Development of Screening Tools to Predict Medication-Related Problems Across the Continuum of Emergency Department Care: A Prospective, Multicenter Study.

Background: Medication-related problems (MRPs) occur across the continuum of emergency department (ED) care: they may contribute to ED presentation, occur in the ED/short-stay unit (SSU), at hospital admission, or shortly after discharge to the community. This project aimed to determine predictors for MRPs across the continuum of ED care and incorporate these into screening tools (one for use at ED presentation and one at ED/SSU discharge), to identify patients at greatest risk, who could be targeted by ED pharmacists. Methods: A prospective, observational, multicenter study was undertaken in nine EDs, between July 2016 and August 2017. Blocks of ten consecutive adult patients presenting at pre-specified times were identified. Within 1 week of ED discharge, a pharmacist interviewed patients and undertook a medical record review to determine a medication history, patient understanding of treatment, risk factors for MRPs and to manage the MRPs. Logistic regression was undertaken to determine predictor variables. Multivariable regression beta coefficients were used to develop a scoring system for the two screening tools. Results: Of 1,238 patients meeting all inclusion criteria, 904 were recruited. Characteristics predicting MRPs related to ED presentation were: patient self-administers regular medications (OR = 7.95, 95%CI = 3.79-16.65), carer assists with medication administration (OR = 15.46, 95%CI = 6.52-36.67), or health-professional administers (OR = 5.01, 95%CI = 1.77-14.19); medication-related ED presentation (OR = 9.95, 95%CI = 4.92-20.10); age ≥80 years (OR = 3.63, 95%CI = 1.96-6.71), or age 65-79 years (OR = 2.01, 95%CI = 1.17-3.46); potential medication adherence issue (OR = 2.27, 95%CI = 1.38-3.73); medical specialist seen in past 6-months (OR = 2.02, 95%CI = 1.42-2.85); pharmaceutical benefit/pension/concession cardholder (OR = 1.89, 95%CI = 1.28-2.78); inpatient in previous 4-weeks (OR = 1.60, 95%CI = 1.02-2.52); being male (OR = 1.48, 95%CI = 1.05-2.10); and difficulties reading labels (OR = 0.63, 95%CI = 0.40-0.99). Characteristics predicting MRPs related to ED discharge were: potential medication adherence issue (OR = 6.80, 95%CI = 3.97-11.64); stay in ED > 8 h (OR = 3.23, 95%CI = 1.47-7.78); difficulties reading labels (OR = 2.33, 95%CI = 1.30-4.16); and medication regimen changed in ED (OR = 3.91, 95%CI = 2.43-6.30). For ED presentation, the model had a C-statistic of 0.84 (95% CI 0.81-0.86) (sensitivity = 80%, specificity = 70%). For ED discharge, the model had a C-statistic of 0.78 (95% CI 0.73-0.83) (sensitivity = 82%, specificity = 57%). Conclusion: Predictors of MRPs are readily available at the bedside and may be used to screen for patients at greatest risk upon ED presentation and upon ED/SSU discharge to the community. These screening tools now require external validation and implementation studies to evaluate the impact of using such tools on patient care outcomes.

Ketamine: Is the current 200 mg product fit for purpose in the emergency department?

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.

Comprehensive identification of medication-related problems occurring prior to, during and after emergency department presentation: An Australian multicentre, prospective, observational study.

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.

Accuracy of general practitioner medication histories for patients presenting to the emergency department.

BACKGROUND: Clinical handover and obtaining best possible medication histories (BPMH) at transition points in care are key patient safety pri-orities. This study aimed to determine the accuracy of medication histories documented on general practitioner (GP) referral letters for patients referred to emergency departments. METHODS: This was a multicentre prospective observational study in eight emergency departments. Patients taking ≥1 regular medication, referred to the emergency department with a GP letter and seen by a pharmacist were included. GP medication regimens were compared with BPMH documented by the emergency department pharmacist. RESULTS: Of the GP letters (total 414), 361 (87%) had one or more discrepancies in the patients' regular medications and 62% had one or more regular medication discrepancies of moderate-high significance. Omission of medication was more prevalent in hand-written letters (P DISCUSSION: GP referral letters should not be used in isolation to determine the medication regimen taken before an emergency department presentation. Interventions are indicated to improve awareness and accuracy of medication documentation.

Can a redesign of emergency pharmacist roles improve medication management? A prospective study in three Australian hospitals.

BACKGROUND: Emergency departments (EDs) face increasing service demands and the imposition of treatment targets which has led to continual process redesign and changes in staff skill mix and functions. OBJECTIVE: To identify extended ED pharmacist roles that could improve medication management and to implement and evaluate one such role change. METHODS: A focus group of clinicians sought to redesign processes around ED medication management. Preparation of medication charts for patients admitted from ED was selected. Baseline data were obtained to define elements of existing medication charting processes. Suitably trained ED pharmacists' trialled the effectiveness of making therapeutic suggestions on a medication chart 'sticker' or by direct 'consultation' with medical staff. At the conclusion of the study focus groups at each site evaluated clinical staff perceptions of the change. RESULTS: Focus group participants thought that ED pharmacists could undertake extended roles in analgesia, nausea control, antibiotic cover, addiction management and preparation of medication charts for admitted patients. In the pre-intervention audit (n = 140), 74% required at least one intervention by the ward pharmacists to address medication discrepancies. Ward pharmacists detected 292 medication discrepancies (median 1, IQR 0-3). In the 'sticker' intervention the ED pharmacist made 84 therapeutic suggestions of which 66 (78.6%) were accepted by medical staff. In the 'consultation' intervention 230 therapeutic suggestions were made of which 219 (95.2%) were accepted. The qualitative evaluation found that pharmacist-prepared medication charts within the processes established were deemed safe, timely, accurate, complete and legible. CONCLUSION: Support exists for ED pharmacists to expand their medication-related roles. ED pharmacists can safely prepare medication charts in a timely fashion and their therapeutic suggestions within a 'consultative' framework are more beneficial than written advice. However, issues relating to resourcing, hours of service, service focus, statutory restrictions and training support for extended roles require resolution.