For personal use only. Not to be reproduced without permission of the editor (permissions@pharmj.org.uk)
By Gail Foreshew, MSc, MRPharmS
Pharmacists can help A&E departments achieve thefour-hour target for dealing with patients
department is one of the busiest in Britain,
Drug history taking
with 131,581 patients attending in 2004. Arecent £6m development has enabled a new
Taking a drug history has been found to be
Roles for hospital pharmacists
have expanded in recent years,with pharmacists working inmore specialties and regularly
a key role for pharmacists working on med-
attending ward rounds, as well as working
and the redesign has allowed for a full-time
specialist emergency department pharmacist
dent and emergency (A&E) departments.
pharmacists are more accurate than doctors
The A&E department is traditionally an
area that has had little pharmacist input
jointly accountable to both the clinical phar-
departments. However, it is the department
patients are admitted to medical admissions
with the highest turnover of patients in a
director for the emergency department.
wards, may have several benefits. For exam-
hospital and is where substantial quantities of
ple, it enables better judgements to be made
medicines are administered. A&E depart-
cialist pharmacist’s post at QMC is: “To
by doctors about adjusting patients’ treat-
ments are chaotic places at times and, for
histories are already known. It also means
resuscitation room may increase the risks
include helping to bridge the gap between
that any drug-related issues on admission, or
associated with the use of medicines. Thus,
there are many challenges for pharmacists
ting wards in the hospital, and improving
highlighted early on in a patient’s stay as rec-
in providing a service to these departments.
made by a pharmacist working in the emer-
drug histories for patients on the medical
Key areas of work
admissions ward, this service also helps to
reduce junior doctors’ workload and speeds
hospitals are using pharmacists in their A&E
emergency care. Current targets for treat-
amount of time patients spend waiting for
ment in the A&E departments, introduced in
December 2004, specify that 100 per cent of
patients attending the A&E must be admit-
pharmacist takes a drug history for those
ted, transferred or discharged within four
hours.1 These targets have led to a hospital-
Background
wide redesign of processes and to changes
in skill mix, with nurses and other health
patients about the medicines they are tak-
ing or, as appropriate, from referring to the
patient’s GP, nursing or residential home
cist’s roles in the emergency department is
Gail Foreshew is an emergency department
to look at initiatives to help achieve the
pharmacist then reviews the patient’s med-
pharmacist, Queen’s Medical Centre, Nottingham
icines in light of the reason for admission. H O S P I TA L P H A R M A C I S T
Any drug-related issues that may be impor-tant to the patient’s treatment are brought tothe attention of medical staff. The pharma-cist may suggest a simplification of amedicine regimen if necessary. A full drughistory and any relevant comments are doc-umented in the patient’s medical notes andthe pharmacist informs ward-based pharma-cists of any patients that may need to befollowed-up.The pharmacist is also involvedin completing drug charts, which are thenreviewed and signed by a doctor. Ward rounds
every morning for patients that have beenadmitted to hospital under the care of the
emergency department.This is a small ward
Gail Foreshew (right) advises registrar Dr Sue West-Jones
round with up to 14 patients and is attendedby the emergency department pharmacist.
ing incidents and drug errors. The multi-
mation on administration of these drugs, any
On the ward round, the pharmacist’s role
copy self-carbonated drug charts used in the
dosage calculations that are required and
is to clarify drug histories, add any new
hard to read and this resulted in patients on
chart, provide advice to medical and nursing
the wards either not receiving their medi-
Teaching other staff
staff and write discharge medication forms.
As well as ensuring the appropriateness of
medicines for patients, having a pharmacist
department’s risk management group, the
A&E department pharmacist’s role. This
complete discharge medication forms speeds
up the discharge process. For patients who
drug charts to rectify the problem. These
are discharged during the ward round, med-
icines are dispensed by the pharmacist, or
piloted and implemented in the department.
education team. Informal educational input
discharge technician, immediately after the
is part of the pharmacist’s daily work and
Intravenous drug therapy A second issue
formal teaching sessions are also undertaken
charge prescriptions can be dispensed on the
ward using pre-packs. This enables patients
errors with intravenous medicines. This led
to be discharged promptly and helps to clear
organising training for all adult and paedi-
induction to ensure that they are aware of
trust and national guidelines.Topics covered
help meet the four-hour target for the emer-
standardised intravenous infusion guidelines.
guidelines and guidelines specific to the
Guidelines Risk management
receive training on various subjects includ-
guidelines in place in the emergency depart-
QMC is part of the department’s risk man-
was created. Since this time, new guidelines
and reviews all incidents. Any trends are
have been developed for treating illnesses
studied and practices altered if appropriate.
and infections only applicable to the emer-
The pharmacist liaises with members of the
hospital’s drug incident group regarding any
department pharmacist has taken a lead role
drug incidents that may have a hospital-wide
in their development.These guidelines have
increasingly flexible use of workforce skills.
management issues have included the intro-
antibiotic guidelines for the treatment of
duction of colour-coded syringe labels in
line with national guidance and reviewing
the treatment of patients who have received
there will still be times when PGDs will be
ampoules in view of similar packaging.
addition, for paediatric patients, guidelines
have been introduced for the dose-rounding
pharmacist is involved in writing new PGDs
of analgesia, as well as a treatment algorithm
and reviewing and updating the old ones.
for patients presenting with anaphylaxis.
