How much time do emergency department physicians spend on medication-related tasks? A time- and-motion study.

BACKGROUND: Medication-related problems are an important cause of emergency department (ED) visits, and medication errors are reported in up to 60% of ED patients. Procedures such as medication reconciliation and medication review can identify and prevent medication-related problems and medication errors. However, this work is often time-consuming. In EDs without pharmacists, medication reconciliation is the physician's responsibility, in addition to the primary assignments of examining and diagnosing the patient. The aim of this study was to identify how much time ED physicians spend on medication-related tasks when no pharmacists are present in the EDs. METHODS: An observational time-and-motion study of physicians in three EDs in Northern Norway was conducted using Work Observation Method by Activity Timing (WOMBAT) to collect and time-stamp data. Observations were conducted in predefined two-hour observation sessions with a 1:1 relationship between observer and participant, during Monday to Friday between 8 am and 8 pm, from November 2020 to October 2021. RESULTS: In total, 386 h of observations were collected during 225 observation sessions. A total of 8.7% of the physicians' work time was spent on medication-related tasks, of which most time was spent on oral communication about medications with other physicians (3.0%) and medication-related documentation (3.2%). Physicians spent 2.2 min per hour on medication reconciliation tasks, which includes retrieving medication-related information directly from the patient, reading/retrieving written medication-related information, and medication-related documentation. Physicians spent 85.6% of the observed time on non-medication-related clinical or administrative tasks, and the remaining time was spent standby or moving between tasks. CONCLUSION: In three Norwegian EDs, physicians spent 8.7% of their work time on medication-related tasks, and 85.6% on other clinical or administrative tasks. Physicians spent 2.2 min per hour on tasks related to medication reconciliation. We worry that patient safety related tasks in the EDs receive little attention. Allocating dedicated resources like pharmacists to contribute with medication-related tasks could benefit both physicians and patients.

First year junior doctors and medical uncertainty - a qualitative study. / LIS1-leger og medisinsk usikkerhet ­ en kvalitativ studie.

BACKGROUND: Few studies have investigated how doctors in Norway deal with medical uncertainty. The purpose of the study was to explore how first year junior doctors perceive and manage uncertainty in clinical practice. MATERIAL AND METHODS: Ten first year junior doctors at two hospitals in Norway were recruited for interviews following response pattern analysis from a mapping questionnaire. The interviews were analysed using systematic text condensation. RESULTS: The analysis revealed three main themes in the interviews: dealing with medical uncertainty, personal response to medical uncertainty, and working environment, feedback and preparation. Within all three thematic areas, the informants used the words 'certain/uncertain' and 'secure/insecure' interchangeably. INTEPRETATION: The first year junior doctors struggled with the inherent uncertainty of medicine and felt a marked sense of insecurity, particularly at the start of their training period. How the doctors were welcomed in the workplace and the feedback they were given were important factors. Their undergraduate medical education had not sufficiently prepared the first year junior doctors for how to deal with medical uncertainty in clinical practice.

Patient perceptions and experiences with medication-related activities in the emergency department: a qualitative study.

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.

Patient characteristics in sepsis-related deaths: prevalence of advanced frailty, comorbidity, and age in a Norwegian hospital trust.

OBJECTIVE: To examine the prevalence of advanced frailty, comorbidity, and age among sepsis-related deaths in an adult hospital population. METHODS: Retrospective chart reviews of deceased adults within a Norwegian hospital trust, with a diagnosis of infection, over 2 years (2018-2019). The likelihood of sepsis-related death was evaluated by clinicians as sepsis-related, possibly sepsis-related, or not sepsis-related. RESULTS: Of 633 hospital deaths, 179 (28%) were sepsis-related, and 136 (21%) were possibly sepsis-related. Among these 315 patients whose deaths were sepsis-related or possibly sepsis-related, close to three in four patients (73%) were either 85 years or older, living with severe frailty (Clinical Frailty Scale, CFS, score of 7 or more), or an end-stage condition prior to the admission. Among the remaining 27%, 15% were either 80-84 years old, living with frailty corresponding to a CFS score of 6, or severe comorbidity, defined as 5 points or more on the Charlson Comorbidity Index (CCI). The last 12% constituted the presumably healthiest cluster, but in this group as well, the majority died with limitations of care due to their premorbid functional status and/ or comorbidity. Findings remained stable if the population was limited to sepsis-related deaths on clinicians' reviews or those fulfilling the Sepsis-3 criteria. CONCLUSIONS: Advanced frailty, comorbidity, and age were predominant in hospital fatalities where infection contributed to death, with or without sepsis. This is of importance when considering sepsis-related mortality in similar populations, the applicability of study results to everyday clinical work, and future study designs.

Low-voltage electric shock - proposed new recommendations. / Strømgjennomgang fra lavspenning ­ forslag til nye anbefalinger.

We propose new recommendations for the emergency treatment of low-voltage electric injuries (<1 000 volts). A large proportion of these patients can be treated as outpatients.

Doctors educated in Bodø - who are they and where do they work? / Leger utdannet i Bodø ­ hvem er de og hvor blir de av?

