Partnered pharmacist medication charting and prescribing in Australian hospitals.

Medication charting and prescribing errors commonly occur at hospital admission and discharge. Pharmacist medication reconciliation, after medicines are ordered by a medical officer, can identify and resolve errors, but this often occurs after the errors have reached the patient. Partnered pharmacist medication charting and prescribing are interprofessional, collaborative models that are designed to prevent medication errors before they occur, by involving pharmacists directly in charting and prescribing processes. In the partnered charting model, a pharmacist and medical officer discuss the patient's current medical and medication-related problems and agree on a medication management plan. Agreed medicines are then charted by the pharmacist on the inpatient medication chart. A similar collaborative model can be used at other points in the patient journey, including at discharge. Studies conducted at multiple Australian health services, including rural and regional hospitals, have shown that partnered charting on admission, and partnered prescribing at discharge, significantly reduces the number of medication errors and shortens patients' length of stay in hospital. Junior medical officers report benefiting from enhanced interprofessional learning and reduced workload. Partnered pharmacist medication charting and prescribing models have the best prospect of success in environments with a strong culture of interprofessional collaboration and clinical governance, and a sufficiently resourced clinical pharmacist workforce.

A cohort study comparing pharmacist activities during participation in general medical ward rounds: telehealth versus in-person during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic created systemic challenges in patient care delivery. AIM: To evaluate the impact on pharmacist activities during pharmacist participation in ward rounds via telehealth, compared to physical attendance. METHOD: A single-centre, retrospective cohort study conducted from 18th Aug through 26th Oct 2020. Patients admitted to COVID and non-COVID general medical teams were included. Pharmacists attended ward rounds via telehealth for COVID teams; physical attendance continued for non-COVID teams. Telehealth involved pharmacists interacting with clinicians and patients virtually via videoconferencing whilst stationed remotely on the ward. Routine clinical pharmacy activities during telehealth ward rounds were compared to those during face-to-face ward rounds using comparative statistics. RESULTS: Among the 1230 patients included (762 COVID, 468 non-COVID), pharmacist participation in telehealth ward rounds demonstrated significantly more documented activities compared with face-to-face rounds (mean 6.7 vs 4.9 per patient per day, p < 0.001). The telehealth cohort exhibited a higher number of orders placed via pharmacy-partnered medication charting (3.0 vs 2.4 per patient per day, p < 0.001), medication orders verified (2.3 vs 1.1, p < 0.001), and documented pharmacy notes (0.6 vs 0.2, p < 0.001). No significant difference was observed in medication requests processed (0.4 vs 0.4, p = 738), whilst non-COVID patients had more discharge prescription items generated (0.3 vs 0.7, p < 0.001). CONCLUSION: Pharmacist involvement in medical ward rounds via telehealth enabled the ongoing provision of advanced clinical pharmacy services to inpatients in isolation rooms during the COVID-19 pandemic. This approach resulted in a greater number of pharmacy activities during telehealth ward rounds compared to standard in-person attendance.

Evaluation of Smart Pump Interoperability with an Electronic Medical Record System to Improve Infusion Safety.

Medications administered via intravenous (IV) infusions have high potential for patient harm. Evaluation of the rate of variances between the medication order on the Electronic Medical Record (EMR) and IV infusion details in the smart pump was performed pre and post- implementation of smart pump and EMR interoperability. Introduction of smart pumps with EMR interoperability resulted in a statistically significant reduction in frequency of variances.

Implementation of Partnered Pharmacist Medication Charting in haematology and oncology inpatients.

AIM: Partnered Pharmacist Medication Charting (PPMC) in patients admitted under general medical units has been shown to reduce medication errors. The aim of this study is to evaluate the impact of the PPMC model on medication errors in patients admitted under cancer units in Victorian hospitals. METHODS: A prospective cohort study comparing cohorts before and after the introduction of PPMC was conducted. This included a 2-month pre-intervention phase and 3-month intervention phase. PPMC was implemented during the intervention phase as new model of care that enabled credentialed pharmacists to chart all admission medications, including pre-admission or new medications and cancer therapies, in collaboration with the admitting medical officer. The proportion of medication charts with at least one error was the primary outcome measure. RESULTS: Seven health services across Victoria were included in the study. The majority of health services were using paper-based prescribing systems for oncology. Of the 547 patients who received standard medical medication charting, 331 (60.5%) had at least one medication error identified compared to 18 out of 416 patients (4.3%) using the PPMC model (p < 0.001). The median (interquartile range) inpatient length of stay was 5 (2.9-10.6) days in pre-intervention and 4.9 (2.9-11) days in intervention (p = 0.88). In the intervention arm, 42 patients had cancer therapy charted by a pharmacist with no errors. CONCLUSIONS: PPMC was successfully scaled into cancer units as a collaborative medication safety strategy. The model was associated with significantly lower rates of medication errors, including cancer therapies. PPMC should be adopted more widely in cancer units in Australia.

