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Medication-related hospitalisations present an opportunity for de-prescribing and simplification of medication regimens. The Medication Regimen Complexity Index (MRCI) is a tool for measuring the complexity of medication regimens. To evaluate whether MRCI changes following medication-related hospitalisations, and to evaluate the relationship between MRCI, length of stay (LOS) in hospital, and patient characteristics. A retrospective medical record review of patients admitted to a tertiary referral hospital in Australia for medication-related problems, January 2019 to August 2020. MRCI was calculated using pre-admission medication lists and discharge medication lists. There were 125 patients who met inclusion criteria. The median (IQR) age was 64.0 years (45.0–75.0) and 46.4% were female. Median MRCI decreased by 2.0 following hospitalisation: from median (IQR) 17.0 (7.0–34.5) on admission vs 15.0 (3.0–29.0) on discharge (p < 0.001). Admission MRCI predicted LOS ≥2 days (OR 1.03, 95%CI 1.00–1.05, p = 0.022). Allergic reaction-related hospitalisations were associated with lower admission MRCI. There was a decrease in MRCI following medication-related hospitalisation. Targeted medication reviews for high-risk patients (e.g., those with medication-related hospitalisations) could further reduce the burden of medication complexity following discharge from hospital and possibly prevent readmissions. [ABSTRACT FROM AUTHOR]

The COVID‐19 pandemic has required an unprecedented surge in the pharmacy workforce to support mass vaccination hubs. This review discusses the challenges faced while training and credentialing a surge pharmacy workforce and how these challenges were overcome. The process used for training and credentialing new employees has been described and recommendations and insights have been provided based on the lessons learned at two COVID‐19 mass vaccination hubs in New South Wales. Operationalising one of the largest mass vaccination hubs in Australia required efficient training and credentialing of the pharmacy workforce. This process included the use of pharmacist‐extenders such as students, assistants, and those from other healthcare and non‐healthcare backgrounds. Training was optimised by using a flipped classroom model, so that the vaccine preparation process was provided via asynchronous online videos. The videos covered each step of vaccine dose preparation with visual cues to guide appropriate technique. On‐site training involved use of simulation and checklists for credentialing. Many factors contributed to the success of this process, including the use of triaging and the re‐allocation of personnel based on skill level, collaboration with the Sydney Pharmacy School to train and support a surge workforce involving students, initial on‐site information technology support in the form of pharmacy superusers, the use of checklists and guides for troubleshooting, and assigned pharmacy educators to train new employees. The public health response to the COVID‐19 pandemic forced us to rapidly adapt to build a pharmacy workforce in record time to support mass vaccination hubs. The recommendations and insights provided from our experience can guide future surges. Some of these concepts may also be applied to pharmacy practice in hospitals when resources are constrained. [ABSTRACT FROM AUTHOR]

Aim: To benchmark annual research output from hospital pharmacy departments in Australian principal referral hospitals. Data sources: Embase, Medline, and Scopus. Study selection: All 29 principal referral hospitals listed by the Australian Institute of Health and Welfare were searched using the institution field from 2018–2020. Articles were included if an author was affiliated with a hospital pharmacy department. Conference abstracts, letters, narrative reviews, opinions, commentaries, or editorials were excluded. Results: A total of 261 research articles were identified from 27 principal referral hospital pharmacy departments from 2018–2020. Median research output over 3 years was five (interquartile range, 3–9) articles. In terms of annual research, hospital pharmacy departments in the 50th and 90th percentile for total publication output published two and ten original research articles every year, respectively. Overall, 56% (n = 145) of the published studies were observational, 35% (n = 90) had a first author with a pharmacy department affiliation, 97% (n = 252) had at least one author with a university affiliation, and in 5% (n = 12) of the articles there was more than one hospital pharmacy department affiliation. Conclusion: On average, hospital pharmacy departments in Australian principal referral hospitals publish two original research articles every year. Nearly all of these articles are published in collaborations with universities. [ABSTRACT FROM AUTHOR]

