bluuebunny/crossref_metadata_2025 huggingface dataset:
Retrospective Analysis of Emergency Readmissions to Rural and Regional Hospitals
Authors: Rothwell Michelle , Jukka Clare , Lum Elaine , Mitchell Charles , Kyriakides Peter
Published: April 2015

Background

According to the evidence, hospital readmissions within a month of discharge occur in approximately one‐third of older patients and that the majority of readmissions are preventable. Missing medication information at discharge was identified as a contributor to hospital readmissions.

Aim

To identify unplanned readmissions within 28 days of hospital discharge attributable to medications; to assess preventability; and in the medication‐related readmissions to identify the medication management information supplied to the GP on initial discharge and whether these patients were seen by a pharmacist during the initial stay and readmission.

Method

Records were analysed of patients who had an unplanned readmission within 28 days of discharge, aged 65 years and over, and on 3 or more medications at the time of discharge. A documented method developed for measuring causality, preventability and contribution of medications to the readmission was utilised.

Results

170 patients from 1 regional and 2 rural hospitals were included in the analysis. 39 (23%) readmissions were medication related and 34 (87%) of these were preventable. Dominant reasons for readmission were inadequate communication/monitoring (41%) and inappropriate/suboptimal pharmacological therapy at discharge (62%).

Conclusion

Gaps in communicating medication management information across the hospital–community interface continue to contribute to avoidable unplanned readmissions.
Evidence on Optimal Prescribing and Medicines Use for Decision Makers: Scope and Application of the Rx for Change Database
Authors: Ryan Rebecca E , Weir Michelle , Leslie Bill , Worswick Julia , Lowe Dianne B , Hill Sophie J
Published: April 2015

Rx for Change, a freely available online database, summarises the evidence on the impact of interventions to improve the quality of prescribing and medicines use. The database serves as a resource for decision makers seeking to find and use the evidence from systematic reviews on interventions to improve prescribing and medicines use by targeting the behaviours of health professionals and consumers. We describe a panel discussion held in 2010 on the database's scope and application. Panellists explored the ways decision makers might use the database to access the evidence as an input to decision making; and presented examples of the range of interventions on which evidence is assembled within the Rx for Change database and through which professional and consumer behaviours might be targeted to improve prescribing and medicines use.
Indicators of a Quality Clinical Placement in Pharmacy: Stakeholder Perspectives
Authors: Stupans Ieva , McKauge Leigh , Owen Susanne
Published: April 2015

Background

The educative role of experiential workplace placements has been discussed in the context of many health professions. Quality assurance and enhancement strategies rely on evaluations that provide valid and reliable data, so that informed decisions can be made about improving learning for students. No research could be located in the literature to determine the gap between stakeholders' perceptions of the importance of indicators and their perceptions of whether these practices occur in experiential placements.

Aim

To develop indicators that can be used to describe a quality clinical placement; and to determine stakeholder perspectives on the occurrence of the indicators in Australian pharmacy student workplace placements.

Method

A questionnaire was developed and administered to students, academics and placement preceptors.

Results

The indicators for placement quality were perceived to be important. However, perceptions of the degree to which these indicators actually occurred on placement varied between the three stakeholder groups.

Conclusion

Stakeholder groups are either not aware or do not necessarily understand the contribution of the other stakeholders to the placement process. This highlights the need for collaboration and recognition of the roles of all participants in quality placements.
Impact of a Pharmacist Intervention on Ambulatory Patients with Heart Failure: A Randomised Controlled Study
Authors: Korajkic Amela , Poole Susan G , MacFarlane Louise M , Bergin Peter J , Dooley Michael J
Published: April 2015

Aim

To determine the impact of a pharmacist intervention on patient–guided diuretic dose adjustment in ambulatory patients with heart failure.

Method

Patients with heart failure were randomised to usual care or usual care plus pharmacist intervention and followed for 3 months. Pharmacist intervention focused on patients improving self‐care, recognising symptoms of fluid retention, measuring weight daily and self‐adjusting diuretic dose using frusemide. The primary outcome was the number of appropriate weight‐titrated frusemide dose adjustments. Secondary outcomes included the number of patients who correctly self‐adjusted their frusemide dose, hospital readmissions due to fluid overload, heart failure‐related knowledge and understanding, and quality of life (using validated tools).

Results

70 patients were recruited: 35 usual care (control) and 35 usual care plus pharmacist intervention. The average number of appropriate weight‐titrated frusemide dose adjustments per patient per month in the control group was 0.32 ± 0.08 and in the intervention group was 0.85 ± 0.13 (p = 0.006). Hospital readmissions due to fluid overload was 31% in the control and 14% in the intervention groups (p = 0.04). There were significant differences between the groups regarding appropriate self‐adjusted frusemide doses, heart failure‐related knowledge and understanding, and quality of life.