The pharmacist is also involved in reviewing
Intravenous infusions can involve compli-
trust-wide PGDs to ensure these are applic-
Documentation Incidents on medical
cated calculations. A set of standardised
wards highlighted problems in identifying
infusion guidelines for the administration of
exactly which medicines had been adminis-
Source of advice
tered while patients were in the emergency
department. Incidents were analysed using
available for use by both medical and nursing
the hospital’s Datix programme for report-
staff. The guidelines contain essential infor-
information to all medical and nursing staff. H O S P I TA L P H A R M A C I S T
related issues they have and to organise their
started in 2004.The group aims to provide a
medicines if they are admitted to residential
link for all emergency care pharmacists and
or nursing homes. For these patients, the
includes A&E department pharmacists. It ran
pharmacist also clarifies drug histories and
its first series of workshops at the UKCPA
reviews medicines, advising on specific areas
such as analgesia and fracture prevention.
study day is expected to be held this year. Research
example, the study day “Introduction to crit-
At QMC, the pharmacist is involved in the
ical care” run by the UKCPA Critical Care
hospital’s emergency department research
group. In addition to undertaking audits, the
pharmacist assists in research projects, help-
Future developments Counselling at discharge
issues. At other hospitals, a number of pilot
studies looking at ways in which the phar-
pharmacist is likely to continue to expand as
selectively counsels patients on discharge,
department have already taken place.
realise the benefits of having pharmacists as
concentrating on seeing patients taking mul-
part of their teams. It is also possible that
pharmacists in the A&E department in see-
there may be new roles for pharmacy tech-
nursing staff. Examples of patients that have
attempts are made to streamline a patient’s
including those with coughs and colds, aller-
● A patient admitted with hypoglycaemia
gic reactions, bites and stings, and reactions
References 1.
Department of Health. Reforming emergency
carried out at Guy’s and St Thomas’ NHS
care. London: Department of Health; 2002. 2.
Hospital pharmacists group. Providing pharmacy
comes of patients presenting with requests
services to medical admissions units. Hospital
for repeat medicines being seen by a phar-
macist were studied.9 The study showed that
3.
Covington T, Pfeiffer F.The pharmacist-aquired
Assessment and care team
the pharmacist was able to supply a faster ser-
medication history.American Journal of Hospital
vice compared to the previous service where
patients waited to be seen by a doctor. 4.
(FACT) team at QMC is a multidisciplinary
Pulver L, Meyer E, et al. Review of pharmacist-
team based in the emergency department.
benefits for patients, some hospitals are dis-
conducted medication histories in three teaching
The team consists of nurses, physiotherapists
couraging the types of patients examined in
hospitals.Australian Journal of Hospital Pharmacy
the studies from attending A&E depart-
patients aged 65 years and over to establish
5.
Tulip S, Campbell D. Evaluating pharmaceutical
whether these patients will be able to man-
minor illnesses are being seen by the primary
care nurse who redirects patients to the most
intermediate care if this is unlikely. Interme-
appropriate health care service, which may
6.
Audit Commission.A spoonful of sugar: medicines
diate care includes admission to residential
include an emergency GP appointment. Clinical decision units 7.
Crown J. Review of prescribing, supply and
administration of medicines. London: Department
QMC plays an integral part in this process
Clinical decision units are attached to the
and patients requiring intermediate care are
A&E departments in some UK hospitals. 8.
Anon. Developing roles for pharmacists in
referred to the pharmacist for any medicines
They are designed for short-stay patients
UK Clinical Pharmacy Association
hours, which may include patients who have
9.
Collignon U, Oborne C, Parfitt A, Ellis C. Emergency Care Group
taken overdoses who need monitoring for a
Pharmacist sees patients in the emergency
few hours or patients admitted with cellulitis
department: new model of care (abstract).
This group is planning to run a study day in
before continuing treatment under a home-
care service. Because of the high patient
Association autumn symposium; 2004 November
care — where are we now?”The day will
turnover, a rapid and efficient pharmacy ser-
be centred around pharmaceutical care and
Paper on accident and emergency
patient’s journey through emergency care,
Training for the role department pharmacists
the developing role of the emergency care pharmacist, the impact of the four hour
A paper determining the incidence of drug
mandatory qualification for A&E department
related problems and comparing the extent
pharmacists. Most training is “on the job”,
to which complete medication histories are
information will be available from the UK
with training needs varying depending on the
recorded by doctors and clinical pharmacists
in an A&E department is set to be published
(www.ukcpa.org.uk)
in next month’s issue of Hospital Pharmacist. H O S P I TA L P H A R M A C I S T
For personal use only. Not to be reproduced without permission of the editor
Any drug-related issues that may be impor-tant to the patient’s treatment are brought tothe attention of medical staff. The pharma-cist may suggest a simplification of amedicine regimen if necessary. A full drughistory and any relevant comments are doc-umented in the patient’s medical notes andthe pharmacist informs ward-based pharma-cists of any patients that may need to befollowed-up.The pharmacist is also involvedin completing drug charts, which are thenreviewed and signed by a doctor.