Impact of preoperative haemoglobin A1c levels on postoperative outcomes in adults undergoing major noncardiac surgery: A systematic review.

AIMS: Diabetes is known to increase morbidity and mortality after major surgery. However, literature is conflicting on whether elevated preoperative haemoglobin A1c (HbA1c) levels are associated with worse outcomes following major noncardiac surgery. We aimed to investigate the effect of incremental preoperative HbA1c levels on postoperative outcomes in adults who had undergone major noncardiac surgery. METHODS: We systematically searched PubMed, EMBASE and the Cochrane Library databases for eligible studies published between January 2012 and July 2023. Randomised controlled trials and observational studies (cohort and case-control studies) which measured HbA1c within 6 months before surgery and compared outcomes between at least three incremental subgroups or analysed HbA1c as a continuous variable were included. The systematic review protocol was registered with PROSPERO (CRD42023391946). RESULTS: Twenty observational studies investigating outcomes across multiple surgical types were included. Higher preoperative HbA1c levels were associated with increased odds of overall postoperative complications, postoperative acute kidney injury, anastomotic leak, surgical site infections and increased length of stay. Each 1% increase in preoperative HbA1c was associated with increased odds of these complications. No association with reoperations and 30-day mortality was identified. The literature was highly variable with respect to composite major complications, perioperative cardiovascular events, hospital readmissions, postoperative pneumonia and systemic thromboembolism. CONCLUSIONS: Current evidence suggested that higher preoperative HbA1c levels were associated with increased odds of postoperative complications and extended length of stay in adults undergoing major noncardiac surgery. Further high-quality studies would be needed to quantify the risks posed and determine whether early intervention improves outcomes.

Measuring the impact of pharmaceutical care bundle delivery on patient outcomes: an observational study.

BACKGROUND: Clinical pharmacists perform activities to optimise medicines use and prevent patient harm. Historically, clinical pharmacy quality indicators have measured individual activities not linked to patient outcomes. AIM: To determine the proportion of patients who receive a pharmaceutical care bundle (PCB) (consisting of a medication history, medication review, discharge medication list and medicines information on the discharge summary) as well as investigate the relationship between delivery of this PCB and patient outcomes. METHOD: Pharmaceutical care bundle activities were defined within state-wide (Queensland, Australia) clinical information systems and datasets were linked. An observational study using routinely recorded data was performed at ten participating sites for adult patients who had a non-same day hospital stay. The association between extent of PCB delivery and three patient outcomes were investigated: length of stay (LOS), unplanned readmission, and mortality. RESULTS: In total 283,813 patient hospital stays were evaluated. The delivery of the PCB occurred in 26.9% of patients at the ten participating hospital sites, ranging from 0.6 to 61.2% across sites. Patients with a longer LOS were more likely to receive delivery of the complete PCB (P < 0.001). There was no correlation between PCB and hospital standardised mortality ratio (r = 0.03, p = 0.93). Higher rates of delivery of the PCB were associated with lower rates of unplanned readmission within 30 days (r = - 0.993, p < 0.001). CONCLUSION: A complete PCB was delivered to 26.9% of patients and was associated with a significantly lower rate of unplanned readmission within 30 days.

Defining quality indicators, pharmaceutical care bundles and outcomes of clinical pharmacy service delivery using a Delphi consensus approach.