Conclusion

A pharmacist intervention improved the ability of heart failure patients to self‐adjust their diuretic dose by using a flexible dosing regimen based on weight, resulting in quality of life improvement and a decrease in hospital readmissions due to fluid overload.
SHPA Standards of Practice for Clinical Pharmacy (Supplement)
Authors:   SHPA Committee of Specialty Practice in Clinical Pharmacy
Published: April 2015

These are standards of professional practice and not standards prepared or endorsed by Standards Australia. They are not legally binding.
Cost‐Minimisation Analysis of Midazolam versus Droperidol for Acute Agitation in the Emergency Department
Authors: Chan Esther W , Knott Jonathan C , Liew Danny , Taylor David McD , Kong David CM
Published: April 2015

Aim

To compare the costs of midazolam and droperidol for the management of acute agitation in the emergency department (ED).

Method

A decision analysis model was used to undertake a cost‐minimisation analysis of resource utilisation in the ED of a Melbourne hospital. Data from acutely agitated patients who received midazolam (n = 74) or droperidol (n = 79) in a randomised clinical trial (February 2002 to April 2004) were reviewed.

Results

All direct medical and non‐medical costs relating to the management of acute agitation in the ED were analysed. The average cost scenario was estimated for the 2 treatments. The model simulated 9 possible outcomes based on whether patients were ‘sedated’ or ‘not sedated’ and whether they required ‘re‐dosing’ or ‘no re‐dosing’. Hospitalisation cost incorporated multiple items as part of the average cost per service code for the ED length of stay. In the base case analysis, midazolam was associated with notably less overall drug costs (A$3.05 vs A$21.10), which contributed to less total treatment costs. The ‘expected’ median ED length of stay was marginally longer in the midazolam group (12 vs 11.8 hours), resulting in slightly higher hospitalisation costs (A$1370 vs A$1361). The midazolam group incurred higher median costs for pathology (A$78.60 vs A$61.60) and imaging (A$5.25 vs A$0.60). The cost of electrocardiograms was similar (A$27.10 vs A$28). With a cost advantage of A$59 per patient, midazolam was 3.8% less costly than droperidol (A$1496 vs A$1555).

Conclusion

Midazolam was marginally more cost saving than droperidol when used to manage acute agitation in the ED. Several challenges were identified that need to be overcome to enable future robust pharmacoeconomic studies.
Medication Information Transfer: An Exploratory Study in a Rural Queensland Community
Authors: Tan Amy CW , Emmerton Lynne M , Hattingh H Laetitia , Jarvis Victoria I
Published: April 2015

Background

Inadequate or inaccurate transfer of medication information can challenge optimal medication management. Studies of medication information transfer typically involve the hospital–community interface in urban settings. There is little research on medication information transfer between community health services, between hospitals (rural and metropolitan) and rural community settings.

Aim

To explore medication information transfer issues faced by rural healthcare providers and their perspectives on initiatives to optimise the process.

Method

Semi‐structured interviews were conducted with 49 health professionals in 4 towns in rural Queensland on issues surrounding medication supply and management. Interviews were recorded, transcribed verbatim and analysed thematically.

Results

Some of the issues identified included: discrepancies in medication records, lack of a coordinated system to communicate medication or prescription information between health professionals, and inadequate communication between secondary/tertiary facilities and rural primary care providers. According to the participants, the root causes of these challenges related to workforce issues and inefficiencies in communication and networking systems.

Conclusion

Key issues were identified relating to medication information transfer between healthcare providers and between healthcare settings, which impacted on optimal medication management for rural patients.
Development and Evaluation of an Hospital Pharmacy Generated Interim Residential Care Medication Administration Chart
Authors: Tran Tim , Elliott Rohan A , Taylor Simone E , Garrett Kent
Published: April 2015

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.
Stability Study of a Thalidomide Suspension
Authors: Hopkins Ashley M , Sharley Nicholas A , Tang Cuong D
Published: April 2015

Background

Thalidomide is being used increasingly for its immunomodulatory, anti‐inflammatory and anti‐angiogenic properties. Data on the stability of an oral liquid thalidomide formulation for use in patients with swallowing difficulties and enteral feeding tubes are lacking.

Aim

To determine the stability of a thalidomide 100 mg/10 mL suspension.

Method

Thalidomide 100 mg/10 mL suspension was formulated (in triplicate) using Thalomid capsules and stored at room temperature (22 ± 1 °C) for 31 days. Stability was assessed via high‐performance liquid chromatography (HPLC) on Days 7, 14, 21 and 31. Assay suitability was analysed via forced degradation products of thalidomide samples under acidic, basic and oxidative conditions.

Results

A validated thalidomide HPLC assay indicated that the original thalidomide content of the suspension remained within 5% throughout the 31‐day study period. After shaking, no visible changes in suspension consistency, colour or sedimentation were observed.

