Improving urgent and emergency care through better use of pharmacists.

1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. A collaborative effort…

8. 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

9. 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

10. 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.”

11. 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

12. 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

13. 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

14. 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.

15. Thank you for listening
Questions?