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Background: Hyperkalaemia is managed in the emergency department (ED) following measurement of potassium results by blood gas analysers (BGA) or laboratory analysers (LAB). Aims: To determine the prevalence of clinically significant differences between BGA and LAB potassium results and the impact on ED hyperkalaemia management. Methods: Retrospective analysis of time‐matched ED BGA and LAB potassium samples from 2019 to 2020 (taken within 15 min, one or both results ≥6.0 mmol/L). Mean differences and 95% limits of agreement (LoA) were determined for pairs with one or both results ≥6.0 mmol/L and a separate 500 consecutive sample pairs. Results: Four hundred eighty‐eight matched BGA and LAB samples met the inclusion criteria. Of these, 201 (41.2%) differed by ≤0.5 mmol/L, 169 (34.6%) included a haemolysed LAB sample, and 12 (2.5%) had an unreportable BGA sample. One hundred six (21.7%) pairs differed by >0.5 mmol/L, and 60/106 (57%) had normal LAB potassium results, but BGA indicated moderate/severe hyperkalaemia (two of these pairs received hyperkalaemia treatment). Of patients with a haemolysed LAB sample, or where pairs differed by >0.5 mmol, 48 were treated with insulin and five (10.4%) experienced hypoglycaemia. Mean differences and LoA for pairs with LAB results <6.0 mmol/L but BGA ≥6.0 mmol/L demonstrated unacceptable agreement, with 18 (25.7%) BGA results exceeding 8.0 mmol/L. Conclusions: Potentially significant discordance may occur between BGA and LAB potassium results. Clinicians need to be aware of factors impacting both analytical methods' accuracy (such as poor venepuncture or sample handling, (K) EDTA interference) and undetectable haemolysis with BGA measurements. We recommend BGA hyperkalaemia be confirmed with LAB results using a non‐haemolysed sample where time permits. [ABSTRACT FROM AUTHOR]

Opioid prescribing requires careful planning to minimise the risk of serious adverse outcomes. However, documentation of discharge opioid plans for patients and their general practitioners (GPs) is inconsistent, particularly when opioids are commenced in the emergency department or after surgery. We describe an initiative to promote consistent discharge opioid plan communication by implementing an opioid management plan (OMP) in our hospital's electronic medical record. Completion of an electronic form by the prescriber generates an OMP note in the medical history, which is used by the pharmacist to provide tailored opioid patient education. The OMP also populates the discharge summary that is sent to the GP and the Australian national digital health record platform, My Health Record. Preliminary evaluation shows incorporating OMP documentation into routine workflows has assisted prescribers to consistently document the plan for supplied opioids, supporting continuity of care. Workflow optimisation is ongoing to further improve discharge summary documentation and provision of patient‐friendly written information. This study was conducted as a quality improvement project and audits conducted as part of the project were approved by Austin Health's Office for Research (Project No: LNR/18/Austin/155). Informed patient consent was not required by Austin Health. [ABSTRACT FROM AUTHOR]