BACKGROUND: Clinical pharmacy quality indicators are often non-uniform and measure individual activities not linked to outcomes. AIM: To define a consensus agreed pharmaceutical care bundle and patient outcome measures across an entire state health service. METHOD: A four-round modified-Delphi approach with state Directors of Pharmacy was performed (n = 25). They were asked to rate on a 5-point Likert scale the relevance and measurability of 32 inpatient clinical pharmacy quality indicators and outcome measures. They also ranked clinical pharmacy activities in order from perceived most to least beneficial. Based upon these results, pharmaceutical care bundles consisting of multiple clinical pharmacy activities were formed, and relevance and measurability assessed. RESULTS: Response rate ranged from 40 to 60%. Twenty-six individual clinical pharmacy quality indicators reached consensus. The top ranked clinical pharmacy quality indicator was 'proportion of patients where a pharmacist documents an accurate list of medicines during admission'. There were nine pharmaceutical care bundles formed consisting between 3 and 7 activities. Only one pharmaceutical care bundle reached consensus: medication history, adverse drug reaction/allergy documentation, admission and discharge medication reconciliation, medication review, provision of medicines education and provision of a medication list on discharge. Sixteen outcome measures reached consensus. The top ranked were hospital acquired complications, readmission due to medication misadventure and unplanned readmission within 10 days. CONCLUSION: Consensus has been reached on one pharmaceutical care bundle and sixteen outcomes to monitor clinical pharmacy service delivery. The next step is to measure the extent of pharmaceutical care bundle delivery and the link to patient outcomes.

A randomised trial of topical polaprezinc to prevent oral mucositis in patients undergoing haematopoietic stem cell transplantation (ToPaZ study).

PURPOSE: Oral mucositis (OM) is a common complication in haematopoietic stem cell transplantation (HSCT). Polaprezinc, an anti-ulcer drug, has been shown to be effective to prevent OM in several studies when administered topically and systemically. This study aimed to evaluate the effectiveness of topical polaprezinc in patients undergoing HSCT. METHODS: This was an open-label randomised clinical trial comparing polaprezinc and sodium bicarbonate mouthwashes for the prevention of severe OM in HSCT patients. Adult patients who received conditioning regimens at moderate to high risk of developing OM were included. The primary endpoint was the incidence of severe (WHO grades 3-4) OM. The secondary endpoints included duration of grades 3-4 OM, incidence and duration of grades 2-4 OM, patient-reported pain and functional limitations. RESULTS: In total, 108 patients (55 test arm and 53 control arm) were randomised. There was no difference in the incidence of grades 3 to 4 OM (35% test arm versus 36% control arm). The secondary endpoints were not significantly different. In both arms, patients reported more throat pain compared to mouth pain. CONCLUSIONS: Topical polaprezinc had no effect in the prevention of OM in HSCT patients. Further research is required to evaluate the effects of systemic polaprezinc. The OM assessment tool needs to be reviewed as throat mucositis was a main issue in this study. TRIAL REGISTRATION: ACTRN12320001188921 (Date Registered: 10th November 2020).

Resilience and empathy in pharmacy interns: Insights from a three-year cohort study.

Background: Resilience and empathy are important attributes for healthcare professionals to navigate challenging work environments and providing patient-centred care. Knowledge about pharmacists' levels of resilience and empathy, particularly during the early stages of their careers, is limited. Objectives: To explore pharmacy interns' levels of resilience and empathy using the Connor-Davidson-Resilience-Scale-25 (CD-RISC-25) and the Kiersma-Chen-Empathy-Scale (KCES), examine potential associations with demographic characteristics and ascertain what challenges interns' resilience and which support mechanisms they identify. Methods: Hard copies of the surveys were distributed to three cohorts during face-to-face intern pharmacy workshops from 2020 to 2022. Additionally, a qualitative questionnaire explored interns' experiences while completing an accredited internship program during the COVID-19 pandemic. Data were analysed using descriptive and inferential statistics, open-ended questions were analysed through qualitative and quantitative content analysis. Results: Among 134 completed surveys, most respondents were female, aged 18-22, and worked in hospitals. The CD-RISC-25 mean score was 66.6 (SD 11.7) and the KCES mean was 84.3 (SD 9.23) indicative of intermediate levels of resilience and empathy. Resilience and empathy scores did not significantly differ between the three cohorts (p-value > 0.05), and both were not consistently correlated with each other (p-value > 0.05). No significant associations were found between demographic characteristics and resilience scores. However, age and pre-internship employment history showed a statistically significant association with empathy scores (p-value < 0.05), with younger age groups and those who worked part-time during undergraduate studies demonstrating higher levels of empathy. Challenges undermining interns' resilience included the COVID-19 pandemic, internship requirements, and feelings of inadequacy and inexperience. Conclusions: This study showed that resilience and empathy scores among interns were at what can be regarded as intermediate levels, largely unaffected by the COVID-19 pandemic or cohort demographics. It highlights professional aspects and strategies which are professionally sustaining and may assist interns in navigating challenges to their resilience and empathy.

