Beate Hennie Garcia

Background: Emergency departments (EDs) provide urgent care to diverse patients. Medication-related tasks, crucial for safe diagnosis and treatment, often receive inadequate attention. Clinical pharmacists, experts in medication management, can improve outcomes and reduce costs. Objectives: To investigate how the introduction of clinical pharmacists affects ED junior physicians’ work-time distribution, with particular focus on medication-related tasks. Design: A stepped-wedge design was employed, introducing pharmacists across three Norwegian EDs over a 9-month period, with each ED starting at staggered intervals. Methods: Using the Work Observation Method By Activity Timing (WOMBAT) methodology, we observed junior physicians’ activities in three EDs. The pharmacists were encouraged to adapt to the ED setting, integrate into the team, and identify ways to apply their expertise effectively. Medication reconciliation became their primary focus. We recorded 251 h of observation in the period without pharmacists present and 287 h in the intervention period, with pharmacists present. The proportion of time spent on different tasks was compared between the two periods. Results: Junior physicians spent 81.0% of their work time on non-medication-related tasks, 11.6% on standby/movement, and 8.7% on medication-related tasks. There was no evidence that the overall time distribution was affected by the intervention. However, in ED2, the proportion of time spent on medication-related documentation was reduced from 6.1% to 2.5%, while standby time increased from 6.1% to 13% with pharmacists present. Face-to-face interactions with pharmacists accounted for less than 2% of the junior physicians’ work time in all EDs. Conclusion: In three Norwegian EDs, junior physicians’ work time was predominantly spent on non-medication-related tasks, with only 8.7% dedicated to medication-related tasks. The introduction of clinical pharmacists did not significantly impact junior physicians’ overall work-time distribution. Further research should investigate pharmacists’ impact on ED care quality and efficiency.

Background: Hospital discharge summaries are crucial for transferring patient information to subsequent care providers, yet they often contain incomplete and incorrect medication details. This may lead to inappropriate medication therapy, medication-related problems and unnecessary patient harm. A 2014 study in Norway highlighted a low level of medication information completeness at a rural hospital. This study aimed to audit the completeness of medication information in discharge summaries from the same hospital and to identify factors that could improve medication safety in future efforts. Methods: We randomly selected 240 discharge summaries from 2019 and applied seven national criteria defining the necessary medication information in discharge summaries; (1) reasons for changes in medication prescribing during hospitalization, (2) generic names, (3) administration forms, (4) dosage strengths, (5) dosage regimes stated, (6) indications for use and (7) the medication status categories new, changed, short course. A quantile regression model was applied to analyze factors associated with the medication information completeness in these summaries, adjusting for both patient- and hospital-related variables. Results: From 2550 assessed medications, information completeness in discharge summaries ranged from 0.0 to 1.0, with a mean of 0.904 (SD 0.15). The criteria with lowest information completeness were ´indication for use´ and ´reasons for changes in medication use stated at discharge´. A significant factor in enhancing completeness was the use of a digital tool for compiling the medication list, which increased the completeness coefficient by 0.23 to 0.83 when applied. Conclusions: The completeness of medication information in discharge summaries from Helgelandssykehuset Mo i Rana was high and has significantly improved since 2014. The use of electronic tools for compiling medication lists notably enhances information completeness, while free-text lists should be avoided. This should be considered when developing future electronic medications management systems and tools to ensure quality of medication information.