Background: Adverse drug events (ADEs) remain a key contributor to hospitalisations, resulting in long hospital stays and readmissions. Information pertaining to the specific medications and clinical factors associated with these outcomes is limited. Hence, a better understanding of these factors and their relationship to ADEs is required.Objectives: To investigate medications involved, clinical manifestations of ADE-related hospitalisations, and their association with length of stay and readmission.Methods: A retrospective medical record review of patients admitted to a major, tertiary referral hospital in NSW, Australia, from January 2019 to August 2020 was conducted. ADEs were identified using Australian Refined Diagnosis Related Group (AR-DRG) codes: X40, X61, X62 and X64. Medications were classified per the Anatomical Therapeutic Chemical (ATC) classification system and clinical symptoms were classified per the International Classification of Disease (ICD) 9-CM. Logistic regression was performed to assess the relationship between medication and presentation classes with length of stay (≥2 days vs <2 days) and readmission.Results: There were 125 patients who met inclusion criteria (median age = 64 [interquartile range, 45-75] years; 53.6% male). Anti-thrombotic agents, opioids, antidepressants, antipsychotics, insulins and NSAIDs were the most implicated pharmacological classes. Neurological medications and falls were associated with a length of stay ≥2 days (adjusted odds ratio [aOR] 3.92, 95% confidence interval [CI] 1.48-10.33 and aOR 3.24, 95% CI 1.05-10.06, respectively). Neurological medications and neurological and cognitive disorders were associated with an increased likelihood of 90-day readmission (aOR 2.63, 95% CI 1.05-6.57 and aOR 3.20, 95% CI 1.17-8.75, respectively).Conclusion: This study identified neurological medications as high-risk for increased length of stay and readmission in those hospitalised due to ADEs. This highlights the need for judicious prescribing and monitoring of these medications. [ABSTRACT FROM AUTHOR]

Aim: To assess the efficacy and safety of metaraminol infusions in comparison to other vasopressors in critically ill patients with shock with regard to hospital mortality, effect on haemodynamics (mean arterial pressure or systolic blood pressure), duration of vasopressor use, and adverse events. Data sources: A systematic review was conducted in eight electronic databases and nine trial registers from inception to 17 March 2021. Study selection: Studies included randomised or non‐randomised controlled trials, and retrospective or prospective observational studies of critically ill adult patients admitted to the intensive care unit or emergency department with shock of any aetiology and who received metaraminol via continuous infusion compared to patients who received other vasopressors. Results: Out of 1387 eligible articles, three observational studies and one controlled trial were included involving a total of 54 patients. Study patients had different types of shock including septic (n = 28), cardiogenic (n = 21), hypovolemic (n = 3) and neurogenic shock (n = 2). All studies compared metaraminol to noradrenaline and were of poor quality and high risk of bias. There was no difference in hospital mortality or effect on mean arterial pressure or systolic blood pressure between metaraminol and noradrenaline in any of the studies. None of the studies reported the duration of vasopressor use or adverse drug events such as extravasation or tissue injury. Conclusion: There is limited and low‐quality efficacy and safety data to support the use of metaraminol over other vasopressors in critically ill patients with shock. Future clinical trials are needed before this agent is routinely used in this patient population. [ABSTRACT FROM AUTHOR]

A recent review of missing data in pharmacy literature has highlighted that a low proportion of studies reported how missing data was handled. In this paper we discuss the concept of missing data in survey research, how missing data is classified, common techniques to account for missingness and how to report on missing data. The paper provides guidance to mitigate the occurrence of missing data through planning. Considerations include estimating expected missing data, intended vs unintended missing data, survey length, working with electronic surveys, choosing between standard and filtered form questions, forced responses and straight-lining, as well as responses that can generate missingness like "I don't know" and "Not Applicable". We introduce methods for analysing data with missing values, such as deletion, imputation and likelihood methods. The manuscript provides a framework and flow chart for choosing the appropriate analysis method based on how much missing data is observed and the type of missingness. Special circumstances involving missing data have been discussed, such as in studies with repeated or cohort measures, factor analysis or as part of data integration. Finally, a checklist of questions are provided for researchers to guide the reporting of the missing data when conducting future research. [ABSTRACT FROM AUTHOR]