Relationships between growth indicators, liver and kidney function markers, and blood concentrations of essential and potentially toxic elements in environmentally exposed young children.

Environmental exposure to multiple metals and metalloids is widespread, leading to a global concern relating to the adverse health effects of mixed-metals exposure, especially in young children living around industrial areas. This study aimed to quantify the concentrations of essential and potentially toxic elements in blood and to examine the potential associations between multiple elements exposures, growth determinants, and liver and kidney function biomarkers in children living in several industrial areas in Dhaka, Bangladesh. The blood distribution of 20 trace elements As, Ag, Bi, Br, Cd, Co, Cr, Cu, I, Mn, Hg, Mo, Ni, Pb, Se, Sb, Tl, V, U, and Zn, growth determinants such as body mass index and body fats, blood pressure, liver and kidney injury biomarkers including serum alanine aminotransferase and alkaline phosphatase activities, serum calcium, and creatinine levels, blood urea nitrogen, and hemoglobin concentrations, and glomerular filtration rate were measured in 141 children, aged six to 16 years. Among these elements, blood concentrations of Ag, U, V, Cr, Cd, Sb, and Bi were measured below LOQs and excluded from subsequent statistical analysis. This comprehensive study revealed that blood concentrations of these elements in children, living in industrial areas, exceeded critical reference values to varying extents; elevated exposure to As, Pb, Br, Cu, and Se was found in children living in multiple industrial areas. A significant positive association between elevated blood Tl concentration and obesity (ß = 0.300, p = 0.007) and an inverse relationship between lower As concentration and underweight (ß = -0.351, p < 0.001) compared to healthy weight children indicate that chronic exposure to Tl and As may influence the metabolic burden and physical growth in children. Concentration-dependent positive associations were observed between the blood concentrations of Cu, Se, and Br and hepatic- and renal dysfunction biomarkers, an inverse association with blood Mo and I level, however, indicates an increased risk of Cu, Se, and Br-induced liver and kidney toxicity. Further in-depth studies are warranted to elucidate the underlying mechanisms of the observed associations. Regular biomonitoring of elemental exposures is also indispensable to regulate pollution in consideration of the long-term health effects of mixed-elements exposure in children.

How early career pharmacists understand resilience - A qualitative study of experiences, challenges and strategies.

INTRODUCTION: Resilience assists healthcare professionals in negotiating challenges, remaining positive when experiencing adversity, and in constructively dealing with difficult work situations and environments. There is increasing research about how early career healthcare professionals, understand and maintain resilience but little is known about support early career pharmacists may need and value. AIMS: To explore early career pharmacists' understanding of resilience, their strategies to enhance and maintain resilience as healthcare professionals and to identify resilience-fostering programmes they perceive could be implemented to support them. METHODS: Three focus groups and 12 semi-structured interviews with a total of 15 hospital pharmacists and 10 community pharmacists (both less than 3 years post-registration) were conducted. An inductive thematic analysis of transcripts was performed to identify main themes and subthemes. RESULTS: Pharmacists understood resilience as the capability to adapt to and learn from challenges and setbacks, which they can build through experience and exposure. Resilience in the workplace was challenged by their working environment and workload, which could lead to ego depletion, the transition from intern to registered pharmacist and working during the COVID-19 pandemic, which both added pressure and uncertainty to their role. Professional resilience was supported on individual, social and organisational levels and through self-care strategies. Pharmacists perceived mentorship and sharing experiences, experiential placements and constructive but challenging role play as potentially beneficial in building resilience during undergraduate studies and internship. DISCUSSION: Pharmacists defined resilience constructively and identified challenges testing but also strategies supporting their resilience in the workplace. Workplaces can support pharmacists by monitoring workload and workplace relationships, creating opportunities for peer and mentor support and by allowing pharmacists to implement their personal, individualised resilience maintaining strategies. Early career pharmacists' experiences and insights would be valuable when considering the design and implementation of resilience-fostering programmes.

