Future enhanced clinical role of pharmacists in Emergency Departments in England: multi-site observational evaluation
Future enhanced clinical role of pharmacists in Emergency Departments in England: multi-site observational evaluation
Elizabeth Hughes 0 1 2 3 4 5
David Terry 0 1 2 3 4 5
Chi Huynh 0 1 2 3 4 5
Konstantinos Petridis 0 1 2 3 4 5
Matthew Aiello 0 1 2 3 4 5
Louis Mazard 0 1 2 3 4 5
Hirminder Ubhi 0 1 2 3 4 5
Alex Terry 0 1 2 3 4 5
Keith Wilson 0 1 2 3 4 5
Anthony Sinclair 0 1 2 3 4 5
0 Academic Practice Unit, Pharmacy Department, Birmingham Women's and Children's Hospital NHS Foundation Trust , Steelhouse Lane, Birmingham B4 6NH , UK
1 Health Education England - St Chads Court , 213 Hagley Road, Edgbaston, West Midlands, Birmingham B16 9RG , UK
2 & David Terry
3 Pharmacy Department, Birmingham Women's and Children's Hospital NHS Foundation Trust , Steelhouse Lane, Birmingham B4 6NH , UK
4 Aston Business School, Aston University , Aston Triangle, Birmingham B4 7ET , UK
5 Pharmacy Department, School of Life and Health Sciences, Aston University , Aston Triangle, Birmingham B4 7ET , UK
Background There are concerns about maintaining appropriate clinical staffing levels in Emergency Departments. Pharmacists may be one possible solution. Objective To determine if Emergency Department attendees could be clinically managed by pharmacists with or without advanced clinical practice training. Setting Prospective 49 site cross-sectional observational study of patients attending Emergency Departments in England. Method Pharmacist data collectors identified patient attendance at their Emergency Department, recorded anonymized details of 400 cases and categorized each into one of four possible options: cases which could be managed by a community pharmacist; could be managed by a hospital pharmacist independent prescriber; could be managed by a hospital pharmacist independent prescriber with additional clinical training; or medical team only (unsuitable for pharmacists to manage). Impact indices sensitive to both workload and proportion of pharmacist manageable cases were calculated for each clinical group. Main outcome measure Proportion of cases which could be managed by a pharmacist. Results 18,613 cases were observed from 49 sites. 726 (3.9%) of cases were judged suitable for clinical management by community pharmacists, 719 (3.9%) by pharmacist prescribers, 5202 (27.9%) by pharmacist prescribers with further training, and 11,966 (64.3%) for medical team only. Impact Indices of the most frequent clinical groupings were general medicine (13.18) and orthopaedics (9.69). Conclusion The proportion of Emergency Department cases that could potentially be managed by a pharmacist was 36%. Greatest potential for pharmacist management was in general medicine and orthopaedics (usually minor trauma). Findings support the case for extending the clinical role of pharmacists.
Clinical pharmacy; Pharmacist; Pharmacist training
Impacts of practice
Advanced trained clinical pharmacists may support the
clinical workload of Emergency Departments.
Up to 8% of patients attending Emergency Departments
may be clinically managed by pharmacists with
existing training, and a further 28% after additional clinical
To ensure the highest impact on clinical workload
advanced training of pharmacists should focus on
general medicine and orthopaedics (usually minor
At present there are concerns about maintaining
appropriate clinical staffing levels in Emergency Departments (ED)
in England [
] and in other countries [
]. One possible
solution is the extension of clinical activity performed by
non-medical staff—including pharmacists . Subsidiary
clinical management of ED attendees may support patient
through-put, relieve pressure on medical staff and reduce
Extending the pharmacist’s role in ED may also
contribute to error minimization [
concerning pharmacists working within ED are usually focused on
drug management, their role in ‘Rapid Response Teams’ or
their role in Medical Admission Units, the usual admission
route following ED [
Over the last 10 years there has been an expansion of
United Kingdom (UK) Universities training pharmacists
and there is now a surplus of registered pharmacists in
Since 2006 clinical pharmacists in UK have been able to
undertake further training to become fully independent
]. In March 2015 there were 2191
pharmacists with independent prescribing rights registered with
the national regulatory body, the General Pharmaceutical
Council. Clinical pharmacist independent prescribers may
benefit from further training beyond prescribing, and are
eligible to take a recently introduced educational
programme to become Advanced Clinical Practitioners (ACP)
]. Pharmacists with ACP training can conduct
comprehensive physical examinations, request and interpret tests,
diagnose and treat illnesses and injuries, and counsel
patients on preventive healthcare. The proposed extended
role for pharmacists with ACP training is not intended to
replace the existing workforce, but to become a
complementary group of clinicians who can diversify and become
part of a fully integrated consultant-led team in the ED
Aim of the study
To determine the potential for pharmacists to clinically
manage patients within ED; and from this investigation
identify the clinical areas most likely to be impacted by
extending the role of the pharmacists; and identify the
training needs for the future ED workforce of pharmacists.
