Pharmacists in the ED?

Advanced Clinical Non-Medical Prescribing for Pharmacists (CENMP)

2014-15 Health Education West Midlands Pilot Projects.

September 2015

Matt Aiello, Special Projects Manager, Health Education West Midlands

2013-2014: Initial Health Education West Midlands (HEWM) research conducted…

HEWM Emergency Department (ED) Pharmacy Pilot (PIED-WM)

PIED-WM Aims:

• To test and justify development of clinical pharmacist roles within the ED • To provide an evidence base for further project work and national scaling

Guiding questions: 1. “To what extent can pharmacists manage patients in the ED?”

2. “What extra training is needed to create an advanced clinical ED pharmacist?”

3. “What can a pharmacist uniquely contribute to the joined up, multi-disciplinary, multi-skilled urgent and acute / emergency care workforce of the future?”

Project Background

Pilot Sites:

• Birmingham Children’s Hospital NHS Foundation Trust• Worcester Acute Hospitals Trust• Heart of England NHS Foundation Trust

Community Pharmacy (3.2%)

Independent Prescriber (5.1%)

Advanced Clinical Pharmacist (39.9%)

Medical Team Only (51.8%)

Patients suitable for management by:

51.8%

3.2%5.1%

39.9%

2014 PIED-WM Study: Findings

• 782 patients surveyed

• Pharmacist categorisations reviewed by EM Consultants & Nursing teams

48.2% of cases could be managed by a pharmacist

Potential new roles for clinical pharmacists identified in Urgent and Acute Care:

• Undertaking medicines-focussed duties in the ED; eg: pre-discharge medicines optimisation, medicines reconciliation, TTO preparation.

• Undertaking minors-focussed clinical duties within ED and clinical decision teams. • Extending urgent and acute service to community and primary care practice.

These duties are often undertaken unnecessarily by junior medical staff and GPs; who face significant demands on their time.

Pharmacists can help!

But….

Pharmacist involvement in clinical patient management is new territory…

Skills gap relating to clinical diagnosis and “minors” (minor injury and minor illness) treatment was identified.

Next Steps?

2014 PIED-WM Study Conclusions

HEWM developed a pilot training course: “Fast Track” Clinically Enhanced Non-Medical Prescribing for pharmacists (CENMP) - 2 phase test-of-concept pilot.

Aims:

• Provide advanced clinical skills training for pharmacists• Develop a medicines-focused clinician; able to practice as a prescriber pharmacist, while also

assisting in clinical duties• Skills training allows for practice in urgent and acute settings across secondary, primary and

community care.

Phase 1:

• To evaluate a 3-4 month “fast track” NMP module (GPhC accredited)• To develop and evaluate suitable range of clinical health assessment and minor injury / illness

training

Phase 2:

• Lessons learned from Phase 1 informed a pilot “brief,” to be circulated to all West Midlands NMP course providers

• Four West Midlands NMP providers to deliver one cohort of CENMP pilot course, to HEWM brief• Collaborative evaluation between the four course providers.

August 2014 – September 2015

To demonstrate the potential of pharmacist clinicians within urgent and acute care teams to:

• Provide effective care to patients with minor injuries and to pre-discharge acutely ill patients.

• Optimise the use of medicines on admission to emergency and acute care.

• Free up doctors to conduct clinical work. • Reduce patient waiting times and deliver

safe patient care.

• To introduce multi-skilled NMP pharmacist clinicians to undertake ‘minors’ focussed clinical duties.

• To introduce a blended clinically enhanced NMP module for pharmacists, which can be standardised across the region and evaluated with a view to national scaling.

Project Aims Project Outcomes

HEWM

Project Management

Backfill and Tuition Funding

Course Providers

Deliver pilot courseCollaborative

evaluation

Pharmacists:Workforce

Transformation

A collaborative effort…

Participants

Practice Areas Represented Employer Organisations Involved (Phase 1 and 2)

Community practice 26

Primary care 5

Secondary (acute) care 23

Cohort Practice Area Pharmacist Numbers

Phase 1 cohort (51 total)

Community practice 4

Secondary (acute) care 47

Phase 2 cohort(56 total)

Community practice 27

Secondary (acute) care 22

Primary care 7

Project Outcomes: Phase 1:

1: 1 of the 2 Withdrawals had opportunity to re-sit – currently enrolled on Phase 2 programme

Overall: All providers reported pass rates and attrition comparable to standard NMP module.

Course Provider Cohort Size Attrition Pass (1st Attempt)

Pass (following resit)

Fail / Withdrawal

Aston 23 0 17 4 21

Worcester 11 1 9 1 0

Wolverhampton 17 2 13 2 0

Project Feedback

Impact of the programme was reported to be wide reaching.

Pharmacist trainees described enhanced workforce utilisation by facilitating wards to reduce winter pressures through prescribing, resolving medication issues and facilitating discharge.

