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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]

On 21 November 2016, during a thunderstorm asthma event, an external disaster was called in our Emergency Department (ED), the first since comprehensive implementation of electronic clinical documentation. This study compared medication ordering and administration documentation during surge (thunderstorm asthma) and non-surge (control) conditions. Retrospective audit of ED patients presenting with asthma between 21 and 23 November 2016 (72-h thunderstorm asthma period) and equivalent 72-h periods of the preceding three weeks (control period). Demographic details, medical history and treatment were extracted from Cerner Millennium. During the thunderstorm asthma and control periods, 318 and 164 patients presented with respiratory symptoms; 302 (95.0%) and 27 (16.5%) were due to asthma, respectively. Salbutamol was ordered and administration signed on the Medication Administration Record for 122/302 (40.4%) thunderstorm asthma and 21/27 (77.8%) control patients (p < 0.01). During the thunderstorm asthma period, 52/302 (17.2%) patients had no documentation on the Medication Administration Record or any ED notes of receiving salbutamol, whilst during the control periods 2/27 (7.4%) patients had no such documentation. Similar disparities with corticosteroids and ipratropium were identified. Quality of medication documentation declined during surge conditions. These data have informed policies for future surge events, when higher risk medications might be required. [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]

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]

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]

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]