The Development, Implementation, and Evaluation of a Pharmacist-Managed Therapeutic Drug Monitoring (TDM) Service for Vancomycin-A Pilot Study.

BACKGROUND: In recent years, pharmacists in Australia have been able to expand their scope to include the provision of a range of services. Although evidence has demonstrated the benefits of pharmacist-managed TDM services, recent studies have shown that these services are not prominent within Australia and that the current TDM workflow may not be optimal. METHODS: An interventional pilot study was conducted of a pharmacist-managed TDM program for vancomycin at a tertiary hospital in Australia. RESULTS: In total, 15 pharmacists participated in the program. They performed 50.5% of the medication-related pathology over the intervention period. Pharmacist involvement in the TDM process was more likely to lead to appropriate TDM sample collection (OR 87.1; 95% CI = 11.5, 661.1) and to an appropriate dose adjustment (OR 19.1; 95% CI = 1.7, 213.5). Pharmacists demonstrated increased confidence after the education and credentialling package was provided. CONCLUSIONS: This study demonstrated that a credentialling package for pharmacists can improve knowledge, skills, and confidence around the provision of pharmacist-managed TDM services for vancomycin. This may lead to the evolution of different roles and workflows enabling pharmacists to contribute more efficiently to improving medication safety and use.

Pharmacist-Managed Therapeutic Drug Monitoring Programs within Australian Hospital and Health Services-A National Survey of Current Practice.

Pharmacist-managed therapeutic drug monitoring (TDM) services have demonstrated positive outcomes in the literature, including reduced duration of therapy and decreased incidence of the adverse effects of drug therapy. Although the evidence has demonstrated the benefits of these TDM services, this has predominately been within international healthcare systems. The extent to which pharmacist-managed TDM services exist within Australia, and the roles and responsibilities of the pharmacists involved compared to their counterparts in other countries, remains largely unknown. A cross-sectional online survey was conducted evaluating pharmacist-managed TDM programs within Australian hospital and healthcare settings. Pharmacist perceptions were also explored about the strengths, weaknesses, opportunities, and barriers associated with implementing a pharmacist-managed TDM service. A total of 92 surveys were returned, which represents a response rate of 38%. Pharmacist-managed TDM programs were present in 15% of respondents. It is only in the minority of hospitals where there is a pharmacist-managed service, with pharmacists involved in recommending pathology and medication doses. The programs highlighted improved patient outcomes but had difficulty maintaining the educational packages and training. For hospitals without a service, a lack of funding and time were highlighted as barriers. Based on the findings of this survey, there is minimal evidence of pharmacist-managed TDM models within Australian hospital and health services. A standardized national approach to pharmacist-managed TDM services and recognition of this specialist area for pharmacists could be a potential solution to this.

Noradrenaline use for neonatal circulatory support.

