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Summary Objectives Effective and efficient communication is crucial in healthcare. Written communication remains the most prevalent form of communication between specialised and primary care. We aimed at reviewing the literature on the quality of written communication, the impact of communication inefficiencies and recommendations to improve written communication in healthcare. Design Narrative literature review. Methods A search was carried out on the databases PubMed, Web of Science and The Cochrane Library by means of the (MeSH)terms ‘communication’, ‘primary health care’, ‘correspondence’, ‘patient safety’, ‘patient handoff’ and ‘continuity of patient care’. Reviewers screened 4609 records and 462 full texts were checked according following inclusion criteria: (1) publication between January 1985 and March 2014, (2) availability as full text in English, (3) categorisation as original research, reviews, meta‐analyses or letters to the editor. Results A total of 69 articles were included in this review. It was found that poor communication can lead to various negative outcomes: discontinuity of care, compromise of patient safety, patient dissatisfaction and inefficient use of valuable resources, both in unnecessary investigations and physician worktime as well as economic consequences. Conclusion There is room for improvement of both content and timeliness of written communication. The delineation of ownership of the communication process should be clear. Peer review, process indicators and follow‐up tools are required to measure the impact of quality improvement initiatives. Communication between caregivers should feature more prominently in graduate and postgraduate training, to become engraved as an essential skill and quality characteristic of each caregiver.

Purpose: The aim of this study was to prospectively evaluate drug interactions and adverse drug reactions (ADRs) in the older patients admitted to the emergency department (ED) and to characterize risk factors. Methods: In 80 patients aged 65 years and older medication history and ED drug administration were analysed. Medical records were analysed for ADRs by an expert panel which also evaluated their avoidability and causality. An interaction program was used to search for potential drug interactions followed by assessment for clinical significance. Data were analysed using a logistic regression model. The significance level was set at α = 0.05. Results: Eighty seven ADRs were identified in 37 patients; 18 were the result of an interaction (15 patients). Causality was assessed as definite (n = 1), probable (n = 62) and possible (n = 24). The reason for admission was definitely and probably related to an ADR in 6 and 18 patients respectively. Only 17 (20%) of the ADRs were assessed as unavoidable, while 23 (26%) and 47 (54%) were classified as definitely and possibly avoidable, respectively. ADRs were related with female gender (p = 0.023) and number of drugs (p = 0.004), but not with high age (p = 0.151). Clinically relevant interactions were related with older age (p = 0.032) and number of drugs (p = 0.003), but not with gender (p = 0.380). None of the interactions with ED initiated medications were considered unjustified. Conclusions: ADRs frequently occur in the older patients admitted to the ED and are an important cause of hospital admissions with a substantial contribution of adverse drug interactions.

Introduction: In many countries out of hours (OOH) care is offered by different health care services. General practitioners (GP) tend to offer services in competition with emergency departments (ED). Patients behaviour depends on a number of factors. In this study, we highlight the knowledge and ideas of patients concerning the co-payment system. Methods: We used a mixed methods design, combining quantitative and qualitative research. During two weekends in January 2005, all patients using the ED or the GP OOH service, were invited for an interview with a structured questionnaire. A stratified random sample of patients participated in a semi-structured interview. Both methods add complementary data to answer the research questions. Results: Most mentioned reasons for seeking help at the ED are: accessibility (15.0%), proximity (6.4%) and competence of the staff (5.6%). Reasons for choosing the GP are: GP is easy to find, minor medical problem or anxiety and confidence in the GP. The odds of not knowing the co-payment system are significantly higher in patients visiting the ED (OR 1.783; 95% CI: 1.493-2.129). Mostly GP users recognize the problem of ED overuse. They suggested especially to provide clear information about the tasks of the different services and about the payment system, to reduce ED overuse. Conclusion and discussion: When intending to shift from ED to GP services for minor medical problems, aiming at just one measure is no option. Information campaigns aiming to address the entire population, can clarify the role of each player in out-of-hours care.