Conclusion

The formulated thalidomide 100 mg/10 mL suspension when protected from light and stored at room temperature was stable for up to 31 days.
Immediate Post‐Administration Safety of Bolus Gentamicin
Authors: Roberts Gregory W , Harbi Ghaleb Al , Khalessi‐Rad Mona
Published: April 2015

Aim

To compare the adverse effect profile in the 1‐hour post‐administration period for a 3‐minute gentamicin 40 mg/mL bolus with a 30‐minute gentamicin 1 mg/mL infusion.

Method

Australian guidelines recommend that IV gentamicin doses greater than 240 mg need to be diluted and infused over 20 to 120 minutes, while lower doses can be administered as a bolus using the undiluted injection solution (40 mg/mL) over 2 to 5 minutes. Patients receiving at least 2 gentamicin doses of 240 mg or greater were administered an undiluted IV bolus (40 mg/mL) over 3 minutes on one occasion and a 1 mg/mL infusion over 30 minutes on another in a randomised crossover design. Patients were assessed for pain, swelling and redness at the injection site, tinnitus, dizziness, headache and nausea at 0, 15, 30 and 60 minutes after administration of the gentamicin dose.

Results

47 patients completed the study. Mean administration rates in the bolus and infusion arms were 105 ± 27 mg/min and 12 ± 8.1 mg/min, respectively. During the bolus phase, more patients complained of increased pain at the injection site immediately after completion of the bolus dose (34% vs 9%, p < 0.01), but this effect had dissipated at the 15‐minute assessment (4% vs 4%). There were no differences in any other parameters at any of the assessment times.

Conclusion

Bolus gentamicin of up to 480 mg (undiluted 40 mg/mL injection) administered over 3 minutes can be used as an alternative to a diluted gentamicin infusion, but may cause transient IV site pain.
Anticoagulation for Non‐Valvular Atrial Fibrillation in Older People
Authors: Grewal Jasmin , Farouque Omar
Published: April 2015

Atrial fibrillation (AF) is a common arrhythmia that increases in prevalence with advancing age. Systemic thromboembolism, a complication of AF and ischaemic stroke, is the most frequent clinical manifestation. The risk of stroke is increased in the presence of factors such as advancing age, heart failure, hypertension, diabetes and history of stroke. Long‐term anticoagulation with warfarin has been the standard treatment for stroke prevention in patients with AF. In older people anticoagulation is associated with an increased risk of bleeding. Therefore, managing AF in older people can be a clinical challenge because not only are they at a high risk of thromboembolism but also of bleeding. Stroke risk stratification schemes have been developed to guide assessment of risks versus benefits. Other considerations in older people include monitoring anticoagulation, and assessing falls risk, compliance and the potential for drug interactions. A range of novel oral anticoagulants, such as direct thrombin inhibitors and factor Xa inhibitors, have been developed. These anticoagulants have demonstrated advantages in safety, efficacy and convenience of use in large randomised clinical trials. These novel anticoagulants could provide alternatives to warfarin for preventing stroke in older people with AF.
Alternatives to Post‐Discharge Home Medication Reviews for High‐Risk Patients: Doctors' and Pharmacists' Views
Authors: Padhye Vaishali , Ponniah Anne P , Spurling Lisa K , Bong Xin Jou , Shakib Sepehr , Angley Manya , Angley Manya
Published: April 2015

Background

We examined health professionals' views of a novel post‐discharge medication review model for high‐risk patients with 2 referral pathways – general practitioners (GPs) referring for home medicines reviews (HMRs) or hospital doctors referring for hospital‐initiated medication reviews (HIMRs).

Aim

To identify positive and negative aspects of the model, barriers and facilitators to implementation and to make recommendations for a post‐discharge home medication review program.

Method

23 semi‐structured interviews were conducted with key stakeholders – hospital doctors, GPs, accredited pharmacists, hospital pharmacists and community pharmacists. Data were analysed thematically based on a conceptual framework.

Results

There was consensus that the availability of flexible pathways to post‐discharge home medication reviews was vital for patient care. Participants highlighted it was crucial that the patient's GP and community pharmacist are kept informed if the HIMR pathway was chosen. Barriers to implementation were time constraints experienced by health professionals to organise and conduct the review within 7 days post‐discharge and lack of awareness of the HMR process. Facilitators to implementation included existing positive working relationships and familiarity and support for the HMR process. Suggestions for future implementation included incorporating the liaison pharmacist role into the usual responsibilities of clinical pharmacists and educating medical interns about the model.

Conclusion

Consensus among medical and pharmacy stakeholders was that streamlined and flexible pathways to post‐discharge medication reviews would enhance quality use of medicines along the continuum of care.
Prescribing Benzodiazepines in Residential Aged‐Care Facilities
Authors: Blogg Lynda C , Suzuki Nao , Roberts Malcolm , Clifford Rhonda M , Clifford Rhonda M
Published: April 2015

Background

Benzodiazepines (BZDs) are used to treat sleep disturbances and behavioural and psychological symptoms of dementia in residents of aged‐care facilities. Older people are vulnerable to the adverse effects of BZDs. In Australia, guidelines exist for prescribing BZDs, however there are a lack of data comparing prescribing patterns with guidelines.