AIM: Noradrenaline (NA) has been used in preterm and term infants for circulatory support due to conditions including sepsis and pulmonary hypertension of the newborn. Treatment in neonates varies widely between institutions and respective neonatologists. The aim of this study is to determine the indications, use and effects of NA in preterm and term infants requiring circulatory support at the Royal Brisbane and Women's Hospital neonatal intensive care unit. We also aim to determine whether there were any differences between neonates who survived versus those who died after NA treatment. METHODS: Data were collected from Royal Brisbane and Women's Hospital neonatal unit database including preterm and term infants between 1 January 2016 and 31 May 2021. Analysis included indication for use, blood pressure response, perfusion parameters, haemodynamic indicators and adverse effects. RESULTS: NA treatment was documented in 37 patients requiring treatment of cardiovascular compromise. In 11 (30%) of these infants the indication for use was due to sepsis, 19 (51%) infants had pulmonary hypertension of the newborn, and 7 (19%) infants were diagnosed with hypotension prior to NA administration. Infants who subsequently died (49%) represented a younger gestational age population and exhibited worse cardiac compromise prior to NA administration. Tachycardia occurred in 15 (31%) infants and 1 (2.7%) infant developed transient hypertension. Overall improvement in poor tissue perfusion was seen after NA use. CONCLUSION: NA use in treating neonates requiring circulatory support appears to be effective. Further prospective trials into NA use as a first- or second-line inotropic agent would be valuable.

The incidence of severe oral mucositis in patients undergoing different conditioning regimens in haematopoietic stem cell transplantation.

PURPOSE: Oral mucositis is a common complication during haematopoietic stem cell transplantation (HSCT). This study aimed to assess the incidence of severe mucositis in patients undergoing different HSCT regimens. METHODS: This single-centre retrospective study reviewed daily oral assessment for 467 consecutive patients who underwent different transplant regimens for matched unrelated or related allogeneic HSCT with post-transplant methotrexate, haploidentical or mismatched HSCT with post-transplant cyclophosphamide (PTCy), or autologous HSCT. Oral care and cryotherapy with melphalan were used. Patient demographic data, oral mucositis WHO grade, use of total parenteral nutrition (TPN) and patient-controlled analgesia (PCA) were collected. RESULTS: Grade 3-4 oral mucositis was common in myeloablative total body irradiation (TBI)-based regimens cyclophosphamide/ TBI (CyTBI) (71%) and fludarabine/ TBI (FluTBI) with PTCy (46%), as well as reduced-intensity fludarabine/melphalan (FluMel) (43%) and carmustine/etoposide/cytarabine/melphalan (BEAM) autologous HSCT (41%). In contrast, grade 3-4 oral mucositis was less common in reduced-intensity haploidentical regimen melphalan/fludarabine/TBI with PTCy (19%), all non-myeloablative regimens (0-9%) and high-dose melphalan autologous HSCT (26%). TPN and PCA use were correlated to oral mucositis severity. CONCLUSIONS: Severe oral mucositis was associated with myeloablative TBI, methotrexate and melphalan in combination with methotrexate and in BEAM. Use of PTCy was preferable over methotrexate to prevent oral mucositis.

A real-world accuracy of oral mucositis grading in patients undergoing hematopoietic stem cell transplantation.

PURPOSE: Oral mucositis is a common complication in patients undergoing hematopoietic stem cell transplantation. Accurate oral mucositis grading is essential for both clinical practice and oral mucositis research. This study aimed to evaluate the accuracy of daily oral mucositis grading by nurses in a tertiary hospital in Australia. METHODS: A retrospective study was undertaken to review the daily patient oral assessment record, including diet, pain, erythema, ulceration and the oral mucositis grade based on World Health Organization (WHO) oral mucositis grading scale. The accuracy of the grade was determined by the observations recorded, and reasons for inaccuracy were documented. Any repetition of the same error in the same patient was noted. RESULTS: In total, 6841 oral assessments in 373 patients, conducted between 2017 and 2020, were reviewed. A total of 70% (N = 4781) were graded correctly. Of these, 64% (N = 3043) were grade 0. When the grade 0 scores were excluded, the accuracy of grading was reduced to 46% (N = 1738). Common reasons for incorrect grading included: unable to grade due to diet not specified, no ulceration and no pain was scored grade 1, no ulceration was scored as grade 2-4, oral intake was not taken into account, and pain without ulcer was scored 0. A total of 77% of the errors were repeated in the same patient on consecutive days. CONCLUSIONS: Our results suggest there is frequent inaccurate evaluation of oral mucositis and a need for nurse training to accurately assess oral mucositis.