Partnered pharmacist medication charting (PPMC) in regional and rural general medical patients.

OBJECTIVE: Errors in hospital medication charts are commonly encountered and have been associated with morbidity and mortality. This study evaluates the impact of the Partnered Pharmacist Medication Charting (PPMC) model on medication errors in general medical patients admitted to rural and regional hospitals. DESIGN/METHOD: A prospective cohort study, comparing before and after the introduction of PPMC was conducted in 13 rural and regional health services. This included a 1-month pre-intervention phase and 3-month intervention phase. In the intervention phase, PPMC was implemented as a new model of care in general medical units. SETTING: Victoria, Australia. PARTICIPANTS: Patients admitted to General Medical Units. OUTCOME MEASURE: The proportion of medication charts with at least one error was the primary outcome measure. Secondary outcome measures included inpatient length of stay (LOS), risk stratification of medication errors, Medical Emergency Team (MET) calls, transfers to ICU and hospital readmission. RESULTS: Of the 669 patients who received standard medical charting during the pre-intervention period, 446 (66.7%) had at least one medication error identified compared to 64 patients (9.5%) using PPMC model (p < 0.001). There were 1361 medication charting errors identified during pre-intervention and 80 in the post-intervention. The median (interquartile range) inpatient length of stay was 4.8 (2.7-10.8) in the pre-intervention and 3.7 days (2.0-7.0) among patients that received PPMC (p < 0.001). CONCLUSION: The PPMC model was successfully scaled across rural and regional Victoria as a medication safety strategy. The model was associated with significantly lower rates of medication errors, lower severity of errors and shorter inpatient length of stay.

A longitudinal time and motion study quantifying how implementation of an electronic medical record influences hospital nurses' care delivery.

AIM BACKGROUND: Many health care services are implementing or planning to undergo digital transformation to keep pace with increasing Electronic Medical Record (EMR) functionality. The aim of this study was to objectively measure nursing care delivery before and following introduction of an EMR. DESIGN AND METHODS: An extensive program of work to expand an EMR across our health service using a 'big bang' methodology was undertaken. The program incorporated digital care delivery workflows including physiological observations, clinical notes and closed loop medication management. The validated Work Observation Method by Activity Timing (WOMBAT) method was applied to undertake a direct observational time and motion study of nurses' work in a major Australian hospital immediately prior to and six months following the introduction of a full clinical EMR. RESULTS: Time and motion results were from observing approximately one week of nursing time pre (paper) to six months post (EMR) implementation. A non-significant 6.4% increase in the proportion of time spent on direct care was observed when using the EMR with a statistically significant increase in mean time per direct care task (2.5 min vs 3.9 min, p = 0.001). The proportion of time spent on medication-related activities did not significantly change although the average time per task rose from 2.0 to 2.9 min (p = 0.008). A significant reduction in proportion of time spent in transit and indirect care tasks when using the electronic workflows was reported. No statistically significant changes to the proportions of time spent on professional communication, direct care or documentation were observed. CONCLUSIONS: Successful EMR implementation is possible without adversely affecting allocation of nursing time. Our findings from deploying a large scale EMR across all healthcare craft groups and workflows have described for nurses that an EMR enables them to spend longer with patients per direct care episode and use their time on other activities more effectively.

Hospital pharmacists' experiences of participating in a partnered pharmacist medication charting credentialing program: a qualitative study.

BACKGROUND: Medication-related errors are one of the most frequently reported incidents in hospitals. With the aim of reducing the medication error rate, a Partnered Pharmacist Medication Charting (PPMC) model was trialled in seven Australian hospitals from 2016 to 2017. Participating pharmacists completed a credentialing program to equip them with skills to participate in the trial as a medication-charting pharmacist. Skills included obtaining a comprehensive medication history to chart pre-admission medications in collaboration with an admitting medical officer. The program involved both theoretical and practical components to assess the competency of pharmacists. METHODS: A qualitative evaluation of the multi-site PPMC implementation trial was undertaken. Pharmacists and key informants involved in the trial participated in an interview or focus group session to share their experiences and attitudes regarding the PPMC credentialing program. An interview schedule was used to guide sessions. Transcripts were analysed using a pragmatic inductive-deductive thematic approach. RESULTS: A total of 125 participants were involved in interviews or focus groups during early and late implementation data collection periods. Three themes pertaining to the PPMC credentialing program were identified: (1) credentialing as an upskilling opportunity, (2) identifying the essential components of credentialing, and (3) implementing and sustaining the PPMC credentialing program. CONCLUSIONS: The PPMC credentialing program provided pharmacists with an opportunity to expand their scope of practice and consolidate clinical knowledge. Local adaptations to the PPMC credentialing program enabled pharmacists to meet the varying needs and capacities of hospitals, including the policies and procedures of different clinical settings. These findings highlight key issues to consider when implementation a credentialing program for pharmacists in the hospital setting.