The study was commissioned and approved by Health
Education England (West Midlands). The Research and
Development departments of the data capture sites
confirmed that the study was classified as service development,
and therefore further approval was not required.
Study design and setting
Multi-site, cross-sectional observational study conducted
by independent prescribing pharmacist data collectors
within 49 hospital sites in England (primary
categorization). A range of hospitals from the regions of England
participated in the study: Buckinghamshire and
Oxfordshire (n = 4), East Anglia (n = 4), East Midlands (n = 4),
London (n = 8), North East (n = 4), North West (n = 8),
South (n = 2), South East (n = 4), South West (n = 5),
West Midlands (n = 2), Yorkshire and Humber (n = 4).
All hospitals were type 1 Emergency
Departments—consultant led 24 hour service with full resuscitation facilities
and designated accommodation for the reception of
accident and emergency patients. Only two West Midland
hospitals were included in the study as two other hospitals
had already taken part in the pilot project that was used to
validate and refine the methodology of data capture [
Selection of participants
A representative sample of cases was taken from a
crosssection of attendees and care pathways at each study site to
reflect the usual workload characteristics of the
departments. An independent prescriber pharmacist (IPP) based
at the participating hospital was seconded from their usual
role to undertake data capture within the ED at their site.
Each IPP was asked to observe 400 ED attendee cases that
would represent the typical case-mix of patients and record
anonymized details of the case. Patients of all age ranges
and presentations who attended ED at the time of the data
collection were included in the study.
This study was non-interventional and was a
cross-sectional observational study where pharmacists were
observing a representative sample of ED attendees, and
assessing each for the potential of the case to be clinically
managed by pharmacists with or without advanced clinical
Methods and measurements
Each data capture pharmacist was asked to record
anonymized details of the cases and categorize each into one of
four possible categories. They made this choice according
to their own experience and knowledge of pharmacist
training and range of competencies. The data capture
instrument had been previously validated by a smaller pilot
project based in the West Midlands [
]. An anonymized
data-set for each attendee was recorded and managed using
Microsoft Excel 2010 and a purpose built Microsoft Access
database. Each site was requested to provide anonymized
details of 400 cases.
The four categorizations were applied to each of the
cases recorded during the study. These were:
• CP, community pharmacist could be managed by a
community pharmacist (CP) working in a community
pharmacy. (That is: attendance at ED was not
necessary). CPs in the UK have at least 5 years training.
• IP, independent prescriber pharmacist could be
managed by a hospital pharmacist with Independent
Prescriber status. IPs have further post-registration
training that gives them some clinical assessment skills
and allows them to be fully independent prescribers. IPs
have at least 8 years training/experience.
• IPT, independent prescriber pharmacist with additional
training could be managed by a hospital pharmacist with
Independent Prescriber status and additional clinical
training, aligned to the Advanced Clinical Practice
training pathway. The study was designed to identify
what further training—in addition to the skills acquired
from the General Pharmaceutical Council accredited
independent prescribing course—would be most useful
to support clinical management of ED attendees.
• MT, medical team unsuitable for pharmacist
management—requires medical team management.
Primary categorization of harvested presentations was
undertaken by the data capture independent prescriber
pharmacists (IPPs, n = 63) at the study sites at the time of
the presentation. These staff had access to the full patient
details at the point of data capture. The pharmacists were
chosen to do the primary review of cases, as they were the
best placed health care professional with an understanding
of the competencies of a pharmacist independent
prescriber, and what additional skills they would need to
extend their role.
The primary outcome measure was the proportion of ED
cases that could be managed by a pharmacist with or
without further ACP training.
The secondary outcome measures:
• Identification of the clinical areas that are most likely to
be impacted by extending the role of the pharmacist.
