A lean approach for improving medicines management in Australia's first cardiac hospital inventory system.

BACKGROUND: Medicines are the cornerstone of healthcare. Lean methodology approach such as Value Stream Mapping (VSM) is being used in healthcare to manage resources wisely to ensure sustainability of medicines and resources. The aim of this quality improvement study was to evaluate and improve the medication management and hospital imprest supply processes in Australia's first dedicated cardiology hospital using VSM. METHOD: We conducted a review of our medicine supply processes at a 180-bed cardiology hospital in Australia. We followed a lean methodology approach over a 4-month period from February to May 2023 and evaluated the outcome of our improvements for another 4 months from July to October 2023. We used VSM to identify non-value adding activities. Cost of medicines holding was calculated, as well as time taken to complete supply processes, pre and post. RESULTS: Pharmacy department stockholdings reduced by 51%; p = 0.000121 (from $539,662 to $275,406). Time taken to manage the inventory system also reduced by 42%; p = 0.025762 (from 148 h/month to 62 h/month). Lean methodology such as VSM can facilitate cost-effective and sustainable system improvements for pharmacy procurement systems.

The impact of frailty on initiation, continuation and discontinuation of secondary prevention medications following myocardial infarction.

AIM: To evaluate the association between frailty and initiating, continuing, or discontinuing secondary prevention medications following myocardial infarction (MI). METHODS: We conducted a cohort study using linked health data, including all adults aged ≥65 years who discharged from hospital following MI from January 2013 to April 2018 in Victoria, Australia (N = 29,771). The Hospital Frailty Risk Score (HFRS) was used to assess frailty. Logistic regression was used to investigate associations of frailty with initiation, continuation, and discontinuation of secondary prevention medications (P2Y12 inhibitor antiplatelets, beta-blockers, renin-angiotensin-aldosterone system (RAAS) inhibitors, and lipid-lowering therapies) in the 90 days from discharge post-MI, by HFRS, adjusted for age, sex, and Charlson Comorbidity Index. RESULTS: Increasing frailty was associated with lower probability of initiating and continuing P2Y12 inhibitors, RAAS inhibitors, and lipid-lowering therapies, but not beta-blockers. At at an HFRS of 0, the predicted probabiliy of having all four medications initiated or continued was 0.59 (95 %CI 0.57-0.62) for STEMI and 0.35 (0.34-0.36) for non-STEMI, compared to 0.38 (0.33-0.42) and 0.16 (0.14-0.18) at an HFRS of 15. Increasing frailty was associated with higher probability of discontinuing these medications post-MI. The predicted probability of discontinuing at least one secondary prevention medication post-MI at an HFRS of 0 was 0.10 (0.08-0.11) for STEMI and 0.14 (0.13-0.15) for non-STEMI, compared to 0.27 (0.22-0.32) and 0.34 (0.32-0.36) at an HFRS of 15. CONCLUSION: People with higher levels of frailty were managed more conservatively following MI than people with lower levels of frailty. Whether this conservative treatment is justified warrants further study.

Assessing the impact of a mixed intervention model on the reduction of medication administration errors in an Australian hospital.

BACKGROUND: Medication errors remain one of the most common types of incidents reported in Australian hospitals. Studies have reported that for every 10 medication administrations, a medication administration error is likely to occur and reach the patient, potentially contributing to a preventable patient harm. OBJECTIVE: To assess the impact of a mixed intervention model on medication administration errors in an Australian hospital. METHODS: Two types of intervention model (human and system orientated) were implemented through collaboration with key stakeholders (nurses, educators, and policy makers) to reduce medication administration errors across this 650-bed multisite Australian hospital from August 2018 to June 2019. To assess the impact of the mixed intervention model, the total number of reported medication errors and the number of medication administration errors were retrieved from the hospital electronic medication management system for 12 months before (from June 2017 to July 2018) and after (from July 2019 to June 2020) implementation of all interventions. RESULTS: Implementation of a mixed intervention model through collaboration with stakeholders resulted in significant reduction in the number of medication administration errors, and those with harm (from 68 to 55%, P < 0.0001 and from 12 to 8%, P = 0.0001 respectively). Additionally, the severity of medication administration errors was also reduced (HR 0.562, 95% CI (0.298-1.062)) in the post-intervention phase. CONCLUSION: Introducing a mixed intervention model reduces medication administration errors across health settings and has the potential to drive excellence in healthcare.

Discrepancies in post-ST-elevation myocardial infarction care in women compared with men: evaluating for implicit bias-a single-centre study.