Background: Obtaining accurate medication histories at transitions of care is challenging, but important for patient safety. Prescription exchange services (PES) securely transfer electronic prescription and dispensing records between prescribers and pharmacies, which is potentially useful data for determining medication histories. Aim: To evaluate the accuracy of PES‐derived medication histories. Methods: Prospective observational study, at two Australian tertiary‐referral health services. A convenience sample of adult inpatients was recruited. The main outcome measure was: proportion of patients with ≥1 errors in their PES‐derived pre‐admission medication histories, compared with gold‐standard best‐possible medication histories, including prescribed and non‐prescribed medications, obtained by pharmacists using multiple sources including patient/carer interview. Results: Of 154 patients (median age 76 years; interquartile range (IQR) 64–84 years; median 10.0 pre‐admission medications; IQR 6.0–14.0), 153 (99.4%) had ≥1 errors in their PES‐derived medication history (median 6.0 errors per patient; IQR 4.0–9.0). Excluding when‐required medications, 146 (94.8%) patients had >1 errors (median 4.0 errors per patient; IQR 2.0–6.0). Omission was the most common error, affecting 549 (33.3%) of 1648 current medications (median 3.0; IQR 1.0–5.0 per patient); 396 (72.1%) omissions were over‐the‐counter medicines. Dose‐regimen errors affected 276 (25.1%) of 1099 current medications captured in PES‐derived medication histories (median 1.0 error per patient; IQR 0.0–3.0). Commission errors (medications in PES‐derived histories that were not current) affected 224 (16.9%) of 1323 medications (median 1.0 error per patient; IQR 1.0–2.0). Conclusions: Medication histories derived solely from a cloud‐based medication record repository had a high error rate compared with patients' actual medication use. Like all medication history sources, data from cloud‐based repositories need to be verified with additional sources including the patient and/or their carer. [ABSTRACT FROM AUTHOR]

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]

Background: Pharmacist‐assisted prescribing (also known as pharmacist charting) has been adopted widely across Australia. The perspectives of medical and nursing staff, however, is poorly understood. Aim: To explore the perceived benefits and drawbacks of pharmacist‐assisted prescribing on admission and discharge, from the perspective of hospital medical officers (HMOs) and nurses. Methods: Face‐to‐face, semi‐structured interviews were conducted with orthopaedic junior HMOs, the orthogeriatric HMO and nurses during a study evaluating pharmacist‐assisted prescribing in an orthopaedic unit. Participants were individually interviewed to explore the perceived impacts of pharmacist‐assisted prescribing on patient safety, workflow and HMO skill development. Interviews were audio‐recorded and verbatim transcriptions were analysed independently by two investigators using a simple thematic analysis. Results: Interviews were conducted with six HMOs and six nurses. Emergent themes highlighted various factors which may affect the ability of HMOs to prescribe medications accurately and in a timely manner when there is no pharmacist assisting with prescribing, and the impact of pharmacist‐assisted prescribing on patient flow, safety and staff workload. Participants felt that having a pharmacist assist with prescribing improved patient safety by reducing prescribing errors and admission charting delays, and assisted with patient flow by reducing delays in discharging patients. Participants felt that pharmacist‐assisted prescribing reduced their workload. They noted a drawback was the potential to de‐skill HMOs, but felt this was outweighed by the benefits. Conclusions: Hospital medical officers and nurses reported that pharmacist‐assisted prescribing had benefits on patient safety, patient flow and workload and that these outweigh the potential drawbacks of potentially de‐skilling junior HMOs. [ABSTRACT FROM AUTHOR]

Background: Despite evidence to support pharmacists practicing in advanced scope roles, embedding such roles into practice is challenging. Upskilling hospital pharmacy technicians (HPTs) to undertake selected clinical support roles under indirect supervision could relieve pharmacists from non‐complex tasks. Aim: To compare patient satisfaction with routine postoperative discharge medication education provided by a HPT or pharmacists in a short‐stay surgery setting. Method: An HPT completed a comprehensive training program to become a credentialed medication education technician (MEdTech). Consecutive overnight‐staying patients were assigned to receive education by the MEdTech or pharmacists according to staff availability. Patient satisfaction with their education experience was measured via telephone calls the day following discharge. The hospital's Research Office approved this study as quality improvement. Results: Overall, 341 patients were screened and 217 met all inclusion criteria. Two hundred patients provided feedback (100 educated by the MEdTech and 100 by pharmacists). All patients reported high levels of overall satisfaction with their education experience, irrespective of which pharmacy staff member provided the education; a finding supported by the qualitative feedback. Significantly more MEdTech‐educated patients were very satisfied with the amount of information provided (92% vs 79%) and ease of following the education (97% vs 86%) than pharmacist‐educated patients, respectively. Conclusion: This study supports advanced practice HPTs assisting with the provision of medication information to patients. This novel workforce model could facilitate pharmacists working in advanced‐scope roles by having advanced HPTs undertake uncomplicated aspects of clinical pharmacy within a defined scope of practice and with specific pharmacist referral criteria. [ABSTRACT FROM AUTHOR]

