as their clinical decision support system but it is not mandated. The key function of any clinical assessment system must be the ability to call an ambulance if clinically required.

NHS Digital (formerly known as HSCIC) has further information on NHS Pathways and its benefits on their website.

The Directory of Services (DoS) is “a central directory - which is integrated with NHS Pathways - provides the call handler with real time information about services available to support a particular patient.”
It is important that all NHS providers of urgent and emergency care are included in the directory with up to date details. Community pharmacy service data about opening times for supplementary hours and bank holidays is particularly important. Local commissioners of NHS 111 services take responsibility for keeping the information updated in the DoS. Local Pharmaceutical Committees and local DoS leads can work together to ensure all entries are updated. Further information on the Directory of Services can be found on the NHS Digital website.

Page 13 of the NHS England Commissioning Standards for Integrated Urgent Care contains information on the Directory of Services.

"The NHS Safety Thermometer provides a 'temperature check' on harm that can be used alongside other measures of harm to measure local and system progress in providing a care environment free of harm for our patients."

Further information is available on the NHS Safety Thermometer website. The tool is useful for a range of settings including the patient’s own home.

Department of Health has produced guidance to support the NHS in implementing the NHS Safety Thermometer.

The following tools have also been developed:

• Medication Safety Thermometer
• Mental Health Safety Thermometer
• Maternity Safety Thermometer
• Children and Young People’s Services Safety Thermometer

Information on the current status of Electronic Health Records (EHR) for England, Scotland and Wales can be found on our Electronic Health Record resource page.
We have published guidance to support pharmacists accessing patient record: ‘Electronic Health Records (EHR): Guidance for Community Pharmacists and Pharmacy Technicians’. The guidance informs pharmacy professionals on key principles concerning the maintenance and use of EHRs of all types, including pharmacy Patient Medication Records, GP systems or national NHS electronic record services. It describes some of the issues associated with using EHRs in pharmacy professional practice and makes recommendations to pharmacy professionals concerning best practice use of EHRs to support high quality practice and patient care.

The NHS England Commissioning Standards  – Integrated Urgent Care has further information on access to records which can be found on page 25-26.

In Scotland currently emergency care summary access is limited to A&E units, the Ambulance Service, some hospital wards and NHS24. 

The Welsh GP Record  is available to doctors and nurses routinely in out of hours services, and is being rolled out for unscheduled care services.

Becoming a prescriber

Pharmacists working in urgent and emergency care settings may take on prescribing duties as part of their role. Find out more about becoming a pharmacist prescriber in our dedicated section.
NHS Education for Scotland (NES) offers education and training for pharmacist prescribers

Prescribing framework for prescribers

In 2015, the RPS started the process of updating the framework with the backing of NICE and in collaboration with all the prescribing professions UK wide. The updated single prescribing competency framework was published on in July 2016, for all regulators, professional bodies, and prescribing professions.

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You might also find the Pharmacist Prescribing Discussion Group, our online network, to be useful.

Pharmacists working in urgent and emergency care settings may be involved in clinical audits. The Royal College of General Practitioners has produced an urgent and emergency care clinical audit toolkit.

The Consultation Skills for Pharmacy Practice website has been developed to support when speaking and consulting with patients and people about their medicines and lifestyle choices. The practice standards for consultation skills set out the knowledge, skills, behaviours and attitudes you need when communicating and consulting with patients. This includes information on telephone consultations. 

WCPPE (Wales) has also produced a learning programme to support development of consultation skills.

The role of an NHS 111/NHS 24/NHS Direct Wales Pharmacist will involve communicating with either patients over the telephone or other staff working with the service. Excellent communication skills are therefore essential for this role. Pharmacists should consider the importance of safe telephone consultation skills (including assessment of red flag symptoms and appropriate safety-netting). The GMC has produced Prescribing guidance: Remote prescribing via telephone, video-link or online, pharmacists may find some of the overarching principles of this guidance useful to consider when conducting telephone consultations. 

We have produced a quality systems resource for pharmacy, Pharmacy QS. Its purpose is to introduce quality systems and quality improvement, acting as a hub to the fantastic improvement resources of others, and as a platform for sharing pharmacy experiences in quality improvement.

The Royal College of Emergency Medicine has also developed resources for Quality Improvement.

In services such as NHS 111, NHS 24, and/or NHS Direct Wales ongoing audit of pharmacy calls will normally be undertaken by the clinical governance lead of each Urgent and Emergency care organisation. In addition, it is best practice to provide a peer-review service of auditing other Pharmacists work as well as self-audit to provide a degree of reflective learning.

Pharmacists working in urgent and emergency care settings will work with a range of other healthcare professionals as part of a multi-disciplinary team. This may involve training or mentoring multi-disciplinary colleagues, in prescribing and medicines optimisation.

We have developed a leadership framework and tools which includes a section on engaging your team which may be helpful. We also provide a mentoring database and support tools to help train and mentor colleagues.

Other resources which may be useful include:

• Multi-disciplinary team handbook to support personalised care delivered through multidisciplinary teams (NHS England)

United Kingdom Clinical Pharmacy Association (UKCPA) has an online forum for emergency care for pharmacists to share good practice.

The Royal College of Emergency Medicine has produced Mental Health in Emergency Departments - A toolkit for improving care.  

The Royal Pharmaceutical Society’s Innovator’s Forum has produced a free online toolkit, Hospital Referral to Community Pharmacy, endorsed by the Royal College of Physicians, on how you can set up an electronic referral system in your area.  It provides the business case for investment in an e-referral system and gives practical advice on how to implement it, along with helpful case studies.

