Pharmacist-Physician Communications in a Highly Computerised Hospital: Sign-Off and Action of Electronic Review Messages

A National Modified Delphi Consensus Process to Prioritize Experiences and Interventions for Antipsychotic Medication Deprescribing Among Adult Patients With Critical Illness

Antipsychotic medications are frequently prescribed to critically ill patients leading to their continuation at transitions of care thereafter. The aim of this study was to generate evidence-informed consensus statements with key stakeholders on antipsychotic minimization and deprescribing for ICU patients.

DESIGN

We completed three rounds of surveys in a National modified Delphi consensus process. During rounds 1 and 2, participants used a 9-point Likert scale (1-strongly disagree, 9-strongly agree) to rate perceptions related to antipsychotic prescribing (i.e., experiences regarding delivery of patient care), knowledge and frequency of antipsychotic use, knowledge surrounding antipsychotic guideline recommendations, and strategies (i.e., interventions addressing current antipsychotic prescribing practices) for antipsychotic minimization and deprescribing. Consensus was defined as a median score of 1-3 or 7-9. During round 3, participants ranked statements on antipsychotic minimization and deprescribing strategies that achieved consensus (median score 7-9) using a weighted ranking scale (0-100 points) to determine priority.

SETTING

Online surveys distributed across Canada.

SUBJECTS

Fifty-seven stakeholders (physicians, nurses, pharmacists) who work with ICU patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Participants prioritized six consensus statements on strategies for consideration when developing and implementing interventions to guide antipsychotic minimization and deprescribing. Statements focused on limiting antipsychotic prescribing to patients: 1) with hyperactive delirium, 2) at risk to themselves, their family, and/or staff due to agitation, and 3) whose care and treatment are being impacted due to agitation or delirium, and prioritizing 4) communication among staff about antipsychotic effectiveness, 5) direct and efficient communication tools on antipsychotic deprescribing at transitions of care, and 6) medication reconciliation at transitions of care.

CONCLUSIONS

We engaged diverse stakeholders to generate evidence-informed consensus statements regarding antipsychotic prescribing perceptions and practices that can be used to implement interventions to promote antipsychotic minimization and deprescribing strategies for ICU patients with and following critical illness.

Factors affecting physician implementation of hospital pharmacists' medication appropriateness recommendations in older adults

AIMS

Non-implementation of pharmacist recommendations by physician prescribers may prolong potentially inappropriate prescribing in hospitalised older adults, increasing the risk of adverse clinical outcomes. The aim of this study was to ascertain the key factors affecting physician prescriber implementation of pharmacists' medication appropriateness recommendations in hospitalised older adults.

METHODS

Semi-structured interviews were conducted with hospital pharmacists and physicians who provided care to older adults (≥65 years) in 2 acute university teaching hospitals in Ireland. Content analysis was employed to identify the key themes that influence physician prescriber implementation of pharmacist recommendations.

RESULTS

Fourteen interviews were conducted with 6 hospital pharmacists and 8 hospital physicians between August 2018 and August 2019. Five key factors were found to affect physician implementation of pharmacist recommendations: (i) the clinical relevance and complexity of the recommendation-recommendations of higher priority and those that do not require complex decision-making are implemented more readily; (ii) interprofessional communication-recommendations provided verbally, particularly those communicated face to face with confidence and assertion, are more likely to be implemented than written recommendations; (iii) physician role and identity-the grade, specialty, and personality of the physician significantly affect implementation; (iv) knowing each other and developing trusting relationships-personal acquaintance and the development of interprofessional trust and rapport greatly facilitate recommendation implementation; and (v) the hospital environment-organisational issues such as documentation in the patient notes, having the opportunity to intervene, and the clinical pharmacy model all affect implementation.

CONCLUSION

This study provides a deeper understanding of the underlying behavioural determinants affecting physician prescriber implementation of pharmacist recommendations and will aid in the development of theoretically-informed interventions to improve medication appropriateness in hospitalised older adults.

Using electronic patient records: defining learning outcomes for undergraduate education

BACKGROUND

Healthcare professionals are required to access, interpret and generate patient data in the digital environment, and use this information to deliver and optimise patient care. Healthcare students are rarely exposed to the technology, or given the opportunity to use this during their training, which can impact on the digital competence of the graduating workforce. In this study we set out to develop and define domains of competence and associated learning outcomes needed by healthcare graduates to commence working in a digital healthcare environment.

METHOD

A National Working Group was established in the UK to integrate Electronic Patient Records (EPRs) into undergraduate education for healthcare students studying medicine, pharmacy, nursing and midwifery. The working group, comprising 12 academic institutions and representatives from NHS England, NHS Digital and EPR system providers, met to discuss and document key learning outcomes required for using EPRs in the healthcare environment. Outcomes were grouped into six key domains and refined by the group prior to external review by experts working in medical education or with EPRs.

RESULTS

Six key domains of competence and associated learning outcomes were identified and defined. External expert review provided iterative refinement and amendment. The agreed domains were: 1) Digital Health: work as a practitioner in the digital healthcare environment; 2) Accessing Data: access and interpret patient data to inform clinical decision-making; 3) Communication: communicate effectively with healthcare professionals and patients in the digital environment; 4) Generating data: generate data for and about patients within the EPR; 5) Multidisciplinary working: work with healthcare professionals with and alongside EPRs; and 6) Monitoring and audit: monitor and improve the quality and safety of healthcare.

