A novel study has attempted to define and describe the role of the emergency department pharmacist practitioner (EDPP) who has overall clinical responsibility for patients in an emergency care setting.
“As well as investigate EDPP care provision, methods to support the evaluation of the impact of these pharmacists have been developed. The quality
evaluation framework will support structured and comprehensive evaluation of EDPP quality impact. The service specification will also support quality evaluation in that it can be compared with existing EDPP service structures and processes; however, it also sets out expectations for hospitals wishing to launch the service.
The report suggests that the role of the pharmacist in emergency departments is currently a ” niche role”.
“EDPPs provide both traditional and practitioner care. Unlike nurse practitioners who seemingly withdraw from their traditional nursing activities, EDPPs continue to carry out drug-focused activities to support both patients and the wider ED which includes educating other staff. The combined nature of the EDPP role supports HEE’s efforts to develop a flexible workforce which can respond to ever-changing patient demand. Further, through the introduction of an EDPP service, those EDs who have limited – if any – pharmacy service could gain 2 types of role from 1 employee; a pharmacist who can both undertake more general pharmaceutical activities and also provide direct patient care when needed.
“EDPPs were the designated care provider/manager of 232 patients (34.0%) of those included. Whilst the 682 patients cared is somewhat a selective sample, it is interesting that this proportion is similar to HEE’s suggestion that 36% of ED patients would be suitable for management by a pharmacist. Due to differences in the clinical groupings, it has not been possible to compare diagnoses of patients managed.
“EDPPs prescribed medicines for 39.0% of patients. Medicines prescribed were typical for an emergency care setting which cares for acutely unwell patients e.g. 15 analgesics, inhalers, antibiotics and steroids. However, there were some unexpected prescriptions e.g. for the biologic medicine etanercept.
“In 2014, Baqir and colleagues found that only 184/1415 medication orders (13.0%) prescribed by pharmacists across were for a newly initiated medicine and 799/1415 (56.5%) for regular medicines that had been missed. In this study, these figures were 273/596 (45.8%) for new medicines prescribed and 291/596 (48.8%) for regular medicines re-prescribed. Whilst this difference could be due to the nature of the clinical setting studied, it does suggest pharmacist independent prescribers are not just repeat authorisers of treatment initiated by others.
“Traditionally, the clinical examination of patients has been the remit of doctors. In this study, EDPPs examined over a third of all patients (38.7%), with types of examination performed primarily of the major systems e.g. respiratory, cardiovascular and abdominal. This demonstrates a change in pharmacists towards the provision of hands-on patient care. Similarly, EDPPs also physically carried out many tests and procedures to both inform patient diagnosis and treat them.
“The framework is purposely independent of any particular study design and therefore can be used to evaluate the role of any pharmacist working in the ED and using any method e.g. randomised control trial or cohort comparison. The inclusion of structures and processes will enable evaluation of outcomes which relate to specific activities in a particular setting.
“In this study, EDPPs did not prioritise financial outcomes, although few of these were identified given the studies focus on patient quality of care in the NHS which is free at the point of use.
“The specification can be used to develop any type of new and existing EDPP services and guide training. The inclusive wording of criteria and the designation of criteria as dependent on local service agreements ensured a single specification could be produced. An alternative would have been to draft two specifications, one each for traditional and practitioner work; however, this would potentially have been divisive and caused conflict between traditional and ‘practitioner’ pharmacists.”
Next steps and future outcomes
“Moving forward, plans are to develop and conduct a study that will conclude the quality impact of EDPPs. This will focus on prescribing errors but also other priority outcomes such as length of ED stay. In addition to evaluation of EDPP impact, other pertinent research themes were identified such as EDPP care pathways. As providers of both traditional and practitioner care, it is important to explore how both types of care can be provided efficiently side-by-side, to the same and different patients, and alongside other healthcare professionals. Further, as the ED workforce continues to diversify, it will also be necessary to improve our understanding of multidisciplinary working in emergency care. Finally, as more pharmacists acquire additional clinical skills and move into new practice settings e.g. general practice and other urgent care settings such as NHS 111 call centres, this research provides a basis for evaluation of these new roles. Indeed, it is vital that we understand how and how well pharmacists in emerging roles care for patients to ensure quality and value for the NHS.”
Research pharmacist Daniel Greenwood commented:
“Funded by Pharmacy Research UK, the UK Clinical Pharmacy Association, Health Education North West and the Centre for Pharmacy Postgraduate Education, the 18-month project is the first to define the role of pharmacist practitioners working in emergency care – and perhaps pharmacists working as ‘true’ practitioners in any setting. A service specification to support the implementation of this novel role, along with a framework to support local quality evaluation, have also been produced.”