Future enhanced clinical role of pharmacists in Emergency Departments in England: multi-site observational evaluation.

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.

THE POTENTIAL FOR PHARMACISTS TO MANAGE CHILDREN ATTENDING EMERGENCY DEPARTMENTS.

AIM: There have been concerns about maintaining appropriate clinical staff levels in Emergency Departments in England.1 The aim of this study was to determine if Emergency Department attendees aged from 0-16 years could be managed by community pharmacists or hospital independent prescriber pharmacists with or without further advanced clinical practice training. METHOD: A prospective, 48 site, cross-sectional, observational study of patients attending Emergency Departments (ED) in England, UK was conducted. Pharmacists at each site collected up to 400 admissions and paediatric patients were included in the data collection. The pharmacist independent prescribers (one for each site) were asked to identify patient attendance at their Emergency Department, record anonymised details of the cases-age, weight, presenting complaint, clinical grouping (e.g. medicine, orthopaedics), and categorise each presentation into one of four possible categories: CP, Community Pharmacist, cases which could be managed by a community pharmacist outside an ED setting; IP-cases that could be managed at ED by a hospital pharmacist with independent prescriber status; IPT, Independent Prescriber Pharmacist with additional training-cases which could be managed at ED by a hospital pharmacist independent prescriber with additional clinical training; and MT, Medical Team only-cases that were unsuitable for the pharmacist to manage. An Impact Index was calculated for the two most frequent clinical groupings using the formula: Impact index=percentage of the total workload of the clinical grouping multiplied by the percentage ability of pharmacists to manage that clinical group. RESULTS: 1623 out of 18,229 (9%) attendees, from 45 of the 48 sites, were children aged from 0 to 16 years of age (median 8 yrs, range 0-16), 749 were female and 874 were male. Of the 1623 admissions, 9% of the cases were judged to be suitable for clinical management by a community pharmacist (CP), 4% suitable for a hospital pharmacist independent prescriber (IP), 32% suitable for a hospital independent pharmacist prescriber with additional training (IPT); and the remaining 55% were only suitable for the Medical Team (MT). The most frequent clinical groups and impact index for the attendees were General Medicine=10.78 and orthopaedics=10.60. CONCLUSION: Paediatric patients attending Emergency Departments were judged by pharmacists to be suitable for management outside a hospital setting in approximately 1 in 11 cases, and by hospital independent prescriber pharmacists in 4 in 10 cases. With further training, it was found that the total proportion of cases that could be managed by a pharmacist was 45%. The greatest impact for pharmacist management occurs in general medicine and orthopaedics.

HOW WELL DO OUTPATIENT PRESCRIPTIONS ADHERE TO GOOD ANTIMICROBIAL STEWARDSHIP?

AIM: Aims of the study included evaluation of outpatient antibiotic prescribing practices relating to good Antimicrobial Stewardship1 focusing on documentation of indication and duration. METHOD: Prescriptions dispensed at the Outpatient Pharmacy over a 6 week were evaluated. Data collected include patient's hospital identification in full, the antibiotic prescribed, duration of treatment, indication (in a specifically allocated area on the prescription) and route of administration, prescriber speciality and grade. Data were entered onto Microsoft Excel and reviewed by a committee that included a medical microbiologist and antimicrobial pharmacist. RESULTS: Five hundred and six antimicrobial prescriptions were reviewed. Therapeutic antibiotics accounted for 484/506 (95.6%) and the remaining 22/506 (4.4%) were prophylactic therapy. Indications were documented in 186/506 (36.8%) cases and 465/506 (91.9%) documented duration of therapy. By speciality, adherence with indication and duration, respectively, for oral medication, were as follows: Haematology 2/55 (3.6%) and 12/55 (21.8%), General paediatrics 26/42 (61.9%) and 41/42 (97.6%), Oncology 4/37 (10.8%) and 34/37 (91.9%), Dermatology 12/35 (34.3%) and 35/35 (100%), Nephrology 24/30 (80%) and 30/30 (100%), Ear Nose and Throat (ENT) 9/31 (29%) and 31/31 (100%). Oral route of administration was the most frequently prescribed 391/506 (77.3%), with topical and eye/ear drops prescribed in 63/506 (12.4%) and 50/506 (9.9%) respectively. Nebulised therapy accounted for only 2/506 (0.4%) prescriptions. Most commonly prescribed antibiotics were Co-amoxiclav 83/391 (21.2%), Flucloxacillin 50/391 (12.8%), Penicillin 35/391 (9.0%), Azithromycin 27/391 (6.9%) and Trimethoprim 26/391 (6.6%). Adherence to antibiotic guidelines was seen to be appropriate with 496/506 (98%).From the ten prescriptions that did not adhere, Azithromycin accounted for 8/10 (80%) with 50% of these used for prophylaxis, with lack of clear documentation. CONCLUSION: A designated area on the Outpatient Pharmacy prescription for indication and duration can aid better Antimicrobial Stewardship. Duration of therapy was better documented than indication, however it is postulated that this was to ensure adequate supply on outpatient dispensing and not always through following good antimicrobial prescribing practice. On the whole, the most commonly prescribed antibiotics were predominantly prescribed by the specialities within the antibiotic guidelines. Azithromycin, which is restricted to respiratory team, was prescribed outside of the policy by other specialties. This study helped prioritise which specialities require further input to improve adherence with Antimicrobial Stewardship in the outpatient setting. As dermatology and ENT had 100% compliance with specifying duration, we are now reviewing their prescribing education which can be used to enhance the practice of the other specialities.

Antimicrobial treatment of serious gram-negative infections in newborns.

The choice of antibiotics for serious Gram-negative bacterial infections in the newborn must balance delivery of effective antibiotics to the site(s) of infection with the need to minimize selection of antibiotic resistance. To reduce the risk of selective pressure from large-scale cephalosporin usage, a penicillin-aminoglycoside combination is recommended as empiric therapy for neonatal sepsis. Where Gram-negative sepsis is strongly suspected or proven, a third-generation cephalosporin should ordinarily replace penicillin. Piperacillin-tazobactam can provide better Gram-negative cover than penicillin-aminoglycoside combinations, without the risk of selecting antibiotic resistance seen with cephalosporins, but further clinical studies are required before this approach to empiric therapy can be recommended. For antibiotic-resistant infections, a carbapenem remains the mainstay of treatment. However, rapid emergence and spread of resistance to these antibiotics means that in the future, neonatologists may have to rely on antibiotics such as colistin, whose pharmacokinetics, safety, and clinical efficacy in neonates are not well-defined.