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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]

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]

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]

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]

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]

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.