Renata Vesela Holis

Background: Systematic reviews are critical for evidence-based decision-making but require significant manual effort during the screening stage, which is labor- intensive and prone to error. Active learning (AL)-assisted screening tools have emerged to address these challenges. However, guidance for using AL-assisted screen- ing in systematic reviews - especially those employing broad search strategies with heterogeneous results - is limited. This study aims to assess the effectiveness and reliability of AL-assisted screening for large, heterogeneous datasets. Specifically, it evaluates the comprehensiveness and necessity of the recommended SAFE proce- dure, examines the influence of different labeling strategies, and investigates whether AL-assisted screening can aid in reducing manual screening errors. Methods: Screening of four large, heterogeneous datasets from medication man- agement systematic reviews was simulated using ASReview. The datasets ranged from 3475 to 16218 records. For these datasets 0.08 to 1% of records were included in the final systematic review. Our simulations systematically varied all parameters defined by the SAFE procedure. Recall versus sampling behavior was analyzed, with a focus on the impact of parameter choices on retrieving records selected for full text inclusions and on reducing the number of records to be screened. Results: AL-assisted screening can effectively reduce the number of records to screen by almost 90% without increasing the risk of missing relevant records in com- parison to manual screening. For three of our datasets, the best performance (100% recall of full text includes and 89-90% reduction in the number of records to screen) is achieved when using the SAFE procedure in combination with the elas-u4 and elas-h3 models and full text labeling. This choice of parameters results in only 87% recall of full text includes for the remaining dataset (16218 records, 0.6% title/ab- stract includes, 0.08% full text includes). For this dataset, the best performance (100% recall, 90% screening reduction) is achieved when using the SAFE procedure with the simpler Naive Bayes model and TF-IDF feature extractor and title/abstract labeling. Conclusions: AL-assisted screening can safely and effectively reduce the workload needed to screen the large, heterogeneous datasets common in medication management systematic reviews. We recommend the modified SAFE procedure using full-text labels and the elas models. If the estimated ratio of full text includes is very low, it may be more appropriate to use the original SAFE procedure with title/abstract labeling.

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.

The emergency department (ED) is a demanding work environment where nurses undertake a variety of clinical and administrative tasks, including medication-related tasks. The integration of a clinical pharmacist into the ED team represents a complex intervention with potential implications for nurses’ distribution of work time, particularly concerning medication-related tasks. This study examined the distribution of work time among ED nurses and assessed the impact of a clinical pharmacist’s presence on this distribution, with an emphasis on medication-related work tasks. A direct observational time and motion study was conducted to evaluate the work time distribution of nurses in three Norwegian EDs, applying the Work Observation Method By Activity Timing (WOMBAT) methodology. Time distributions were measured for non-medication-related tasks, medication-related tasks, standby and movement, both in the absence and presence of a clinical pharmacist in the same ED. A total of 298 h of nursing work time were observed, comprising 138 h without pharmacists present and 160 h with pharmacists present. In the absence of a pharmacist, nurses spent 62.7% of their time on non-medication-related tasks, 34.7% on standby and movement, and 3.3% on medication-related tasks. The introduction of a clinical pharmacist did not significantly change the overall distribution of nurses’ work time, although some variations were noted across the EDs. ED nurses in three Norwegian EDs dedicated only 3.3% of their work time to medication-related tasks. The presence of clinical pharmacists did not substantially affect the distribution of nurses’ work time.

Background Length of stay (LOS) is an essential metric for hospital efficiency, patient outcomes and satisfaction. Studies indicate hospital pharmacy interventions positively affect LOS and other outcomes, yet results vary due to study differences. No systematic review or meta-analysis has been conducted on this topic; thus, the aim of this study is to systematically assess the effect of interventions on LOS. Methods This review will conduct a systematic search across MEDLINE, EMBASE, Cochrane Trials, Cochrane Reviews and the Cumulative Index to Nursing and Allied Health Literature to identify pertinent studies. An expert librarian will craft the search strategy, ensuring our review adheres to standard guidelines. We will use Covidence, a specialized systematic review management software, to optimize data management, the selection process and data extraction. A dedicated team of reviewers will independently evaluate titles and abstracts in duplicate, progressing to full-text examination of articles, to determine inclusion in our review and analysis. Data will be extracted by one reviewer, with independent data extraction by a second reviewer in a proportion of papers, and checking for consistency by a third. A template in Covidence will guide extraction of study, setting, participant, intervention and outcome characteristics and findings. The findings will be described narratively, and if possible given the methodological and statistical heterogeneity, meta-analysis will be undertaken. Discussion Considering the inconsistency of previous studies, this systematic review aims to clarify the potential impact of hospital pharmacy interventions on LOS. It will expand and reinforce existing knowledge, and provide detail about which intervention types have the most impact on LOS.

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.

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 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.

Introduction The ‘emergency department (ED) pharmacist’ is an integrated part of the ED interdisciplinary team in many countries, which have shown to improve medication safety and reduce costs related to hospitalisations. In Norway, few EDs are equipped with ED pharmacists, and research describing effects on patients has not been conducted. The aim of this study is to investigate the impact of introducing clinical pharmacists to the interdisciplinary ED team. In this multicentre study, the intervention will be pragmatically implemented in the regular operation of three EDs in Northern Norway; Tromsø, Bodø and Harstad. Clinical pharmacists will work as an integrated part of the ED team, providing pharmaceutical care services such as medication reconciliation, review and/or counselling. The primary endpoint is ‘time in hospital during 30 days after admission to the ED’, combining (1) time in ED, (2) time in hospital (if hospitalised) and (3) time in ED and/or hospital if re-hospitalised during 30 days after admission. Secondary endpoints include time to rehospitalisation, length of stay in ED and hospital and rehospitalisation and mortality rates. Methods and analysis We will apply a non-randomised stepped-wedge study design, where we in a staggered way implement the ED pharmacists in all three EDs after a 3, 6 and 9 months control period, respectively. We will include all patients going through the three EDs during the 12-month study period. Patient data will be collected retrospectively from national data registries, the hospital system and from patient records. Ethics and dissemination The Regional Committee for Medical and Health Research Ethics and Local Patient Protection Officers in all hospitals have approved the study. Patients will be informed about the ongoing study on a general basis with ads on posters and flyers. Trial registration number NCT04722588.