• Identification of training needs for future ED
pharmacists—via content analysis of the IPT training needs
described by the primary categorizer pharmacists.
All data were recorded on Microsoft Excel 2010, managed
using Microsoft Access 2010 and exported into IBM SPSS
version 21 and Minitab 17 for descriptive and statistical
Qualitative analysis of the IPT training needs specified
by the primary categorizer was done via NVIVO version
10, and qualitative content analysis on the recorded text of
training needs based on case observations [
training need themes identified and coded from the recorded
text, were allocated into one of four main categories:
clinical examination and assessment, diagnosis skills,
medical management, and treatment and training course
components. The frequency of occurrences for each theme
of training needs were determined. The training needs were
coded by a trained research assistant (LM) and confirmed
by a research pharmacist (CH) for consistency.
Primary categorizations (on-site, by IPPs, in realtime)
Summary statistics for each category—CP, IP, IPT and MT
Secondary categorizations (off-site, by ED physicians, ED nurses and pharmacists)
Secondary categorization was undertaken by reference to
the anonymized summary information recorded for this
purpose by the data capture IPPs. The data-set included
age, presenting complaint and clinical grouping. The
clinical cases were recorded and randomised using a
purpose designed Microsoft Access database. The database
was programmed to generate 800 cases of ED attendees for
each secondary categorizer to consider—who was asked to
categorize each into the four categories defined within the
study (CP, IP, IPT, MT). The primary categorization for
the cases were removed prior to secondary categorization.
Blind secondary categorization was undertaken by 15
pharmacists, 6 ED physicians and 4 ED nurses. This was
completed personally by each of the secondary
categorizers, without consultation, and without reference to
categories assigned by others. Summary secondary
categorization is expressed either as cases (based on a
mean of all categorizations awarded for an individual
case—type A calculation) or counts (summation of all
categorizations—type B calculation).
The primary and secondary categorizations were
compared and the level of agreement between the two identified
across the four categories (presumed to be non-ordered/not
ranked)—assessed using a kappa statistic via Minitab
version 17. A non-ranked categorical kappa statistic was
considered to be most appropriate in this case because,
although there was increasing levels of training
(community pharmacist least, through to medical team the most),
the consistency of such differences are not clear.
The categorization data for both the primary and secondary
data was split into regions across England for regional
Cases were assigned a clinical grouping in relation to the
nature of their admission. The clinical groupings were:
An impact index score was calculated for each clinical
grouping. This provides a measure of the potential for
pharmacists to support the clinical workload in that
grouping. The impact index algorithm accommodates both
the workload associated with the clinical group (frequency
of presentation) and the potential proportion of patients that
may be managed by pharmacists.
The impact index was calculated as:
Total cases of CP; IP; IPT in the clinical group
Total number of cases in the clinical group
Total number of cases per clinical group
total number of cases
ðexcluding those where clinical grouping was not assignedÞ
The algebraic expression is: Impact (i) = proportion of workload of grouping (w) 9 proportion ability of pharmacists to manage that clinical group (a) 9 100
IðiÞ ¼ w
The higher the Impact Index the greater potential for
pharmacists to support the clinical workload in that group
presenting to EDs.
Clinical grouping is not fully synonymous with the usual
case mix of clinical specialties, but rather is a subset of
Emergency Department attendees. Clinical grouping is
used in this study to group presentations to identify clinical
areas suitable for inclusion in advanced clinical practice
18,613 ED cases were observed from 49 sites between
March to July 2015. The age of cases ranged from
0–115 years with a median age of 44 years and mode age
of 27 years (interquartile range 27–67 years). The results
of the categorization of cases from the primary data
collection independent prescriber pharmacists are shown in
Table 1 below.
The total number of cases that can be managed by a
pharmacist (including cases where pharmacists specified
what additional training beyond that currently undertaken
by independent prescriber pharmacists—category IPT) is
Secondary categorizations were undertaken by pharmacists
(n = 15), ED physicians (n = 6) and ED nurses (n = 4);
results are shown as ‘counts’ in Table 1 above. By design a
single case may be assigned for secondary categorization
more than once, and by any combination of pharmacists,
physicians or ED nurses. During the study a total of 13,990
cases were secondary categorized at least once, which was
undertaken a total of 19,977 times (described as ‘counts’).