Background: Medication reconciliation aims to prevent unintentional medication discrepancies that can result in patient harm at transitions of care. Pharmacist-led medication reconciliation has clear benefits, however workforce limitations can be a barrier to providing this service. Pharmacy students are a potential workforce solution. Objective: To evaluate the number and type of medication discrepancies identified by pharmacy students. Methods: Fourth year pharmacy students completed best possible medication histories and identified discrepancies with prescribed medications for patients admitted to hospital. A retrospective audit was conducted to determine the number and type of medication discrepancies identified by pharmacy students, types of patients and medicines involved in discrepancies. Results: There were 294 patients included in the study. Overall, 72% (n=212/294) had medication discrepancies, the most common type being drug omission. A total of 645 discrepancies were identified, which was a median of three per patient. Patients with discrepancies were older than patients without discrepancies with a median (IQR) age of 74 (65-84) vs 68 (53-77) years (p=0.001). They also took more medicines with a median (IQR) number of 9 (6-3) vs 7 (2-10) medicines per patient (p<0.001). The most common types of medicines involved were those related to the alimentary tract and cardiovascular system. Conclusions: Pharmacy students identified medication discrepancies in over 70% of hospital inpatients, categorised primarily as drug omission. Pharmacy students can provide a beneficial service to the hospital and contribute to improved patient safety by assisting pharmacists with medication reconciliation. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this study was to compare emergency department (ED) length of stay (LOS) between patients treated with opioid analgesia versus non-opioid analgesia for low back pain (LBP) in the ED.Methods: We conducted a secondary analysis of National Hospital Ambulatory Medical Care Survey (NHAMCS) data (2014-2015). Adults (age ≥18 years) who presented to the ED with a reason for visit or primary diagnosis of LBP were included in the final study sample. Patient visits were categorized into two groups based on whether they received opioid analgesia (with or without non-opioid analgesia) or non-opioid analgesia only in the ED. The primary outcome measure was ED LOS, which was log-transformed (as ED LOS was not normally distributed) for analysis. A multivariable linear regression analysis was used to evaluate the association between opioid use and ED LOS.Results: The study sample consisted of a national estimate of approximately 8.6 million ED visits for LBP (during 2014-2015), of which 60.1% received opioids and 39.9% received non-opioids only. The geometric mean ED LOS for patient visits who received opioids was longer than patient visits who received non-opioids (142 versus 92 min, respectively; p < 0.001). After adjusting for confounders in the multivariable analysis, patient visits that received opioids had a significantly longer ED LOS (coefficient 0.25; 95% CI 0.11 to 0.38; p < 0.001).Conclusions: In a nationally representative sample of patient visits to ED due to LBP in the US, use of opioids in the ED was associated with an increased ED LOS. [ABSTRACT FROM AUTHOR]

Objectives: The primary objective of this study was to determine the proportion of patients with medication discrepancies when using a self-administered medication history form in the emergency department (ED). The secondary objectives were to identify predictors of medication discrepancies and determine the proportion of patients with a high-risk medication discrepancy.Methods: This was a cross-sectional study conducted in an urban ED in Australia. Patients completed a self-administered medication history form while waiting to be seen by a physician. Subsequently, a best possible medication history was taken by a pharmacist to determine accuracy of the self-reported medication lists for patients with planned admissions. Discrepancies between the two medication lists were reported descriptively. A Poisson regression analysis was conducted to identify predictors of the rate of discrepancies. Associations were reported as incident rate ratios (IRR).Results: A total of 138 patients were included in the study. The total number of discrepancies was as follows: 0 (25%, n = 34), 1 (34%, n = 47), 2 (11%, n = 15), and ≥3 (30%, n = 42). The number of medications (IRR 1.11, 95% CI 1.09 to 1.14, p < 0.001), female (IRR 1.51, 95% CI 1.18 to 1.92, p = 0.001), and missing community pharmacy information (IRR 2.10, 95% CI 1.64 to 2.68, p < 0.001) were significantly associated with rate of discrepancies. Overall, 20% (n = 28) of patients had one or more high-risk medication discrepancies.Conclusion: Patient self-administered medication history forms have a high rate of discrepancies and should be verified by a best possible medication history. [ABSTRACT FROM AUTHOR]