BACKGROUND: Recent research has demonstrated discrepancies in care post-ST-elevation myocardial infarction (STEMI), showing that women often have delays in time to percutaneous coronary intervention (PCI) and are less often prescribed evidence-based medications for secondary prevention. This single-centre study evaluated gender differences in management and local prescribing patterns of STEMI patients on discharge consistent with implicit bias, benchmarked against Australian clinical guidelines. METHOD AND RESULT: A retrospective, consecutive study of 318 patients admitted with a STEMI was conducted at a large tertiary hospital from January 2018 until October 2019. Data was collected from medical records including patient demographics, door-to-balloon (DTB) time, and pharmacological management. The mean age of women with a STEMI was higher (67.90 years in women; 64.17 in men, p = 0.013). DTB times were unaffected by gender with 88% of both men and women receiving PCI in less than 90 min (1.04 95% CI (0.44-2.46). Women were less likely to be prescribed an angiotensin-converting enzyme (ACE)-inhibitor/angiotensin receptor blocker (ARB) on discharge (p = 0.003). However, all other medications prescribed were appropriate between genders based on recommended guidelines. CONCLUSIONS:  Our study identified excellent adherence with recommended guidelines, challenging recent data both internationally and from the Victorian Cardiac Outcomes Registry (VCOR). Pharmacological and revascularisation management post-STEMI for both male and female patients was equal, suggesting implicit bias is not universal and may be institutional. Health services should evaluate their practices to identify sources of implicit bias, which may influence their management of women presenting with a STEMI.

Vitamin B for treating diabetic peripheral neuropathy - A systematic review.

This systematic review assesses the effectiveness and safety of vitamin B supplements for the management of neuropathy in people with diabetes. METHODS: Several databases including, the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL Plus were searched from their inception until May 2020. RESULTS: Five studies were eligible to be included in this review with a total of 348 participants. Overall, the evidence is too uncertain to draw conclusions on the effects of B vitamins in people with DPN. CONCLUSION: It is uncertain whether vitamin B supplements change pain intensity or impairment in the short or long term in people with DPN.

Redesign of computerized decision support system to improve Non Vitamin K oral anticoagulant prescribing-A pre and post qualitative and quantitative study.

BACKGROUND: Inappropriate prescribing of non-vitamin K agents (NOAC) contributes to significant economic and personal burden to our society. Studies have shown that when well designed and targeted, computerized alerts can be effective in improving prescribing without contributing to alert fatigue. METHOD: A collaborative multidisciplinary review group was set up to review and endorse an upgrade and modification to the hospital electronic medication management system (EMS). The intervention focused on implementing tailored electronic patient specific physiological alerts (such as age, renal function weight and drug interactions) built in EMS to improve the appropriateness of NOAC prescribing at this multisite teaching Australian hospital. To assess the qualitative and quantitative impact of the intervention, a pre and post retrospective study of NOAC prescribing of 100 patients' pre and post the implementation stage was conducted in a multisite Australian 650 bed hospital. Appropriateness of NOAC prescribing was assessed by an experienced pharmacist using approved prescribing product information recommendations. Prescriber satisfaction and experience survey was assessed in both stages of the study using a standard satisfaction survey. Associated hospital acquired complications (HAC) with potential inappropriate NOAC prescribing were evaluated as well as related admission cost and average length of stay. RESULTS: Redesign of computerised decision support in EMS improved appropriateness of NOAC prescribing from 48 % to 91 %, P < 0.05. A total of 67 prescribers accepted the invitation to participate in the qualitative satisfaction study. Half the respondents (n = 33, 50 %) answered positively to a question assessing the usefulness of implementing NOAC alerts in the EMS in improving their practice and patient safety. This rate has increased to 72 % (n = 48) in the post intervention phase. P < 0.05. Additionally, the total number of reported HAC that are likely to be associated with inappropriate NOAC prescribing was reduced by 36 % in the post intervention phase (from 29 to 22 (RR = 0.7454 95 %CI (0.4283-1.2972), P = 0.2986). The cost of associated HAC has also reduced by 29 % (from $1,282,748 to $911,117) as well as the mean length stay by 11 % (from 18 days to 16 days) post the intervention phase. CONCLUSION: This study highlights that well-designed electronic prescribing alerts that provide context-relevant information to prescribers are likely to result in benefits to clinicians and patients as well reduction in economic burden. Moreover, they could also contribute to reducing hospital acquired complications and lessen the economic burden on our society.

Evaluation of a pharmacist-led shared decision-making in atrial fibrillation and patients' satisfaction-a before and after pilot study.