Objectives: To explore wastage of hospital‐supplied medications for patients discharged to residential care facilities (RCFs). Methods: Telephone interviews with staff at 52 RCFs and nine community pharmacies after patients were discharged from three hospitals in metropolitan Victoria, Australia, with medication supplied in original packs. Results: Hospital‐supplied medication was used by most RCFs, for a median of 48 hours, while waiting for community pharmacies to deliver medications packed in the RCFs' preferred dose administration aid system (unit‐dose or multi‐dose blister packs or sachets). All RCFs reported sending unused hospital‐supplied medications to their community pharmacy. Six of the nine community pharmacies (managing 83% patients) indicated they did not reuse hospital‐supplied medications, with the exception of select difficult‐to‐source medications. Conclusion: There was significant wastage of hospital‐supplied discharge medications. Changes to the way hospital discharge medications are funded and quantities supplied are needed to ensure continuity of medication administration while minimising financial and environmental impacts of medication wastage. [ABSTRACT FROM AUTHOR]

Background: The "Pharmacy Technician and Assistant Role Redesign within Australian Hospitals Project" outcomes were released in November 2016. Aim: To assess pharmacy staff attitudes towards expanded hospital pharmacy technician (HPT) roles in a Victorian metropolitan teaching hospital. Method: An electronic questionnaire circulated to all pharmacists, interns and HPTs remained open for 4 weeks during September 2018. Questions focused on three key domains: HPT involvement in final accuracy checking of inpatient supplies and manufactured items, drugs of addiction (DA) management and clinical support roles. The hospital's Office for Research deemed the study a quality improvement activity. Results: The questionnaire was undertaken by 61 of 122 (50%) pharmacy staff. Fewer than 10% of respondents believed that HPTs are adequately used in current practice. Final accuracy checking technicians for inpatient medication supplies was supported by 82% of respondents. HPTs signing entries into dispensary DA registers for discharge and outpatient prescriptions was supported by 81% of respondents. Best possible medication history taking conducted by an HPT was supported by 52% of respondents, but support differed between pharmacists and HPTs, with 38 and 92% supportive, respectively (p < 0.01). Forty percent of respondents supported HPT involvement in patient medication counselling. Key themes identified from qualitative data included: the need for clarification of legal and indemnity issues, training and credentialing and professional attributes for expanded HPT roles. Conclusion: These findings are informing HPT role expansion within the pharmacy department and have identified potential barriers to change. Such findings may be useful to pharmacy departments undertaking similar role redesign work. [ABSTRACT FROM AUTHOR]

Background: Problems with continuity of medication administration after discharge from hospitals to residential care facilities (RCFs) have been reported in Australia and internationally. The MedGap study in 2009 reported a significant decline in post‐discharge missed or delayed doses and locum doctor call‐outs at RCFs following implementation of a hospital pharmacy‐prepared interim residential care medication administration chart (IRCMAC). Aim: To determine whether reductions in missed or delayed doses and locum doctor call‐outs were sustained nearly 10 years after the IRCMAC was implemented, and evaluate RCFs' use of IRCMACs and discharge medications supplied in original packaging. Method: Structured telephone interviews with nurses at 52 RCFs were conducted approximately 48‐h after discharge for randomly selected patients discharged from hospitals within a major metropolitan health service in Melbourne, Australia in 2018. Results were compared with pre‐ and post‐intervention data collected using the same method in 2009. Primary endpoints were the proportion of patients for whom the RCF used the hospital‐supplied IRCMAC and discharge medications, and the incidence of missed or significantly delayed medication doses in the first 24 h post‐discharge. The number of locum doctor call‐outs was a secondary endpoint. Results: RCFs received IRCMACs for 71/73 (97.3%) patients and used them for 61/71 (85.9%). Hospital‐supplied medication, in original packaging, was received for 65/73 (89.0%) patients and used for 59/65 (90.8%). One or more doses were missed or significantly delayed for 2/73 (2.7%) patients and locum doctors were called for nine patients (12.3%), which was similar to the 2009 post‐intervention study (6/226, 2.7% and 25/226, 11.1%, respectively) and significantly lower than the 2009 pre‐intervention study (37/202, 18.3% and 66/202, 32.7%, respectively; P < 0.01 for both endpoints). Nearly 100% of RCF staff believed IRCMACs and hospital‐supplied medication improved continuity of care. Conclusion: Hospital pharmacy‐prepared IRCMACs and discharge medication in original packaging were highly used and valued by RCF staff, and associated with sustained low rates of missed and delayed doses and locum doctor call‐outs. [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]

