Integrating a clinical pharmacy service in the ED

Development and pilot of an integrated clinical pharmacy service in a teaching hospital NHS Trust emergency department, and quantification of the type and severity of interventions made, are discussed.

Emergency departments (EDs) across the country are under considerable strain both from increased demand, and an ever more ageing and complex patient profile.¹ This congestion at the ‘front door’ of secondary care is further compounded by poor flow of patients through hospitals, with high numbers of medically fit patients occupying bed space for social purposes.

Quarter 1 NHS England (2016/17) data² for A&E admissions had shown a 90.3% compliance with the four-hour discharge/transfer/admit target, with a reduction to 85.4% compliance in Trusts with a type 1 ED service. Both numbers are below the 95% national target.

Furthermore, data provided around time from decision to admission to actual admission shows approximately 8% of these patients spend greater than four hours until actually reaching the ward.

Within Nottingham University Hospitals (NUH) ED, Quarter 1 NHS England data showed that NUH ED has a total of 49,321 unique attendances (approximately 550 attendances per day). Further analysis of a sample data set in May 2016, determined that of a total of 3949 patients who presented to NUH ED were actually admitted. Approximately 15.5% of these patients spent a total of greater than ten hours physically in the department prior to transfer.

EDs have often been identified as high risk environments for medication error^3–5 and considerable literature is available demonstrating that a pharmacy presence in ED improves quality of care and reduces the risk of error.

Furthermore, when pharmacy services are established in EDs, the team has been well received by ED staff,⁶ and has resulted in improvement on access to medications in a timely manner, as well as identification of adverse drug reactions related to admissions and medicines reconciliation. Nevertheless, only a few Trusts have a dedicated consistent pharmacy presence in the ED.

Patients facing extended waits in the ED in the care of emergency physicians and an environment ill-suited to inpatient care are at high risk of deterioration.^7,8

A Health Education England9 pilot collected data nationally in 2015 around ED patient cases from 49 separate EDs, and concluded that with existing training, community pharmacists or independent prescriber community pharmacists could manage 8% of the cases examined. This total could extend to 36% with pharmacists following an advanced clinical training pathway.

A number of case reports have demonstrated successful clinical pharmacy services within EDs that have yielded cost savings¹⁰ as well as reducing the risk of errors and improving patient safety.^11,12

In light of these findings, a fixed one year secondment position to Nottingham University Hospitals NHS Trust ED funded by Nottingham City CCG was created to further explore a clinical pharmacy service in the ED.

This article aims to share the preliminary learning on the design, development and experience of the first three months of service.

Service design

An ED integrated clinical pharmacy service was developed whereby a single senior clinical pharmacist would work a shift pattern of Monday to Friday 7.30–15:00 for approximately three months within the ED.

‘See and Treat’ was not possible as an initial service style mainly due to training and assessing the pharmacists’ competence to perform these tasks.

The key duties performed by the pharmacist included:

• Medicines information provision and advice to all healthcare professionals within the ED
• Patient counselling on discharge from the ED
• Medicines reconciliation for patients identified as for admission.

After review, while conducting the service, an additional duty was added which involved the review of all cases coming through the Majors and Resus areas of ED (both areas identified as housing the highest proportion of patients requiring inpatient admission).

The aim was to identify pharmacologically high risk patients, obtaining a primary drug history and medicines reconciliation where possible (rather than simply all patients requiring admission).

High-risk patient groups comprised:

• Patients identified as taking any high risk or critical medication
• Patients over the age of 65 admitted with a fall/collapse
• Patients diagnosed with acute kidney injury or chronic kidney disease.

High-risk groups were chosen in discussion with senior pharmacists and ED staff due to demonstrable evidence,¹³ of benefit in pharmacist involvement in these patient types and the potential impact on aiding both physician and nursing workload. A focus on drug history and medicines reconciliation was a key area of intervention, again due to the potential for improved medicines management within ED.¹⁴

Details of all interventions and advice provided were logged for later analysis. This included recording the type of intervention made (prescribing, administration or miscellaneous advice) alongside the severity of the intervention (as defined by internal guidance).

Figure 1: Severity of contributions by intervention type

Results 

The pharmacy service was piloted and commenced between 18 April 2016 and 1 August 2016. A total of 299 service hours were logged, and a total of 586 individual clinical interventions (1.96/hr) were made throughout the period (Table 1; Figure 1). Data were incomplete for 17 clinical interventions and were excluded from data analysis.

A total of 478 drug histories (1.6/hr) were taken, and 190 (0.6/hr) medicines reconciliations were made prior to transfer to base ward.