Objective: A change in Arizona State law in 2017 required prescribers to review data from a prescription drug monitoring program (PDMP) prior to opioid prescribing. The objective was to determine the effect of this change on opioid prescribing for patients who presented to the emergency department (ED) for back pain.Methods: This was a retrospective cohort study conducted in a 50-bed community ED in the United States. Consecutive adult patients who presented to the ED with back pain were included. Patients were categorized based on when they presented to the ED in reference to the law mandating PDMP review: 1) pre-PDMP and 2) post-PDMP. The outcome measures included the proportion of patients who were prescribed opioids upon discharge and the total amount of opioids prescribed per patient in oral morphine milligram equivalents (MME).Results: A total of 268 patients were included (134 in pre-PDMP and 134 in post-PDMP). Opioid prescribing on discharge from the ED occurred in 46% (n = 62) of patients in the pre-PDMP group and 48% (n = 64) of patients in the post-PDMP group (difference 2%, 95% CI -11 to 13%). Of those who received opioid prescriptions, the median total prescribed MME was 75 mg (IQR 60-120 mg) in the pre-PDMP group and 75 mg (IQR 60-90) in the post-PDMP group (mean difference 8 mg, 95% CI -9 to 24 mg).Conclusion: A legislative requirement for provider PDMP review did not change opioid prescribing for patients in the ED who presented with back pain. [ABSTRACT FROM AUTHOR]

Objective: To quantify the extent and identify predictors of potentially inappropriate antidepressant use among older adults with dementia and newly diagnosed major depressive disorders (MDD).Methods: This retrospective cohort study included older adults (aged ≥65 years) with dementia and newly diagnosed MDD using Medicare 5% sample claims data (2012-2013). Based on Healthcare Effectiveness Data and Information Set guidelines, intake period for new antidepressant medication use was from May 1, 2012, through April 30, 2013. Index prescription start date was the first date of antidepressant prescription claim during the intake period. Dependent variable of this study was potentially inappropriate antidepressant use as defined by the Beers Criteria and the Screening Tool of Older Persons' potentially inappropriate Prescriptions criteria. The authors conducted multiple logistic regression analysis to identify individual-level predictors of potentially inappropriate antidepressant use.Results: The authors' final study sample consisted of 7,625 older adults with dementia and newly diagnosed MDD, among which 7.59% (N = 579) initiated treatment with a potentially inappropriate antidepressant. Paroxetine (N = 394) was the most commonly initiated potentially inappropriate antidepressant followed by amitriptyline (N = 104), nortriptyline (N = 35), and doxepin (N = 32). Initiation of a potentially inappropriate antidepressant was associated with age and baseline use of anxiolytic medications.Conclusion: More than 7% of older adults in the study sample initiated a potentially inappropriate antidepressant, and the authors identified a few individual-level factors significantly associated with it. Appropriately tailored interventions to address modifiable and nonmodifiable factors significantly associated with potentially inappropriate antidepressant prescribing are required to minimize risks in this vulnerable population. [ABSTRACT FROM AUTHOR]