BACKGROUND: Chronic complex diseases like atrial fibrillation have potential long-term economical and personal consequences. Shared decision-making principles may promote therapeutic compliance, satisfaction and outcomes. Pharmacists, as patient-advocates, play a key role in guiding them through complex clinical decisions about their chronic disease management and anticoagulation choices. AIM: To evaluate the impact of pharmacist-led shared decision making on patients' satisfaction and appropriateness of their anticoagulation therapy in newly diagnosed atrial fibrillation patients. METHODS: A prospective 2-phase before and after single-centre study was conducted in an Australian hospital. Phase 1 provided usual care, and patients' satisfaction and appropriateness of their anticoagulation therapy were evaluated. Phase-2 assessed the impact on satisfaction and appropriateness of anticoagulant therapy following pharmacist-led interventions of shared decision making to promote patients' involvement. RESULTS: Patients with pharmacist-led shared decision making reported higher degree of appropriateness of anticoagulation therapy and satisfaction (36% vs 92%, P < 0.001; 25% vs 68, P < 0.001), respectively. Additionally, patients who had a pharmacist input during their hospital stay received guideline-recommended anticoagulant therapy and reported satisfaction with their management was also higher in stage 2 (21% vs 65%, p < 0.001). CONCLUSION: The study highlights pharmacist-led shared decision making in atrial fibrillation that contributes to patient satisfaction and appropriateness of therapy.

Evaluating the impact of various medication safety risk reduction strategies on medication errors in an Australian Health Service.

Background Medication errors remain the second common type of preventable incidents reported in Australian hospitals contributing to a significant morbidity and mortality to the society. Objectives The primary objective was to evaluate the impact of multiple patient-centred and system redesign strategies on medication errors across an Australian Health service. The secondary aim is to assess the impact of these strategies on patients 'satisfaction. Methods Multiple patient centred and system redesign stratrgies were implemented to reduce medication errors across a 450 bed Australian hospital through optimising steps in the medication management cycle to improve patient care and experience. The various types of strategies have been implemented over 2.5 years (May 2015-Dec 2017) through successful engagement with various stakeholders including doctors, pharmacists, nurses, and patients. Baseline data of total medication errors, the number of prescribing errors and medication errors with harm reported in the hospital's electronic incident medication management systems were collected for 6 months pre and post implementation of all medication safety strategies to measure their overall impact on the medication management cycle. A qualitative and quantitative standard patient satisfaction survey was also sought pre and post intervention phase. Results The various strategies were successfully implemented with stakeholders. The number of reported medication errors has reduced in the post intervention phase (656 vs 534). The total number of prescribing errors and reported medication errors with harm have also reduced post the intervention phase P < 0.0076 and P < 0.05 respectively. Error rates for common medications errors have significantly reduced, P < 0.001. Additionally, patients' satisfaction has also increased, P < 0.0001. Conclusion Introducing multifaceted redesign strategies across hospitals coupled with a patient centred care approach drive excellence in healthcare.

Evaluation of prescribing patterns of nonsteroidal anti-inflammatory agents in a tertiary setting.

BACKGROUND: Non steroidal anti-inflammatory agents (NSAIDS) are among the most commonly prescribed analgesics despite their adverse effect profile. The main objective of this pilot study is to assess the prescribing patterns of NSAIDs in an Australian hospital and to examine predictors for prescribing patterns. METHOD: A retrospective cross sectional study was conducted. Patients' gastrointestinal and cardiovascular comorbidities were recorded for stratifications according to international guidelines. Pharmacist input was recorded to examine its effect on NSAIDs' prescribing patterns. Appropriateness of prescribing patterns was determined according to published international prescribing guidelines for NSAIDs. Univariate and multivariate regression analyses were conducted to determine predictors of patients' variables on prescribing patterns. RESULTS: A total of 300 patients were eligible to be included in the study. Fifty-five percentage of patients audited were prescribed NSAIDs according to the guidelines. There was an association between the type of NSAIDs prescribed and patients' gastrointestinal and cardiovascular risks, P less than 0.01. Multiple logistic regression analysis has shown: age more than 75 years, a history of peptic ulcer disease or a moderate gastrointestinal risk were all predictors for receiving a NSAID with a gastroprotectant agent [odds ratio (OR) = 3.54, 95% confidence interval (CI) (1.10-11.79), P < 0.05; OR = 9.51, 95% CI (3.70-26.72), P < 0.01; and OR = 5.04, 95% CI (51.72-15.54), P < 0.01, respectively]. Naproxen was more likely to be prescribed in patients with moderate-to-high gastrointestinal risk [OR = 16.24, 95% CI (2.70-132.70) and OR = 81.47 95% CI (3.38-2436.53), P < 0.01, respectively]. Patients who had their medications reviewed by a pharmacist were prescribed cyclo-oxygenase-2 inhibitors more frequently [OR = 3.36, 95% CI (1.05-15.34), P < 0.05] than any other agent. CONCLUSION: About half of the patients audited were prescribed NSAIDs appropriately. Factors affecting the prescribing of NSAIDs included: older age, patients' gastrointestinal risks as well as pharmacist input. This pilot study presents an opportunity for pharmacists to promote adherence to NSAIDs prescribing guidelines.

