Pharmacists are becoming an increasingly important part of the emergency department multidisciplinary team. One area in which they can make a big difference to patient care is safeguarding, and this is the subject of a recent qualitative study. Lead author Daniel Greenwood discusses the context around ED pharmacist practitioners in the UK and elsewhere, how they fit into the safeguarding process and the training and education required to ensure best practice.
The emergency department (ED) is a unique clinical setting immediately accessible to patients of differing clinical needs. Those with life-threatening illnesses often arrive by ambulance, whereas other patients might self-present with relatively minor, self-limiting complaints.
Clinical pharmacy services have historically been developed in ward settings, including acute medical wards or units, often co-located with EDs. Approximately a third of patients who attend the ED are admitted to an acute medical ward,1 and it is here that they would have first encountered a pharmacist and received direct pharmaceutical care.
Given the pressures on inpatient care, notably bed capacity and blocking (bottlenecks in patients being able to leave the ED because of lack of capacity in the downstream system), moving pharmaceutical care closer to the hospital front door– that is, to the ED – is logical. So, UK ED pharmacy practice was born.
ED pharmacy services were surveyed for the first time in 2004. Of 25 hospital organisations, 19 (76%) had ED pharmacy facilities and 14 (56%) had a pharmacist working in the ED.2 Among these, the most common activities were developing guidelines for medicine use, drug history taking, providing medicines-related advice to other clinicians and educating medical and nursing colleagues.
Interestingly, despite being a traditional role for pharmacy, only eight (32%) of the EDs had pharmacists responsible for medicines supply including discharge prescriptions.
Current state of play in ED pharmacy practice
Fast-forward to 2015 and, due to shortages of physicians and nurse practitioners, NHS England commissioned the Pharmacists in Emergency Departments (PIED) study.3
The authors concluded that up to 37% of ED patients could be independently treated by a pharmacist with prescribing rights and additional clinical skills training such as clinical assessment as part of a multidisciplinary team.
In 2023, the Royal College of Emergency Medicine and the UK Clinical Pharmacy Association recommended all EDs have a dedicated pharmacist and, as of 2024, approximately 77 of 170 UK EDs (45%) have a clinical pharmacy service.4,5
The 2019 ENDPAPER study found that of 20 ED pharmacists working in 15 UK hospitals, there were two types of ED pharmacist: those working in a traditional pharmaceutical care role (similar to inpatient ward pharmacists) and those taking a more hands-on role assessing new patients on arrival at the ED.6
Those pharmacists working in a hands-on role are titled variably, such as advanced clinical practitioner or emergency department pharmacist practitioner.
In the study, 11 of 20 ED pharmacists were the ‘designated care provider’ for 232 of 682 patients (34%), that is, they had ultimate responsibility for those patients as part of a multidisciplinary team.6
Of all the pharmacists studied, their most common activities were taking a history (particularly drug history, but also a broader clinical history), reviewing vital signs, clinical examinations and investigations, and prescribing medicines. ED pharmacists also diagnosed 238 of 682 (35%) of the patients studied.
A global context
In a global context, the UK ED pharmacist practitioner role is unique, but pharmacists have long worked in the EDs of other countries, including in Spain.
The emergency medicine pharmacist (EMP) role emerged in the US in the 1970s.7 Although EMPs do not take ultimate responsibility for a patient’s care as part of a multidisciplinary team, they work to reduce medication error rates, support antimicrobial stewardship and reduce the time taken to treat critically ill patients.
In critical care, EMPs support patient resuscitation by calculating drug doses and drawing up parenteral medicines ready for rapid sequence intubation, for example. Unlike the UK, many US hospitals require all prescriptions to be checked by a pharmacist for clinical appropriateness beforeadministration, with some exceptions such as when a delay would likely cause patient harm.
Other countries, including Canada, Colombia and Saudi Arabia, also have ED pharmacy services.
Extended responsibilities
Back to the UK, with a move towards providing hands-on patient care as practitioners, pharmacists increasingly have different patient responsibilities.
One particularly pertinent example for the ED is safeguarding. Safeguarding protects people’s health, wellbeing and human rights and enables them to live free from harm, abuse and neglect.8
Approximately 10% of children who visit the ED have suffered abuse, whether this be physical, psychological/emotional or sexual.9
Patients might also be suffering from neglect, where their basic needs – such as nutrition – are not being met. Those who have been abused or neglected require a clinician who can identify this and put in place appropriate safeguards, whether they be immediate, longer-term or both.