Background: To address the opioid crisis, much work has focused on minimizing opioid supply to surgical patients upon hospital discharge. Research is limited regarding handover to primary care providers. The aim of this study was to evaluate the communication of post‐operative opioid prescribing information provided by hospitals to general practitioners (GPs). Methods: This study comprised two components. First, a retrospective audit of discharge summaries for opioid‐naïve surgical patients supplied with an opioid on discharge was conducted to evaluate accuracy of opioid documentation and presence of an opioid management plan. Second, a survey was distributed to GPs to seek their opinions regarding adequacy of communication about hospital‐initiated opioids in discharge summaries, challenges experienced in opioid management and suggestions for improvement. Results: Discharge summaries for 285 patients were audited. Twenty‐seven (9.5%) patients had no discharge summary completed. Of the remaining 258, 63 (24.4%) summaries had at least one discrepancy between the opioid(s) listed and the opioid(s) dispensed. Only 33 (12.8%) summaries contained an opioid management plan. From 57 GP‐completed surveys, 41 (71.9%) GPs rarely or never received an opioid management plan from hospital surgical units and 34 (59.7%) were dissatisfied/very dissatisfied with information provided about opioid supply and management. Qualitative responses highlighted difficulties GPs experience managing opioid treatment for post‐surgical patients after discharge, differing patient expectations and the need to improve communication at times of transition. Conclusion: When opioid‐naive patients are discharged from hospital on opioids, communication from hospitals to GPs is poor. Future interventions should focus on strategies to improve this. [ABSTRACT FROM AUTHOR]

Aim: To evaluate whether pharmacist‐assisted electronic warfarin charting and monitoring reduces warfarin‐related errors and improves post‐discharge continuum of care. Method: Cardiology and medical patients admitted for at least 24 h and prescribed at least one warfarin dose were included in a pre/post‐intervention study. The intervention involved pharmacists proactively charting warfarin and ordering international normalised ratios (INRs) using electronic prescribing software, following discussion with medical doctors. Endpoints included: percentage of patients with one or more warfarin errors, INR > 5.0 during admission, readmission within 30 days for anticoagulant‐related issues and warfarin discharge plan (WDP) completeness (including documentation of next dose/s, and when and where the next INR was to be checked). Results: Pre‐ and post‐intervention groups comprised 130 and 108 patients, respectively. Post‐intervention, more patients received warfarin following heart valve replacement and fewer for venous thromboembolism. Post‐intervention, pharmacists ordered 130 doses (72 patients) and 98 INRs (59 patients). Percentage of patients with one or more warfarin errors declined from 27.7 to 7.4% (p < 0.01), with INR> 5.0 decreased from 7.7 to 2.8% (p = 0.17) and readmission within 30 days for anticoagulation problems occurred in 4 and 0 cases pre‐ and post‐intervention, respectively. While there was a non‐significant decline in the proportion of patients with a WDP post‐intervention, when patients had a WDP it was more comprehensively completed (p < 0.01). Conclusion: Pharmacists proactively charting and monitoring warfarin reduced warfarin‐related errors during hospitalisation and improved elements of post‐discharge communication. Closer multi‐disciplinary communication and 7‐day pharmacy services may result in further continuum of care improvements. [ABSTRACT FROM AUTHOR]