Antidiabetics' usage in type 2 diabetes mellitus: Are prescribing guidelines adhered to? A single centre study.

AIM: The primary aim of this study was to examine the prescribing patterns of antidiabetic agents (AA) in this hospital according to current prescribing contraindications (PCI). The secondary aims are to assess factors affecting the prescribing of AA and to evaluate the pharmacist impact on their prescribing. METHOD: A retrospective cross sectional study was performed to review all prescribed AA over a 3 month period. Data extracted from medical records included: patients' demographics, management and pharmacists' interventions. Appropriateness of prescribing was determined according to the AA prescribing information of the Medical Index of Medical Specialities (MIMS). RESULTS: A total of 314 AA were examined, of which 74(23%) orders were prescribed despite contraindications. Metformin was the AA to have the most PCI in dosage adjustments in renal impairment (RI). Logistic regression analysis showed patients with severe RI were less likely to be prescribed metformin (OR = 0.115 95%CI(0.048-0.274) P < 0.01), instead insulin was preferred (OR = 2.210 95%CI (1.028-4.751) P < 0.05). Insulin was also more likely to be prescribed in patients with hypertension and hyperglycaemia (OR=2.005 95%CI(1.005-4.001) P < 0.05, OR = 3.535 95%CI(1.756-7.113) P < 0.01) respectively. Sulphonylureas were less likely to be prescribed in patients with cardiovascular disease (OR = 0.339 95%CI(0.163-0.708), P < 0.01. There was low PCI in the other AA. Pharmacists reviewed 89% of AA. PCI was lower in this group compared to those with no pharmacist input (23% vs 28%). CONCLUSION: The audit showed good adherence to PCI. Pharmacist involvement has a positive impact on AP. Prescriber education is required in relation to dosage adjustments of AA in RI.

An audit of adherence to heart failure guidelines in an Australian hospital: A pharmacist perspective.

RATIONALE, AIMS, AND OBJECTIVES: The Australian National Heart Foundation Guidelines have been developed to guide clinicians on how to best manage chronic heart failure (CHF) patients according to the current best available evidence. The primary aim of this study is to evaluate the proportion of patients prescribed evidence-based therapy (EBT) for CHF on discharge at this Australian metropolitan hospital and factors affecting its prescribing. The secondary aims are to examine the proportion of patients prescribed EBT on discharge on cardiac wards compared to medical wards and to explore the role of the pharmacist in the management of these patients. METHOD: A retrospective audit of patients' medical notes who were admitted consecutively for CHF management was conducted over 6 months to examine their management. RESULTS: The results showed at discharge, a total of 52% of patients were discharged on angiotensin converting enzyme inhibitors/angiotensin receptor blockers, 49% were discharged on ß-blockers, 15% were on Aldosterone receptor antagonists, 90% were discharged on diuretics, and 29% were discharged on Digoxin. The main determinants of prescribing EBT on discharge were the presence of prescribing contraindications and patients' comorbidities. Patients discharged from cardiac wards were more likely to be prescribed EBT than if discharged on medical wards. Furthermore, in the subset of the cohort who was reviewed by a pharmacist during admission, a higher percentage of patients were discharged on EBT compared with those who did not have a pharmaceutical input. CONCLUSION: This study highlighted existing gaps between the National CHF Guidelines and clinical prescribing practice in this hospital. Patients who were discharged from cardiac wards were more likely to be prescribed medications concordant with the guidelines, and there is further opportunity for pharmacists to assist in closing gaps in prescribing practice by the promotion of adherence to these guidelines.

The impact of pharmacists' input to reduce serotonin syndrome drug interactions in an Australian hospital.