BACKGROUND: Every year since 2009, up to 24 medical students at UiT The Arctic University of Norway have undertaken the last two years of their undergraduate medical education in Bodø (referred to as the Bodø model). We mapped the municipalities where the students had grown up, their preferences as to future specialties, where they worked and what they worked with after Part 1 of their specialist training. MATERIAL AND METHOD: Medical students who graduated from the Bodø model in the period 2012-18 completed a questionnaire in the first week of their sixth year of study, containing questions about where they had grown up and their preferences for future place of work and specialty. We mapped their place of work and specialty as of January 2021 as well as that of the two cohorts graduating in 2010-11. The place where the latter had grown up was mapped via direct contact, contact with their cohort or open internet sources. The covariation between where they grew up and their place of work, specialty preferences and choice of specialty were analysed using chi-square tests and logistic regression. RESULTS: Out of a total of 146 doctors, 91 of whom were women (62.3 %), who had completed their undergraduate medical education under the Bodø model as well as Part 1 of their specialist training, 40 (27.4 %) had grown up in Bodø municipality and for 56 (38.4 %) this was their place of work. For the remainder of the county of Nordland, the corresponding figures were 54 (37.0 %) and 38 (26.0 %), for Troms og Finnmark 23 (15.8) and 19 (13 %) and for the remainder of Norway 29 (19.9 %) and 33 (22.6 %). A total of 51 (34.9 %) worked as GPs, of whom 34 (66.7 %) worked in rural municipalities. There was a higher probability of working in a rural area if the doctor had grown up in a rural community (odds ratio (OR) 3.0 (95 % CI 1.5 to 6.1)) and of working in general medicine if this had been their preference as a student (OR 3.7 (95 % CI 1.8 to 7.6)). INTERPRETATION: The Bodø model has mainly attracted students with an affiliation to the region. At the time of the survey, a large percentage of the graduates who took part of their undergraduate medical education in Bodø worked at the Nordland Hospital in Bodø and in general practice, particularly in rural municipalities.

Patients with low-voltage electric shock referred to an Emergency Department. / Pasienter med strømgjennomgang fra lavspenning henvist til et akuttmottak.

BACKGROUND: Patients exposed to electricity are often referred to the Emergency Department, but guidelines differ as to how they should be managed. In this article, we describe patients with low-voltage electric shock in the Emergency Department at St Olav's Hospital, Trondheim University Hospital. MATERIAL AND METHOD: Retrospective data from patients referred to the Emergency Department following low-voltage electric shock (< 1,000 V) in the period 1.1.2012-31.12.2017 (N = 210) were included. RESULTS: The median age was 26 years and 186/210 (89 %) were men. Out of the 210 patients, 165 (79 %) had symptoms following electric shock. Localised pain and chest discomfort occurred in 84/165 (51 %) and 57/165 (35 %) of patients respectively. ECG findings were normal in 168/209 (80 %), and no patients had arrhythmias requiring treatment or elevated troponin T or creatine kinase. No patients had serious complications or died. INTERPRETATION: Low-voltage electric shock did not cause serious arrhythmias or elevated levels of troponin T or creatine kinase. It should be possible to manage asymptomatic patients with normal findings on clinical examination and ECG in a prehospital setting without reducing patient safety.

Integrating the clinical pharmacist into the emergency department interdisciplinary team: a study protocol for a multicentre trial applying a non-randomised stepped-wedge study design.

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.

Threshold concepts in group-based mentoring and implications for faculty development: A qualitative analysis.

INTRODUCTION: The literature on faculty development programs for mentors is scarce. This study examines mentors' experiences and challenges, with the aim of identifying threshold concepts in mentoring. It also discusses the implications for the faculty development of mentors. METHODS: Semi-structured interviews solicited personal narratives and reflections on mentors' lived experiences. Data analysis was guided by the threshold concepts framework allowing for the identification of significant and transformative shifts in perspectives. RESULTS: We interviewed 22 mentors from two Norwegian and one Canadian medical school with group-based mentoring programs. The mentoring experience involved four significant threshold concepts: focusing on students' needs; the importance of creating a trusting learning space; seeing oneself through the eyes of students; and aligning mentor and physician identities. CONCLUSION: Taking on a mentor role can provoke personal and professional dilemmas while also sparking growth. The trajectories of developing as a mentor and as a professional physician may be seen to mutually validate, mirror and reinforce each other. Faculty development programs designed specifically for mentors should aim to stimulate reflection on previous learning experiences and strive for a successful alignment of the distinct pedagogical and clinical content knowledge required to fulfill various professional roles.

Patient with severe COVID-19 treated with corticosteroids. / Pasient med alvorlig covid-19 behandlet med steroider.

