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Objective: To describe the epidemiology, treatment and monitoring of treatment outcomes of patients presenting to the ED with hyperkalaemia. Methods: We undertook a retrospective observational study in a mixed adult/paediatric ED over five 3‐month periods. Consecutive patients were included if they had an initial serum or blood gas potassium ≥6.0 mmol/L. Patients were excluded if their principal diagnosis was diabetic ketoacidosis, their blood sample was haemolysed or the blood gas result was inconsistent with a subsequent serum potassium. Data were extracted from electronic medical records and two senior emergency registrars independently assessed available ECGs. Moderate and severe hyperkalaemia were potassium 6.0–6.4 and ≥6.5 mmol/L, respectively. Results: Overall, 392 patients were included (mean age 73.7 years, triage category 1 or 2 28.3%, admitted 91.3%). Three hundred and twenty‐one (81.9%, 95% confidence interval [CI] 77.6–85.5%) patients took one or more medications that predispose to hyperkalaemia and 335 (85.5%, 95% CI 81.5–88.7%) had one or more predisposing comorbidities. Two hundred and seventy‐one (69.1%, 95% CI 64.3–73.6%) patients had moderately severe and 121 (30.9%, 95% CI 26.4–35.7%) had severe hyperkalaemia. Two hundred and fifty‐nine (66.1%, 95% CI 61.1–70.7%) patients were administered at least one medication in ED to lower the potassium concentration and 51 (13.0%, 95% CI 9.9–16.8%) were dialysed. One hundred and eighty‐seven patients received intravenous insulin: 40 (21.4%) had documented biochemical hypoglycaemia, but 45 (24.1%) had no post‐insulin blood glucose level documented. Hyperkalaemia‐associated ECG changes were uncommon. Conclusion: Most ED patients with hyperkalaemia have identifiable clinical and medication‐related risk factors. Variations in care were widespread and monitoring for iatrogenic adverse events was suboptimal. [ABSTRACT FROM AUTHOR]

Objective: Patients present to EDs with various medication‐related problems (MRPs). MRPs are also associated with ED care, occurring during ED presentation or shortly afterwards. The aim of the present study is to describe the prevalence and nature of MRPs that occur prior to, during or shortly after leaving ED. Methods: We undertook a prospective, observational study in nine Australian EDs. Blocks of 10 consecutive adult patients who were not seen by a pharmacist in ED and who presented at pre‐specified times were identified. Within 1 week of ED discharge, a pharmacist interviewed patients and undertook a medical record review to determine their medication history, patients' understanding of treatment, potential MRP risk factors and manage any identified MRPs. Results: A total of 904 patients were recruited: 14.8% aged ≥80 years, 18.9% taking more than eight regular medications; 581 MRPs were identified; 287 (49.4%, 95% confidence interval [CI] 45.3–53.5%) of moderate‐high significance. Most highly significant MRPs involved high‐risk medications, particularly strong opioids, insulin and anti‐coagulants. The most common types of MRPs were prescribing errors (46.8%), patient adherence/knowledge issues (31.2%) and adverse drug reactions (7.4%). Of all patients, 381 (42.1%, 95% CI 38.9–45.5%) had at least one MRP; 31.4% (95% CI 28.4–34.6%) had MRPs that could be identified or managed by screening at ED presentation and 12.4% (95% CI 10.4–14.8%) had MRPs that could be identified or managed by screening at ED discharge. Conclusions: Patients experienced a range of MRPs throughout the ED continuum of care. From these data, screening tools will be developed so that ED clinicians may identify patients at greatest risk of MRPs. [ABSTRACT FROM AUTHOR]

Objective: To determine medications used by ED doctors to improve work and academic performance, and to manage stress and anxiety. Methods: We undertook an online, voluntary, anonymous survey of ACEM fellows and trainees. Results: One hundred and thirty‐nine (46.5%) respondents used a medication under examination. Sleep aids included melatonin (19.1% of respondents) and benzodiazepines (8.7%). Medications to improve performance included modafinil (4.7%), pseudoephedrine (2.0%), melatonin (2.0%) and beta blockers (1.3%). Some medications were taken prior to shifts. Medications to manage stress and anxiety included benzodiazepines (3.0%) and beta blockers (2.0%). Conclusion: Medication use is common and support for some doctors may be required. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To assess the accuracy of medication information sources available for adult patients presenting to the ED, compared to a best possible medication history (BPMH). Methods: This prospective observational study was undertaken in the ED of a major tertiary‐referral teaching hospital. A convenience sample of consecutive adult patients taking one or more regular medications was included. A BPMH was ascertained using patient/carer interviews, where available, and confirmed with one or more other sources. For residential care facility (RCF) patients, the RCF medication chart and at least one other source were used. Information sources compared with the BPMH were community pharmacy dispensing history, patient's own medications, patient's medication list, general practitioner letter, medications stored in and labelled on dose administration aids (DAAs) and the RCF chart. Number of discrepancies per patient for each source was determined by comparing medications and dose regimens to those documented in the BPMH. Results: A total of 455 patients (median age 71 years) took a median of six ‘regular’ and two ‘as required’ medications. The median number (range) of discrepancies per patient for regular medication names and dosages were RCF chart 0 (0–3), DAA contents 2.0 (0–9), patient's medication list 2.5 (0–16), DAA medications label 3.0 (0–7), community pharmacy history 3.0 (0–19), general practitioner letter 3.0 (0–18) and patient's own medications 4.0 (0–16). Overall, 40.4% of discrepancies were deemed ‘moderate’ or ‘high’ clinical significance. Omission errors accounted for 55.6% of discrepancies. Conclusions: A combination of sources is essential to determine the BPMH. RCF charts provided the most accurate information. Other sources had two to four regular medication‐related discrepancies per patient. [ABSTRACT FROM AUTHOR]

