A number of emergency departments across the country have developed roles for pharmacists as advanced clinical practitioners. We are also aware of some emergency departments that have roles for clinical pharmacists in emergency departments. However it may be worth noting that there may be some overlap between the two roles.
Clinical pharmacists in emergency departments are involved in supporting medicines management, drug history taking and medicines reconciliation, ensuring medicines safety, dealing with medicines related queries and support medicines optimisation.
Pennine Acute Trust has shared the job description for senior clinical pharmacist – emergency medicine. It is worth noting that this role is expected to advance as pharmacists develop their clinical skills and become more integrated into emergency department teams.
Health Education England - West Midlands (HEE-WM) has conducted studies both locally and nationally to identify the potential for pharmacist clinician roles within emergency departments.
HEE-WM, in consultation with the General Pharmaceutical Council (GPhC), the Royal Pharmaceutical Society, Centre for Pharmacy Postgraduate Education (CPPE) and regional and national stakeholders, aim to test and justify development of pharmacist clinician roles within the ED and wider urgent and acute care settings.
From December 2013, HEE-WM finalised their initial consultation and launched a world-first pilot study. The pilot methodology would follow a dual-site, cross-sectional, observation study of patients attending Emergency Departments in the West Midlands. The project pharmacists, with support from their ED teams and supervised by an EM consultant, surveyed a cross-section of ED patient presentations over a five week period during 2014 “winter pressures” and categorised according to whether the patient could be managed:
- “CP:” By a community pharmacist (avoided ED attendance)
- “IP:” By an Independent Prescriber pharmacist as part of a multi-disciplinary ED team.
- “IPT:” By an Independent Prescriber pharmacist in the ED, with an additional 12 months of clinical skills training, aligned to an “advanced practice” framework (See Table 1 - as part of a multi-disciplinary team approach)
- “MT:” By the medical team only – unsuitable for pharmacist intervention.
Primary and secondary categorisation of data was undertaken by the project pharmacists, their EM consultant supervisors and ED nurse triage teams.
The Health Education England – West Midlands team commissioned an external evaluation through Aston University – the report can be downloaded from the HEE website.
The West Midlands observational study was conducted across three sites to establish the potential for pharmacist clinical management. Of the 782 patients surveyed over the three sites, the study suggested that 48.2% of patients could be managed by a pharmacist practising within a multi-professional clinical team, where those patients present with symptoms likely to be seen in the Minors Area of the ED, under the overall supervision of a doctor
With the West Midlands pilot raising interest in a wider study, HEE commissioned a national project to investigate whether pharmacist prescribers, trained in clinical diagnostics and examination through an Advanced Clinical Practice programme, could have a positive impact on patient care in the A&E. The project would build on the West Midlands pilot and, through a similar methodology aim to evidence an enhanced role for pharmacist clinicians in the A&E.
The national study (“PIED-ENG”) commenced in March 2015, covering a cross-section of 49 English Emergency Departments. A total of 18,613 sets of patient data were received, making this the largest (known) study of its kind to date, in the world. Patient presentations were analysed from a cross-section of attendees, to reflect a “normal” patient flow through A&E.
The pharmacists, with support from their A&E teams and each supervised by an Emergency Medicine consultant doctor, categorised patient data.
In summary, categorization of 18,613 ED cases evidenced the potential for pharmacists to clinically manage up to 36% of study patients. With existing training, pharmacists could manage 8% of study cases. However, with a maximum 12 months’ further training - aligned to the Advanced Clinical Practice training pathway - the potential of pharmacists to manage study cases rose to 28% of all cases.
“Further training” for the purposes of this project included a 12 month (Postgraduate Diploma) Advanced Clinical Practice training course - with modules in Clinical Examination Skills and Clinical Health Assessment and Diagnostics. Such a training programme would be aligned to the Advanced Clinical Practice framework, currently being delivered by Health Education England, in cooperation with national stakeholders and course providers. Within the ED, the pharmacist would typically practice within a multi-professional clinical team, under the overall supervision of a doctor.
From the study data, clinical groupings where pharmacists were felt to have the highest potential impact were identified as: General Medicine, Minor Trauma, Cardiology, General Surgery and Respiratory. Impact index findings suggested that pharmacists with advanced training (“IPT” category) may be most usefully directed to patients in the general medicine and orthopaedic clinical groupings. If training were tailored to concentrate on these two areas, then (achievable) IPT becomes 19%.
It is contended that the pharmacist clinician who follows such a training pathway could confidently and competently conduct advanced clinical practice as a “specialist generalist” clinician in Urgent, Acute and Emergency care, working as part of the multi-professional, multi-skilled team, under the supervision of a doctor.