Figure 2: Relative % of medication group interventions

Contribution subtypes

Interventions were made on a variety of drug types (Table 2; Figure 2). Approximately 67% of the total interventions made were related to medications classed as ‘critical’.

Appendix 1 contains a complete listing of all contributions types made by severity. Miscellaneous interventions (as shown in Appendix 1) comprise approximately 39.4% of the total interventions made, clinical advice to the prescriber comprised 31.2% of interventions and reconciling and supplying as a result of a failure to prescribe a critical medication comprised 29.4% of the total interventions.

Critical medications 

Interventions correcting situations regarding a combination of failure to prescribe a critical drug or failure to administer a prescribed critical drug comprised a total of 215 (172 failure to prescribe, 43 critical drug not given). This comprised a total of 36.7% of the total interventions (Tables 3 and 4; Figures 3 and 4).

Figure 3: Relative % severity of contribution types

Figure 4: Critical dose failure to prescribe/administer

Medicines information 

A total of 77 medicines information inquiries were made during the intervention period, with decision-making staff (doctors or advanced nurse practitioners) making the highest number of inquiries (Table 5).

Figure 4: Review and suitability of patient cases over intervention period

Figure 5 : Review and suitability of patient cases over intervention period (per hour)

Workload 

As of 30 May 2016, service design changed to reflect seeing a higher proportion of high-risk patients.

Between the period 30 May 2016 to 1 August 2016, 1757 individual attendances were reviewed by pharmacists (under criteria laid out above). A total of 566 attendances (32%) met the criteria and were listed for pharmacy input. A total of 302 (53.3%) were seen and had a drug history completed (with any associated intervention), and 190 (33.6%) had their medicines fully reconciled (Figures 4 and 5).

Example interventions 

Several examples were collected of pharmacy service making interventions which directly affected the care of the patient within the ED (changing a diagnosis, treatment plan or triage category), as well as several incidental findings in patients who were seen and treated in the ED who did not require discharge (Table 6).

ED staff feedback 

The presence of a pharmacist in the ED was generally extremely well received, with exclusively positive comments collected from a variety of differing members of staff in the ED team:

‘Having a pharmacist in our Emergency Department has without doubt improved patient safety. Concentrating on the 30% of patients we admit has helped ensure that time critical medications in particular are not missed. The benefit for the patients lasts throughout their whole hospital stay. All staff are using the pharmacist’s knowledge regularly, whether for simple advice or help with complex medications. The role has huge future additional potential if they can prescribe and help with medicine reconciliation, particularly in the frail elderly population’ (Senior Consultant). 

‘It has been invaluable having a phamacist in the ED. I believe it improves patient safety through improving our prescribing practice and ensuring regular and critical medications are given. The ED pharmacist is also a valuble resource not only for clinical guidance but also for teaching. I have learnt a great deal about the pharmacological management of chronic conditions. This is such a valuable role, I really hope the service continues’ (Trainee Advanced Nurse Practitioner). 

‘I think he [the pharmacist] is very good. He makes the department safer especially at a time when we have no flow. This is crucial. I think even when we have flow this service improves patient safety’ (Consultant). 

‘..desperately needed a pharmacist over winter to help with the ward’s worth of patients waiting >18h to get a hospital bed with ensuring / minimising prescribing error, risk and sourcing meds, ensuring drug charts completed etc..’ (Sister). 

‘I think it would be time-saving to have a pharmacist permanently on the ED’ (Nurse). 

Discussion

These results are typically in line with other similar studies demonstrating a potential role for pharmacists to provide a clinical service within the ED.

Dose omissions 

Of particular note were the percentage of interventions classed as ‘serious’ or ‘severe’ (%), which are defined as having the potential to cause temporary or permanent harm respectively without the intervention. A large relative proportion of these interventions were regarding failure to prescribe or administer a critical drug (which accounted for %) of the total contribution types. Considering that a significant proportion of patients spend more than ten hours in the department, the potential for considerable critical drug delay and patient deterioration while waiting in the ED is high.

In effect, once a diagnosis is established and the patient has been stabilised by the ED team and a decision to admit has been reached, in the interim waiting period prior to ward admission, the responsibility for treating and monitoring any of the patients’ further chronic conditions falls to the ED team, who are often under-resourced to deal with the task.

Two incidents were reported regarding harm caused by an omitted critical medication during the service period.