Pharmacists in emergency departments (EDs) can alleviate physicians’ workload by handling medication-related tasks and offer valuable contributions in interprofessional teams. We aimed to explore physicians’ experiences working with pharmacists in EDs, and their perspectives on future permanent collaboration. We conducted semi-structured interviews with twenty physicians from two EDs and analyzed the data using thematic analysis. Four main themes emerged, comprising twelve subthemes that highlighted both challenges and motivations. Theme 1: time addressed physicians’ time constraints, and the potential for time reallocation with assistance from pharmacists. Theme 2: various roles of pharmacists focused on the diverse roles of pharmacists who supported patient care and junior physicians, but faced challenges like availability and space constraints. Theme 3: teamwork concerned how pharmacists were trusted, brought valuable insights, and enhanced patient safety, yet there were ambiguous views on responsibility and cultural differences. Theme 4: future perspectives focused on how physicians favored a permanent inclusion of pharmacists in the ED, suggesting that they could independently conduct MedRec. Our findings suggest that pharmacists should be permanently integrated in ED teams. However, there is a need to address challenges related to space and legal regulations to enhance interprofessional collaboration.

Background Inappropriate prescribing may have detrimental consequences for the patient and increase healthcare utilisation and costs. Academic detailing (AD) is an interactive outreach method to deliver non-commercial evidence-based medical information to healthcare professionals, aiming to improve patient care. Performing AD virtually has recently become more relevant, especially with the COVID-19 pandemic. Objectives The aim of this study was to explore general practitioners’ (GP’s) experiences and perceptions of virtually delivered AD. Methods We invited practicing GPs that had received virtual AD in Norway during autumn 2020. Semistructured individual interviews were audio and video recorded during February–May 2021. Interviews were transcribed and analysed applying thematic analysis according to Braun and Clarke. Results From interviews with nine GPs, we identified five themes concerning (1) informants’ satisfaction with virtual AD and their opinions about the detailers and their characteristics, (2) factors that are important for participation in AD, with the campaign topic being the most important, (3) a paradox between the informants’ desire for more time for discussion and the time constraint they are facing, (4) the many benefits of virtual AD compared with in-person AD and (5) the informants’ perceived learning outcomes are unaffected by mode of AD delivery. Conclusion Virtual AD worked very well in terms of scheduling the visit, using technology to facilitate the visit and achieving the same learning outcomes. Virtual AD should be offered to GPs as an alternative to the traditional in-person AD, especially in remote geographical areas or in circumstances when physical outreach is challenging.

Emergency departments (EDs) handle urgent medical needs for a diverse population. Medication errors and adverse drug events pose safety risks in the ED. Clinical pharmacists, experts in medication use, play a crucial role in identifying and optimizing medication therapy. The aim of this study was to investigate how clinical pharmacists introduced into the ED interdisciplinary teams distribute their work time. In a time and motion study, we used the Work Observation Method By Activity Timing (WOMBAT) to observe pharmacists in two Norwegian EDs. The pragmatic approach allowed pharmacists to adapt to ED personnel and patient needs. The pharmacists spent 41.8% of their work time on medication-related tasks, especially those linked to medication reconciliation, including documenting medication-related issues (16.2%), reading and retrieving written information (9.6%), and obtaining oral information about medication use from patients (9.5%). The remaining time was spent on non-medication-related tasks (41.8%), and on standby and movement (17.4%). In conclusion, ED pharmacists spent 42% of their work time on medication-related tasks, predominantly medication reconciliation. Their relatively new role in the interdisciplinary team may have limited their broader clinical impact. Relative to other ED healthcare professionals, ED pharmacists’ goal remains to ensure accurate patient medication lists and appropriate medication use.