Table 1 shows the sum of all secondary categorizations
expressed in the four categories (CP, IP, IPT,
MT)—calculation type B (counts)
Table 2 below shows secondary categorization by
cases—calculation type A (cases).
Secondary categorization, using mean per case
[calculation (type A): award numerical values to ordinal data
(CP = 1, IP = 2, IPT = 3, MT = 4). Take mean of score
for each case, and express each case to one of 7 categories
(CP, CP/IP, IP, IP/IPT, IPT, IPT/MT, MT)].
The most frequent clinical groupings were: general
medicine (36.4%), orthopaedics (16.5%), cardiology (5%),
general surgery (4.9%) and respiratory (4%).
The clinical groupings where pharmacists can
potentially have the highest impact are listed in Table 3 below.
The level of agreement between the primary
categorizers (Pharmacist Independent prescriber data collectors) and
physician secondary-categorizers was calculated on a case
by case basis. A kappa statistic of 0.26 (standard error
0.011, with a 95% confidence interval of 0.24–0.28) was
obtained—indicating a fair agreement. See Table 4 for a
cross-tabulation of the primary versus doctor
secondarycategorizer. Exact agreement of the category on a
case-bycase basis was obtained in 60.1% of cases. If category is
considered as ordered, disagreement by more than one
category occurred in just 10.6% of cases. Overall the total
cases categorized to a pharmacist (sum of CP, IP and IPT)
by secondary categorization physicians was 1667 from
4421 (37.7%)—primary categorization of the same cases to
a pharmacist category is 1659 (37.5%).
Regional analysis of the data
The categorization data in different regions varied
concerning pharmacists’ potential to manage ED patients, with
results ranging from 16.1 to 43%—with the West Midlands
being a clear outlier according to their primary
The Pearson Chi square test comparing
pharmacistcategories (combined) across regions gave a value of
365.533, DF = 10, with a p value \0.001.
Table 5 below shows the summary regional data.
Figures 1 and 2 shows the percentage of ED cases that
were deemed manageable by a pharmacist per region
(primary-categorization and secondary-categorization
Training needs content analysis
The training needs described by the primary categorizers
(primary categorizers from 46 sites provided suggestions as
free text) were considered using content analysis, and four
main themes were identified. These are:
Total cases PCP ? IP ? IPT
1. Clinical examination and assessment (42 sites,
n = 4510)
2. Diagnostic skills (36 sites, n = 1381)
3. Medical management and treatment (46 sites,
n = 1236)
4. Training course component (16 sites, n = 359)
The most frequent top 10 subthemes for each of the four
mains themes are described in Tables 6, 7, 8 and 9 below.
This study found that approximately 1 in 13 of recorded
ED attendee cases (7.8%) were considered manageable by
pharmacists with existing training (CPs and IPs combined).
This rises to a maximum of 36% if pharmacists are given
further advanced clinical practice training (CP, IP and IPT
combined) as identified by the study respondents.
An additional outcome measure evaluated during the
course of the study was which particular clinical groups
within the ED would benefit from having a pharmacist
manage that group, based on the calculated Impact Index.
The Impact Index was defined to be sensitive to both the
pharmacist’s potential to manage the cases, and the
workload of that group. General Medicine and
Orthopaedics were found to have the highest Impact Index. To
enable pharmacists to best support the clinical workload of
ED further advanced clinical practice training should focus
on these two clinical areas, and if achieved would enable
Advanced Clinical Practitioner Pharmacists
(ACP-Pharmacists) to manage 27% of all ED attendees.
This study is the first published work to evaluate the
potential of future ACP-Pharmacists within EDs—working
beyond traditional clinical pharmacist roles. This study
estimates for the first time the proportion of ED attendees
ACP-Pharmacists may be able to manage, when situated
within the ED, and as part of the multi-disciplinary team.
Other clinical professions who have ACP status such as
Advanced Nurse Practitioners (ANP) and Paramedic
Fig. 2 Secondary categorization percentage of cases manageable by
the pharmacist (with 95% CI)
Practitioners (PP) have a long establish role in clinical
practice, however the body of published evidence
supporting these roles is limited. The only published study
which has evaluated the proportion of cases that ANPs can
manage (one hospital site over 8 months) found that 20%
of all ED cases classified as ‘minor’ (1577/7768) could be
managed by the nurse [
]. The evidence base for PPs
showed via a randomized controlled trial that they were
key in preventing hospital admission to ED for older adults
by being part of the ambulance team [
]. To date there are
no published studies considering the role of PPs working
within the ED.