Objectives The objective of this study was to evaluate the impact of an educational intervention on ED discharge opioid analgesic ( OA) prescribing. Methods A brief, one-on-one, educational intervention was delivered to ED OA prescribers by an ED clinical champion. The percentage of patients receiving (i) written advice regarding appropriate oxycodone use, (ii) written or verbal advice regarding appropriate post-discharge follow up and (iii) written general practitioner notification that oxycodone had been prescribed were determined pre- and post-intervention, through review of electronic patient records and structured patient telephone interviews conducted 3-7 days after ED attendance. Secondary outcomes included total amount prescribed and use of non- OA therapies. ED OA prescribers were surveyed to evaluate perceived effectiveness and intervention acceptability. Results A total of 30 ED OA prescribers received the 5-min intervention. Pre- and post-intervention, 80 and 81 patients were interviewed, respectively. Percentage of patients given written OA information increased from 10% to 22% ( P = 0.04) and those receiving follow-up advice increased from 61 to 94% ( P < 0.01). General practitioner notification of OA prescription increased from 15% to 88% ( P < 0.01). Risk ratio for achieving all three end-points was 7.5 (95% confidence interval 1.8-32, P = 0.01). Median total amount of oxycodone prescribed/patient decreased from 100mg to 50mg ( P = 0.04). Non- OA therapies were used by 49% of pre-intervention and 85% of post-intervention patients ( P = <0.01). All ED OA prescribers agreed the intervention would change their prescribing practices; 70% deemed the intervention appropriate for delivery in their work environment. Conclusion A brief, one-on-one educational intervention targeting ED OA prescribers was well received by clinicians and associated with improved quality of OA prescribing. [ABSTRACT FROM AUTHOR]

Objective To determine the prevalence and nature of off-label and unlicenced (off-label/unlicenced) medicine administration to paediatric ED patients. Methods We undertook a retrospective, observational study in six EDs ( July 2011 to June 2012, inclusive). Patients, aged 0-17 years, who were administered a medicine in the ED were included. At each site, 50 eligible patients were randomly selected each month of the study period. An explicit review of each patient's records was undertaken. Medicines were classified as on or off-label/unlicenced according to categories of use approved by the Therapeutic Goods Administration. Results There were 3343 patients enrolled (56.5% men, mean ± SD age 6.7 ± 5.4 years). Of the 6786 medicine doses administered, 2072 (30.5%, 95% CI 29.4-31.7%) were off-label/unlicenced. The off-label/unlicenced doses were administered to 1213 (36.3%, 95% CI 34.7-37.9%) patients. Patients administered an off-label/unlicenced medicine were younger than those who were not ( P < 0.01). Salbutamol, ondansetron, ipratropium, fentanyl and oxycodone were the medicines most commonly administered off-label. In 910 (44.0%) cases, the dose/frequency was not approved; in 592 (28.6%), there was an unapproved indication for treatment; in 158 (7.6%), the medicine was administered via an unapproved route; in 154 (7.4%) the medicine was not approved for the weight or age; and in 74 (3.5%) an unlicenced product was administered. The remaining cases had combinations of reasons. Conclusions Off-label/unlicenced medicine administration is common. A registry of commonly used off-label medicines is recommended in which the safety and efficacy of their off-label use have been demonstrated by published evidence. [ABSTRACT FROM AUTHOR]

Objective: To describe the magnitude of ketamine doses administered in the ED, to identify an appropriate product to minimise risk of administration errors and diversion. Methods: Retrospective audit of patients prescribed ketamine in two mixed adult/paediatric EDs over 12 months. Results: Ketamine was administered to 386 patients (722 doses). The most common dose was ≤20 mg (52.1%), followed by 21–50 mg (30.5%). Overall, 215 patients required one dose only (71 received a dose ≤20 mg), while 299 required no more than two doses. Conclusion: Over three‐quarters of ketamine doses were ≤50 mg; therefore, 50 mg in 1 mL may be an appropriate product. [ABSTRACT FROM AUTHOR]