Purpose: To describe the longitudinal change of health-related quality of life (HRQoL) over 12 months from acute hospitalization in older adults ≥ 70 years (IMMENSE study), and associated factors, to investigate how a medication optimization intervention influenced this change. Methods: The EQ-5D-3L was used at discharge and 1, 6 and 12 months after discharge during a randomized controlled trial including 285 participants. Multilevel logistic (EQ-5D-3L dimensions) and mixed model regression (EQ-5D-3L index scores, EQ-VAS) were used to explore the longitudinal change with/without the intervention, and associations with medications, comorbidities, and socioeconomic variables. Subgroup analyses were performed for non-long and long stayers with hospitalizations < or ≥ 14 days. Results: EQ-5D-3L index scores significantly declined after 12 months (β −0.06 [95% confidence interval (CI:) −0.10–−0.02], p = 0.003). Non-long stayers showed significant improvement 1 month from discharge (β 0.05 [0.00–0.09], p = 0.040). The number of medications and receiving home-care services were the main factors associated with reduced HRQoL. Being home-dwelling was the main factor associated with higher HRQoL. Non-long stayers of the intervention group reported significantly higher EQ-VAS than the control group (β 4.02 [0.11–7.93], p = 0.044). Conclusion: We observed no significant difference in the longitudinal change in HRQoL between the two IMMENSE study groups over 12 months after hospitalization. However, the non-long stayer subgroup analysis indicates that the intervention may have had a long-term effect on HRQoL in some of intervention patients. The number of medications and the ability to live and care for oneself should be taken into consideration when planning future patient care and health-care services. Trial registration: The trial was registered in clinicaltrials.gov on 28/06/2016 before enrolment started (NCT02816086).

Background: Inappropriate medication prescribing in older patients increases the risk of poorer health outcomes and increased costs. The IMMENSE trial, integrated a clinical pharmacist into the health care team, to improve medication therapy among older patients, and to investigate the impact on acute revisits to hospital. Objectives: This study investigated the prevalence of potentially inappropriate medications (PIMs) and prescribing omissions (PPOs) at hospital admission and discharge. It also explored the impact of the pharmacist intervention on PIMs and PPOs, and other factors associated with PIMs and PPOs at discharge. Design: The STOPP/START criteria version 2 were retrospectively applied at admission and discharge. PIM and PPO changes were compared, and Poisson regression was used to assess factors influencing prevalence at discharge. Results: At hospital admission, PIM prevalence was 58.6% among intervention patients and 64.8% among control patients. PPO prevalence was 55.3% and 55.5%, respectively. A larger proportion of PIMs identified at admission were resolved by discharge in the intervention group (42.9%) compared to the control group (27.4%). No difference was seen for PPOs. Poisson regression identified a significantly higher risk for PIMs at discharge in the control group compared to the intervention group (IRR 1.255; 95% CI 1.063–1.480, p = 0.007), but no effect for PPOs. Patients living in a nursing home, a home care facility, or an institution showed a higher risk of PPOs at discharge compared to patients living at home (IRR 1.378; 95% CI 1.156–1.644, p < 0.001). Conclusion: The IMMENSE intervention significantly reduced the risk of PIMs at discharge, with no effect on PPOs. Living in nursing homes, home care facilities, or institutions prior to hospitalization increased the risk of PPOs at discharge. Pharmacists may contribute to improved medication appropriateness in older hospitalized patients.

Background: Medication lists prepared in the emergency department (ED) form the basis for diagnosing and treating patients during hospitalization. Since incomplete medication information may lead to patient harm, it is crucial to obtain a correct and complete medication list at hospital admission. In this cross-sectional retrospective study we wanted to explore medication information completeness in admission notes from Norwegian EDs and investigate which factors were associated with level of completeness. Methods: Medication information was assessed for completeness by applying five evaluation criteria; generic name, formulation, dose, frequency, and indication for use. A medication completeness score in percent was calculated per medication, per admission note and per criterion. Quantile regression analysis was applied to investigate which variables were associated with medication information completeness. Results: Admission notes for patients admitted between October 2018 and September 2019 and using at least one medication were included. A total of 1,080 admission notes, containing 8,604 medication orders, were assessed. The individual medications had a mean medication completeness score of 88.1% (SD 16.4), while admission notes had a mean medication completeness score of 86.3% (SD 16.2). Over 90% of all individual medications had information about generic name, formulation, dose and frequency stated, while indication for use was only present in 60%. The use of an electronic tool to prepare medication information had a significantly strong positive association with completeness. Hospital visit within the last 30 days, the patient’s living situation, number of medications in use, and which hospital the patient was admitted to, were also associated with information completeness. Conclusions: Medication information completeness in admission notes was high, but potential for improvement regarding documentation of indication for use was identified. Applying an electronic tool when preparing admission notes in EDs seems crucial to safeguard completeness of medication information.