Objectives: To compare a phenobarbital-adjunct versus benzodiazepine-only approach for the management of alcohol withdrawal syndrome in the emergency department (ED) with regard to the need for intensive care unit (ICU) admission, severity of symptoms on ED discharge, and complications.Methods: This was a retrospective cohort study conducted in two academic EDs in the United States. Adult patients seen in the ED with a diagnosis of alcohol withdrawal syndrome were included. Patients were categorized into two groups based on whether phenobarbital was administered in the ED: 1) phenobarbital group (with or without benzodiazepines) or 2) non-phenobarbital group. The primary outcome measure was the need for ICU admission. Secondary outcomes included Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scores at ED discharge, and complications. Complications were a composite of death, need for intubation, hypotension or vasopressor use, seizures, and hospital acquired pneumonia.Results: The study cohort included 209 patients (phenobarbital = 97, non-phenobarbital = 112). The mean (standard deviation) age was 49 (12) years and 85% (n = 178) were male. A similar proportion of patients in the phenobarbital (14%, n = 14) and non-phenobarbital (11%, n = 12) groups required ICU admission (p = 0.529). The median CIWA-Ar score on ED discharge was 7 (IQR 4-12) points in the phenobarbital group and 7 (IQR 4-14) points in the non-phenobarbital group (p = 0.752). The occurrence of complications was also similar in the phenobarbital (9%, n = 9) and non-phenobarbital groups (11%, n = 10).Conclusion: Adjunctive phenobarbital use in the ED for alcohol withdrawal syndrome did not result in decreased ICU admission, severity of symptoms, or complications. [ABSTRACT FROM AUTHOR]

A self-administered patient medication history form may improve efficiency of workflow in the emergency department. The objective of this study was to evaluate the patient perspective of completing a self-administered medication history form in the emergency department. This was a cross-sectional survey of patients who presented to an urban emergency department in Australia. Face and content validity of the survey was established via an iterative process that included pharmacists and patients. After completing a self-administered medication history form, patients were surveyed regard their perspective of this approach. The results of each survey question were evaluated descriptively. A total of 113 completed the survey. The mean age was 59 ± 19 years, and 52% were male. Most patients (87%, n = 98) did not think there were any problems completing a self-administered list while waiting to be seen by a physician or pharmacist in the emergency department. Some patients preferred other modalities for clinicians to obtain the list due to their lack of recollection or confusion (4%, n = 4), preferred that clinicians utilised existing lists or evaluated medications brought with them (2%, n = 2), preferred the convenience of answering questions rather than writing (1%, n = 1), or did not list a reason (1%, n = 1). Most patients who present to the emergency department view a self-administered medication history form positively. [ABSTRACT FROM AUTHOR]

Background: Prothrombin complex concentrate (PCC) is used as an alternative to fresh frozen plasma (FFP) for emergency bleeding. The primary objective of this study was to compare the time from order to start of administration between 3-factor PCC (PCC3), 4-factor (PCC4), and FFP in the emergency department (ED). The secondary objective was to evaluate the effect of an ED pharmacist on time to administration of PCCs.Methods: This was a single center three-arm retrospective cohort study. Adult patients in the ED with bleeding were included. The primary outcome measure was the time from order to administration, which was compared between PCC3, PCC4, and FFP. The time from order to administration was also compared when the ED pharmacist was involved versus not involved in the care of patients receiving PCC.Results: There were 90 patients included in the study cohort (30 in each group). The median age was 69years (IQR 57-82years), and 57% (n=52) were male. The median time from order to administration was 36min (IQR 20-58min) for PCC3, 34min (IQR 18-48min) for PCC4, and 92min (IQR 63-133) for FFP (PCC3 versus PCC4, p=0.429; PCC3 versus FFP, p<0.001; PCC4 versus FFP, p<0.001). The median time from order to administration was significantly decreased when the ED pharmacist was involved (24min [IQR 15-35min] versus 42min [IQR 32-59min], p<0.001).Conclusions: Time from order to administration is faster with PCC than FFP. ED pharmacist involvement decreases the time from order to administration of PCC. [ABSTRACT FROM AUTHOR]