It is reasonable to conclude pharmacist identification, review and early medicines reconciliation, and ultimately supplying medication, prevents undue delay and safeguards these patients while waiting in the ED. Unfortunately quantification of this benefit was not possible due to constraints on the amount of data collected, time period of delays/omissions and patient follow up was not possible given the scope of the intervention. There is, however, evidence available demonstrating extended hospital admission and poorer outcomes for patients who have critical medications omitted.^10,15

Involvement in diagnosis and incidental findings 

A total of 11 interventions related to the pharmacist identifying a potential adverse reaction or medications that would require review in respect of the new diagnosis. These were relayed to the responsible physician and investigated accordingly (Table 6).

Throughout the second phase of the intervention period, a high proportion of patients were reviewed who were discharged from the ED and did not require hospital admission.

This is a relatively unique patient population, as, in effect, these patients underwent a pharmacist medication review, as they were identified as a ‘high- risk’ patient group. A number of examples were noted where GP and pharmacy related errors unrelated to the admission were identified by the ED pharmacist (Table 6). These were investigated and corrected if time permitted, or flagged to the patient’s GP.

Scale of service

The initial specification of the service involved targeting patients who had been identified for admission. The rationale behind this was earlier medicines reconciliation and supply. This approach was quickly altered to targeting a higher risk population, as it was felt a considerable population of patients who would benefit from pharmacy input would be missed.

This altered service style was effective, because it alllowed pharmacists to review all cases in the ED, with set criteria for input while also allowing for professional discretion to provide input to other cases. This approach maximised the number of patient cases that a pharmacist could have input into, while also maintaining the benefit of early medicines reconciliation and supply.

The results clearly indicated that a single pharmacist working a nine-hour period could not see all the patients identified as being suitable for pharmacy input, with only approximately 53.3% of suitable patients actually seen and 33.6% of suitable patients having their medicines reconciled (Figure 4). This fact would be compounded considering the pharmacist was only present to review patients for a relatively short time (07:30–15:00) with no service being provided in the evening or overnight. No data were collected over the weekend period.

Furthermore, a significant quantity of the time spent in the ED involved obtaining and checking drug histories for patients, a role which within NUH is traditionally deferred to technicians to allow pharmacists greater time for clinical input. Pharmacy technicians fulfilling this role within the ED have demonstrated mixed results in other hospital programmes.^16,17

These results tend to suggest that an extended daily service, with multiple pharmacy staff, may be required to enable review of all the patients required under this criteria.

Further analysis

The results found prove that a clinical pharmacy service is feasible, and provides a potential structure for a service to be undertaken. Results also strongly indicate that a pharmacy presence in the ED, reviewing patients and providing advice, improves patient care and quality within the ED.

However, little evidence has yet been analysed around how this service impacts on flow through the ED, aiding in improving four-hour waiting time targets. Furthermore, little evidence has yet been analysed around a reduction in patient admission durations or readmission rates in this service. Without concrete outcome related and statistically proven evidence to assess the impact of an ED clinical pharmacy service, only limited financial resources can be provided.

Retrospective and prospective analysis will be undertaken in patients who had pharmacy interventions within the ED and who were then admitted to base wards, to assess any benefits in these outcomes.

Ongoing work and training

As previously stated, ED staff were generally extremely positive about a consistent shop floor pharmacy presence, with a considerable number of the emergency practitioners keen for a pharmacist to take a greater extended role in assessment and prescribing. It was observed that generally medication charts completed by ED staff were incomplete and contained considerable errors.

It is possible that an independent prescribing pharmacist may have the ability to take the role of completing medication charts for patients requiring admission to hospital, which would benefit base ward medics in clerking patients and reduce workload within the ED. Evidence is already available of a beneficial effect of a similar model¹⁸

Conclusions

A clinical pharmacy service was successfully introduced into NUH ED, with positive feedback from a variety of ED staff members. The number of interventions made demonstrates EDs are high risk environments where there is considerable potential for medication related errors to occur. Pharmacy input at the source mitigates a proportion of this risk; however, a more robust service is likely required to fully achieve this, and baseline data analysis would be required to fully quantify this benefit.

Further retrospective and prospective analysis will be required to determine the impact this clinical pharmacy service will have on key metrics in ED and hospital flow, as well medicines reconciliation CQUIN targets and patient experience.

• Emergency departments (EDs) are high-risk environments for medication prescribing and administration.
• Time-critical medication delay and dose omission are a considerable problem in patients facing extended waits in ED.
• Clinical pharmacy presence in ED can safeguard patients, and offer a resource to ED clinicians both in the acute treatment of patients and management of chronic conditions.
• Further resources are required in order to fully realise the benefits of a fully integrated clinical pharmacy service within EDs.
• Further analysis and data gathering is required to quantify the impact on pharmacy services in the ED on length of inpatient stay, flow, patient satisfaction and all-round quality of patient care.

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