BACKGROUND: Treatment with corticosteroids for COVID-19 and ARDS (acute respiratory distress syndrome) is controversial and has generally not been recommended. CASE PRESENTATION: A woman in her sixties was admitted to hospital after ten days of flu-like symptoms. She was confirmed as Sars-CoV-2-positive and experienced a steady decrease in oxygen saturation (SaO2), despite being given increasing amounts of supplemental oxygen. On day three she was intubated and placed on a ventilator. She had a three-phased trajectory where ventilation was extremely challenging, prone positioning and permissive hypercapnia were necessary, and inflammation markers increased. There was no improvement in the third phase, and on day 19 on the ventilator, we decided to give her corticosteroids. Two days later she could be weaned from the ventilator. INTERPRETATION: In our patient with severe ARDS from COVID-19, we saw rapid improvement after she was given corticosteroids, and her case is a contribution to the discussion regarding use of corticosteroids for the most severely ill COVID-19 patients.

Clinical decisions presented to patients in hospital encounters: a cross-sectional study using a novel taxonomy.

OBJECTIVE: To identify and classify all clinical decisions that emerged in a sample of patient-physician encounters and compare different categories of decisions across clinical settings and personal characteristics. DESIGN: Cross-sectional descriptive evaluation of hospital encounters videotaped in 2007-2008 using a novel taxonomy to identify and classify clinically relevant decisions (both actions and judgements). PARTICIPANTS AND SETTING: 372 patients and 58 physicians from 17 clinical specialties in ward round (WR), emergency room (ER) and outpatient (OP) encounters in a Norwegian university hospital. RESULTS: The 372 encounters contained 4976 clinically relevant decisions. The average number of decisions per encounter was 13.4 (min-max 2-40, SD 6.8). The overall distribution of the 10 topical categories in all encounters was: defining problem: 30%, evaluating test result: 17%, drug related: 13%, gathering additional information: 10%, contact related: 10%, advice and precaution: 8%, therapeutic procedure related: 5%, deferment: 4%, legal and insurance related: 2% and treatment goal: 1%. Across three temporal categories, the distribution of decisions was 71% here-and-now, 16% preformed and 13% conditional. On average, there were 15.7 decisions per encounter in internal medicine specialties, 7.1 in ear-nose-throat encounters and 11.0-13.6 in the remaining specialties. WR encounters contained significantly more drug-related decisions than OP encounters (P=0.031) and preformed decisions than ER and OP encounters (P<0.001). ER encounters contained significantly more gathering additional information decisions than OP and WR encounters (P<0.001) and fewer problem defining decisions than WR encounters (P=0.028). There was no significant difference in the average number of decisions related to the physician's and patient's age or gender. CONCLUSIONS: Patient-physician encounters contain a larger number of clinically relevant decisions than described in previous studies. Comprehensive descriptions of how decisions, both as judgements and actions, are communicated in medical encounters may serve as a first step in assessing clinical practice with respect to efficiency and quality on a provider or system level.

Eliciting patient preferences in shared decision-making (SDM): Comparing conversation analysis and SDM measurements.

OBJECTIVE: To explore how physicians bring up patient preferences, and how it aligns with assessments of shared decision-making. METHODS: Qualitative conversation analysis of physicians formulating hypotheses about the patient's treatment preference was compared with quantitative scores on SDM and 'patient preferences' using OPTION(5) and MAPPIN'SDM. RESULTS: Physicians occasionally formulate hypotheses about patients' preferences and then present a treatment option on the basis of that ("if you think X+we can do Y"). This practice may promote SDM in that the decisions are treated as contingent on patient preferences. However, the way these hypotheses are formulated, simultaneously constrains the patient's freedom of choice and exerts a pressure to accept the physician's recommendation. These opposing effects may in part explain cases where different assessment instruments yield large variations in SDM measures. CONCLUSION: Eliciting patient preferences is a complex phenomenon that can be difficult to reduce into an accurate number. Detailed analysis can shed light on how patient preferences are elicited, and its consequences for patient involvement. Comparing CA and SDM measurements can contribute to specifying communicative actions that SDM scores are based on. PRACTICE IMPLICATIONS: Our findings have implications for SDM communication skills training and further development of SDM measurements.

Confusion in and about shared decision making in hospital outpatient encounters.

OBJECTIVE: To explore how physician efforts to involve patients in medical decisions align with established core elements of shared decision making (SDM). METHODS: Detailed video analysis of two hospital outpatient encounters, selected because the physicians exhibited much effort to involve the patients in decision making, and because the final decisions were not what the physicians had initially recommended. The analysis was supplied by physician, patient, and observer-rated data from a total of 497 encounters collected during the same original study. The observer-rated data confirmed that these physicians demonstrated above average patient-centred skills in this material. RESULTS: Behaviours of these two not trained physicians demonstrated confusion about how to perform SDM. Information provided to the patients was imprecise and ambiguous. Insufficient patient involvement did not prompt the physicians to change strategy. Physician and patient reports indicated awareness of suboptimal communication. CONCLUSION: Inadequate SDM in hospital encounters may introduce confusion. Quantitative evaluations by patients and observers may reflect much effort rather than process quality. PRACTICE IMPLICATIONS: SDM may be discredited because the medical community has not acquired the necessary skills to perform it, even if it is ethically and legally mandated. Training and supervision should follow regulations and guidelines.