BACKGROUND: Drug interactions contribute significantly to adverse-related events and hospital admissions. Example of common drug interactions includes combinations of medications that induces serotonin syndrome. Pharmacists are well placed in the multidisciplinary team to alert prescribers of these drug interactions and offer an alternative management. OBJECTIVE: The objective is to evaluate the effectiveness of pharmacists' input in preventing patients being discharged on clinically relevant drug interactions that have the potential to cause serotonin syndrome in an Australian hospital. METHOD: A retrospective cross-sectional audit of patients' case notes who were prescribed a combination of drugs likely to induce serotonin syndrome on admission were examined over a 3-month period. A predefined list of serotonin syndrome-inducing drugs of severity 1 and 2 was used to search for patients on these drug combinations on admission. The severities of the drug combinations were classified as per the Monthly Index of Medical Specialties drug interactions guide. Subsequent pharmacists' interventions were recorded on discharge to observe any change in prescribing practice. Descriptive statistics were used to analyze the data. P values were obtained using the Student's t-test and Fisher's exact tests. RESULTS: A total of 144 patients over 3 months were identified to have been prescribed a combination of drugs with a potential to cause serotonin syndrome during admission. Of these patients, 79 and 21% were prescribed combination of serotonergic drugs that were classified as severity 1 and 2, respectively, according to Monthly Index of Medical Specialties. A total of 56% (n = 81) of the audited patients were discharged with no serotonin syndrome-inducing drug combinations and 44% (n = 63) were discharged on serotonin syndrome-inducing drug combinations of severity 1 or 2. Pharmacist input has led to a significant reduction (relative risk reduction 44%; P < 0.0001) in the total number of patients who were discharged on severity 1 and 2 serotonin syndrome-inducing drug combinations. There were 87 patients (60%) who had a pharmacist input during admission. In this subset of the cohort, 36% (n = 31) of patients were discharged on serotonin syndrome-inducing drug combinations (combined both severity 1 and 2) compared with 56% (n = 32) in those who did not get a pharmacist input, P = 0.017. In addition, 64% (n = 56) of patients in this group were discharged on no serotonin syndrome-inducing drug combinations compared with 44% (n =  25) in the nonpharmacist group, P = 0.017. CONCLUSION: The audit highlights the pharmacists' role in significantly reducing clinically relevant drug interaction in patients prescribed serotonin syndrome-inducing drug combination in a single-center Australian hospital on discharge.

An audit of the pharmacological management of ischaemic stroke patients in a metropolitan Australian hospital.

BACKGROUND: According to the Australian Bureau of Statistics, stroke is the second leading cause of death in Australia. The clinical Guidelines for stroke management published by the National Stroke Foundation provide a series of evidence based recommendations to assist clinicians in the management of stroke patients. Appropriate management of patients admitted to stroke units reduces death and disability by 20 %. Moreover, a multidisciplinary team approach also improves patient outcomes. OBJECTIVE: To retrospectively review the pharmacological management of ischaemic stroke patients in a metropolitan Australian hospital, and to compare adherence with the guidelines for stroke management with the national stroke foundation data with and without pharmacist intervention. METHOD: A retrospective audit of medical records was undertaken of all patients admitted to a large teaching hospital with the diagnosis of stroke or cerebral infarction from January 2013 to May 2013. RESULTS: A total of 124 patients were included in the study. Most patients were discharged on appropriate pharmacological intervention for the prevention of secondary stroke: antihypertensive agents (71 %), lipid lowering agents (67 %) and antithrombotic (85 %) medications. CONCLUSION: The majority of the cohort was discharged on the appropriate evidence based medications for the management of secondary stroke. Further improvement may be achieved by pharmacist intervening as part of a multidisciplinary team.

Drug allergy documentation--time for a change?

OBJECTIVE OF THE STUDY: To audit patients' allergy documentation in a large rural hospital an to make recommendations about accurate drug allergies in hospital settings. SETTING: A 257 bed large hospital and fully integrated health service in Australia, providing a range of services including; medicine, surgery, aged care, cancer care, mental health, maternity and rehabilitation. METHOD: A retrospective design was used to fulfil the aims of this study. Patient medical records were randomly selected and checked for allergy documentation over a 6 month period. RESULTS: A total of 521 patients' medical records were reviewed. Of all the medical records examined in total, 269 (52%) had no allergy, while 252 (48%) reported some kind of allergy. Overall, only three patients (0.6%) had their allergy details fully and accurately recorded in the three places audited and they are the front cover of the patients' notes, the admission notes and the drug chart. CONCLUSION: Many preventable medical errors are caused by poor documentation which is often due to lack of drug allergy information. All health professional should be more pro-active in determining the manner of any drug allergy or adverse drug reactions (ADR) along with the extent of the reaction.