Aim

To review BZD prescribing patterns in residential aged‐care facilities and to compare these with best‐practice guidelines.

Method

A cross‐sectional analysis of BZD prescribing for residents aged 65 years and over was undertaken in 6 aged‐care facilities. Data on patient demographics and BZD prescribing were obtained from medication charts, medical records and case notes. BZD prescribing patterns were compared to guidelines from the National Prescribing Service and Therapeutic Guidelines.

Results

Prescribing data for 193 residents were analysed. 71 (37%) residents were prescribed a BZD, mostly temazepam and oxazepam. The majority of prescriptions complied with the guidelines with respect to dose, but all exceeded the recommended duration of therapy. 55 (77%) residents had comorbidities for which guidelines recommended avoiding BZDs, such as a history of falls.

Conclusion

Although the choice and dose of BZD were appropriate, prescribing did not adhere to guidelines because of the extended duration of therapy. Residents with comorbidities where BZDs should be avoided were frequently prescribed a BZD.
Establishing Clinical Pharmacy Services in the Operating Suite
Authors: Booth Jane C , Garrett M Kent , Taylor Simone E , Trajceska Ljubica
Published: April 2015

Despite having well‐established clinical roles in many specialties, hospital pharmacists have not traditionally provided clinical services in the operating suite (OS). This paper describes the introduction of a clinical pharmacy service in the OS of a large metropolitan public hospital network. The initial focus of the service was on non‐clinical issues that were priorities for pharmacy and OS staff, such as medication supply, waste minimisation, expenditure, interdepartmental communication and legal compliance. Once ongoing funding for the positions was secured, cognitive clinical pharmacy services have become the focus. Benefits of the service have been demonstrated in medication safety, antibiotic stewardship and quality use of medicines. The 2 pharmacists have now become essential members of the OS. Work is underway to further develop pharmacists' roles in areas such as perioperative antimicrobial prescribing and perioperative management of patient's regular medication regimens to optimise the continuum of care.
Stability of Two Long‐Acting Insulin Formulations after 28 Days
Authors: Silva Matthew A , Chuong Monica , Kerr Stephen , Cabrera Adriana
Published: April 2015

Background

Insulin when stored according to manufacturers' recommendations offer at least 28 days of use after opening. A realistic understanding of room temperature storage at home includes exposure to heat and light. Pharmacy refill data suggest that patients tend to use opened insulin beyond 28 days. Insulin quality could be effected after 28 days when stored under uncontrolled conditions.

Aim

To evaluate the stability of two long‐acting insulin formulations, Humulin 70/30 and Levemir, after 28 days.

Method

A high‐performance liquid chromatography assay was used to quantify insulin area under the curve (AUC) profiles as an indicator of insulin quality. Human recombinant insulin (Humulin) 70/30 and insulin detemir (Levemir) vials were stored in refrigerated (2–8 °C, 36–46 °F) and room temperature (22–24 °C, 72–75 °F) conditions for up to 42 days, emulating patient managed storage and use patterns. Samples were taken on opening (time 0) and vials were randomised and stored in refrigerated or at room temperature conditions. Samples were taken and evaluated at Days 7, 14, 21, 28, 35 and 42.

Results

Humulin 70/30 and Levemir generated chromatograms with characteristic peaks at 12 and 21 minutes. Refrigerated Humulin 70/30 and Levemir AUCs were compared to time 0 and no differences were found. By Day 35, some Humulin 70/30 samples at room temperature had changes in AUC (p = 0.002) and loss of symmetry when compared to time 0 and all samples at Day 42 had changes in AUC (p < 0.0001). A similar pattern occurred with Levemir; some samples at room temperature had changes in AUC (p = 0.005) and loss of symmetry when compared to time 0 and all samples at Day 42 had changes in AUC (p < 0.0001).

Conclusion

Room temperature storage may effect Humulin 70/30 and Levemir AUCs and chromatograms by Day 42. Patients should be advised to store insulin in the refrigerator when possible and reminded that insulin quality can be effected by room temperature storage and beyond date use.
Paediatric Pharmacy in Australia: Where Have We Come From and Where Do We Need To Go?
Authors: Stacey Sonya R , Turner Sean C , Coulthard Kingsley P , Miller Hugh
Published: April 2015

Paediatric pharmacy has evolved swiftly over the last 40 years, with pharmacists across Australia working to improve the health of children at an individual and population level. A number of professional groups have been formed to share information, educate staff and lobby for change. Paediatric pharmacists in Australia need access to specialist training as is available to their international peers and other paediatric disciplines. Research and advocacy need to continue for better access to medicines and appropriate information resources to improve medicines use in children.
Cardiovascular Risk Reduction in the Extreme Elderly
Authors: Parikh Seema , Sharkey Kerith , Workman Barbara
Published: April 2015