This study builds on and adds generalizability to the
previous pilot study conducted in the West Midlands. The
pilot study found that 45% of ED attendees were
potentially manageable by pharmacists across the two study sites
], which is higher than the overall findings of this
present national study (36%). However, the proportion of
cases that were considered manageable by pharmacists
with current training (CPs and IPs) was 1 in 13 for this
study, which is similar to the pilot study proportion of 1 in
The results show that the proportion of cases deemed to
be manageable by pharmacists according to primary
categorization vary from region to region—range 16.1–41.7%,
mean 35.7% (95% CI 35.0–36.4%). Interestingly
secondary categorization gives a narrower range—
31.1–41.5%, mean 36.7% (95% CI 35.85–37.45%), which
may indicate an outlier amongst the primary categorizers.
Although pharmacist independent prescribers have the
same qualification and must have at least 2 years
postregistration experience, this does not fully standardize the
data categorization across the 49 sites. Years of experience
prior to becoming a prescriber may vary.
Current literature indicates that the work of hospital
pharmacists in the EDs of the UK have been limited to
traditional pharmacy roles. These include: medicines
reconciliation for high risk patients, transcription of drug
charts, increasing patient-own-drugs use, reviewing
medication and direct support of transfer of changed medicines
information on discharge from the ED, e.g. liaising with
the family physician, community pharmacist and care
]. In the United States of America (USA), the
roles of the pharmacist in the ED are a collaborative
supportive role and mainly involve medicines management,
medicines reconciliation, educating and counseling patients
and carers on safe and effective use of their medication.
They provide direct patient care, but only as part of the
interdisciplinary emergency care team [
]. Our study
suggests that pharmacists with additional training can
undertake clinical management of a wide range of patients
as part of the multi-disciplinary ED workforce.
Due to the size of the study, it was not feasible in terms of
resources to conduct the secondary categorization by direct
observation of each case prior to making a clinical
judgement. However 75% of cases were categorized twice (both
primary and secondary categorization). The method of
secondary categorization (summary anonymized data) was
validated in a previous pilot study. This present study
recruited 63 pharmacist independent prescribers to observe
cases within the ED and judge whether these were
manageable by a pharmacist (n = 18,613, 400 cases per site).
For sites with more than 1 independent prescriber data
collector, the 400 cases were shared across the data
collectors, with one data collector per observation. It would
not have been feasible to ask the data collectors to see the
patients and manage them in real time. Future studies may
include identifying the contribution Advanced Clinical
Practitioner pharmacists can actually make towards
managing the workload in EDs once training has been
completed; and the in-practice experience needed to ensure
Table 9 Training course
components (16 sites, n = 359)
1. Minor injuries course
3. Dermatology clinical skills
4. Knowledge of compartment syndrome
This study did not assess in detail cases managed by the
medical team that could not be resolved without the need
of a clinical contribution by a pharmacist, e.g. cases where
the medical team would contact a pharmacist for advice to
resolve a case.
In summary, primary categorization of 18,613 ED cases
confirms the potential for pharmacists (all categories) to
clinically manage up to 36% of ED attendees. With
existing training (CPs and IPs) pharmacists can potentially
manage 8% of ED cases. Further training aligned to the
Advanced Clinical Practice training pathway
(IPTs—Advanced Clinical Practice Pharmacists) increases the
potential of pharmacists to manage a further 28% of cases.
Secondary categorization of the data (a total of 75%,
n = 13,990) supports the validity of the primary
categorization findings. Impact Index calculations suggest that
pharmacists with advanced training (IPTs—Advanced
Clinical Practice pharmacists) may be most usefully trained
in general medicine and orthopaedics/minor trauma. If
training were to concentrate on the two areas with the
highest Impact Index (probably achievable with 12 months
advanced clinical training) then, (achievable) IPT becomes
19%, i.e. pharmacists overall could manage 27% of cases
attending ED. In order for pharmacists to manage cases,
they require clinical examination assessment skills as well
as diagnostic skills to broaden and extend their role and
case management potential.
Acknowledgements This project was commissioned and funded by
Health Education England, UK.
Funding The study was funded by Health Education England.
Conflict of interest None.
Open Access This article is distributed under the terms of the
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