Objective: The objective was to describe the incidence, nature, and risk factors for adverse events (AEs) among patients who received parenteral sedation for acute agitation in an emergency department (ED) setting. Methods: We undertook a prospective observational study and a clinical trial of parenteral sedation for the management of acute agitation. We included agitated adult patients who required parenteral sedation from 2014 to 2017 in 12 Australian EDs, excluding those with incomplete information or aged under 18 years. The primary outcome was the number of patients who experienced at least one AE. Multivariable logistic regression was used to determine factors associated with AEs. Results: A total of 904 patients were included in the analyses (62.3% male; median age = 34 years, range = 18 to 95 years). Of these, 144 (15.9%) patients experienced at least one AE. The most common AEs were oxygen desaturation (7.4%), airway obstruction (3.6%), bradycardia (1.9%), hypotension (1.7%), and prolonged QTc interval (1.3%). No deaths or serious AEs were reported. The following factors had an increased adjusted odds ratio (OR) for experiencing an AE: age 65 years and older (OR = 2.8, 95% confidence interval [CI] = 1.2 to 7.2), more than one type of parenteral sedation administered within 60 minutes (OR = 2.1, 95% CI = 1.4 to 3.1), and alcohol intoxication (OR = 1.8, 95% CI = 1.2 to 2.6). Conclusions: Sedation‐related AEs are common, especially respiratory events. Elderly patients, sedation with multiple sedatives within 60 minutes, and alcohol intoxication increased the risk. [ABSTRACT FROM AUTHOR]

Background: Behavioural emergencies (BEs) are complex situations in the emergency department (ED) setting. Treatment decisions always must be made within a limited time and are based on incomplete patient data. As a result of the urgency and complexity, patients often are exposed to increased risk of harm. Aim: The aim of this paper is to describe the prescribing patterns and adverse events (AEs) associated with parenteral sedation for the management of BEs in Australian EDs. Methods: Ten Australian EDs enrolled a convenience sample of adult patients (aged ≥18 years) requiring parenteral sedative medication for BEs. Data were collected prospectively between March 2015 and April 2017 using a designated case report form. Results: In all, 564 cases were enrolled in this study. Incomplete cases (n = 17; 3%) were excluded. Of the 547 remaining cases, 63% were male and the median age was 34 years (range 18–95 years). Approximately half the patients (n = 230; 42.1%) required mechanical restraint and parenteral sedation to manage their BEs. Intramuscular monotherapy was administered in most cases (n = 390; 71.3%). The main sedative medications used as monotherapy were droperidol (n = 381; 69.7%), midazolam (n = 54; 9.9%) and olanzapine (n = 26; 4.8%). The most common combination therapy was midazolam + droperidol (n = 36; 6.6%). The incidence of AEs from sedative administration was 13.5%. No deaths or irreversible AEs were reported. Conclusions: Overall, the participating EDs provided safe pharmacological management for BEs. AEs following parenteral sedation are common, although serious AEs are rare. Because all patients receiving parenteral sedation for BEs are at risk of AEs, ongoing monitoring of vital signs after parenteral sedation should be a standard protocol in all EDs. [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]