Objective The study aims to evaluate the impact of a nurse-initiated analgesia pathway ( NIAP) intervention for paediatric patients in the ED. Methods We undertook a pre- and post-intervention trial in a large, tertiary referral, mixed ED. The intervention comprised development and implementation of a comprehensive NIA Standing Order. In addition to paracetamol, which nurses could initiate pre-intervention, they were authorised to administer ibuprofen, paracetamol/codeine combinations and topical local anaesthetics prior to a doctor assessing the patient. All nurses were trained and credentialed prior to administering the NIAP. Patients aged 5-17 years with a triage pain score of ≥4 ( Wong- Baker or numerical rating scale) were eligible for enrolment. The primary outcome was time to analgesia. Secondary outcomes were the proportion of patients who received 'adequate analgesia' and parental satisfaction with ED pain management (measured 48 h post-discharge). Results Fifty-one children were enrolled in both the pre- and post-intervention periods. Patient sex and mean age, weight and triage pain score did not differ between the groups ( P > 0.05). At post-intervention, significantly more patients received nurse-initiated analgesia (3.0% vs 43.9%; P < 0.001) and the median time to analgesia was significantly reduced (58 min vs 23 min; P < 0.01). Also, significantly more patients received 'adequate analgesia' post-intervention (41.2% vs 72.5%; P < 0.001). At follow up, the proportion of parents who were very satisfied with their child's overall pain management trended upwards in the post-intervention period (47.1% vs 66.7%; P = 0.07). No adverse events were observed during either period. Conclusion The NIAP significantly reduced time to analgesia. It was associated with high levels of parental satisfaction. [ABSTRACT FROM AUTHOR]

We aimed to determine factors that are significantly associated with a high level of patient satisfaction with their pain management. We undertook an observational study in a large metropolitan ED. Adult patients with a triage pain score of ≥4 (0-10 scale) were enrolled. Data collected included demographics, presenting complaint, pain scores every 30 min, whether nurse-initiated analgesia was administered, the nature of the pain relief administered, time to first dose of analgesia, elements of staff communication and whether 'adequate analgesia' was provided (defined as a decrease in pain score to <4 and a decrease from the triage pain score of ≥2). The primary end-point, determined at follow up within 48 h, was the level of satisfaction with pain management (6-point scale: very unsatisfied-very satisfied). One hundred and sixty-seven (82.7%) of 202 enrolled patients were followed up - mean (SD) age 46.4 (18.3) years, 75 (44.9%) men. Eighty-one (48.5%) patients were very satisfied with their pain management. Only two clinical variables were significantly associated with a high level of satisfaction: receipt of 'adequate analgesia' (as defined) and specific communication regarding pain management. Forty-four (58.7%) versus 37 (40.2%) patients who did/did not receive 'adequate analgesia', respectively, were very satisfied (difference 18.5%, 95% CI 2.3-34.7, P= 0.027). Seventy-seven (53.9%) and four (16.7%) patients who were/were not advised by ED staff that their pain management was important, respectively, were very satisfied (difference 37.2%, 95% CI 17.7-56.6, P= 0.002). Our 'adequate analgesia' definition might provide a useful clinical target, which, combined with adequate communication, might help maximize patient satisfaction. [ABSTRACT FROM AUTHOR]

Objective: To undertake and evaluate a multifaceted intervention to encourage paramedics to bring patients' own medications (POM) to the ED. Method: Adult patients were enrolled in each of the pre-intervention (March 2006) and post-intervention (December 2006) periods if they were brought to ED by ambulance, taking four or more medications, admitted to hospital and were not referred to a pharmacist prior to the admission medication chart being written. ED pharmacists determined patients' regular medication and details of medications brought in by ambulance. Medication charts were assessed for discrepancies related to medications taken prior to presentation. These were recorded as errors if a change was made to the medication chart after discussion with the prescriber. The intervention, conducted in October and November 2006, involved meetings with Metropolitan Ambulance Service * team managers and dissemination of promotional material. Paramedics of the Metropolitan Ambulance Service were participants for the intervention. Main outcome measures were: percentage of regular medications incorrectly prescribed; and percentage of POM brought to ED by paramedics. Results: One hundred patients were enrolled in each of the pre- and post-intervention periods. The percentage of regular medications incorrectly prescribed significantly decreased from 18.9% (151/800, 95% CI 16–22%) to 8.8% (73/834, 95% CI 7–11%) in the pre- and post-intervention periods, respectively ( P < 0.001). Pre-intervention, paramedics brought some or all POM to ED in 67.0% (67/100, 95% CI 57–76%) of cases compared with 87.0% (87/100, 95% CI 78–93%) of cases, post-intervention. Conclusion: The multifaceted intervention encouraging paramedics to bring POM to ED was effective. POM were brought into ED more frequently and prescribing errors reduced. [ABSTRACT FROM AUTHOR]