Medication Utilisation Program, Quality Improvement and Research Pharmacist-Implementation Strategies and Preliminary Findings.

Judicious use of medicines that considers evidence-based practice, together with cost-effectiveness, is a priority for all health care organisations. We describe an initiative to lead a Medication Utilisation Program, incorporating medication quality improvement and research activities. In August 2020 an advanced pharmacist position was implemented to lead the Program. The purpose was to provide oversight and facilitate initiatives promoting medication optimisation to create sustainable change in practice. A strategic plan was developed with key performance indicators. A governance structure was implemented with relevant reporting mechanisms. Strategic planning and collaboration with medical, nursing and allied health professionals has seen the successful implementation of seven codesigned medication-use evaluations and eight quality improvement projects centred around patient safety, quality and value-based care. Several research studies have been designed with subsequent commencement of pharmacists enrolled in university Research Higher Degree programs. Cost containment initiatives have realised potential savings approximating AUD 250,000. Educational programs included protocol design, ethics approvals and report writing. Key success criteria for a Medication Utilisation Program include dedicated pharmacist resources, structured governance and reporting mechanisms. Alignment of study complexity with staff experience and interdisciplinary collaboration are also critical.

Gentamicin Dosing in Neonates with Normal Renal Function: Trough and Peak Levels.

BACKGROUND AND OBJECTIVE: Gentamicin is commonly used in neonates, and it requires drug concentration monitoring. The objective of this study was to determine the extent of high trough (≥ 2 mg/l) and therapeutic peak serum gentamicin concentrations (5-12 mg/l) using our current gentamicin regimen and to adjust the dosing regimen accordingly and reassess. METHODS: This was a prospective cohort study of neonates, with normal renal function, who were prescribed gentamicin. Group 1: March 2014-July 2017-gentamicin intravenous (IV) 2.5 mg/kg given every 36 h if < 30 weeks gestational age (GA) and every 24 h if ≥ 30 weeks GA; Group 2: August 2019-February 2020-gentamicin IV 3.5 mg/kg given every 36 h if < 30 weeks GA and every 24 h if ≥ 30 weeks GA. We assessed the number of neonates with aberrant trough and peak serum gentamicin concentrations. RESULTS: Forty-eight neonates < 30 weeks GA and 34 ≥ 30 weeks GA were given 2.5 mg/kg gentamicin. Eleven (23%) neonates < 30 weeks GA and four (13%) ≥ 30 weeks GA had subtherapeutic peak concentrations (< 5 mg/l); none had supratherapeutic (> 12 mg/l) or toxic trough concentrations (≥ 2 mg/l). Forty-four neonates < 30 weeks GA and 54 ≥ 30 weeks GA were given 3.5 mg/kg gentamicin. Eighty-four (86%) had non-toxic trough concentrations (< 2 mg/l). One (1%) < 30 weeks GA neonate had subtherapeutic (< 5 mg/l) and one (1%) neonate ≥ 30 weeks GA had supratherapeutic (> 12 mg/l) peak concentrations. CONCLUSIONS: Gentamicin regimen of 2.5 mg/kg given every 36 h for neonates < 30 weeks GA and every 24 h for neonates ≥ 30 weeks GA was suboptimal at achieving therapeutic gentamicin peak. Increasing the dosage to 3.5 mg/kg achieved therapeutic peak concentrations in 98% and non-toxic trough concentrations in 86% of all neonates (prior to dose interval adjustment).

Developing Grit, Motivation, and Resilience: To Give Up on Giving In.

Developing grit, motivation, and resilience within the pharmacy workforce has become a topic of increasing interest, heightened by the recent COVID-19 pandemic. Even prior to the global pandemic, the health care field has been associated with a rapidly changing, challenging, and pressured work environment that can often lead to stress and burnout. Developing resilience in health care workers has been identified as a strategy to combat burnout by improving their ability to thrive in stressful situations, thus enhancing physical and mental well-being. In this commentary, we consider the use of a resilience framework that encompasses the overlapping attributes of emotional balance and physical and mental strength to develop resilience. The importance of finding purpose and meaning is also explored within the framework, as well as the association between grit, motivation, autonomy, mastery, and connection. Practical strategies and reflections are outlined to challenge, inspire, and motivate the development of grit and resilience, in order to combat the challenges faced by pharmacists in a constantly changing health care system.