Abstract: Rationale, aims, and objectives: Whilst many dose omissions cause no patient harm, inappropriate dose omissions have been associated with increased length of hospital stay, risk of sepsis, and mortality. This study aimed to comprehensively describe the prevalence and nature of omitted doses overall and of high risk medication dose omissions in an organization using an electronic Medication Management System. Methods: A retrospective cross‐sectional study was undertaken in an Australian tertiary referral health service. All routinely documented electronic inpatient dose administration records from 1st July 2014 to 30th June 2015 were included. Period prevalence and characteristics of dose omissions overall and of high‐risk medication dose omissions were determined. Results: During the study period, 3.3 million inpatient doses were scheduled for administration, with doses endorsed as “not given” comprising 6.2% of all scheduled doses. Non‐valid dose omissions (medication not available or no justification documented) comprised 1.2% of scheduled doses. Patient refusal accounted for one third of all dose omissions, while for 12% no explanation was provided and 7% were endorsed “medication not available”. High‐risk medications accounted for 20% of all dose omissions. One in 20 antimicrobial doses scheduled were omitted, and of these, 17% were due to patient refusal. Conclusion: The period prevalence of dose omissions in this large study after electronic Medication Management System implementation is similar to that found when paper charts were used. Although most dose omissions appear appropriate, many orders were not given due to patient refusal or with no documented justification. Interventions to minimize unintentional dose omissions are indicated. [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]

Aim To examine the efficacy and safety of (1) midazolam-droperidol versus droperidol and (2) midazolam-droperidol versus olanzapine for methamphetamine-related acute agitation. Design and setting A multi-centre, randomized, double-blind, controlled, clinical trial was conducted in two Australian emergency departments, between October 2014 and September 2015. Participants Three hundred and sixty-one patients, aged 18-65 years, requiring intravenous medication sedation for acute agitation, were enrolled into this study. We report the results of a subgroup of 92 methamphetamine-affected patients. Intervention and comparator Patients were assigned randomly to receive either an intravenous bolus of midazolam 5 mg-droperidol 5 mg combined, droperidol 10 mg or olanzapine 10 mg. Two additional doses were administered, if required: midazolam 5 mg, droperidol 5 mg or olanzapine 5 mg, respectively. Measurements The primary outcome was the proportion of patients sedated adequately at 10 minutes. Odds ratios with 95% confidence intervals (ORs, 95% CI) were estimated. Findings The baseline characteristics of patients in the three groups were similar. At 10 minutes, significantly more patients in the midazolam-droperidol group [29 of 34 (85.3%)] were sedated adequately compared with the droperidol group [14 of 30 (46.7%), OR = 6.63, 95% CI = 2.02-21.78] or with the olanzapine group [14 of 28 (50.0%), OR 5.80, 95% CI = 1.74-19.33]. The number of patients who experienced an adverse event (AE) in the midazolam-droperidol, droperidol and olanzapine groups was seven of 34, two of 30 and six of 28, respectively. The most common AE was oxygen desaturation. Conclusion A midazolam-droperidol combination appears to provide more rapid sedation of patients with methamphetamine-related acute agitation than droperidol or olanzapine alone. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Inpatient bed access decreases when ward discharge is delayed. This contributes to prolonged emergency department (ED) length of stay (LOS) which has been associated with increased hospital LOS and mortality. Delays in preparation of discharge medication prescriptions by ward doctors may contribute to delayed ward discharge. This project aimed to evaluate the effect on patient flow of having a pharmacist collaborate with ward doctors to prepare discharge prescriptions at a hospital with an electronic prescribing system. Method Eight-week pre- and post-intervention study on two surgical wards at a major metropolitan Australian hospital. During the intervention, a project pharmacist (PP) electronically prepared discharge prescriptions, in consultation with ward doctors, which were reviewed by the regular ward pharmacist before being dispensed. Outcome measures, based on hospital performance indicators, included: * Percentage of patients transferred to wards from ED within four and six hours of presentation; * Median time (minutes) past 9 am that patients were discharged from the wards; * Percentage of patients discharged from wards by 9 am; * Staff satisfaction. Results Pre- and post-intervention, there were 259 and 246 patients transferred from ED to the study wards, respectively. The percentage of patients transferred within four and six hours of presentation did not change. There were 320 and 341 patients discharged, pre- and post-intervention, respectively, who required a discharge prescription. The PP prepared 273 (80%) prescriptions during the post-intervention period. Patients were discharged 57 minutes earlier with the intervention (median 211 vs. 154 minutes past 9 am, P = 0.01). The percentage of patients discharged before 9 am increased from 6% to 12% (P = 0.01). All 26 health-professional respondents (79% response rate) were satisfied with the service and recommended its continuation. Conclusions Pharmacist collaboration with doctors to prepare discharge prescriptions did not impact upon ED access targets, but resulted in patients being discharged earlier. [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]

