Family Practice Vol. 20, No. 1, 54-57
© Oxford University Press 2003
Clinical Research |
Identification of patients attending Accident and Emergency who may be suitable for treatment by a pharmacist
Guy’s and St Thomas’ Hospital Trust, London, UK.
Correspondence to Duncan McRobbie, Pharmacy Department, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK; E-mail: duncan.mcrobbie{at}gstt.sthames.nhs.uk
Bednall R, McRobbie D, Duncan J and Williams D. Identification of patients attending Accident and Emergency who may be suitable for treatment by a pharmacist. Family Practice 2003; 20: 54–57.
Received 4 December 2001; Revised 12 June 2002; Accepted 9 September 2002.
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Abstract |
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Background. Several studies have demonstrated that 25–40% of Accident & Emergency department attendances are for conditions that could be managed by the patient’s general practitioner. The number of these who could be appropriately managed by a community pharmacist, has not previously been established.
Objective. To establish the frequency with which patients attend an inner city A&E department with problems that could be managed by a community pharmacist.
Methods. A cross-sectional, retrospective review of A&E records for adult patients (>16 years) was conducted during the first two weeks of March 1999. Application of recognised criteria identified patients whose conditions were suitable for treatment by a pharmacist. Associated patient characteristics were investigated.
Results. During the study period 2636 adult patients attended the A&E department. Pharmacist management was considered appropriate in 8% of adult attendances (95% CI 6.8–8.9). The most commonly presented symptoms considered appropriate for pharmacist treatment included those of upper respiratory, gastrointestinal and pain conditions and reflect those previously identified in the literature.
Conclusions. A pharmacist could manage an estimated 8% of adult attendances at this A&E department. Efforts should be made to increase the awareness of the general public of the role of a community pharmacist to reduce demand on A&E and GP services.
Keywords. Accident and Emergency, management, primary care, pharmacist.
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Introduction |
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There is evidence that
40%1,2 of attendances at Accident and Emergency (A&E) departments are for conditions that are suitable for management by primary care. Pharmacist management of minor illness is receiving increasing acceptance from GPs.3,4 In view of the nature of many of A&E cases, it is probable that a proportion could be managed by a community pharmacist. We wanted to test this hypothesis and establish whether or not patients with certain types of conditions could reasonably have attended a pharmacist as a first point of contact. Our aim was to quantify this based on a representative sample of adult patients attending an inner city A&E department.
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Methods |
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A cross-sectional retrospective review of a representative series of case notes of adult patients attending A&E at St Thomas’ Hospital, London, was undertaken during a 2-week period in March 1999.
Identification of ‘primary care’ patients used established patient selection criteria to allow comparability of results with published literature.5 Identification of ‘pharmacy’ patients used standard protocols for practice as recommended by the Royal Pharmaceutical Society of Great Britain.6,7
Data collection
The volume of data predicted required the design of a data collection form for scanning into a suitable database (TeleformRT, Cardiff Software; Microsoft Access 97RT).
All adult patients attending A&E during the defined period were entered into the study.
Statistical analysis
The study sample was analysed statistically to ensure that it was a representative period (Friedman test). Chi-squared testing was applied to demographic data to establish significance of characteristics of the different subgroups identified. A primary care physician and a community pharmacist peer reviewed samples of the data. Statistical analysis to the rate of level of agreement was done using Cohen’s kappa coefficient.
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Results |
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During the study period, 2636 adult patients attended the A&E department of St Thomas’ Hospital. Forty-nine per cent were female, and the predominant users of A&E were under the age of 55 years (81%). The number of attendances per day did not vary significantly throughout the week (329–428/day). The majority of attendances were between 8 a.m. and 8 p.m. (72%). Most of the A&E users were residents of the capital (87%), although only 57% were local to the hospital. Three-quarters of patients attending A&E were registered with a GP.
The selection process identified 493 (19%) cases suitable for management by a GP; of these, 208 (8%, n = 2636) were considered to be suitable for management by a community pharmacist (see Table 1
). Application of Cohen’s kappa coefficient to the peer review of these results demonstrated a good level of agreement. The ‘pharmacy’ patient group were found to be significantly younger than the A&E population (chi-squared test P = 0.004) and significantly more likely to be non-UK resident (chi-squared test P = 0.003). All other demographics reflected those of the study sample.
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Cases not available for review in the study
The notes of 706 patients were not available for review. Notes were retrieved for study purposes from the A&E filing system shortly after the attendance. Missing notes included those requiring follow-up letters to be written, cases being reviewed by senior staff or subsequent re-attendance at the department in the interim period. All these suggest that these cases would not have met the criteria for pharmacy management and so, for the purposes of the study, were classed as A&E cases.
