The challenge of involving old patients with polypharmacy in their medication during hospitalization in a medical emergency department: An ethnographic study.

Pia Keinicke Fabricius,Ove Andersen,Jeanette Wassar Kirk,Karina Dahl Steffensen,Adam Todd

doi:10.1371/journal.pone.0261525

Abstract

More than 70% of patients admitted to emergency departments (EDs) in Denmark are older patients with multimorbidity and polypharmacy vulnerable to adverse events and poor outcomes. Research suggests that patient involvement and shared decision-making (SDM) could optimize the treatment of older patients with polypharmacy. The patients become more aware of potential outcomes and, therefore, often tend to choose less medication. However, implementing SDM in clinical practice is challenging if it does not fit into existing workflows and healthcare systems. The aim was to explore the determinants of patient involvement in decisions made in the ED about the patient's medication. The design was a qualitative ethnographic study. We observed forty-eight multidisciplinary healthcare professionals in two medical EDs focusing on medication processes and patient involvement in medication. Based on field notes, we developed a semi-structured interview guide. We conducted 20 semi-structured interviews with healthcare professionals to elaborate on the findings. Data were analyzed with thematic analyses. We found five themes (determinants) which affected patient involvement in decisions about medicine in the ED: 1) blurred roles among multidisciplinary healthcare professionals, 2) older patients with polypharmacy increase complexity, 3) time pressure, 4) faulty IT- systems, and 5) the medicine list as a missed enabler of patient involvement. There are several barriers to patient involvement in decisions about medicine in the ED and some facilitators. A tailored medication conversation guide based on the SDM methodology combined with the patient's printed medicine list and well-functioning IT- systems can function as a boundary object, ensuring the treatment is optimized and aligned with the patient's preferences and goals.

Highlights

The prevalence of patients with polypharmacy is set to rise as the population ages and more people suffer from multiple long-term conditions taking numerous medicines
A tailored medication conversation guide based on the shared decision-making (SDM) methodology combined with the patient’s printed medicine list and well-functioning IT- systems can function as a boundary object, ensuring the treatment is optimized and aligned with the patient’s preferences and goals
The observations and interviews revealed that managing medication to- and communication with the patients in the medical emergency departments (EDs) is a fragmented process involving various healthcare professionals, medical specialties, time pressure, and faulty IT- systems, which influence patient involvement in medication decisions and may impede medication optimization

Summary

Introduction

The prevalence of patients with polypharmacy is set to rise as the population ages and more people suffer from multiple long-term conditions taking numerous medicines. More than 1,000,000 out of 1,300,000 yearly hospital admissions in Denmark are acute admissions in emergency departments (EDs), and more than 70% of these admissions are older patients (65 + years) with comorbidity conditions and polypharmacy [3, 4], defined as taking five or more medications [5]. There has been an increasing focus on dealing with patients with polypharmacy, as treatment is getting more and more complex [1] This complexity is seen inside hospitals, where historically, the medication process has been a simple task performed mainly by physicians and nurses [7], but in recent years, more healthcare professionals with different roles and responsibilities for medication have been introduced into hospitals; e.g., pharmacists have been introduced into ED departments to optimize rational use of medication, and ensure patient safety [8]. Implementing SDM in clinical practice is challenging if it does not fit into existing workflows and healthcare systems

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