The process of safeguarding
In healthcare, the initial safeguarding process comprises four stages: recognition, ensuring patient safety, documentation and escalation.
Recognition is about developing concerns or suspicions as to whether a patient has been maltreated. Pharmacists should use their interactions with patients and those who accompany them to explore potential risk factors. These include relatives’ controlling behaviour or medication misuse.
Instinct also plays a role, which is developed through training and experience.
If a safeguarding issue is suspected, local safeguarding policies should be followed to ensure patient safety. Depending on their role and experience, ED pharmacists may hand over their suspicions to another clinician at this first stage. However, pharmacists are well-placed to explore concerns related to medicines further with the wider multidisciplinary team, such as covert administration or omitted doses.
This may involve discussing sensitive topics with patients and understanding how they are cared for. Contemporaneous records must be made to ensure suspected maltreatment can be investigated and either confirmed or refuted. For example, these records may be relied on later if a case is taken to court.
The final stage of the initial safeguarding process is escalation. This might initially be to a senior colleague, such as the consultant physician in charge of the ED, followed by escalation to a ‘named professional’, typically a social worker, who will alert the relevant local authorities.
ED pharmacists must know who to escalate their concerns to, as poor communication between professionals and organisations hinders patient safeguarding.
Safeguarding training and knowledge gaps
Training in the safeguarding process and the type of maltreatment increases victim recognition. In the UK, safeguarding training for healthcare professionals comprises six levels, which increase in complexity, with separate learning packages for those who care for children or adults.
Although the Royal College of Nursing recommends that ED pharmacists have Level 3 safeguarding training as a minimum, a study published in 2024 found that only six of 13 ED pharmacists definitively met this standard.10
The same study found that ED pharmacists generally had a broad and often detailed knowledge of safeguarding. They frequently described the four stages of the safeguarding process and how patients should be central to it. They also acknowledged that non-clinical hospital workers have a role in recognising safeguarding issues.
The ED pharmacists also had a strong understanding of medicines-related safeguarding issues, including the misuse and abuse of medication, but were less comfortable recognising other presentations of physical and sexual abuse.10
Pharmacists also needed some clarification about the roles and responsibilities of different healthcare workers.
In addition to potential knowledge gaps, those interviewed identified more general factors that influenced the effectiveness of the safeguarding process.
Although electronic record systems were thought useful to monitor patients who make repeat visits to the ED – a surrogate for potential abuse or neglect – clinicians are unable to view records from other hospitals and organisations and so can be unaware of potential trends indicative of abuse or neglect.
Cultural and religious differences of patients and their families were also important considerations. For example, in some cultures, it is traditional for the patriarch of the family to take the lead in consultations, whereas, in other cultures, that would be atypical and thus a potential cause for concern.
The study also found that ED pharmacists felt they needed more education and training to safeguard patients effectively. This was particularly true for those who rarely took overall responsibility for a patient’s care within the multidisciplinary team, where ongoing experiential learning was lacking.
Delivering appropriate safeguarding training
To develop their intuition, ED pharmacists should ideally encounter potential safeguarding issues working with the multidisciplinary team, supplemented with interactive training, which incorporates simulated scenarios.
However, opportunities to apply learning to real-world safeguarding issues may be limited, so simulated training must be used frequently to maintain ongoing proficiency.
To increase pharmacists’ ability to recognise maltreatment, training should cover different types of potential abuse and neglect and, particularly for elderly patients, help pharmacists distinguish between the physiological changes of ageing and maltreatment.
Neglect or self-neglect might be suspected when an elderly patient is malnourished or dehydrated. However, these signs could be due to the malabsorption associated with ageing or the use of diuretics, respectively.
Depending on their role, training should also include exploring potential safeguarding issues and safely discussing concerns with the patient. This is important as a suspected abuser might accompany their victim to the ED.
Training should also include how to make complete, contemporaneous records.
Finally, safeguarding training for ED pharmacists should include local escalation processes, that is, who to report their concerns to. If relevant to their role, this should consist of training in communicating with other providers and authorities and how to access and use relevant IT systems.
Author
Daniel Greenwood MPharm PhD
Associate professor of clinical pharmacy, School of Healthcare, University of Leicester, UK
References
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8. Care Quality Commission. Safeguarding People. 2015. [Accessed June 2024].
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