An American Heart Association statement on secondary prevention of coronary heart disease in the elderly reported that 50% of women and 70% to 80%) of men over 75 years have obstructive coronary artery disease. The total direct and indirect costs of cardiovascular disease and stroke in the US for 2007 was around $286 billion and annual costs are projected to rise to over $1 trillion by 2030. Significant emphasis is now placed on prevention and risk factor modification of cardiovascular disease. The proportion of the population aged 85 years and older (the ‘extreme elderly‘) is projected to increase to 151% by 2030. This review focuses on reducing risk in coronary heart disease and congestive heart failure in the extreme elderly. We review modifiable cardiovascular risk factors (hypertension, lipid profile, lifestyle modification), pharmacological strategies (statins, beta‐blockers, angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, aspirin) and the available evidence for their use in extreme old age. There is insufficient evidence to reach major conclusions with respect to cardiovascular risk reduction in the extreme elderly. Further trials involving older patients are needed before evidence‐based recommendations can be formulated for this population.
Pneumonia Severity Scores and Prescribing Antibiotics for Community‐Acquired Pneumonia at an Australian Hospital
Authors: Brett Jonathan , Lam Vincent , Baysari Melissa T , Milder Tamara , Killen Louise , Chau Anthony MT , McMullan Brendan , Harkness John , Marriott Deborah , Day Richard O
Published: April 2015

Aim

To evaluate the use of pneumonia severity scores for diagnosing community‐acquired pneumonia (CAP) and to assess whether antibiotic prescribing was compliant with guidelines as determined by the calculated pneumonia severity score.

Method

A retrospective chart review was undertaken of consecutive adults admitted via the emergency department with a diagnosis of CAP during a 6‐month period. Charts were reviewed for symptoms and radiographic evidence of pneumonia and for recorded pneumonia severity scores. Pneumonia severity scores were calculated using CORB, CURB‐65 and SMART‐COP for patients with available data and used to assess compliance with the Therapeutic Guidelines: Antibiotic.

Results

Of the 204 patients reviewed Of the 204 patients reviewed CURB‐65 and SMART‐COP scores for the remaining 68 patients, 13 (19%), 3 (4.4%) and 1 (3.6%) patients had severe pneumonia. 93% of patients received ceftriaxone. An average of 8% of patients were prescribed antibiotics compliant with the Therapeutic Guidelines: Antibiotic. Compliance varied with the pneumonia severity scoring tool used.

Conclusion

Pneumonia severity scores were rarely calculated to guide treatment and antibiotic prescribing for CAP. Compliance with the Therapeutic Guidelines: Antibiotic was poor and varied with the pneumonia severity scoring tool used. An easy‐to‐use pneumonia severity score to guide patient admission and choice of antibiotic is needed.
Development of a Postgraduate Educational Program for Pharmacist Prescribers in New Zealand
Authors: Shaw John P , Print S Adele , Duffull Stephen B
Published: April 2015

Background

Pharmacist prescribing is now well established in several western countries. In New Zealand, an independent prescribing authority for suitably experienced clinical pharmacists has been approved, subject to successful delivery of a postgraduate educational program.

Aim

To describe the development of an educational program for pharmacist prescribers in New Zealand and to reflect on its suitability in producing safe and competent pharmacist prescribers.

Method

The educational program was based on similar courses in the UK and adapted to the competency requirements of the Pharmacy Council of New Zealand. The 2‐semester program comprises 2 courses: Principles of Prescribing and Prescribing Practicum. A key feature of the Practicum is the requirement for 150 hours of prescribing practice supervised by a designated medical practitioner.

Results

The educational program was delivered for the first time in 2012 with 14 students enrolled. 10 students passed at the first attempt and 4 students passed after repeating elements of the Practicum. The program has been granted conditional accreditation by the Australian Pharmacy Council.

Conclusion

An educational program for pharmacist prescribers in New Zealand has been successfully developed and delivered. Graduates are eligible to register in the Pharmacist Prescriber Scope of Practice.
Should Pharmacists in Australia have Access to a Structured General Level Training Program?
Authors: Shah Simon S , Avent Minyon L , Coombes Ian D
Published: April 2015

Hospital pharmacists in Australia do not have access to a formal or structured post‐registration training program to enhance practitioner development in order to offer improved, consistent and equitable patient care. Enrolling in a postgraduate course through an educational facility is one of few options available to gain further experience of different clinical areas. This option may only allow theoretical learning to occur and new knowledge and skills acquired may not be utilised in a timely manner, thus resulting in their loss. There are established rotational training programs across developed countries' pharmacy services. Ideally, Australia will develop a similar program as a component of professional development. We describe a proposed rotational training program for pharmacists including rotation to rural sites as part of a foundation program. Barriers to the development and implementation of a rotational training program have been identified, e.g. accommodation and transport costs, lack of a suitable funding model, lack of suitably trained pharmacists to conduct training and provide supervision. We propose that there is a need for a standardised rotational training program, which is supported by appropriate mentoring and a documented record of learning outcomes.
Probable Case of Ibuprofen‐Induced Neutropenia
Authors: Murphy Catherine E
Published: April 2015

Background

Approximately 6% of admissions to Australian hospitals are due to adverse drug events. This incidence increases to around 30% of admissions for elderly Australians. Neutropenia associated with ibuprofen is documented as a haematological side effect with an incidence of less than 1%.