Objective: We aimed to evaluate a multifaceted education initiative designed to reduce the prophylactic use of metoclopramide. Methods: This was a pre- and post-intervention trial undertaken in a single ED. All ED doctors and nurses were targeted. The intervention comprised a specifically designed, 19-slide ‘e-learning module’, accessible via the ED intranet, supplemented by in-service training and a range of reminder techniques (posters, emails and drug room flyers). The primary end-point was the proportion of patients administered metoclopramide prophylactically with their initial morphine dose. Data were collected on random samples of patients who received morphine, using explicit medical chart review. Results: Both pre- and post-intervention periods were of 3 month duration. The charts of 146 cases were reviewed in each period. In the post-intervention period: • The proportion of patients administered metoclopramide prophylactically decreased from 22.6% to 4.1% (difference 18.5% [95% CI 10.3–26.7], P < 0.001) • The proportion of patients administered metoclopramide appropriately (for known morphine sensitivity, established nausea and rescue anti-emesis) rose marginally from 28.8% to 32.9% (difference 4.1% [95% CI −7.2–15.4], P = 0.53) • There was a 12.7% decrease in the number of ampoules of metoclopramide issued to the ED without a concurrent rise in the issue of other anti-emetic drugs Conclusion: The education initiative resulted in a significant improvement in the evidence-based use of metoclopramide. [ABSTRACT FROM AUTHOR]

Background: Pain management experts have recommended a diminished role for pethidine because of lack of superiority for any indication and greater potential for adverse effects compared with morphine. Objectives: To evaluate the impact of a multifaceted education initiative on prescribing patterns and to minimize pethidine use in the ED. Methods: This was a pre- and post-intervention study. The intervention was an education initiative, introduced between December 2003 and January 2004. It comprised ED pharmacist in-services for medical and nursing staff, championing by senior medical staff (ED consultants, surgical units, Drug and Therapeutics Committee) and concurrent prescriber feedback by ED pharmacists. The pre-intervention prescribing practices guided the development of in-services and the educational programme. The intervention was evaluated by a medical record review of analgesic prescribing in March–April of both 2003 (pre-intervention period) and 2004 (post-intervention period). Outcome measures were the proportions of patients who were prescribed pethidine and the proportions of pethidine ampoules supplied to the ED. Results were analysed as differences in proportions. Results: In the pre-intervention period, 60 ampoules of pethidine (7.2% of opiate doses) and 777 ampoules of morphine (92.8% of opiate doses) were administered compared with 15 ampoules of pethidine (1.7%) and 869 ampoules of morphine (98.3%) in the post-intervention period ( P < 0.001). Of patients who received an opiate dose, 50 of 798 (6.3%) and 11 of 747 (1.5%) received pethidine in the pre- and post-intervention periods, respectively ( P < 0.001). Conclusion: Our education initiative resulted in a sustained and significant reduction in pethidine prescribing in the ED. Sustainability requires ongoing in-services for ED staff, usually as part of the orientation programme. [ABSTRACT FROM AUTHOR]

To determine the prevalence and type of complementary and alternative medicines (CAM) used by ED patients, to identify patient subgroups more likely to use CAM, the conditions for which they were taken, and the prevalence of side-effects and toxicity associated with CAM use.This was an analytical cross-sectional survey of patients at a large tertiary referral ED. Consenting patients completed a specifically designed study questionnaire, in their preferred language if required. Information was collected on CAM use on the day of presentation and within the previous week and previous year.Four hundred and four patients were enrolled (participation rate 97.1%). Fifty (12.4%, 95% CI 9.4, 16.1) patients had taken a CAM on the day of presentation, 203 (50.2%, 95% CI 45.3, 55.2) within the previous week and 275 (68.1%, 95% CI 63.2, 72.5) within the previous year. CAM users were significantly younger, better educated and more likely to be female than non-CAM users (P < 0.01). 103 different CAM had been taken for a wide variety of reasons. Side-effects were experienced in 53 of the 1182 CAM courses taken (side-effect rate of 4.5%). One patient presented suffering specifically from CAM toxicity.Complementary and alternative medicines are used by a considerable proportion of ED patients. The potential for side-effects, toxicity and interaction with traditional medication indicates the need for consideration of CAM use in patient assessment.See also pp. 378–381 [ABSTRACT FROM AUTHOR]