NHS England  has produced Urgent Repeat Medication Requests: Guide for NHS 111 Services How to refer directly to pharmacy and optimise use of GP out of hours service.

The Care Quality Commission (CQC) are the independent regulator of health and social care in England. They monitor, inspect and regulate services to ensure they meet fundamental standards of quality and safety. CQC has produced guidance for providers.

Health Improvement Scotland  are the health improvement organisation for Scotland. As well as providing quality improvement support, Health Improvement Scotland also provide clinical standards, guidelines and advice.

Health Inspectorate Wales  are the independent inspectorate and regulator of health care in Wales.

It is a regulatory requirement for all registered pharmacists to "make sure that all your work, or work that you are responsible for, is covered by appropriate professional indemnity insurance".

The RPS is not regulated by the Financial Conduct Authority and cannot recommend professional indemnity insurance providers, however NHS employers has published guidance and a series of questions and answers regarding professional indemnity insurance.

The GPhC website contains information on Professional indemnity requirements.

We have published a set of professional standards for hospital pharmacy services, that provide the profession with developmental standards that are supportive, enabling and professionally challenging.

They were developed to help organisations across Great Britain (GB) to ensure patient safety – making healthcare safer by the development of quality services. These professional standards provide a broad framework to support Chief Pharmacists, Directors of Pharmacy and their teams to improve services, and to shape future services and pharmacy roles to deliver quality patient care. The standards are relevant to providers of pharmacy services in or to acute, mental health, private, community service, prison, hospice and ambulance settings. 

NHS Protect has prepared, on behalf of the Ambulance Pharmacists Network,Security standards and guidance for the management and control of controlled drugs in the ambulance sector.

A PGD is a written direction that allows the supply and/or administration of a specified medicine or medicines, by named authorised health professionals, to a well-defined group of patients requiring treatment for a specific condition.

It is important that pharmacists involved with PGDs understand the scope and limitations of PGDs as well as the wider context into which they fit to ensure safe, effective services for patients.

The supply and administration of medicines under a PGD should only be reserved for those limited situations where this offers an advantage for patient care, without compromising patient safety. A PGD should only be developed after careful consideration of all the potential methods of supply and/or administration of medicines, including prescribing, by medical or non-medical prescribers.

Since the 23 April 2012, pharmacists have been empowered by legislation to supply, offer to supply and administer diamorphine or morphine under a PGD for the immediate, necessary treatment of sick or injured persons. Further information about this is available from the NHS PGD website.

The following are useful resources relating to Patient Group Directions: 

• Online resources (Specialist Pharmacy Services website)
• Patient group directions education & training (NES)
• Patient group directions: who can use them. (MHRA)

Record keeping is an integral component of clinical governance and safe practice. The GPhC Standards state that you must "keep full and accurate records of the professional services you provide in a clear and legible form".

NHS East & South East England Specialist Pharmacy Services have produced the Retention of Pharmacy Records document. This document includes guidance for all pharmacy settings as well as some sector specific information. 

The need to protect patient confidentiality and obtain patient consent is layered through legislation, regulation and contractual frameworks.

Useful resources include:

• The NHS code of practice for confidentiality
• The NHS constitution
• Information commissioner's office guide to data protection

Registered pharmacists also need to be aware of GPhC regulatory guidance for consent and confidentiality:

• GPhC guidance on consent
• GPhC guidance on confidentiality

The Royal College of Emeregency Medicine has produced Best Practice Guidelines on Consent, Capacity and Restraint of Adults, Adolescents and Children in Emergency Departments.

Covert administration

UKMI has published comprehensive information on What legal and pharmaceutical issues should be considered when administering medicines covertly?

NICE has produced Quality Statement 6: Covert medicines administration.

CPPE run a workshop on The Mental Capacity Act 2005 and covert administration of medicines. 

The Mental Welfare Commission for Scotland has published the Good Practice Guide Covert Medication which applies to situations in which an individual lacks capacity to make a decision regarding medical treatment and refuses treatment.

Betsi Cadwaladr University Local Health Board (East) has published NEWT Guidelines for the administration of medication to patients with enteral feeding tubes or swallowing difficulties. (Please have a look at the guidance on the NEWT Guideline website on how to use the information obtained on each drug in practice).

The  Handbook of Drug Administration via Enteral Feeding Tubes, 3^rd Edition (March 2015) Rebecca White and Vicky Bradnam, Pharmaceutical Press , covers the technical, practical and legal aspects that you should consider before prescribing or administering drugs via enteral feeding tubes. 
 

Deprivation of Liberty safeguards (DoLS)

The Deprivation of Liberty safeguards, exist as part of the Mental Health Act 2005 to protect vulnerable patients in hospital and people in care homes who lack the mental capacity to consent to treatment or care they may need.

Further information on DoLS can be found on the Department of Health website.

The Royal College of Paediatrics and Child Health has worked with 19 different bodies to produce Safeguarding children and young people: roles and competencies for health care staff; a framework for healthcare staff, which describes the level of competency and training required for different roles.

Other sources of information include:

• Protecting vulnerable adults quick reference guide (RPS)
• Protecting children and young people quick reference guide (RPS)
• Safeguarding training - Level 1 and 2 (CPPE)
• Safeguarding training - Level 1 and 2 (wCPPE - Wales)