Clinical details

A 44‐year‐old man presented to his GP with fever, cough, lymphadenopathy, mouth ulcers, night sweats and lack of energy. His neutrophil count was 0.07times109/L. He had taken 6 to 8 ibuprofen 400 mg tablets in the previous 24 hours to alleviate his symptoms. He had also used ibuprofen on an ‘as required’ basis for body aches during the 2 weeks prior to presentation.

Outcomes

The patient was given filgrastim 300 micrograms daily. Piperacillin+tazobactam and gentamicin were also commenced. Bone marrow biopsy showed active normocellular marrow with ‘maturation arrest‘, consistent with a drug‐induced reaction. The patient was discharged 48 hours after presentation with 2 further doses of filgrastim. The patient was advised to avoid nonsteroidal anti‐inflammatory drug use in the future.

Conclusion

While ibuprofen is thought by many to be a safe over‐the‐counter medicine, it is not without life‐threatening side effects. The possibility of ibuprofen‐induced neutropenia should be considered in all cases of unexpected isolated neutropenia in patients taking this drug, with prompt referral to specialist care in cases of severe neutropenia or sepsis.
Afatinib after Disease Progression with Gefitinib in Advanced Adenocarcinoma of the Lung
Authors: Belz Stephen A , Grima Geoffrey J
Published: April 2015

Background

Non‐small cell lung cancer (NSCLC) is the most common form of lung cancer and comprises 75% to 85% of all lung cancer diagnoses. Epidermal growth factor receptor (EGFR) mutation positive disease comprises 10% of patients in the USA and is higher in people of Asian ancestry. Gefitinib and erlotinib are reversible tyrosine kinase inhibitors (TKIs) approved for advanced or metastatic disease but utility is limited by the emergence of resistance. Afatinib, an irreversible TKI, is under investigation for people who have developed TKI resistance.

Aim

To report a case of a patient with EGFR mutation positive NSCLC who developed resistance to gefitinib and was treated with afatinib.

Clinical details

A 61‐year‐old female presented with history of cough, malaise and anorexia that had not resolved with antibiotics and increased doses of inhaled corticosteroid. The only other medical history of note was gastro‐oesophageal reflux disease, lupus (mild arthralgia) and irritable bowel syndrome. A CT scan showed unusual lesions throughout the lungs. Bronchial washing (left upper lobe), bronchoalveolar lavage, bronchial brushing (left upper lobe) and transbronchial biopsy were consistent with adenocarcinoma. Biopsy of a right scapular lesion confirmed metastatic adenocarcinoma of the lung. The tumour was found to be positive for an EGFR mutation.

Outcomes: After 12 months of therapy, the patient experienced disease progression and afatinib was commenced. After 1 month of treatment, respiratory symptoms and energy levels began to improve. CT imaging showed stable disease. The patient is being followed up on a monthly basis.

Conclusion

Emerging resistance to reversible TKIs poses a significant problem. Oral irreversible TKIs such as afatinib may offer an effective treatment option with minimal lifestyle interruptions and a predictable toxicity profile.
Management of Obesity in Older People
Authors: Haywood Cilla , Proietto Joe
Published: April 2015

Obesity rates are on the rise in most developed countries. This phenomenon is also seen in people over the age of 65 years. Although obesity in older people is believed to be protective in some instances (the obesity paradox), there is evidence that obesity in older age can increase the risk of disability. Modest weight loss achieved with hypocaloric diets and exercise is safe and efficacious in improving physical function. Good quality evidence for other obesity management measures in older people, such as bariatric surgery, very low energy diets and anti‐obesity medications are lacking, as is pharmacokinetic data. We review current evidence for management of obesity in older people and the role of anti‐obesity medications.
Capturing Pharmacy Activities Using Barcode Technology
Authors: Samios Peter A
Published: April 2015

Background

Recording pharmacy activities beyond clinical pharmacist interventions is challenging. Traditional methods of manual data collection are cumbersome and time consuming. Technology, such as barcode scanners, has the potential to provide a portable, reproducible and simplified approach to data collection. Allied health disciplines at St Vincent's Hospital, Sydney successfully switched from manually collecting daily activity data to an electronic system using barcode technology (Activity BarCoding).

Aim

To introduce Activity BarCoding into the pharmacy department and collect data on daily pharmacy activities.

