A new member joins the emergency room

Pharmacists are making their mark in busy A&E departments. Virginia Matthews reports

The next time the scriptwriters at Casualty introduce a new member of the healthcare team into the show, they may well be modelled on 30-year-old Gail Foreshew, a pharmacy graduate from the University of Nottingham.

Appointed four years ago as emergency department pharmacist at Queen's Medical Centre, Nottingham, Foreshew is one of only a handful of pharmacists in the country who devotes all her time to the frenetic world of A&E and who includes attending consultant ward rounds on her list of daily duties.

Although A&E has traditionally not included a major input from pharmacists; leaving much of the routine medication work to doctors, emergency departments have the highest turnover of patients in a hospital and are obliged to administer a large quantity of complex medicines, including pain relief.

They may also be faced with patients who have collapsed as a direct result of their medication, diabetics who have forgotten to take their insulin, sun-worshippers with extreme sunburn or asthmatics who are struggling with inhalers.

Foreshew's position in one of the busiest emergency departments in the country - and there are many other pharmacists who now spend at least some of their time in A&E - highlights the further development of the hospital pharmacist's role in managing medicines throughout the entire hospital organisation.

"My job is to bridge the gap between the emergency department and the admissions wards and to provide a more seamless service to patients when they come in as emergencies and then need to be admitted," says the pharmacist, who is currently studying to become a supplementary prescriber.

"When it comes to taking a drug history from patients, assessing their medication regime and perhaps making changes to drugs or adjusting doses, a pharmacist's skill in being able to communicate with patients can be very valuable," she adds.

"Although A&E can be traumatic and noisy, I find the patient-centred environment very challenging and absorbing. I never wanted to be a medic, but I do enjoy being with patients all day."

The benefits of having trained pharmacists in a hospital emergency department are varied. The prior knowledge of a patient's drug history enables better judgements to be made about adjusting treatments during ward rounds, it helps to highlight medication problems promptly after admission and it reduces delays in treatment.

Since the introduction of the four-hour target in 2004 - which says that patients should be admitted, transferred or discharged within this time frame - the attention of many hospitals has focussed on an expansion of the pharmacist's role in A&E work.

"At QMC, the emergency department pharmacist takes a drug history for those patients being admitted to the wards and having spoken to patients as well as their GP's, relatives, carers and perhaps nursing home staff, it is possible to review their current medicines in the light of the reason for admission," says Foreshew.

"On the ward round, it is my job to clarify a medications history, add any new medicines such as antibiotics to the drug chart, provide advice to medical and nursing staff on how to administer the drugs and write discharge medication forms.

"For patients who are discharged during the ward round, medicines are dispensed by the pharmacist or discharge technician immediately after the round has finished and this speeding up of the discharge process helps to clear beds for new admissions from the emergency department," she adds.

With the pressure on junior doctors considerably relieved by having a full-time emergency department pharmacist to call on, it is little wonder that the SHO's at QMC are, she says, "fairly relieved" that she is around to help.

Identifiable as the only member of the team dressed in ordinary clothes, an emergency pharmacologist will assess the drug regimes of a variety of patients brought in with anything from renal failure or a heart attack to problems with persistent coughs.

As the only expert pharmacologist in the department, it is also their role to identify any unfamiliar drugs brought in to hospital by patients from overseas, to pinpoint what drugs are involved in a deliberate or accidental overdose and to come up with antidotes for unusual insect stings or even snake bites.

While the actual administering of drugs is still carried out by the medical staff, a pharmacist can offer advice on analgesics and pain relief for people who have recently been admitted and advise nursing staff on possible side effects.

At QMC, Foreshew's job is enormous. "Although I can't see everyone individually, I am on hand to discuss medication with patients who request it and I am available to offer advice on alternative therapies when a patient's current medicine regime is making them ill," she says.

"My job may involve reminding people why they are on medication in the first place, listening to their concerns or even changing their medication altogether."

Many of the people who come into the department are elderly, and many are already on a lot of medication that they may have forgotten to take or may be confused about the reason for taking in the first place, she says.

"People only retain about 30 per cent of what they are told, so it is very easy to forget what a GP has told you about your medication between leaving the surgery and arriving back home."

In her view though, it is often patients who expect to be given a magic a pill for every occasion.

"Patients are undoubtedly on a lot more medication now, but that is mostly because we have learned how to prolong peoples' lives through better use of drugs.

"Sometimes a patient doesn't actually need medication, but many people want something prescribed for them in order to give them some reassurance.

"There is a clear trade-off between living longer, but at the same taking far more drugs to keep alive."