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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]

The article provides information on a study which analyzed whether regular medications taken routinely before hospital admission are more accurately prescribed on the hospital medical chart when patients' own medications (POM) are brought to the emergency department (ED) with the patient. Common prescribing errors noted were omissions of medications taken and prescription of wrong dosages. One advantage of having POM in the hospital is the opportunity to assess proper medication storage and to check issue and expiry dates.

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]

Study Objective. To determine the nature and prevalence of potential interactions between prescription drugs and complementary and alternative medicines (CAMs) and the reasons some patients do not advise their physicians of CAM use. Design. Cross-sectional survey. Setting. The emergency department of the Royal Melbourne Hospital, a tertiary referral center. Patients. Four hundred four adult patients (≥ 18 yrs) who visited the emergency department between February 1, 2002, and March 31, 2003. Intervention. A specifically designed, self-administered questionnaire, available in seven languages. Measurements and Main Results. Main outcome measures were the prevalence of potential prescription drug-CAM interactions and the reasons some patients do not advise their physicians of CAM use. Mean ± SD patient age was 50.6 ± 20.0 years; 220 patients were men (54.5%, 95% confidence interval [CI] 49.5-59.4%). When asked about use during the previous year, 275 patients (68.1%, 95% CI 63.2-72.5%) reported having taken a CAM; of these, 138 were also taking a prescription drug. We identified 15 documented potential drug-CAM interactions in nine patients (3.3% of CAM users, 95% CI 1.6-6.3%) and 97 theoretical potential drug-CAM interactions in 51 patients (18.6% of CAM users, 95% CI 14.2-23.8%). Aspirin and warfarin were the most commonly involved drugs. Of CAM users, 197 (71.6%, 95% CI 65.9-76.8%) never informed their physician about CAM use, most frequently because they were not asked. Conclusion. The prevalence of potential drug-CAM interactions among patients in the emergency department is considerable, and some of these interactions could be clinically significant. Practitioners should increase their awareness of potential drug-CAM interactions, and education initiatives aimed at encouraging patient-physician discussion of CAM use are recommended, such as a CAM history in their patient evaluation. Further research is required to better determine the clinical significance of drug-CAM interactions. [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]

Abstract Amiodarone is a highly efficacious antiarrhythmic agent for many cardiac arrhythmias, ranging from atrial fibrillation to malignant ventricular rhythm disturbances. Significant interest has developed in recent years with the publication of randomized controlled trials supporting the efficacy of amiodarone over placebo and lignocaine for improving survival to hospital in patients with shock-resistant ventricular fibrillation. Amiodarone has complex pharmacological and pharmacokinetic properties. It has significant long-term adverse effects, but short-term administration of intravenous amiodarone is generally well tolerated. This article will explore issues related to the clinical use of amiodarone from an emergency medicine perspective. [ABSTRACT FROM AUTHOR]

The article focuses on Acetaminophen intoxication. The standard regimen used in Australia is intravenous N-acetylcysteine administered over approximately 20 hours, comprising an initial dose of 150 mg/kg infused over either 15 or 60 minutes. followed by 50 mg/kg over 4 hours, then lOU mg/kg over 16 hours. In Australia, N-acctylcysteine is available as both a nebulizable solution and a specifically manufactured intravenous formulation. The standard practice in many emergency departments in Australia is for patients presenting with uncomplicated acetaminophen overdoses to be admitted to a short-stay unit for administration of the 20-hour infusion.