Method

Activity BarCoding software was installed and barcode scanners were purchased. Based on the Society of Hospital Pharmacists of Australia's definitions, pharmacy activities were divided into: clinical care, management, distribution services, research, and teaching and training. Sub‐categories were developed for each activity type, as well as interventions to describe clinical activity. Barcodes were produced for all activities. After a 6‐month development phase, implementation began in June 2011. The system was rolled out over 18 months to all pharmacy staff. 12 months after implementation, pharmacists were surveyed about their perceptions of the Activity BarCoding system.

Results

During November 2012, 39 users recorded 5809.5 hours of activity − 22% (1279.3 h) clinical care, 44% (2573.7 h) distribution services, 13% (777.5 h) management, 2% (96.6 h) research and 1% (61.5 h) teaching and training. Inpatient and outpatient dispensary activities accounted for 40% (1033.5 h) and 28% (712.5 h) of the distribution hours, respectively. Of the 20 users surveyed, 55% disagreed and 15% strongly disagreed that data collection was too labour intensive.

Conclusion

Activity BarCoding was successfully introduced into the pharmacy department to collect data on daily pharmacy activities. The system was flexible, easy to use and integrated well into a busy work place.
Stability of Paracetamol Tablets Repackaged in Dose Administration Aids for prn Use: Implications for Practice
Authors: Kockler Jutta , Robertson Sherryl , Hope Denise , Haywood Alison , Glass Beverley
Published: April 2015

Background

Paracetamol tablets are often repackaged into dose administration aids (DAAs) for prn use. Pharmacists have limited information regarding the long‐term stability of prn medicines stored in DAAs for extended periods due to infrequent dosing. According to current guidelines, in the absence of specific data, medicines should not be stored in a DAA for longer than 8 weeks.

Aim

To determine the physicochemical stability of paracetamol tablets repackaged into DAAs and stored for 12 months.

Method

Paracetamol (Panamax) tablets were removed from primary packaging, repackaged into DAAs (Multi Dose Webster‐pak) and stored under ambient (25 °C; 60% relative humidity) and accelerated (40 °C; 75% relative humidity) conditions for 12 months. Physical characteristics of the tablets, such as appearance, weight uniformity, thickness, hardness, friability, disintegration and dissolution rates were evaluated at baseline, 3, 6 and 12 months. Chemical stability was confirmed by high performance liquid chromatography.

Results

All compendial requirements for physical stability were met for tablets stored under ambient and accelerated conditions over the 12‐month period. Chemical stability was confirmed, with paracetamol content in the tablets within the British Pharmacopoeial range of 95% to 105% of the labelled amount.

Conclusion

This study provides data on the stability of paracetamol tablets repackaged into DAAs and stored under ambient and accelerated conditions for 12 months. Pharmacists will be able to make risk–benefit assessments and recommend a 12‐month expiry on paracetamol prn DAAs.
Antimicrobial Prescribing in a Rapid Assessment Medical Unit – A Multi‐Phase Pilot Study
Authors: Koning Sonia I , Rhodes Jessica , Rofe Olivia C , Sundararajan Vijaya , O'Reilly Mary , Koning Sonia I
Published: April 2015

Background

Increased awareness of antimicrobial resistance has resulted in the introduction of institutional antimicrobial stewardship programs.

Aim

To evaluate antimicrobial prescribing in a Rapid Assessment Medical Unit (RAMU) after the introduction of an antimicrobial stewardship pharmacist (ASP) and antimicrobial stewardship team (AST); and to review acceptance rates of recommendations on antimicrobial prescribing made by a ward pharmacist, ASP and AST.

Method

Data were collected over a 4‐week period for all patients admitted to the RAMU and prescribed antimicrobials. Weeks 1 and 4 acted as controls. During Week 2 the ASP and during Week 3 the AST reviewed the restricted antimicrobials prescribed daily. Recommendations were recorded concurrently and medication charts were reviewed to determine if these were accepted. Appropriateness of antimicrobial prescribing was assessed retrospectively over the 4 weeks by the ASP and an infectious diseases physician.

Results

137 patients were eligible and 344 antimicrobials were evaluated. Antimicrobial prescribing varied over the 4 weeks but improved significantly with the ASP (vs standard care; p = 0.006) and AST reviews (vs standard care; p = 0.03). Treating teams were more likely to accept recommendations made by the AST than the ward pharmacist or the ASP.

Conclusion

Introduction of a AST in a RAMU improved antimicrobial prescribing. Recommendations made by the AST were accepted more often than those made by a pharmacist with or without formal infectious disease training.
Post‐Operative Warfarin Re‐Initiation – Modelling Loading Dose Strategy
Authors: Roberts Gregory W , Quinn Steven , Druskeit Tina , Helboe Trine , Jørgensen Lisbeth E , Johansen Cathrine
Published: April 2015

Background

Guidelines recommend re‐initiating post‐operative warfarin at the previous maintenance dose. This results in prolonged re‐establishment of a therapeutic international normalised ratio (INR). Modelling warfarin initiation and subsequent INR response using previously published data indicated that re‐initiation with twice the maintenance dose for 3 days may provide a rapid alternative.

