typically are older, and are at higher risk of both
medical and traumatic injuries.
Deterioration within the ED
A total of 62.6% APM doses were missed within
the ED with no clinical reasoning, which
demonstrates extremely poor compliance with
internal guidance on continuation of time-critical
medications, as well as national guidance. 7 This
figure is consistent with a similar previous
study, 17 which found a 74.6% dose omission rate
at another acute hospital Trust, indicating the
problem may not be isolated to individual EDs
and may be explained by systems failures. This
may be due to compounding factors in the ED
such as time pressure, overcrowding, lack of
awareness of missed APMs and other priorities
set by clinicians focusing on treatment of the
presenting complaint – rather than maintenance
of chronic therapies.
As previously discussed, 18-20 APM omissions can
be associated with potentially rapid and severe
deterioration in symptoms. These are of
particular concern in secondary care owing to
development of dysphagia, potentially leading to
aspiration, and mobility reduction increasing the
likelihood of falls. Of the cases reviewed, clear
documentation was found in ten cases (11.2%)
where omissions may have lead to clinically
significant deterioration of symptoms. These
situations occurred exclusively in patients who
did not have pharmacist review.
Decisions to admit may have been influenced
by these deteriorations in conjunction with
pathogenic disease, and caused extensions in
inpatient stay as a result.
Impact of the pharmacist in the ED
Pharmacist intervention occurred in 21.3% of the
cases examined. This figure could be expected
considering the level of service provision, which
equates to 37.5 hours per working week, and that
pharmacist responsibilities would have also
extended to other high-risk patients. Pharmacists’
skill sets are well suited for this particular role,
and would likely be superior to either a nurse- or
medic-led approach to identifying and prioritising
PD patients, due to innate knowledge of dosing
schedules, formulation substitutions and rapid
sourcing and supply.
Pharmacist intervention was associated with
statistically significant reduction in dose
omissions while in the ED and within the first 24
hours of inpatient admission. The effect within
the ED can be explained by pharmacists
identifying patients as high-risk at an early stage,
having APMs prescribed and supplied and
implementing treatment plans while in the ED.
Thus, prescribing, supply and administration of
APMs are all accelerated.
This approach has a completely different
prioritisation strategy to typical ED processes.
The effect was not expected to be as profound
at a ward level; however, data clearly demonstrate
dramatic reductions in dose omissions after
transfer from ED to base ward. This effect at base
ward level is potentially explained by the
improved handover and continuity of care that
a pharmacist can provide in regards to medication
supply and documentation of checked medication
regimes. It was also noted from the results that a
FIGURE 9
Co-morbidities and total length of inpatient stay*
>5
3–4
1–2 *Excludes patients who died as inpatients
100
90
80
70
60
50
40
30
20
10
0
<7 Days <1 month >=1 month
>5 24 16 4
3-4 13 110 4
1-2 7 5 2
FIGURE 10
Age and total length of stay*
>70
70–80 years
>80 years *Excludes patients who died as inpatients
100
90
80
70
60
50
40
30
20
10
0
>=1 month
<7 Days <1 month >70 9 1 70-80 years 11 13 3
>80 years 24 17 7
reduction in dose omissions (although not
statistically significant) was observed in patients
who had regular APMs prescribed within ED
against those who did not. Patients might
experience extended base ward waits prior to
medical clerking which, when combined with
omission in the ED, can lead to considerable
proportions of time before normal medication
can be reconciled and given.
It was, however, important to note that
pharmacist intervention was unable to eliminate
dose omissions. This is likely explained by
pharmacists identifying patients once doses had
already been missed in the department, and
relying on nurse administration of medications by
prompting rather than administering themselves.
These data indicate a tangible benefit in
patient care and a clear prevention of
deterioration within the department facilitated by
early pharmacist intervention. These included
two cases where patients attended the ED unable
to resume oral therapies due to acute illness,
where pharmacists rapidly recommended
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