CONCLUSION

The six domains of competence and associated learning outcomes can be used by academics to guide the integration of EPRs into undergraduate healthcare programmes. This is key to ensuring that the future healthcare workforce can work with and alongside EPRs.

The impact of computerised physician order entry and clinical decision support on pharmacist-physician communication in the hospital setting: A qualitative study

BACKGROUND

The implementation of Computerised Physician Order Entry (CPOE) and Clinical Decision Support (CDS) has been found to have some unintended consequences. The aim of this study is to explore pharmacists and physicians perceptions of their interprofessional communication in the context of the technology and whether electronic messaging and CDS has an impact on this.

METHOD

This qualitative study was conducted in two acute hospitals: the University Hospitals Birmingham NHS Foundation Trust (UHBFT) and Guy's and St Thomas' NHS Foundation Trust (GSTH). UHBFT use an established locally developed CPOE system that can facilitate pharmacist-physician communication with the ability to assign a message directly to an electronic prescription. In contrast, GSTH use a more recently implemented commercial system where such communication is not possible. Focus groups were conducted with pharmacists and physicians of varying grades at both hospitals. Focus group data were transcribed and analysed thematically using deductive and inductive approaches, facilitated by NVivo 10.

RESULTS

Three prominent themes emerged during the study: increased communication load; impaired decision-making; and improved workflow. CPOE and CDS were found to increase the communication load for the pharmacist owing to a reduced ability to amend electronic prescriptions, new types of prescribing errors, and the provision of technical advice relating to the use of the system. Decision-making was found to be affected, owing to the difficulties faced by pharmacists and physicians when trying to determine the context of prescribing decisions and knowledge of the patient. The capability to communicate electronically facilitated a non-interruptive workflow, which was found to be beneficial for staff time, coordination of work and for limiting distractions.

CONCLUSION

The increased communication load for the pharmacist, and consequent workload for the physician, has the potential to impact on the quality and coordination of care in the hospital setting. The ability to communicate electronically has some benefits, but functions need to be designed to facilitate collaborative working, and for this to be optimised through interprofessional training.

Implementation of patient-centered prescription labeling in a safety-net ambulatory care network

PURPOSE

An initiative to implement patient-centered medication labeling at 4 pharmacies within a publicly funded safety-net healthcare system is described.

SUMMARY

Medication nonadherence negatively affects patient outcomes and safety. Nonadherence has been attributed to poor understanding of instructions on medication labels. Research has demonstrated that patient-centered labeling (PCL) can improve adherence and produce safer medication-taking practices. As part of a mixed-methods study by a safety-net health system, audits of nearly 9,000 prescription labels generated at 4 pharmacy sites, as well as interviews with 6 stakeholder informants, were conducted to determine PCL adoption rates and factors contributing to success. Descriptive statistics were used to analyze audit data; constructs of the Consolidated Framework for Implementation Research were used to analyze interview data. Among the 4 sites, 3 pharmacies successfully converted more than 85% of audited prescriptions to a PCL format; 1 pharmacy converted less than 25% of prescriptions. Barriers to implementation included pharmacists' reluctance to modify prescriber instructions and inadequate real-time data on conversion rates. Interviewees perceived that leadership and policy directives promoted PCL conversion efforts. Successful pharmacies used adaptable software, had closer communication networks with prescribers, and/or used automation to facilitate PCL conversion.

CONCLUSION

Three pharmacies successfully converted more than 85% of labels for audited prescriptions to a PCL format; 1 pharmacy converted less than 25% of prescriptions. Barriers to implementation included pharmacists' reluctance to modify prescriber instructions, inadequate real-time data on conversation rates, and lack of customizable software to automate changes.

What is involved in medicines management across care boundaries? A qualitative study of healthcare practitioners' experiences in the case of acute kidney injury

OBJECTIVES

To examine the role of individual and collective cognitive work in managing medicines for acute kidney injury (AKI), this being an example of a clinical scenario that crosses the boundaries of care organisations and specialties.

DESIGN

Qualitative design, informed by a realist perspective and using semistructured interviews as the data source. The data were analysed using template analysis.

SETTING

Primary, secondary and intermediate care in England.

PARTICIPANTS

12 General practitioners, 10 community pharmacists, 7 hospital doctors and 7 hospital pharmacists, all with experience of involvement in preventing or treating AKI.

RESULTS

We identified three main themes concerning participants' experiences of managing medicines in AKI. In the first theme, challenges arising from the clinical context, AKI is identified as a technically complex condition to identify and treat, often requiring judgements to be made about renal functioning against the context of the patient's general well-being. In the second theme, challenges arising from the organisational context, the crossing of professional and organisational boundaries is seen to introduce problems for the coordination of clinical activities, for example by disrupting information flows. In the third theme, meeting the challenges, participants identify ways in which they overcome the challenges they face in order to ensure effective medicines management, for example by adapting their work practices and tools.

CONCLUSIONS

These themes indicate the critical role of cognitive work on the part of healthcare practitioners, as individuals and as teams, in ensuring effective medicines management during AKI. Our findings suggest that the capabilities underlying this work, for example decision-making, communication and team coordination, should be the focus of training and work design interventions to improve medicines management for AKI or for other conditions.