Objectives: The use of etomidate and rocuronium for rapid sequence intubation (RSI) results in a duration of paralysis that exceeds the duration of sedation. The primary objective of this study was to compare the number of analgosedative (AGS) interventions early versus late post-RSI, with this drug combination. The secondary objective was to descriptively assess time to first AGS intervention.Methods: This was a retrospective cohort study conducted in an academic ED in the United States between January 2015 and June 2016. The study was conducted after a pharmacy-led education program. Consecutive adult patients who received the combination of etomidate and rocuronium for RSI were included. The primary outcome measure was the number of AGS interventions post-RSI. An AGS intervention was defined as initiation of an opioid or sedative, or a dose increase of an infusion rate. Interventions were categorized as early (0-30min post-RSI) or late (60-90min post-RSI).Results: The sample (n=108) had a mean age of 58±19years, and the majority was male (n=62, 57%). The mean rocuronium dose was 1.1±0.3mg/kg. There was a median of 2 interventions (IQR 1-3) that occurred early versus 0 interventions (IQR 0 to 1) that occurred late post-RSI (p<0.001). The median time to first AGS intervention was 7min (IQR 3 to 13min).Conclusions: When rocuronium was used for RSI in the ED there was no delay in provision of post-intubation sedation or analgesia, after a pharmacy-led educational program. [ABSTRACT FROM AUTHOR]

Purpose To evaluate the extent of student use of flipped classroom videos. Methods This was a cross-sectional study conducted in a college of pharmacy therapeutics course in the Unites States. In one section of the course (four sessions) all content was provided in the form of lecture videos that students had to watch prior to class. Class time was spent discussing patient cases. For half of the sessions, there was an electronic quiz due prior to class. The outcome measure was video view time in minutes. Adequate video view time was defined as viewing ≥75% of total video duration. Video view time was compared with or without quizzes using the Wilcoxon signed-rank test. Results There were 100 students in the class and all were included in the study. Overall, 74 students had adequate video view time prior to session 1, which decreased to 53 students for session 2, 53 students for session 3, and 36 students for session 4. Median video view time was greater when a quiz was required [80 minutes (IQR: 38–114) versus 69 minutes (IQR: 3–105), p < 0.001]. The mean score on the exam was 84 ± 8 points (out of 100). There was a significant association between video view time (per 50% increment) and score on the exam (coefficient 2.52; 95% CI: 0.79–4.26; p = 0.005; model R 2 = 7.8%). Conclusion Student preparation prior to the flipped classroom is low and decreases with time. Preparation is higher when there is a quiz required. [ABSTRACT FROM AUTHOR]

Background: Patients who present to the emergency department (ED) with mild skin and soft tissue infections (SSTIs) are often given a single dose of an antibiotic before being discharged home on oral antibiotics. The objective of this study was to determine if administration of antibiotics in the ED increases length of stay. Methods: This was cross-sectional study using data from the National Hospital Ambulatory Medical Care Survey. Patients with SSTIs who were discharged home with antibiotics were included. Patients were categorized into 2 groups based on whether any antibiotics were administered in the ED. The ED length of stay was compared between the groups. A multivariate analysis was conducted to adjust for pertinent confounders. Results: There were 3000895 cases of patients with SSTIs who presented to the ED and directly discharged home on antibiotic therapy from 2008 to 2010. Of these, 46.8% (n = 1403710) involved the administration of an antibiotic in the ED, whereas the others only received antibiotic prescriptions upon discharge. The mean ED length of stay was 83.8 ± 160.6 minutes with no antibiotics vs 112.2 ± 193.6 minutes for antibiotic use in the ED (P < .05). After adjusting for confounders, there was a 43% increase in ED length of stay associated with administration of first dose of antibiotics in the ED (exp[b] = 1.43; 95% confidence interval, 1.19-1.70; P< .001). Conclusion: The administration of an antibiotic in the ED before discharge is associated with an increased ED length of stay in patients with SSTIs. [ABSTRACT FROM AUTHOR]