ABSTRACT
Background: Prescribing antibiotics is a demanding and complex task where decision-making skills are of critical importance to minimize the risk of antimicrobial resistance. Despite its importance, little is known about the decision-making skills and cognitive strategies new Nurse Practitioners (NPs) use when prescribing antibiotics. Objective: To identify the cognitive demands of antibiotic prescribing complexity and to explore the cognitive strategies that new NPs in New Zealand use when prescribing antibiotics. Design: A qualitative approach using Applied Cognitive Task Analysis (ACTA) methodology. Participants: A purposive sample was recruited consisting of five NPs who had been registered within the last five years and were prescribing antibiotics as part of their scope of practice. Methods: In-depth face-to-face interviews consisting of a task diagram interview and a knowledge audit were conducted and analyzed following the ACTA protocol. Results: Four cognitive elements were identified from the data which showed the cognitive demands of prescribing antibiotics, and the cues and strategies NPs use for safe practice. These were: 1 prescribing in the face of uncertainty (complex patients and diagnostic uncertainty); 2 making clinical decisions with insufficient/poor guidance (lack of guidelines, conflicting information); 3 producing an individualized treatment plan in view of clinical and non-clinical patient factors (patient demand/expectation, inadequate patient education, risks versus benefits of antibiotic treatment); 4 ensuring treatment efficacy and continuity of care (ineffective treatment, patient care follow up). Conclusion: The ACTA framework has given insight into the current antibiotic prescribing practice of new NPs, identifying areas where professional development courses and treatment resources can be targeted to support antibiotic prescribing. NPs are likely to benefit from resources that are freely available and reflect national or local antimicrobial data. Further work is also warranted to determine whether targeted education resources and clinical pathways will help with diagnostic uncertainty, and how this could be embedded into existing curricula.
ABSTRACT
In New Zealand, there are no liquid formulations of omeprazole commercially available, therefore suspensions must be extemporaneously compounded from solid dosage forms for patients with swallowing difficulties. The funding for solid dosage forms of omeprazole changes frequently, often every one to two years, without consideration of the impact this may have when extemporaneously compounded liquid dosage forms are required. This study examined suspensions compounded from various solid dosage forms of omeprazole with the purpose of identifying suitable quality formulations and evaluating their chemical and physical stability. Six different solid dosage forms of omeprazole that are available in New Zealand, including capsules, tablets, and powder, were used to prepare 2-mg/mL suspensions in 8.4% w/v sodium bicarbonate solution. The suspensions were then assessed visually for quality and by quantifying sedimentation rate over 120 minutes. Two products, stored in amber bottles at either 4°C or 25°C, demonstrated acceptable quality over a 30-day period whilst monitoring physical and chemical stability on day 0, 7, 14, 20, and 30. Four of the formulated suspensions were deemed to be of poor quality due to either a lack of uniformity or rapid sedimentation, attributes that could lead to inaccurate dosing. Acceptable quality suspensions were prepared from Losec and Dr. Reddy's brands of omeprazole 20-mg capsules. For both brands, a change in color was observed after 20 days and 7 days when stored at 4°C and 25°C, respectively. Chemical stability was determined using a stability-indicating high-performance liquid chromatographic method, with >90% of the active remaining for 30 days when kept at 4°C, and 20 days when stored at 25°C. Not all brands are suitable for extemporaneously compounding omeprazole suspensions. Losec and Dr. Reddy's brands of capsules were suitable to prepare quality omeprazole suspensions. Omeprazole suspensions compounded from these products are stable for 20 days if stored at 4°C and protected from light.
