Medication supply at hospital discharge via community pharmacy: a quality improvement study.

BACKGROUND: Patient delays at the point of their discharge account for more than half a million additional bed days every year in Scotland, United Kingdom. Bottlenecks in discharge medication dispensing contribute to such delays. AIM: To test whether the discharge process could be made more time-efficient by utilising community pharmacy supply of medicines on the day of discharge, rather than hospital pharmacy supply. SETTING: Glasgow Royal Infirmary, Scotland. DEVELOPMENT: Local community pharmacy staff received training and communication about each patient discharge. Pharmacies could access an immediate discharge letter (IDL) on a shared electronic record. The existing pandemic law allowed medication dispensing from this IDL, without a prescription. IMPLEMENTATION: The programme was implemented from June to November 2020, across three Plan-Do-Study-Act (PDSA) cycles. Comparisons were made between the new community pharmacy model and standard hospital model. EVALUATION: Across three PDSA cycles, in total 335 patients had community pharmacy supply compared to 376 patients eligible for hospital pharmacy supply. The median time taken from creation of the IDL to final completion was significantly lower in the new community pharmacy model compared to the hospital pharmacy model; 154 min (interquartile range (IQR) 82-272 min) vs 296 min (IQR 197-1281 min) p value < 0.000 CONCLUSION: A community pharmacy supply model compared to a standard hospital pharmacy model resulted in a median time saving of 142 min per patient. Such a time saving has the potential to deliver a transformational change in patient flow and free up hospital pharmacy staff to deliver other clinical interventions.

The impact of fetal growth restriction on latency in the setting of expectant management of preeclampsia.

BACKGROUND: Fetal growth restriction is a common complication of preeclampsia. Expectant management for qualifying patients has been found to have acceptable maternal safety while improving neonatal outcomes. Whether fetal growth restriction influences the duration of latency during expectant management of preeclampsia is unknown. OBJECTIVE: The objective of the study was to determine whether fetal growth restriction is associated with a reduced interval to delivery in women with preeclampsia being expectantly managed prior to 34 weeks. STUDY DESIGN: We performed a retrospective cohort of singleton, live-born, nonanomalous deliveries at the University of Cincinnati Medical Center between 2008 and 2013. Patients were included in our analysis if they were diagnosed with preeclampsia prior to 34 completed weeks and if the initial management plan was to pursue expectant management beyond administration of steroids for fetal lung maturity. Two study groups were determined based on the presence or absence of fetal growth restriction. Patients were delivered when they developed persistent neurological symptoms, severe hypertension refractory to medical therapy, renal insufficiency, nonreassuring fetal status, pulmonary edema, or hemolysis elevated liver low platelet syndrome or when they reached 37 weeks if they remained stable without any other indication for delivery. Our primary outcome was the interval from diagnosis of preeclampsia to delivery, measured in days. Secondary outcomes included indications for delivery, rates of induction and cesarean delivery, development of severe morbidities of preeclampsia, and select neonatal outcomes. We performed a multivariate logistic regression analysis comparing those with fetal growth restriction with those with normally grown fetuses to determine whether there is an association between fetal growth restriction and a shortened interval to delivery, neonatal intensive care unit admission, prolonged neonatal stay, and neonatal mortality. RESULTS: A total of 851 patients met the criteria for preeclampsia, of which 199 met inclusion criteria, 139 (69%) with normal growth, and 60 (31%) with fetal growth restriction. Interval to delivery was significantly shorter in women with fetal growth restriction, median (interquartile range) of 3 (1.6) days vs normal growth, 5 (2.12) days, P < .001. The association between fetal growth restriction and latency less than 7 days remained significant, even after post hoc analysis controlling for confounding variables (adjusted odds ratio, 1.66 [95% confidence interval, 1.12-2.47]). There were no differences in the development of severe disease (85.9 vs 91.7%, P = .26), need for intravenous antihypertensive medications (47.1 vs 46.7%, P = .96), and the development of severe complications of preeclampsia (51.1 vs 42.9%, P = .30) in normally grown and growth-restricted fetuses, respectively. Fewer women with fetal growth restriction attained their scheduled delivery date, 3 of 60 (5.0%), compared with normally grown fetuses,12 of 139 (15.7%), P = .03. Admission to the neonatal intensive care unit, neonatal length of stay, and neonatal mortality were higher when there was fetal growth restriction; however, after a logistic regression analysis, these associations were no longer significant. CONCLUSION: Fetal growth restriction is associated with a shortened interval to delivery in women undergoing expectant management of preeclampsia when disease is diagnosed prior to 34 weeks. These data may be helpful in counseling patients regarding the expected duration of pregnancy, guiding decision making regarding administration of steroids and determining the need for maternal transport.

Effect of cement selection and finishing technique on marginal opening of cast gold inlays.

STATEMENT OF PROBLEM: The standard cement for partial-veneer cast gold restorations has been zinc phosphate. With increasing interest in using resin and resin-modified glass ionomer cements for this purpose, marginal adaptation with use of these newer cements must be assessed. PURPOSE: The purpose of this in vitro study was to determine if the marginal adaptation of cast gold inlays is comparable for 3 different luting agents and 3 finishing techniques. MATERIAL AND METHODS: Cast gold inlays were cemented into triangular preparations on the buccal surface of 45 extracted human molars. Three operators each used a different technique for finishing margins: finishing during cementation (FD), finishing before cementation (FB), and finishing before and during cementation (FBA). The 15 teeth for each operator were divided into 3 subgroups of 5 each to accommodate 3 cements: zinc phosphate (Fleck's zinc phosphate: ZP), resin-modified glass ionomer (RelyX Luting: RXL), and self-adhesive modified resin (RelyX Unicem: RXU). For all specimens, fine sandpaper disks followed by fine cuttle disks were used for finishing the castings. The marginal gap was measured using a Nikon measuring microscope at x50 magnification. Data were analyzed with a 1-way ANOVA for each cement (alpha=.05). RESULTS: There were significant differences among finishing techniques for each cement (P<.05). For ZP, the smallest mean marginal gaps were for FD (31 microm) and FBA (42 microm). For RXL, FBA produced the smallest gap (19 microm). For RXU, FB (23 microm) and FBA (22 microm) were optimal. CONCLUSIONS: Within the limitations of this in vitro study, the marginal gap attained with cementation of partial-veneer cast gold restorations with ZP (31 microm) can also be obtained using RXL or RXU. The techniques of FD or FBA are best used for ZP, whereas the FBA technique is best for RXL, and either FB or FBA is optimal for RXU. The FBA technique yielded a small gap; this was common to all 3 cements.