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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: 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]

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]

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]