Building on Antimicrobial Stewardship Programs Through Integration with Electronic Medical Records: The Australian Experience.

Antimicrobial stewardship (AMS) is well established in Australian hospitals. Electronic medical record (EMR) implementation has lagged in Australia, with two Healthcare Information and Management Systems Society (HIMSS) Stage 6 hospitals and one Stage 7 hospital as of September 2020. Specific barriers faced by AMS teams with paper-based prescribing and medical records include real-time identification of antimicrobials orders; the ability to prospectively monitor antimicrobial use; and the integration of fundamental point of prescribing AMS principles into routine clinical practice. There are few local guidelines to assist Australian hospitals and AMS teams beyond "out of the box" EMR functionality. EMR implementation has enormous potential to positively impact AMS teams through more efficient workflows and the ability to expand the reach and coverage of AMS activities. There are inevitable limitations associated with EMR implementation that must be considered. In this paper, four Australian hospitals share their experience with EMR roll out, AMS customisation and how they have overcome specific barriers in local AMS practice.

Multi-site evaluation of partnered pharmacist medication charting and in-hospital length of stay.

AIMS: To undertake a multicentre evaluation of translation of a partnered pharmacist medication charting (PPMC) model in patients admitted to general medical units in public hospitals in the state of Victoria, Australia. METHODS: Unblinded, prospective cohort study comparing patients before and after the intervention. Conducted in seven public hospitals in Victoria, Australia from 20 June 2016 to 30 June 2017. Patients admitted to general medical units were included in the study. Medication charting by pharmacists using a partnered pharmacist model was compared to traditional medication charting. The primary outcome variable was the length of inpatient hospital stay. Secondary outcome measures were medication errors detected within 24 h of the patients' admission, identified by an independent pharmacist assessor. RESULTS: A total of 8648 patients were included in the study. Patients who had PPMC had reduced median length of inpatient hospital stay from 4.7 (interquartile range 2.8-8.2) days to 4.2 (interquartile range 2.3-7.5) days (P < 0.001). PPMC was associated with a reduction in the proportion of patients with at least 1 medication error from 66% to 3.6% with a number needed to treat to prevent 1 error of 1.6 (95% confidence interval: 1.57-1.64). CONCLUSION: Expansion of the partnered pharmacist charting model across multiple organisations was effective and feasible and is recommended for adoption by health services.

Evaluation of pharmacist-led physician-supported inpatient deprescribing model in older patients admitted to an acute general medical unit.

OBJECTIVE: To evaluate the need for and the feasibility of a pharmacist-led physician-supported deprescribing model. METHODS: All patients aged ≥65 years, with polypharmacy, admitted to the acute general medical unit (GMU) of an Australian tertiary hospital over a 6-week period were prospectively evaluated for deprescribing by team pharmacists. Clinical decision-making was supported by physicians. RESULTS: One hundred and twenty-nine patients met inclusion criteria, and 58 (45%) were identified for deprescribing. Ninety-two (7.2%) deprescribing instances were identified of 1277 medications prescribed. Of these, 46 (50%) were successfully deprescribed during inpatient admission in 35 (60%) patients. The most prevalent rationale for deprescribing was "harm outweighing benefits." Outpatient deprescribing was planned in 16 (17%) of instances, and 39 (42%) would require outpatient follow-up to ensure adherence to recommendations and safety. No predictors for deprescribing were identified on univariate analyses. CONCLUSIONS: A pharmacist-led physician-supported deprescribing model is feasible in GMU patients who have polypharmacy.

Renal safety of short-term empiric gentamicin therapy in aged patients.

