Is this England's only community pharmacist with a clinical A&E role?
Ravinder Singh Cholia believes he is the only community pharmacist advanced clinical practitioner in a hospital emergency department. He tells C+D what it's like in his role
If I travelled back in time two and a half years and asked myself, “Ravinder, what’s an advanced clinical practitioner (ACP)?” I would have said something like: “I haven’t got a clue.” But ask me now and I could write an essay on it.
I'm a community pharmacist and a fully qualified ACP in the emergency department at Queen's Hospital in Romford, Essex. On a typical day, I have a handover meeting at 8am; listening, learning, and contributing as part of a multidisciplinary team, which includes consultants, nurses, a paramedic, community treatment teams, and ambulatory care units, among others.
Exposure to different clinical areas
After the meeting, I am assigned an area to work in, which could be the resuscitation department, the major or minor injury units, paediatrics, or the urgent care centre. While I was a trainee, I exposed myself to all these areas, so that I could use my skills in any part of the emergency department.
I then pick the next patient to be seen. This isn’t like doing a medicines use review, or a regular consultation a patient would usually have with a pharmacist. It’s something new, unique and exciting for the profession. It’s also new for patients, who are seen by a fully qualified advanced clinical practitioner who just happens to be a pharmacist – and I won’t let them go without a thorough medicines review.
I walk into the busy waiting room, where patients wait with bated breath, hoping it's their name on my lips. “Mr Jones?” I call out. Just like in community pharmacy, the patient leaps up as if he’s got a winning lottery ticket, but in this case it’s a consultation with me – which is just as valuable.
I take his history, conduct a physical examination, and request relevant blood tests, as well as scans, if required. If I feel the patient needs cannulating then I can also do this, as well as prescribe fluids and medicines. Having these additional skills, as well as being an independent prescriber, means Mr Jones gets the care he needs from one highly trained professional. He can ask questions and I make sure he understands that we are making decisions about his care together.
"My title doesn't define me"
After I note my differential diagnoses, I present my findings to a senior clinician – which may be a registrar, my clinical mentor, or a consultant – if I feel a review of the patient is required. If this is the case, we discuss my findings and decide on the best course of action. Does Mr Jones need to be referred for surgery? Do we need to conduct an ultrasound, or shall we send him for a CT scan?
If the senior clinician wishes to see the patient they can, but as we have built a rapport over time, I have a certain amount of autonomy. If they concur with my diagnosis, it’s pleasing to know I am on the right track; if they do not then this is still positive – it means this is a learning point. That is what I like most, learning and developing.
At the end of the consultation, I let Mr Jones know that I am also a pharmacist. So far, I haven’t had anyone raise any eyebrows – and why should I? In the patient's eyes they have received the same care as they would expect from a doctor. My title doesn’t define me. The level of care I give defines me.
I see many patients throughout the day, with cases ranging from tonsillitis, to seeing a child with a rash with the GPs in urgent care, to aiding a full cardiac arrest in resuscitation. The first time I did this, a consultant asked me to do chest compressions. It's not as easy as it is on a mannequin, although doing the compressions in time to Stayin’ Alive by The Bee Gees did help me keep time.
I am fortunate to be allowed to take some ownership of my learning, and have taken advantage by working in all areas of the emergency department, following the patient journey.
There's still a long way to go to before I become a master of my trade. So far my journey has included one day a week at university, with modules in physiology, examination skills, the complexities of different body systems, and clinical reasoning with diagnoses.
There’s also been what’s known as the four pillars of advanced practice: clinical practice, leadership and management, education, and research. This is coupled with practice portfolios, and a lot of blended and self-directed learning at home.
In the future, I would hope that there will be many more pharmacists in my role. As a profession, we can do anything with the right mindset.
Ravinder Singh Cholia has a postgraduate diploma in advanced clinical practice and will be discussing his role at a session at the Pharmacy Show on October 7.