The geriatric clinical pharmacist at the emergency department: a novel front-door transdisciplinary care model

We refer to our article entitled ‘Emergency Department Interventions for Frailty (EDIFY): front-door geriatric care can reduce acute admissions’, which reported a success rate of up to 81.4% in preventing acute hospital admissions in older adults, with no compromise in health outcomes such as rehospitalisation, institutionalisation and mortality.¹ In this letter, we present our novel transdisciplinary care model, describing the unique role of the EDIFY pharmacist.

Front-loading geriatric assessments and interventions right from the emergency department (ED), to meet multidimensional needs of vulnerable older adults and to reduce adverse outcomes, have been coined as ‘front-door geriatrics’.² At our centre, the EDIFY programme aims to minimise potentially avoidable acute admissions and deliver early integrated geriatric interventions at the ED. Team members consist of professionals trained in geriatric care, including a geriatrician, specialist registrar, geriatric advanced practice nurse (APN), board-certified geriatric pharmacist, and a physiotherapist. Planned admissions to inpatient geriatrics were routinely screened and reviewed by the APN, and patients identified for potential discharge from the ED or transfer to low-acuity care areas (eg, short-stay observation units, subacute care units, or community hospitals) were highlighted to a geriatrician for further review. Care planning, discharge education, and telephonic follow-up consultation are provided to those who are discharged. Patients who are deemed unfit will proceed with acute admission as planned.³

Using a novel transdisciplinary care model, the role of the EDIFY pharmacist transcends traditional boundaries of pharmacy practice. In addition to providing standard pharmacy services, including medication reconciliation, medication review, and patient education, the EDIFY pharmacists are trained to perform similar duties as the APN, such as¹ identifying patients at the ED who are suitable for discharge or step-down care²; obtaining histories and performing physical examinations³; reviewing and ordering investigations⁴; escalating ill cases for urgent doctor review; and prescribing of inpatient/discharge medications (table 1). Regular work-based assessments were conducted with a geriatrician to ensure satisfactory competencies in performing the above-mentioned clinical work.

Table 1.

Traditional and additional transdisciplinary roles of the geriatric front-door pharmacist

Traditional roles	Descriptions
Medication reconciliation	Construct an up-to-date patient medication list to ensure accurate and complete medication information is available
Medication review	Conduct structured evaluations of patients’ medicines with the aim of optimising medicine use and improving health outcomes
Drug-related counselling and consultation	Provide evidence-based information and advice on safe and effective use of medications to patients, caregivers, and healthcare professionals
Pharmaceutical care services	Provide direct and responsible medication-related care for the purpose of achieving definite outcomes that improve a patient’s quality of life
Drug-related policies	Formulate drug policies and recommendations to improve standards of care and practices
Research and education	Facilitate experiential education and practice advancements via research and education

Additional transdisciplinary roles	Descriptions
Identify suitable patients at the ED	Assess illness severity and evaluate need for specialised investigations, expected time to recovery, and existing social and community support
Review patients at the ED	Initiate CGA (including basic history-taking and physical examination), order and interpret investigations, prescribe medications, develop and discuss care plans with EDIFY doctors

CGA, comprehensive geriatric assessment; ED, emergency department; EDIFY, emergency department interventions for frailty.

Between June 2020 and June 2022, 3300 patients were screened by the EDIFY team and 217 cases were deemed suitable for intervention. The EDIFY pharmacist screened 704 cases, of which 26 patients were identified for potential acute admissions avoidance. Five patients were successfully discharged from ED, 19 patients were transferred to lower-acuity care areas, and two patients were admitted to the acute ward as planned. Due to constraints on healthcare resources and changing landscapes amid the pandemic, the statistics may not be reflective of the true potential of our service as reported in our study.¹

To our knowledge, our centre is the first to pioneer such transformative care between the geriatric APN and pharmacist in the ED. This care model has helped EDIFY provide sustainable and effective care at times of pandemic and during staff shortages with high caseloads. Patients do not need to see multiple healthcare professionals, comprehensive assessments can be done timely, and deployment of personnel/resources can be made flexibly. We believe that transdisciplinarity is a key milestone in transforming healthcare delivery, especially in the ED.⁴

Ethics statements

Patient consent for publication

Not applicable.