Seven pharmacists (all female, mean age 35.4 years (range 29–42)) were observed and six were interviewed (F1-6). Three of the pharmacists had less than two years’ experience working in the hospital (F1, F5 and F7). Six of them worked one day per week at the Emergency Department and every eighth weekend, whereas one worked there on a less regular basis.
The interviews and observations were carried out on nine separate whole days from March 29 to May 5, 2021. The observations lasted at least one whole workday for each of the seven pharmacists.
The observations showed firstly, that changes implemented, according to the wishes of the ward management, affected the study. Secondly, there were some notable differences between pharmacists that could be linked to their clinical experience.
Changes in procedures
A few days prior to the initiation of the study, a change in workflow was instated at the Emergency Department. The ward leadership wished to put a higher focus on medication histories rather than thorough medication reviews, and that medication lists were prepared for doctors’ approval in the EHR. The management from the Capital Region of Denmark's Pharmacy at Nordsjællands Hospital therefore set up a group to investigate how this could be implemented. This resulted in a Plan-Do-Study-Act process (PDSA) which was initiated in early February 2021. Patients were to be selected according to three prioritization criteria. The pharmacists should 1) ensure that all patients had their medication entered in the EHR; 2) then prioritize patients according to length of stay. When all patients had their medication entered, the pharmacist could turn their attention to other patients where it was believed a medication review would be beneficial. 3) Regardless of these two criteria, referrals from a physician for a medication review were to be prioritized first.
(insert Fig. 1)
The PDSA went through two rounds during the observation period (Fig. 1). During the first round, all patients were to undergo a medication history assessment and medication review. However, due to the fact that there was only one pharmacist on call, it was not always possible to assess medicines of all admitted patients. During the second round, several exclusion criteria were added such as: patients with deep venous thrombosis (DVT) or anaemia, since these patients would likely be discharged quickly, and patients who only used 1–2 medications. After completion of the study, the PDSA went through further rounds in order to optimize workflow.
Pharmacists’ work experience in relation to prioritization decisions and workflow
One key observation during this study was the difference in workflow and prioritization of patients according to the pharmacists’ clinical experience.
Pharmacists with less experience (less than two years of clinical hospital experience) worked in the following way: Sorting patients by length of stay, and selecting those where medications had not been entered into the EHR. In contrast, experienced pharmacists (two or more years of clinical hospital experience) worked in the following way: The patients' length of stay was noted and used to prioritize the patients. The reason for admission was noted for each patient and whether the medications had been added to the EHR or not. If medications had been added to the EHR, the pharmacist would then critically evaluate if a medication review should be carried out based on the medication list in the EHR and the shared medication record (a prescription records system covering all of Denmark). With the notes from the morning conference in mind, they decided which patients to prioritize.
In addition, most pharmacists with less clinical experience used the medication list in the EHR and not in the shared medication record to check whether the usual medication had been added or not. This could potentially be misleading as some patients upon admission were prescribed medication for their acute condition without transferring the usual medication list (as apparent in the shared medication record) to the EHR. The observations generally showed that the prioritization guidelines were only used as a rough guidance, although less experienced pharmacists followed them more closely than their more experienced colleagues.
The interviews were held for the most part on the same day as each pharmacist was observed. One pharmacist was interviewed the following day. The interviews shed light on what kinds of considerations pharmacists went through when prioritizing patients, how they used the ground rules (as set out in the PDSA process), their collaboration with physicians, and how pharmacists could better contribute to the ward team.
Factors to focus on when prioritizing patients
Pharmacists have complex considerations when prioritizing patients during their workday at the Emergency Department. They all agreed that not all medications are important when scanning a patient’s medication list. Missing a few regular doses of preventive medications for patients during their stay at the ward could for instance, be viewed lightly as the patients would soon be discharged from the ward.
Whether it is a simvastatin or losartan or something like that, I am a bit more, like oh well (…) I am a bit more laid back about that. But of course, they need their medication, however [for these drugs], they won’t die from missing a single dose. (F2)
The seven risk-situation medications were mentioned, but not found to be enough help. Conversely, the whole medication list, looking for interactions, and evaluating the appropriateness of dosages were more important to consider. Age of the patient was not always relevant, but the number of medications and the reason for admittance could be important factors.
They [elderly patients] use more medications than the younger patients. But sometimes the younger patients are also important since a few [in this patient group] might also be using a lot of medications, even though they are young. (F3)
So I think it is important [to do a medication review] where there is a fair number of medications – and it doesn’t have to be a lot [of medicines], because there could be an interaction that we need to address. It could also be a decreased kidney function where we need to look at the dosages. Or that there is some medication that actually caused the admission or the general diagnosis. Is there some sort of a [prescribing] cascade? (F5)
Views on the implemented guidelines (PDSA)
The interviews also shed light on how the pharmacists viewed the guidelines implemented during the observation period and how they chose to work with these or around them. They saw both positive and negative aspects. On the positive side, they felt that they became more efficient due to the PDSA process; that they reviewed a higher number of patient charts per shift and identified a higher number of appropriate patients.
