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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]

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]

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]

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]

Aim: To assess continuity of medication management during transition from hospital to residential care facilities (RCFs). Method: Telephone interviews with RCF staff were performed 24 hours after patient transfer to determine the proportion of patients with: missed or significantly delayed doses; RCF medication chart not written/updated in time for the first dose; suitably packed medications not available for the first dose; and RCF medication chart written/updated by a locum doctor. Retrospective audit was used to identify discharge summary discrepancies. Results: Seventy-five doses for 37/202 (18.3%) patients were missed or significantly delayed in the 24 hours after discharge. One hundred and twenty-five (61.9%) patients did not have their medication chart written/updated and 77 (38.1%) did not have suitably packed medications available for the first dose. Locum doctors wrote RCF medication charts for 66 (32.7%) patients. One hundred and ninety-seven of 392 (50.3%) changes to regularly scheduled medications were communicated. Conclusions: Strategies are needed to address gaps in the continuity of medication management. [ABSTRACT FROM AUTHOR]

Background: An interim residential care medication administration chart (IRCMAC), usually handwritten by hospital medical officers, is provided by some hospitals to reduce the risk of medication administration delays and errors for patients discharged to residential care facilities (RCFs). Aim: To describe a novel method for IRCMAC preparation; and to determine the percentage of patients discharged from hospital to RCFs who received an IRCMAC, the accuracy of the IRCMAC, and the time IRCMAC preparation added to the pharmacy discharge process. Method: Software and processes were developed to enable integration of IRCMAC preparation into the pharmacy discharge process, with auto-population of the IRCMAC with patient, prescriber and medication data. The percentage of patients for whom RCF staff reported receiving an IRCMAC over a 3-month study period was determined by telephone interview 24 to 72 hours post-discharge. Accuracy was determined by retrospective comparison of a random sample of IRCMACs with pharmacist reviewed and reconciled discharge prescriptions to identify discrepancies. Time added to pharmacy discharge processes was recorded prospectively by pharmacy staff. Results: RCF staff reported receiving IRCMACs for 214/226 (95%) patients discharged to 84 RCFs. The medication discrepancy rate (excluding nutritional supplements) in 76 randomly selected IRCMACs was 9/877 (1%). The IRCMAC took a mean of 8.7 (SD 4.1) minutes to prepare. Conclusion: Accurate IRCMACs can be provided for a high percentage of patients discharged to RCFs by hospital pharmacists using a semi-automated process linked to dispensing software. [ABSTRACT FROM AUTHOR]

Aim: To investigate complementary and alternative medicines (CAM) knowledge and use in patients on warfarin and matched controls, and the association between CAM use and adverse events (bleeding or clotting). Method: A retrospective cohort study was undertaken in the emergency department of a Melbourne hospital. Patients in the warfarin and control groups were those taking/not taking warfarin, respectively (groups matched for age and gender). An investigator-administered questionnaire was used to collect data on CAM knowledge and use, and bleeding/clotting events during the previous 6 months. The international normalised ratio (INR) data during the previous 6 months were obtained from medical and pathology records. Results: 246 warfarin and 246 control group patients were enrolled. Approximately 50% in each group indicated that they knew of the potential for CAM-drug interactions. Only 60 (24%) patients in the warfarin group reported having been advised about CAM use. Compared to controls, a similar proportion of warfarin patients reported CAM use (29% vs 37%; p = 0.07) and significantly fewer used a CAM known to interact with warfarin ('interacting CAM') (11% vs 19%; p = 0.03). In the warfarin group, CAM users and non-users reported a similar number of events below and above their therapeutic INR range and when the INR exceeded 5. CAM users in the warfarin group tended to have more abnormal bleeding events (42% vs 30%; p = 0.06) but a similar number of clotting events (9% vs 10%; p = 0.8) than CAM non-users. Warfarin patients who used 'interacting CAM' had significantly more clotting events than those who used CAM not known to interact with warfarin (18% vs 2%; p = 0.02). Conclusion: CAM knowledge in people on warfarin was poor. 'Interacting CAM' used concomitantly with warfarin may be associated with increased rates of clotting events. [ABSTRACT FROM AUTHOR]