Others identified increased patient safety as an impact of the programme; this was attributed to the skills that they acquired on the course, their enhanced pharmacy knowledge and being more involved in patient care.

Respondents reported that patient experience had been positively impacted through increased communication with patients.

Overall perception of the course was positive:

- Use of study days, support from course leaders / peers and course length identified as positive features

Participants Comments:

“I think it's very much needed. Especially, I think we will be at an advantage compared to all our other colleagues. We will be able to use our skills a lot more.”

“I work in acute medicine with consultants, with advanced nurse practitioners, with junior doctors and they are very much open arms… can’t wait for me to finish... ‘We can see where you can slot in and be part of the team…’ Essentially on ward rounds and patient assessments on the AMU.”

“Constantly you’re hearing about bed management and A&E delays and it kind of makes sense for us to go into acute medicine and help and work with national targets.”

Key Messages

CENMP-style training is relevant to pharmacist workforce’ across community, primary and secondary care.

Programme supports and follows the NHS Five Year Forward View…development of Multi-Specialty Community Providers and the joined up, multi-professional, frontline clinical workforce of the future. “In order to achieve an understanding of how different health care services can work collectively, new models of training are needed to prepare healthcare professionals for a career in a more joined-up workforce, with the knowledge and skills that span the management of acute health needs across community and secondary care environments.” Demonstrating potential for scale and spread of the concept, Manchester Metropolitan University collaborated with the HEWM programme team to develop their enhanced clinical NMP programme - launching from September 2015. “It's great to see the compressed fast-track NMP programme being recognised as a credible learning route. We've emulated a similar model in Manchester. It is ideal for skilled, well-motivated and focussed pharmacists to meet the overwhelming demand for medicines optimisation support in the NHS.”

Prof Christopher Cutts, Professor of Professional Development and Practice; Director, Centre for Pharmacy Postgraduate Education Centre for Pharmacy Postgraduate Education, Manchester Pharmacy School “The GPhC deemed the project to be a worthy and valuable step in providing high quality care for patients seeking emergency assistance in the West Midlands...We fully support this initiative and recently invited HEWM to share their initial findings of this worthy project at our national seminar for NMP providers in London. This was received with great enthusiasm by the delegates representing both pharmacists and nurse NMP programmes. The outcomes of further work with this valuable project will provide the GPhC with vital evidence, as we develop NMP programmes in the future and guidance for pharmacist independent prescribers.”

Joanne Martin (MRPharmS), Quality Assurance Manager, General Pharmaceutical Council

March- April 2015:

HEWM team led for HEE: Delivered a national version of the West Midlands PIED project.

• 49 Acute Trusts engaged nationally, each categorising up to 400 sets of patient data against the PIED-WM methodology.

• The 49 Hospital Trusts were drawn from 12 of the 13 national Local Education and Training Boards (LETB);

• Project Trusts representative of a national cross-section.

• Data would demonstrate variance in patient presentations at UK EDs, during winter pressures period.

Aim: To expand upon West Midlands project and demonstrate evidence base for national consideration of a near-patient clinical pharmacist in the Emergency Department, as part of a multi-skilled, multi-disciplinary workforce.

National ED Pharmacy Project

Professor Sir Bruce Keogh, National Medical Director (NHSE), confirmed that key outcomes from the ED Pharmacy work would include a positive impact on patient safety, improved patient experience and throughput, expediting safe discharge of patients from hospital and increased capacity in the acute care pathway.

“The RPS believes that pharmacists could make a significant impact on patient care by adding both capacity and capability to emergency departments.  Hospital pharmacy has been at the forefront of advanced clinical practice for some time and I have no doubt chief pharmacists and their teams will respond positively to this opportunity.

We are fully supportive of the work being undertaken by HEE to further evidence the value of pharmacists within emergency departments.”

Dr David Branford, Royal Pharmaceutical Society (RPS) English Pharmacy Board chair

“We are pleased with how the pilot went here and are very keen to take this work forward. We are now looking at putting a pharmacist in the emergency department, who can be part of the team there and support with the triaging of patients.” 

Neil Fletcher, clinical director of pharmacy at East Lancashire Hospitals NHS Trust

Project Support and Feedback

The Future?

The project team are confident in proposing enhanced clinical development pathways for pharmacists, as a model for future clinical workforce planning.

Through the evidence base of the HEWM ED Pharmacy projects and linked Advanced Practice / NMP pilots, it is contended that the such a training pathway could be aligned

to national (multidisciplinary) advanced practice training.

The end result?

A multi-specialty clinical practitioner… a “Generalist Specialist” Pharmacist

 The project team believe that the pharmacist clinician can positively influence

and should be considered an integral part of the future Urgent and Acute, front-line, clinical workforce.

Thank you for listening

Questions?