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Discussion |
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The loss of cases to the study reduced the overall potential number that met the criteria for pharmacy management, but the outcome of those studied implies that
5500 patients per year access St Thomas’ A&E for health care needs who could have been managed by a community pharmacist. Those suitable for such management were likely to be in the younger age group or to be foreign residents. It may be that this reflects the itinerant daytime working population in the vicinity of the hospital or lack of understanding of the types of health care available in the UK.
The most commonly presenting conditions that could be managed by a pharmacist reflected those already described in the literature: pain, gastrointestinal problems, upper respiratory infection and skin problems.8 Pharmacy management would have been appropriate in the light of published work on recommended referral patterns.8
Pharmacists can already supply a wide range of medicinal products without reference to a medical practitioner. Recent changes to prescribing legislation following the Crown Report9 have presented the opportunity to extend this further under specified circumstances using Patient Group Directions (PGDs).10 PGDs enable the protocol prescribing of medicinal products for specific patient groups, by non-doctors, as agreed by the medical practitioner responsible for patient care. These are already used routinely, for example by emergency nurse practitioners within the A&E setting and by pharmacists and nurses running warfarin clinics, and could be used within Primary Care Trust (PCT) areas to extend the ability of pharmacists to manage minor illness in primary care settings.
Limitations of the study
Retrospective case study review was necessary for the study design because resources did not allow for 24-h research cover in the A&E department. A prospective study would have been more accurate and allowed for the review of all attending cases. The loss of numbers due to unfiled case notes would have been avoided.
Review of notes was undertaken by a single investigator and, whilst this allowed for consistency in the decision-making process, any bias would be enhanced. However, the process of peer review ensured a degree of validation of the process, as demonstrated by the use of Cohen’s kappa coefficient. Further validation of the decision-making process subsequently has reaffirmed this.
Implications of the outcome
Clearly A&E departments are keen to reduce the number of inappropriate attendances to an already overstretched service, and this study goes some way to quantifying the potential advantages of encouraging patients to consider alternative sources of advice. It may be that A&E departments should consider including a pharmacist within the triage process either to redirect patients to a more appropriate source or to deal with relevant problems at the time.
The study also shows that a community pharmacist rather than the GP could reasonably deal with a large proportion of work falling into the definition of ‘primary care’ problems.
A greater awareness of the range of available sources of health care and the circumstances where each should be used would be a valuable addition to patient education, as would some form of information on these matters to tourists and temporary workers visiting the UK.
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Conclusions |
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A pharmacist could have managed at least 5500 (8%) adult attendances at a central London A&E department.
Greater awareness or acceptance of the role of the community pharmacist by patients has the potential to reduce the demand on both A&E units and GP primary care.
The opportunity to utilize all the skills of a pharmacist, including drug information, patient counselling and management of minor illnesses, should be encouraged further.
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Acknowledgments |
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The authors wish to acknowledge the help given by Dr Anne Ward in facilitating the project within the A&E department; Dr Graham Davies, University of Brighton for his general guidance; Mr Joshi for validating the ‘Community Pharmacy’ data; Paul Seed (UMDS) and Rob Thompson (University of Brighton) for their statistical advice; and the significant contribution of Dr David Jenkins in the preparation of the manuscript.
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References |
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1 Dale J, Green J, Reid F et al. Primary care in the Accident & Emergency department: 1 prospective identification of patients. Br Med J 1995; 31:423–426.
2 Campbell J, Tait C, Lacy C. Primary Care on the Guy’s Site: A Project to Inform Developments. Consultation Document. Guy’s & St Thomas’ Medical & Dental Schools: Division of Primary Health Care, Department of General Practice, 1998.
3 Erwin J, Britten N, Jones R. General practitioners’ views on over the counter sales by community pharmacists. Br Med J 1996; 312:617–618.
4 Spencer JA, Edwards C. Pharmacy beyond the dispensary: general practitioners’ views. Br Med J 1992; 304:1670–1672.
5 Lowy A, Nicholl J, Kohler B et al. Changes in the Use of A&E Departments Following the Introduction of the New GP Contract. University of Sheffield: Department of Public Health Medicine, 1992.
6 RPSGB. Medicines, Ethics and Practice. A Guide for Pharmacists. London: Royal Pharmaceutical Society of Great Britain, 2002: 88.
7 Blenkinsopp A, Paxton P. Symptoms in the Pharmacy. A Guide to the Management of Common Illness, 2nd edn. Oxford: Blackwell Science, 1995.
8 Smith FJ. Referral of clients by community pharmacists: views of general medical practitioners. Int J Pharm Pract 1996; 4:30–35.
9 Statutory Instrument 2000 No. 1917. London: HMSO, 2000.
10 Crown J. Review of Prescribing, Supply & Administration of Medicines. Final Report. London: Department of Health, 1999.
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