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Background: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are now indicated for heart failure and chronic kidney disease (CKD), irrespective of the presence of diabetes. Hence, cardiologists and nephrologists have an important role in initiating these drugs., Aims: To explore cardiologists' and nephrologists' perspectives regarding initiating SGLT2i and their safety monitoring practices when initiating SGLT2i., Methods: Purposive and snowball approaches were used to recruit participants working in diverse areas in New South Wales, Australia. Semi-structured interviews were conducted with 12 cardiologists and 12 nephrologists. Interviews were conducted until thematic saturation was reached. Emergent themes were identified from transcripts. An iterative general inductive approach was used for data analysis., Results: There was a reluctance amongst most non-heart-failure subspecialist cardiologists to initiate SGLT2i. Reasons included the perception of SGLT2i as diabetes drugs, concern about side effects, lack of experience and issues with follow-up. In contrast, nephrologists reported feeling confident to initiate SGLT2i. Nephrologists varied in their opinions about the severity of CKD at which SGLT2i initiation was reasonable and monitoring of renal function following initiation. Government subsidisation was an important factor in the decision to prescribe SGLT2i to people without diabetes., Conclusions: Our findings highlight the complex transition from the perception of SGLT2i as diabetes drugs to cardiometabolic and reno-protective agents. Interdisciplinary collaboration may enable greater confidence amongst specialists to initiate SGLT2i, including in patients with CKD. Additionally, there is a need for clear and detailed guidance about SGLT2i prescription in patients with renal dysfunction and renal function monitoring following SGLT2i initiation., (© 2023 The Authors. Internal Medicine Journal published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Physicians.)

Background: Deprescribing, the supervised withdrawal of inappropriate medications, intends to manage polypharmacy, which is prevalent in older patients., Aims: To examine general practitioner (GP) perceptions of communication processes between clinicians in hospital and GP in the community about deprescribing decisions made in hospital., Methods: Focus groups and interviews were held with 15 GP, exploring deprescribing in hospitals, communication of deprescribing information and the format of communications. Sessions were audiotaped, transcribed and analysed using an inductive approach., Results: GP stated that they should be involved in deprescribing decisions, especially for older complex patients, because of their good knowledge of their patients. Barriers to effective communication included the acute nature of hospital stays and lack of time. Facilitators included long-term relationships of GP with their patients and engaged patients. GP preferred communication of deprescribing decisions to be over the telephone while the patient was still in hospital, and with a concise, electronic discharge summary at the time of discharge. GP indicated that rationale for medication changes and recommended follow-up actions were crucial in a discharge summary to enable care post-discharge., Conclusions: GP welcome increased communication with hospital clinicians regarding deprescribing decisions made while patients are in hospital. Communication needs to be timely, transparent, succinct and accessible. Lack of time and difficulties contacting hospital clinicians challenge this process., (© 2021 Royal Australasian College of Physicians.)

Background: Vancomycin is the primary treatment for methicillin-resistant Staphylococcus aureus infections. Hospital audits have showed that dosing and therapeutic drug monitoring practices for vancomycin are suboptimal. Limited studies have examined the current educational resources used to support vancomycin use., Aims: To explore and compare the perceptions of health educators and recipients of education on the methods currently used to educate health professionals about vancomycin and to identify ideal methods of education., Methods: Semi-structured interviews were conducted with health educators around Australia and with recipients of education (doctors and nurses). Interview questions explored previous experiences of education and perceptions of ideal methods of education. Interviews were audio-taped, transcribed and thematically analysed., Results: Health educators explained that current vancomycin education comprises large-scale presentations, but they perceived these to be ineffective. The recipients of vancomycin education reported a lack of formal education on vancomycin. Despite this, both educators and recipients agreed on the ideal methods of education: nurses are reported to be protocol driven, and education for nurses should be through in-services or e-learning modules, while doctors require an evidenced-based approach. Senior doctors initially require convincing that education is needed. Once convinced, they respond well to brief emails and case-based and one-on-one education strategies. Technology-based strategies and problem-based learning were observed to be effective methods for junior doctors., Conclusions: Vancomycin dosing and therapeutic drug monitoring involves multiple health professionals, but current education strategies do not take this into account. Ideal education strategies need to be multimodal and targeted to specific health profession groups., (© 2019 Royal Australasian College of Physicians.)

