Implementing a novel strategy for interprofessional medication review using collegial mentoring and systematic clinical evaluation in nursing homes (COSMOS)

Abstract

Background: Multimorbid patients in nursing homes are prescribed long lists of medication, often without sufficient clinical evaluations beforehand. This results in poor clinical effects of the prescribed medication and significant side-effects, especially in patients with impaired cognition. The aim of this paper is to describe the process, content and implementation of a clinical medication review encompassing clinical testing and collegial support to prescribers.

Methods: The implementation process of a novel approach to medication review in nursing homes was logged thoroughly by structured staff feedback. Staff experienced promotors and barriers to implementation also were collected. The study was part of a cluster randomized controlled trial, in which 36 long-term care units received the COSMOS intervention. Nurses and physicians randomized to the intervention group participated in educational programs, training in clinical evaluation of the patients, and interprofessional medication review with collegial mentoring.

Results: The intervention group contained 297 patients from 36 nursing home units. There were 105 staff attendees for the education program. The units were served by 21 different physicians. Clinical medication reviews were performed in all units and all patients were assessed prior to the medication reviews. Of the 240 patients with a logged intervention process, 220 (92%) underwent a medication review. The intervention generated enthusiasm and improved communication among nursing staff and between nursing staff and physicians. The interprofessional discussions helped to facilitate difficult decisions pertaining to treatment levels. Reported barriers were lack of time, low engagement of all nursing staff and physicians, and ethical dilemmas.

Conclusions: Clinical medication reviews were implemented for almost all patients, and every patient was systematically assessed prior to the medication review. The physicians perceived collegial mentoring as an asset, learning from each other facilitated decision making in terms of difficult aspects of prescribing. Knowledge about barriers and promotors can improve implementation of similar interventions in other nursing homes.

Trial registration: Clinicaltrials.gov ( NCT02238652 ). Registered July 7th 2014.

Keywords: Behavioral and psychological symptoms of dementia; Implementation; Medication review; Needs assessment; Neuropsychiatric symptoms; Nursing homes; Symptom assessment.

Conflict of interest statement

Ethics approval and consent to participate

We informed all patients and their relatives about the study. Patients with an MMSE score of ≥16 were asked to provide signed an informed consent. All capable patients gave written informed consent to participate. For patients with reduced cognitive ability, the relatives signed a presumed informed consent on the patient’s behalf. This approach and the study design were approved by Regional Ethics Committee, West Norway (2013/1765). The trial was registered at clinicaltrials.gov (NCT02238652). We followed the Consort checklist for cluster randomized trials when reporting this study.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Figures

Fig. 1

The medication review process: 1: Researchers educated nursing home staff (“COSMOS ambassadors”), physicians, and nursing home leaders in safe use of drugs and the medication review intervention. 2: The COSMOS ambassadors used the lessons from the education to train the other staff in their units. 3: The researchers trained the nursing home staff in assessing the patients’ pain, neuropsychiatric symptoms, cognition, daily function, and quality of life. 4: Multidisciplinary medication reviews with the researchers, nurses, and nursing home physician were performed in each unit. The researcher gave collegial mentoring for the other participants. The results from the clinical assessments were used in evaluation of the prescriptions for each patient. 5: After two months, the nursing home staff was gathered for a midway evaluation to discuss promotors and barriers towards the implementation among themselves and with the researchers. 6: During the whole study period, the researchers regularly called the COSMOS ambassadors to follow up on the implementation. The researchers gave advice on how to overcome barriers, and collected practical tips from the COSMOS ambassadors that could be spread to other units