Delayed or missed doses of time critical medication (TCM) in emergency departments (EDs) is putting patient safety at risk, according to a new report by the Royal College of Emergency Medicine (RCEM) as it urges EDs to prioritise embedding clinical pharmacy services.
Its ‘Time Critical Medication QIP 2023-24’ report found that less than half of eligible patients (46.6%) taking TCM for conditions such as diabetes and Parkinson’s disease were identified within 30 minutes of their arrival in ED.
Out of 10,850 eligible doses, only 32.4% were administered within 30 minutes of the expected time, increasing the risk of patient harm.
TCM clinical standards
The findings come from the first year of RCEM’s three-year Quality Improvement Programme (QIP), which runs until 2026 and is supported by Parkinson’s UK and Diabetes UK.
Collating and analysing data from 136 EDs across the UK, the QIP seeks to improve the timely administration of medication in EDs, focusing particularly on drugs such as insulin and levodopa.
The report highlights three clinical standards that were included as part of the QIP:
- Standard 1: All patients taking TCM should be identified within 30 minutes of arrival
- Standard 2: All TCM should be administered within 30 minutes of the expected time
- Standard 3: No doses of a TCM should be missed during a patients stay in the ED.
The majority of patients on TCM were identified by their named clinician (39.2%), however the named clinicians’ average time to TCM identification was 182 minutes.
Triage nurses identified 38.3% of patients on a TCM within an average time of 35 minutes.
Only 0.27% of patients on a TCM were identified by a pharmacist.
From mid-August 2024, the report findings show a positive shift in patients identified as being on a TCM within 30 minutes of arrival in the ED to 53.13%, which the RCEM said signalled significant improvements.
RCEM recommendations for pharmacists and TCM
The report lists a series of recommendations for departmental, Trust and national levels. This includes TCM being part of all ED inductions so that the process of patients getting all of their doses while in the ED can be started as early as possible.
EDs are also advised to ensure patients who have been identified to be on TCM, and have no medical reason not to give them, have an alert or task added by the triage nurse, assessment team, ED nurse or ED pharmacist, highlighting that all TCM doses need to be prescribed.
The report also stresses the need for EDs to ensure they are working towards previous RCEM recommendations regarding embedding clinical pharmacy services to support timely access to time critical medications.
A further recommendation is for systems to be in place that will facilitate the timely administration of TCM, including self-administration, such as nursing staff having access to portable digital devices that alert when a TCM dose is due.
‘We need to allow and empower patients to manage their own TCM in the ED when appropriate, as this will reduce the risks of missed and delayed doses whilst their care needs are being assessed,’ the report said.
This follows the recent publication of a joint advisory statement on TCMs between the RCEM, the Association of Ambulance Chief Executives and the UK Clinical Pharmacy Association. It provides clear and practical guidance on allowing patients who are able to self-administer their own time critical medications to do so.
‘A call to action’
Dr Jonny Acheson, an emergency medicine consultant at the Leicester Royal Infirmary who is leading the QIP and lives with Parkinson’s himself, said the findings should ‘serve as a call to action… to ensure no dose is ever missed in A&E’.
He added: ‘These medicines are critical to the quality of these patients’ lives, and we have a duty of care to ensure that they receive them when they should.
‘Despite continued pressure on ED staff, they have shown great commitment and resolve as we strive for further improvements nationally.’
Dr Ian Higginson, RCEM president elect who also leads on clinical quality at the College, added: ‘Missing doses of medication for illnesses such as Parkinson’s or diabetes is not just inconvenient, it is dangerous; and missing multiple doses can have serious consequences.
‘This first-year report reveals there is already some good work happening across the country. Now we just need to ensure that it is replicated in every ED and becomes embedded so that no one fears not being able to access their medication while in our care.
‘It is really critical we get this right – and we are determined to do so.’
Patient organisations have welcomed the spotlight on TCM management. Juliet Tizzard, director of external relations at Parkinson’s UK, said: ‘People with Parkinson’s are at risk of significant harm if they don’t receive their medication on time, every time, and so we are proud to support the college’s vital work in this field.
‘We have long called for people with Parkinson’s in hospital to get their medication on time but have found that over half don’t.’
Helen O’Kelly, assistant director of services, communities and improvement at Diabetes UK, said the positive shift seen in the first year of the QIP is ‘encouraging’, adding that the charity ‘[looks] forward to seeing the results as the programme continues.’