I feel like I am covering more, which means that I am getting more done. Which also means that there might be a higher percentage [of patients reviewed] who aren’t important, but I also think that I am catching more relevant [cases], where I might [before] have said “Well, we’ll wait and see [before performing a review]. (F2)
The negative aspects were that pharmacists feared that the focus on the longest stays and entering medicines into the EHR made for a more haphazard selection of patients. This could make them miss patients in great need of pharmaceutical care.
But I think it’s a bit due to chance that I catch them [patients in need of a medication review]. So it all comes down to when you [the patient] enter [the Emergency Department]. It is left up to the time factor [to prioritize]. (F5)
In principle we just have to note if they [the patients] have had their medication entered [into the EHR] and [if they have] you aren’t supposed to look any more at the patient. (…) I can’t help it, because sometimes I think there is something problematic, that I spot right away [and need to act upon]. (F6)
When the pharmacists talked about the PDSA and guidelines, it was clear that they felt that their clinical experience and use of pharmaceutical competencies were undervalued. Most of the pharmacists uttered that this process did not utilize the competencies of the pharmacists optimally and that they as professionals would be more valuable in direct patient care.
I just don’t think that our focus with the doctors should be that we can enter the medication [into the EHR]. I think we need to show that “We are pharmacists. We are specialists within the pharmaceutical treatment”. So we are able to do something else than this. (F6)
This indicated that the pharmacists felt that they were viewed more as technical staff than professionals who have clinical skills.
Collaboration with physicians
All respondents talked about how they see their collaboration with physicians at the Emergency Department. Firstly, how being situated close to physicians facilitates the collaboration and how they wish to have more referrals from physicians. They related to how the Covid-19 pandemic had removed morning briefings and the location of the pharmacists within the department was changed so they did not sit with the physicians anymore.
I was used to have a lot more [contact with the physicians] when I was sitting next to them compared to now (…). And I felt more like a part of the team [then] than now (…) Also, during Covid-19 this [contact with the physicians] has been lost, the morning briefing, and then you are a bit lost [in regards to prioritizing patients]. And now I still think we [pharmacists] are lost [when not sitting in close proximity to physicians], because you don’t know if the patients are about to be discharged. (F6)
Secondly, many pharmacists mentioned how a better collaboration between physicians and pharmacists on prioritization of patients could improve both the workflow and the impact of medication reviews. Getting referrals from physicians about patients to review had the benefits of providing the pharmacists with more clinically relevant cases and led to a higher rate of acceptance of recommended changes to the patient’s medications.
I wish that we [physicians and pharmacists in collaboration] were a bit better at prioritizing patients together – what is it we want to look at? So, in the ideal world, the referrals would always be prioritized first [because they always are important for medication review]. (F5)
Ideas for improvements – using and developing clinical competencies
The pharmacists had ideas for improving their prioritization and work with patients needing a medication review. The ideas reflected that, although they had a quantitative sense that they were more efficient, they were still not satisfied with the PDSA criteria set out for their work at the Emergency Department. Especially the longest stay criterion was criticized for not being useful.
I don’t think we should prioritize based on the length of stay. I think you need to assess which [individual] patients are important. Thereby obtaining tools to help defining “this is an important patient; this isn’t an important patient. (F6)
Another dissatisfaction among pharmacists was that they felt they were not allocated to the most appropriate patient groups within the Emergency Department. Being a department with several specialties, the pharmacists primarily worked with the acute medicine specialty. This specialty has a high turnover rate and patients are often discharged after a short stay. Therefore, the pharmacists’ medication review would not always be ready before the patient was discharged.
Another important improvement they note is that each pharmacist should work more frequently at the Emergency Department. Being there only once per week hampers them in getting a routine and competencies in working with acutely admitted patients and belonging to the ward team. They stated that it takes some time to become professionally strong and experienced in this type of setting. In relation to this improvement idea, they talked about how much they could benefit from being more than one pharmacist at the time on the ward in order to get the professional sparring in their medication reviews. Some also suggested that pharmacists at the hospital or across the region should exchange experience and knowledge better than what was currently the case.
… There is so much knowledge and learning potential in each other’s way of working which we don’t really obtain (F5)
Lastly, the pharmacists talked about how the “clinical insight” of the pharmacist needed to come more into play. This would aid them in identifying patients more effectively using the medication lists and the EHR information.
So eventually, it’s just experience, it’s just something you know instinctively. “IS there something here [in the medication list]? There is just something strange here [in the medication list]”. Or… not that I can remember exactly what it is, but there is just something that tells me that I need to look into this patient. (F3)