Standardising and expanding pharmacy services in the emergency department improves safety for high-risk patients and increases standards of care

Emergency departments are under unprecedented levels of pressure and strain across the UK and now more than ever are caring for an increasing number of undifferentiated patients that are both more acutely and chronically unwell and for a longer period of time^​1–3​.

Underpinning reasons behind this are numerous and include^​4​:

• High inpatient bed occupancy rates;
• Exit block driven by lack of access to social care;
• Difficulty in accessing primary care healthcare services;
• An ageing population with more comorbidities and complex care needs;
• Stretched mental health services;
• Greater expectations and access to medical information from the public;
• Expanding clinical and treatment options;
• Medical workforce retention issues.

Traditional approaches to emergency medicine revolve around the fundamentals of resuscitation, stabilisation, differential diagnosis, initial treatment and triage to the most appropriate speciality^​5​. Owing to increased trolley wait times, emergency department clinical teams now also take responsibility for ongoing monitoring and treatment plans as well as personal care needs. 

It is well-established that emergency departments are high-risk settings for medication related error given the undifferentiated patient cases of potentially any medical speciality, limited early clinical information, environmental barriers and the time pressures associated with decision making.

This high risk-profile has been compounded owing to the increased care needs emergency departments are now required to provide, involving:

• Reconciling and providing access to specialised chronic medication therapies for patients awaiting admission (which may often be time critical and cause acute deterioration if not continued in a timely manner);
• Providing access to acute medication therapies that may have previously been typically initiated on an inpatient ward;
• Reviewing a larger number medication for potential adverse effects;
• Logistics around increased medication stock holdings and replenishment;
• Discharge medications for patients requiring support devices (i.e. blister packs or dossette boxes);
• Palliative or end-of-life discharges.

The benefits of clinical pharmacy services located within secondary care are long established and have been shown to improve patient safety, flow and efficiency^​6​. Clinical pharmacy services in emergency departments (though less developed than in secondary care as a whole) have exponentially grown over the past five to ten years, with management teams recognising the potential benefit these services can have in the emergency department. 

These emergency department pharmacy services are typically uniquely designed to aid individual emergency department clinical services in solving medication-related issues created by the greater pressure, often specifically determined by local population, local interface and admission procedures as well as size and emergency department type. 

Owing to being tailored around the local service model, services are variable in terms of their specific clinical focus, the skill-mix of pharmacy, the hours of service and the number of staff employed.

Examples of approaches to emergency department clinical pharmacy services include:

• Medicines reconciliation and supply of medications for those awaiting admission;
• Independent prescribing of chronic therapies and consultant led discharge plans;
• High-risk patient identification and review (time critical medication, high-risk medications, chronic or acute renal disease);
• Specialist review of polypharmacy within frail and elderly patients;
• Provision of advanced clinical practice and a designated primary clinician for particular patient case types;
• Medication administration in particular circumstances;
• Opportunistic and structured education for the multidisciplinary team, as well as patients.

The UK Clinical Pharmacy Association (UKCPA) emergency care committee, through engaging with the emergency department pharmacy community as a whole, has worked closely with the Royal College of Emergency Medicine to highlight and acknowledge the essential role these clinical pharmacy services play in the fundamental care of patients. 

This culminated in a joint position statement containing a series of recommendations that aim to standardise clinical pharmacy services in emergency departments across the UK. 

We hope all trusts with emergency departments will closely study the statement and make provisions for deploying appropriately staffed and trained pharmacists, pharmacy technicians and support staff into their emergency departments and improve the care of this uniquely high-risk patient population.

Kunal Gohil, specialist clinical pharmacist, enhanced independent prescriber in emergency medicine, Nottingham University Hospitals NHS Trust and Thomas Harris, emergency department pharmacist practitioner, Sunderland Royal Hospital on behalf of the UKCPA Emergency Care Committee