Exploring How Postmillennial Pharmacy Students Balance Life Priorities and Avoid Situations Known to Deplete Resilience.

Objective. Students are facing increasing academic pressures that can contribute to poor wellbeing. Evidence to inform the development of better student support services is weak. This study aimed to explore Bachelor of Pharmacy students' self-reported life priorities and ways they strategize to avoid resilience-depleting events on a day-to-day basis.Methods. Postmillennial (those born after 1996) pharmacy students enrolled in their final year of pharmacy school were introduced to the coaching concepts of the Wheel of Life and anti-goals. Students' top eight life priorities were collected and categorized. Students were asked to submit one anti-goal targeting a strategy used to avoid resilience depletion. Anti-goals were coded according to student priority areas and overarching themes were interpreted.Results. The top priorities of 110 final-year pharmacy students were: family, finance, health, friends/relationships, study, career prospects, fitness, personal growth, travel, and mental health/wellbeing. Priorities were both similar and dissimilar to traditional coaching priorities. Sixty-eight anti-goals were coded. The themes "being prepared" and "being present" were used to summarize strategies that students employed to avoid resilience depletion.Conclusion. The life priorities of newer student generations may be changing to be more individualistic and include a greater focus on self-help, while maintaining the core priorities of family, health, and finance. These findings uphold the notion that student support mechanisms must be modernized to accommodate students' needs.

The impact of an electronic hospital system on therapeutic drug monitoring.

WHAT IS KNOWN AND OBJECTIVE: Australian hospitals have undergone a transformation with both a review and expansion of traditional roles of healthcare professionals and the implementation of an ieMR. The implementation of an ieMR brings large scale organizational change within the health system especially for staff with direct patient contact. This is changing the future of healthcare and the roles of healthcare professionals. There is minimal research on the impact of these electronic systems on the people and processes required to realise the improvements in patient care such as therapeutic drug monitoring (TDM) and the role of the pharmacist within the TDM process. The literature has discussed the use of computerised programs to assist with the interpretation of results and calculating of doses but the impact of an ieMR on the TDM process has not been discussed. This study undertook a retrospective analysis at an Australian tertiary hospital to investigate the impact of a digital hospital system on TDM within the facility. METHODS: A 2-year retrospective audit was conducted on TDM at an Australian Tertiary Hospital. The periods were 2016 (a paper-based hospital) and 2018 (ieMR). Patients were identified using the pathology database. Patients were excluded if under the age of 18, in an outpatient setting or the emergency department. Progress notes, medication charts, ieMR and other relevant pathology were reviewed. They were assessed for appropriateness of the timing of collection, compliance to recommended TDM guidelines, and pharmacist documentation. RESULTS AND DISCUSSION: A total of 2926 observations were included in the analysis. There was as similar percentage of appropriately collected samples between the paper-based system (2016) and the digital hospital system (2018) with 59% and 58% respectively. Results of logistic regression analysis models show the effect of year was not significant with regards to TDM for either a sample being appropriate or the dose adjustment being appropriate. Samples for TDM were more likely to be appropriate if the pharmacist had documented advice but less likely with regards to appropriate dose adjustment. This study considered the effect of introducing a hospital wide digital system on TDM processes. Overall, the results indicate no difference between the paper-based system and ieMR for appropriate samples and doses adjustments. WHAT IS NEW AND CONCLUSION: To our knowledge, this is the first study of this kind looking at the impact of a digital hospital system on TDM. The introduction of a digital hospital system does not appear to have made improvement on the effective use of TDM. Inappropriate sampling as seen in this study can lead to ineffective clinical management of patients, inefficient use of time, and waste of financial resources. Further work is required to incorporate specific guidance and recommendations within the digital system to optimize TDM.