Background Older adults are at greater risk of medication-related harm than younger adults. The Integrated Medication Management model is an interdisciplinary method aiming to optimize medication therapy and improve patient outcomes. Objective We aimed to investigate the cost effectiveness of a medication optimization intervention compared to standard care in acutely hospitalized older adults. Methods A cost-utility analysis including 285 adults aged ≥ 70 years was carried out alongside the IMMENSE study. Quality-adjusted life years (QALYs) were derived using the EuroQol 5-Dimension 3-Level Health State Questionnaire (EQ-5D-3L). Patient-level data for healthcare use and costs were obtained from administrative registers, taking a healthcare perspective. The incremental cost-effectiveness ratio was estimated for a 12-month follow-up and compared to a societal willingness-to-pay range of €/QALY 27,067–81,200 (NOK 275,000–825,000). Because of a capacity issue in a primary care resulting in extended hospital stays, a subgroup analysis was carried out for non-long and long stayers with hospitalizations < 14 days or ≥ 14 days. Results Mean QALYs were 0.023 [95% confidence interval [CI] 0.022–0.025] higher and mean healthcare costs were €4429 [95% CI − 1101 to 11,926] higher for the intervention group in a full population analysis. This produced an incremental cost-effectiveness ratio of €192,565/QALY. For the subgroup analysis, mean QALYs were 0.067 [95% CI 0.066–0.070, n = 222] and − 0.101 [95% CI − 0.035 to 0.048, n = 63] for the intervention group in the non-long stayers and long stayers, respectively. Corresponding mean costs were €− 824 [95% CI − 3869 to 2066] and €1992 [95% CI − 17,964 to 18,811], respectively. The intervention dominated standard care for the non-long stayers with a probability of cost effectiveness of 93.1–99.2% for the whole willingness-to-pay range and 67.8% at a zero willingness to pay. Hospitalizations were the main cost driver, and readmissions contributed the most to the cost difference between the groups. Conclusions According to societal willingness-to-pay thresholds, the medication optimization intervention was not cost effective compared to standard care for the full population. The intervention dominated standard care for the non-long stayers, with a high probability of cost effectiveness. Clinical Trial Registration The IMMENSE trial was registered in ClinicalTrials.gov on 28 June, 2016 before enrolment started (NCT02816086).

Background Emergency department (ED) pharmacists reduce medication errors and improve quality of medication use. Patient perceptions and experiences with ED pharmacists have not been studied. The aim of this study was to explore patients’ perceptions of and experiences with medication-related activities in the ED, with and without an ED pharmacist present. Methods We conducted 24 semistructured individual interviews with patients admitted to one ED in Norway, 12 before and 12 during an intervention, where pharmacists performed medication-related tasks close to patients and in collaboration with ED staff. Interviews were transcribed and analysed applying thematic analysis. Results From our five developed themes, we identified that: (1) Our informants had low awareness and few expectations of the ED pharmacist, both with and without the pharmacist present. However, they were positive to the ED pharmacist. (2) Our informants expressed a variation of trust in the healthcare system, healthcare professionals and electronic systems, though the majority expressed a high level of trust. They believed that their medication list was automatically updated and assumed to get the correct medication. (3) Some informants felt responsible to have an overview of their medication use, while others expressed low interest in taking responsibility regarding their medication. (4) Some informants did not want involvement from healthcare professionals in medication administration, while others expressed no problems with giving up control. (5) Medication information was important for all informants to feel confident in medication use, but the need for information differed. Conclusion Despite being positive to pharmacists, it did not seem important to our informants who performed the medication-related tasks, as long as they received the help they needed. The degree of trust, responsibility, control and information varied among ED patients. These dimensions can be applied by healthcare professionals to tailor medication-related activities to patients’ individual needs.