OBJECTIVE: To determine the incidence of acute kidney injury (AKI) in aged patients receiving empiric gentamicin therapy. METHODS: Patients aged ≥65 years receiving gentamicin upon admission between 2013 and 2015 at two Australian hospitals were retrospectively studied. AKI was defined as a rise in creatinine by ≥50% and/or ≥26.5 µmol/L. RESULTS: Most patients (95%) received a single dose of gentamicin. The incidence of AKI was 15% (36/242 patients). A composite outcome of persistent kidney injury, requirement for renal replacement therapy or inpatient death in a patient with AKI occurred in 10 (4%) patients. Patients who developed AKI were older (median 80.5 vs 78 years, P = 0.03), had higher Charlson Co-morbidity Index (median 7 vs 5, P = 0.0004) and had more advanced chronic kidney disease at baseline (Stages IV and V) (OR 4.38, 95% confidence interval 1.45-13.2, P = 0.01). CONCLUSION: Empiric gentamicin use in patients with advancing age is associated with low rates of predominantly transient renal impairment.

Geriatric Psychotropic Stewardship Team to de-escalate inappropriate psychotropic medications in general medicine inpatients: An evaluation.

OBJECTIVES: To assess the feasibility and effectiveness of a Geriatric Psychotropic Stewardship Team (GPST) and to achieve inpatient de-escalation of inappropriate psychotropic medications in patients aged over 65 years on a general medicine ward. METHODS: A multidisciplinary GPST conducted twice-weekly rounds on general medicine inpatients known to be taking psychotropic medications. A consensus recommendation was generated, with subsequent treating team action recorded. RESULTS: A total of 125 patients taking 180 psychotropic medications were identified for GPST review. Of these, 32 medications (18%) had been ceased by the treating team prior to GPST review. Adoption of GPST recommendations at 24 hours and at discharge occurred for 85 medications (57%) and 79 medications (53%), respectively. CONCLUSIONS: This study demonstrates the feasibility of a structured multidisciplinary approach in the de-escalation of inappropriate psychotropic medications in older hospital patients on a general medicine ward. Further studies are required to assess scalability and long-term clinical outcomes.

Reducing medication errors in hospital discharge summaries: a randomised controlled trial.

OBJECTIVES: To evaluate whether pharmacists completing the medication management plan in the medical discharge summary reduced the rate of medication errors in these summaries. DESIGN: Unblinded, cluster randomised, controlled investigation of medication management plans for patients discharged after an inpatient stay in a general medical unit. SETTING: The Alfred Hospital, an adult major referral hospital in metropolitan Melbourne, with an annual emergency department attendance of about 60000 patients. PARTICIPANTS: The evaluation included patients' discharge summaries for the period 16 March 2015 - 27 July 2015. INTERVENTIONS: Patients randomised to the intervention arm received medication management plans completed by a pharmacist (intervention); those in the control arm received standard medical discharge summaries (control). MAIN OUTCOME MEASURES: The primary outcome variable was a discharge summary including a medication error identified by an independent assessor. RESULTS: At least one medication error was identified in the summaries of 265 of 431 patients (61.5%) in the control arm, compared with 60 of 401 patients (15%) in the intervention arm (P<0.01). The absolute risk reduction was 46.5% (95% CI, 40.7-52.3%); the number needed to treat (NNT) to avoid one error was 2.2 (95% CI, 1.9-2.5). The absolute risk reduction for a high or extreme risk error was 9.6% (95% CI, 6.4-12.8%), with an NNT of 10.4 (95% CI, 7.8-15.5). CONCLUSIONS: Pharmacists completing medication management plans in the discharge summary significantly reduced the rate of medication errors (including errors of high and extreme risk) in medication summaries for general medical patients.Australia New Zealand Clinical Trials Registry number: ACTRN12616001034426.

Partnered medication review and charting between the pharmacist and medical officer in the Emergency Short Stay and General Medicine Unit.

OBJECTIVE: A partnered medication review and charting model involving a pharmacist and medical officer was implemented in the Emergency Short Stay Unit and General Medicine Unit of a major tertiary hospital. The aim of the study was to describe the safety and effectiveness of partnered medication charting in this setting. METHODS: A partnered medication review and charting model was developed. Credentialed pharmacists charted pre-admission medications and venous thromboembolism prophylaxis in collaboration with the admitting medical officer. The pharmacist subsequently had a clinical discussion with the treating nurse regarding the medication management plan for the patient. A prospective audit was undertaken of all patients from the initiation of the service. RESULTS: A total of 549 patients had medications charted by a pharmacist from the 14th of November 2012 to the 30th of April 2013. A total of 4765 medications were charted by pharmacists with 7 identified errors, corresponding to an error rate of 1.47 per 1000 medications charted. CONCLUSIONS: Partnered medication review and charting by a pharmacist in the Emergency Short Stay and General Medicine unit is achievable, safe and effective. Benefits from the model extend beyond the pharmacist charting the medications, with clinical value added to the admission process through early collaboration with the medical officer. Further research is required to provide evidence to further support this collaborative model.