Developing a Global Community of Practice for Pharmacy Workforce Resilience-Meet GRiT.

Workforce resilience in pharmacy is required to ensure the practice, education, and administrative systems remain viable and sustainable over time and when facing challenges. Whether it is addressing burnout of pharmacists or students, or the structure and policies/procedures of employment and professional organizations, working to increase resilience across all individuals and sectors is essential to relieve pressure and promote better well-being, especially during the recent pandemic. The purpose of this article is to describe the development of a community of practice global group focused on development of resilience within the pharmacy workforce that is inclusive of students, pharmacy interns/preregistration and registered pharmacists. The steering group meets monthly and has representation of 24 members across eight countries. Members meet to discuss pertinent issues they are facing in practice, as well as to share and progress ideas on education, research, and practice initiatives. To date, members have collectively implemented resilience training in pharmacy education, researched burnout and resilience in both students and pharmacists, and facilitated international collaborations both within and outside core group members. Future activities will focus on strengthening the community of practice in order to harness the power of the collective.

Effects of storage conditions on the stability and distribution of clinical trace elements in whole blood and plasma: Application of ICP-MS.

BACKGROUND: Knowledge of trace element stability during sample handling and preservation is a prerequisite to produce reliable test results in clinical trace element analysis. METHOD: An alkaline dissolution method has been developed using inductively coupled plasma mass spectrometry to quantify eighteen trace element concentrations: vanadium, chromium, manganese, cobalt, nickel, copper, zinc, arsenic, selenium, bromine, molybdenum, cadmium, antimony, iodine, mercury, thallium, lead, and bismuth in human blood, using a small sample volume of 0.1 mL. The study evaluated the comparative effects of storage conditions on the stability of nutritionally essential and non-essential elements in human blood and plasma samples stored at three different temperatures (4 °C, -20 °C and -80 °C) over a one-year period, and analysed at multiple time points. The distribution of these elements between whole blood and plasma and their distribution relationships are illustrated using blood samples from 66 adult donors in Queensland. RESULTS: The refrigeration and freezing of blood and plasma specimens proved to be suitable storage conditions for many of the trace elements for periods up to six months, with essentially unchanged concentrations. Substantially consistent recoveries were obtained by preserving specimens at -20 °C for up to one year. Ultra-freezing of the specimens at -80 °C did not improve stability; but appeared to result in adsorption and/or precipitation of some elements, accompanied by a longer sample thawing time. A population sample study revealed significant differences between the blood and plasma concentrations of six essential elements and their relationships also varied significantly for different elements. CONCLUSION: Blood and plasma specimens can be reliably stored at 4 °C for six months or kept frozen at -20 °C up to one year to obtain high quality test results of trace elements.

Maintaining and maximising motivation to progress scholarly work during challenges times - Reflections from the pandemic.

INTRODUCTION: Maintaining self-motivation during challenging times can be difficult. In this commentary, we consider self-determination theory to explore factors that can influence intrinsic motivation to progress scholarly work. The place of extrinsic motivation is also considered, on the continuum of self-determination. COMMENTARY: Using the components of self-determination theory, autonomy, mastery, and connection; academics, clinicians, and students, working in different environments, were asked to provide personal experiences and perspectives on their ability to maintain motivation during the 2019 coronavirus disease (COVID-19) pandemic. Self-assessment questions were used to guide reflections. IMPLICATIONS: Motivation, and in particular intrinsic motivation, can be impacted negatively during challenging times. Using a motivation framework can help identify personal factors that can be strengthened and developed over time. It is recognised that extrinsic factors are important in maintaining motivation. However, intrinsic motivation is a powerful driver to sustain and progress high quality work. Practical strategies and ideas are described to harness and develop self-motivation to pursue scholarly work, during challenging times.