Aim

To compare the time to a stable therapeutic INR for conventional maintenance dose re‐initiation of warfarin with a loading dose strategy.

Method

Warfarin maintenance doses were adjusted by using the standardised maintenance dose – a theoretical dose resulting in an INR of 2.5. The test group was re‐initiated on warfarin doses twice their standardised maintenance dose on Days 1, 2 and 3 and on Day 4 reverted to their maintenance dose. The guideline group was re‐initiated on warfarin doses equivalent to their standardised maintenance dose on these days.

Results

The test group (n = 17) achieved a therapeutic INR more rapidly than the guideline group (n = 23; p < 0.001) with median times to therapeutic INR of 3 and 6 days respectively. After 3 doses the test group INR on Day 4 was in the therapeutic range (2.1±0.4) and significantly higher than the guideline group (1.7±0.5; p = 0.002). No patient in the test group experienced an elevated INR (maximum INR 3.3).

Conclusion

INR response to the warfarin re‐initiation dose was dependent on the magnitude of the induction dose relative to the maintenance dose. The loading dose strategy achieved a stable therapeutic INR more rapidly than conventional practice. Prospective investigation in surgical patients is needed to confirm its clinical applicability.
Audit of the Use of a Smart Infusion Pump's Drug Libraries
Authors: Tan Ivy SP , Dinh Nhi T , Kong Raymond E , MacMillan Kent B , McGain Forbes , Kong Raymond E , McGain Forbes
Published: April 2015

Background

Lack of compliance with drug libraries among users of smart infusion pumps undermines the efforts to prevent intravenous medication errors. There are little data on drug library use in Australian clinical practice and the barriers to compliance and effective use remain uncertain.

Aim

To evaluate the use of a smart infusion pump's drug libraries and to identify barriers to effective drug library use.

Method

Prescription and programming details of the infusions administered via Alaris IV pumps at a health service were audited. Data were used to assess compliance with and use of the drug libraries. In the event of non‐compliance or incorrect use of a drug library, a consented interview was conducted with the nurse to identify barriers.

Results

Of the 86% (95%CI 83–89) of infusions administered via a drug library, 11% (95%CI 9.1–14) were programmed incorrectly. Interviews with nurses revealed several reasons for non‐compliance, e.g. difficulty in using smart infusion pump technology, composition of the drug library. Incorrect drug library use was mainly attributed to failure to check programming during change of nursing shift, change of clinical area or change to a new fluid bag.

Conclusion

Despite high compliance with correct drug library use, 11% of infusions were programmed incorrectly due to incorrect selection of a drug library or therapy or both. The interviews revealed concerns with understanding smart pump technology and deficiencies in routine checks of drug library programming.
Electronic Medication Information Sources: Understanding the Needs and Preferences of Health Professionals
Authors: Baysari Melissa T , Lehnbom Elin C , Richardson Katrina , O'Reilly Benison , Heywood Maureen , Melocco Teresa
Published: April 2015

Background

To improve the accessibility and usability of local medication information, the pharmacy department at the study hospital consolidated the electronic medication information and restructured the manner in which it is presented to clinicians.

Aim

To examine the electronic medication information needs of clinicians and to explore their preferences and views on the proposed ‘new’ medication information repository.

Method

Doctors (n = 12), nurses (n = 15) and pharmacists (n = 8) from the study hospital participated either in a 30‐minute focus group or semi‐structured interview.

Results

Doctors and nurses did not use the local medication information and viewed the new medication information repository as not very useful. Users identified a range of issues related to the design and layout of the new repository. Clinicians are unlikely to use information if it is not visible during their work processes.

Conclusion

Electronic medication information needs and preferences of clinicians were identified as well as areas where redesign of electronic medication information sources is needed. It is not possible to meet the electronic medication information needs and preferences of all clinical users of a system or application.
Case for Pharmacist Administered Vaccinations in Australia
Authors: Bushell Mary‐Jessimine A , Yee Kwang Choon , Ball Patrick A , Ball Patrick A
Published: April 2015

Background

Pharmacists in Portugal, New Zealand, the UK and USA are able to administer vaccines. Despite international trends, current jurisdictional regulations prevent Australian pharmacists from administering vaccines.

Aim

To assess if there is a case for pharmacist administered vaccination (PAV) in Australia.

Discussion

Studies and government data indicate suboptimal uptake of some vaccines in Australia. Over the past two decades, PAV services have been introduced successfully in some developed countries. Available literature revealed PAVs provided significant benefits in these countries, such as increased vaccination uptake and subsequent decreased disease burden and associated cost benefits. PAVs are in line with Australian government policy and priorities. The pharmacy profession, guided by peak professional bodies, has demonstrated a willingness to embrace PAVs based on appropriate competencies and broadening health delivery options to the public.

Conclusion

There is a case for PAV services in Australia. It is not possible to adopt an overseas model of PAVs in Australia without significant modification to its unique immunisation program, which incorporates a different funding and governance system.