Introduction Improving pain management in the ED might be attained by adequate teaching of medical students. We assessed the skills in pain treatment of ED physicians who teach the students. Methods All physicians working in an ED who provide elective training to undergraduate medical students from the Ghent University were asked to complete a questionnaire consisting of vignette patient cases concerning acute pain management of abdominal colic pain, and non-traumatic abdominal pain. Results Thirty two physicians completed the cases. In the renal colic case 91% of the respondents proposed a NSAID as first line treatment. Butylhyoscine was still suggested by 18%. After initial failure of analgesia 31% administered a strong opioid. In biliary colic pain NSAIDs and butylhyoscine were proposed as first line analgesics by 59% and 31% respectively. In second line, butylhyoscine would be given by 22%. The patient case with right fossa abdominal pain would initially be treated with acetaminophen by 81%. Thirteen % of the respondents would not give further analgesia if the first line treatment was insufficient. Conclusion Our results indicate that adherence by teachers to evidence based guidelines of acute pain management is insufficient. Therefore improving knowledge and skills in pain management of the teachers should receive more attention.

The effect-plasma concentration relationship of etomidate was studied in the rat using electroencephalographic changes as a pharmacodynamic parameter. Etomidate was infused (50 mg/kg/h) in chronically instrumented rats (n=6) until isoelectric periods of 5 s or longer were observed in the electroencephalogram (EEG). The EEG was continuously recorded during the experiment and frequent arterial blood samples were taken for determination of etomidate plasma concentrations. The changes observed in the raw EEG signal were quantified using aperiodic analysis in the 2.5-7.5 Hz frequency band. The return of the righting reflex was used as another parameter of anesthesia. A mean dose of 8.58+/-0.41 mg/kg needed to be infused to reach the end point of 5 s isoelectric EEG. The plasma concentration time profiles were most adequately fitted using a three-exponential model. Systemic clearance, volume of distribution at steady-state and elimination half-life averaged 93+/-6 ml/min/kg, 4.03+/-0.24 l/kg and 59.4+/-10.7 min respectively. The EEG effect-plasma concentration relationship was biphasic exhibiting profound hysteresis. Semi-parametric minimization of this hysteresis revealed an equilibration half-life of 2.65+/-0.15 min, and the biphasic effect-concentration relationship was characterized nonparametrically by descriptors. The effect-site concentration at the return of the righting reflex was 0.44+/-0.03 microg/ml. The results of the present study show that the concentration-effect relationship of etomidate can be characterized in individual rats using aperiodic analysis in the 2.5-7.5 Hz frequency band of the EEG. This characterization can be very useful for studying the influence of diseases on the pharmacodynamics of etomidate in vivo.

BackgroundTransition between different healthcare settings is a risk factor for medication discrepancies in the patient’s medication list. A large number of discrepancies has the potential to cause adverse drug events.PurposeObtaining a complete medication list of a patient is very important to avoid unintentional medication discrepancies and medication related problems at admission. We aimed to evaluate the added value of a structured medication review in the emergency department by a pharmacy technician.Material and methodsWell trained pharmacy technicians performed a medication review of patients admitted to the emergency department by using a structured form and different sources (patient, family, medication list, family doctor, etc). The physician acquired medication list was compared with that acquired by the technician to identify unintentional discrepancies (any difference between the two medication lists). The clinical impact was evaluated by a multidisciplinary team of pharmacists and pharmacologists.ResultsFrom February to April 2016, 279 (74.9%) medication discrepancies were identified in 113 medication lists. The most common discrepancies were omission of a drug (43.7%), omission of frequency (17.2%) and omission of dose (14.7%). Drugs belonging to the class of analgesics (21.1%) and obstructive airway disease (18%) were associated with the highest discrepancy rates. There was a positive association between the number of discrepancies and the number of drugs (p=0.002) and information sources (p=0.026) and the time needed to perform the reconciliation (p=0.001). 6.5% were evaluated as having a potentially very significant impact on the patient’s health; 30.6% were evaluated as having the potential to cause moderate clinical impact and 2.2% as potentially having a minor or no impact.ConclusionThis study provides evidence that structured medication review is useful to obtain a complete medication history, to avoid medication related problems and to guarantee the patient’s safety.References and/or acknowledgementsMueller SK, et al. Arch Intern Med2012;172:1057–69.No conflict of interest