Background: Patients admitted to hospital on weekends have a greater risk of mortality compared to patients admitted on weekdays. Junior medical officers (JMO) make up the majority of medical staff on weekends. No previous study has quantified JMO work patterns on weekends., Aim: To describe and quantify JMO work patterns on weekends and compare them with patterns previously observed during the week., Methods: Observational time and motion study of JMO working weekends using the Work Observation Method by Activity Timing (WOMBAT; Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia) software. Descriptive statistics were used to determine the proportion of total observed time spent in tasks., Results: Weekend JMO predominately spent time in indirect care (32.0%), direct care (23.0%) and professional communication (22.1%). JMO spent 20.9% of time multitasking and were interrupted, on average, every 9 min. Weekend JMO spent significantly more time in direct care compared with weekdays (13.0%; P < 0.001) and nights (14.3%; P < 0.001). Weekend JMO spent significantly less time on breaks (8.5%), with less than 1 h in an 11-h shift, compared with JMO during weekdays (16.4%; P = 0.004) and nights (27.6%; P = <0.001). Weekend JMO were interrupted at a higher rate (6.6/h) than on weekdays (rate ratio (RR) 2.9, 95% confidence intervals (CI) 2.6, 3.3) or nights (RR 5.1, 95% CI 4.2, 6.1). Multitasking on weekends (20.9%) was comparable to weekdays (18.9%; P = 0.19) but significantly higher than nights (6.4%; P = <0.001)., Conclusion: On weekends, JMO had few breaks, were interrupted frequently and engaged in high levels of multitasking. This pattern of JMO work could be a potential contributing factor to the weekend effect in terms of JMO abilities to respond safely and adequately to care demands., (© 2016 Royal Australasian College of Physicians.)

Background: An emphasis on renal function in deciding maintenance doses of allopurinol to prevent allopurinol hypersensitivity has resulted in ineffective prevention of attacks of gout. New therapeutic guidelines for gout have shifted the focus back to titrating maintenance doses to reach a serum uric acid (SUA) concentration target of ≤ 0.36 mmol/L., Aims: To examine trends in the prescribing of allopurinol in a teaching hospital and their concordance with the new guidelines for gout management, and to explore prescribers' approaches and attitudes to the use of allopurinol., Methods: An audit was conducted of all inpatients prescribed allopurinol at a teaching hospital between January 2008 and December 2012. Allopurinol dose, SUA, serum creatinine concentrations and estimated glomerular filtration rates were extracted from the hospital databases. Doctors from medical units who regularly prescribed allopurinol were interviewed., Results: The allopurinol dose prescribed in gout patients most commonly was a continuation of the pre-admission dosage. Dosage change during admission was rarely observed. Dosages reflected a consideration of renal function. SUA concentrations were measured in only 21% (n = 269) of gout patients. Prescriber interviews (n = 12) reflected adequate knowledge regarding allopurinol use, but most maintained that the primary care setting was more suitable for the management of dose titration in gout., Conclusions: SUA concentrations were not routinely measured in the majority of admitted gout patients taking allopurinol. Without SUA measurements and allopurinol dose titration, patients with SUA > 0.36 mmol/L are at increased risk for acute attacks of gout in hospital., (© 2015 Royal Australasian College of Physicians.)

Background: Previous work has examined the impact of technology on information sharing and communication between doctors and patients in general practice consultations, but very few studies have explored this in hospital settings., Aims: To assess if, and how, senior clinicians use an iPad to share information (e.g. patient test results) with patients during ward rounds and to explore patients' and doctors' experiences of information sharing events., Methods: Ten senior doctors were shadowed on ward rounds on general wards during interactions with 525 patients over 77.3 h, seven senior doctors were interviewed and 180 patients completed a short survey., Results: Doctors reported that information sharing with patients is critical to the delivery of high-quality healthcare, but were not seen to use the iPad to share information with patients on ward rounds. Patients did not think the iPad had impacted on their engagement with doctors on rounds. Ward rounds were observed to follow set routines and patient interactions were brief., Conclusions: Although the iPad potentially creates new opportunities for information sharing and patient engagement, the ward round may not present the most appropriate context for this to be done., (© 2014 The Authors; Internal Medicine Journal © 2014 Royal Australasian College of Physicians.)

Background: It is imperative to understand the current work practices of hospital personnel to inform efforts and secure resources towards the improvement of hospital systems. Research examining doctors' work during night-shifts is limited., Aim: To describe and quantify the night-shift work practices of junior doctors., Methods: An observational time and motion study was conducted. Eight resident doctors in four general wards were observed for 96 h during night shifts (Monday-Friday, 2200-0800)., Results: Doctors spent the highest proportion (28%; 95% CI 21-35) of their time performing social/personal tasks (e.g. sleeping, eating) and indirect care (24%; 95% CI 22-25) (e.g. reviewing notes, ordering tests). Work-related discussion comprised 15% (95% CI 13-17), and most took place at the beginning of the night. Medication-related tasks consumed a small proportion of time (4%; 95% CI 3-4) but attracted a higher level of multitasking and interruptions than most other tasks. On average, 2 h of every shift were spent at a computer and 1.3 h with patient notes. Doctors spent 72% of the night-shift alone, multitasked 6.4% of the time and were interrupted, on average, once every 46 min., Conclusions: This study provides new data about junior doctors' work at night. Relative to doctors during the day, greater proportions of time were devoted to social/personal tasks (including sleep) and indirect care, but a similar proportion to direct care. Multitasking and interruptions were minimal. Computer activities were an integral part of work. Handovers were observed at the beginning but not the completion of the night shift, which may have implications for patient safety., (© 2013 The Authors; Internal Medicine Journal © 2013 Royal Australasian College of Physicians.)