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Background: Sodium‐glucose cotransporter 2 inhibitors (SGLT2i) are now indicated for heart failure and chronic kidney disease (CKD), irrespective of the presence of diabetes. Hence, cardiologists and nephrologists have an important role in initiating these drugs. Aims: To explore cardiologists' and nephrologists' perspectives regarding initiating SGLT2i and their safety monitoring practices when initiating SGLT2i. Methods: Purposive and snowball approaches were used to recruit participants working in diverse areas in New South Wales, Australia. Semi‐structured interviews were conducted with 12 cardiologists and 12 nephrologists. Interviews were conducted until thematic saturation was reached. Emergent themes were identified from transcripts. An iterative general inductive approach was used for data analysis. Results: There was a reluctance amongst most non‐heart‐failure subspecialist cardiologists to initiate SGLT2i. Reasons included the perception of SGLT2i as diabetes drugs, concern about side effects, lack of experience and issues with follow‐up. In contrast, nephrologists reported feeling confident to initiate SGLT2i. Nephrologists varied in their opinions about the severity of CKD at which SGLT2i initiation was reasonable and monitoring of renal function following initiation. Government subsidisation was an important factor in the decision to prescribe SGLT2i to people without diabetes. Conclusions: Our findings highlight the complex transition from the perception of SGLT2i as diabetes drugs to cardiometabolic and reno‐protective agents. Interdisciplinary collaboration may enable greater confidence amongst specialists to initiate SGLT2i, including in patients with CKD. Additionally, there is a need for clear and detailed guidance about SGLT2i prescription in patients with renal dysfunction and renal function monitoring following SGLT2i initiation. [ABSTRACT FROM AUTHOR]

Aims: We aim to examine and understand the work processes of antimicrobial stewardship (AMS) teams across 2 hospitals that use the same digital intervention, and to identify the barriers and enablers to effective AMS in each setting. Methods: Employing a contextual inquiry approach informed by the Systems Engineering Initiative for Patient Safety (SEIPS) model, observations and semistructured interviews were conducted with AMS team members (n = 15) in 2 Australian hospitals. Qualitative data analysis was conducted, mapping themes to the SEIPS framework. Results: Both hospitals utilized similar systems, however, they displayed variations in AMS processes, particularly in postprescription review, interdepartmental AMS meetings and the utilization of digital tools. An antimicrobial dashboard was available at both hospitals but was utilized more at the hospital where the AMS team members were involved in the dashboard's development, and there were user champions. At the hospital where the dashboard was utilized less, participants were unaware of key features, and interoperability issues were observed. Establishing strong relationships between the AMS team and prescribers emerged as key to effective AMS at both hospitals. However, organizational and cultural differences were found, with 1 hospital reporting insufficient support from executive leadership, increased prescriber autonomy and resource constraints. Conclusion: Organizational and cultural elements, such as executive support, resource allocation and interdepartmental relationships, played a crucial role in achieving AMS goals. System interoperability and user champions further promoted the adoption of digital tools, potentially improving AMS outcomes through increased user engagement and acceptance. [ABSTRACT FROM AUTHOR]

Aim: Gout is a common form of inflammatory arthritis with suboptimal management. Management guidelines for gout highlight the importance of both pharmacological and non‐pharmacological treatments. Dietitians can potentially assist in improving gout's associated dietary and lifestyle factors, and thereby play a role in improving its management. The aim of this study was to investigate perspectives of Australian community dietitians on whether their role in gout management could be expanded to improve management and treatment of gout. Method: A snowballing recruitment strategy was used. Dietitians known to the research team were invited to participate and then they suggested further dietitians. Semi‐structured interviews (one‐on‐one) were conducted with 16 dietitians. The focus was on their experiences of contributing to the management of gout, including any barriers and facilitators experienced. Interviews were transcribed verbatim and independently analyzed by 2 reviewers to identify themes. Results: The main reported role of dietitians in gout management was providing patient education. An identified facilitator was dietitians' understanding of gout and its dietary management. Barriers included the emphasis placed on medications for treatment by clinicians and patients, consultation costs, limitations in the evidence for the efficacy of dietary changes and lack of specific training in gout for dietitians. Dietitians predominantly managed the other metabolic conditions commonly associated with gout. Conclusion: Currently, the role dietitians play in gout management is limited. However, dietitians have the potential to take on larger roles in gout education and can also indirectly contribute by way of management of commonly associated comorbidities in gout patients. [ABSTRACT FROM AUTHOR]

Aims: Accurate documentation of medication administration time is imperative for many therapeutic decisions, including dosing of intravenous antimicrobials. The objectives were to determine (1) the discrepancy between actual and documented administration times for antimicrobial infusions and (2) whether day of the week, time of day, nurse‐to‐patient ratio and drug impacted accuracy of documented administration times. Methods: Patient and dosing data were collected (June–August 2019) for 55 in‐patients receiving antimicrobial infusions. "Documented" and "actual" administration times (n = 660) extracted from electronic medication management systems and smart infusion pumps, respectively, were compared. Influence of the day (weekday/weekend), time of day (day/evening/night), nurse‐to‐patient ratio (high 1:1/low 1:5) and drug were examined. Monte Carlo simulation was used to predict the impact on dose adjustments for vancomycin using the observed administration time discrepancies compared to the actual administration time. Results: The median discrepancy between actual and documented administration times was 16 min (range, 2–293 min), with discrepancies greater than 60 minutes in 7.7% of administrations. Overall, discrepancies (median [range]) were similar on weekends (17 [2–293] min) and weekdays (16 [2–188] min), and for high (16 [2–157] min) and low nurse‐to‐patient ratio wards (16 [2–293] min). Discrepancies were smallest for night administrations (P <.05), and antimicrobials with shorter half‐lives (P <.0001). The observed discrepancies in vancomycin administration time resulted in a different dose recommendation in 58% of cases (30% higher, 28% lower). Conclusions: Overall, there were discrepancies between actual and documented antimicrobial infusion administration times. For vancomycin, these discrepancies in administration time were predicted to result in inappropriate dose recommendations. [ABSTRACT FROM AUTHOR]

Aims: Despite the availability of international consensus guidelines, vancomycin dosing and therapeutic drug monitoring (TDM) remain suboptimal. This study aimed to assess concordance of vancomycin dosing and TDM with institutional guidelines and to identify factors taken into consideration by clinicians when prescribing vancomycin. Methods: A retrospective audit of 163 patients receiving vancomycin therapy (≥48 hours) was undertaken. Data collected included patient characteristics, dosing history and plasma vancomycin and creatinine concentrations. Concordance of dosing and TDM with institutional guidelines was evaluated. Semi‐structured interviews, including simulated prescribing scenarios, were undertaken with prescribers (n = 17) and transcripts analysed. Results: Plasma vancomycin concentrations (n = 1043) were collected during 179 courses of therapy. Only 24% of courses commenced with a loading dose with 72% lower than recommended. The initial maintenance dose was concordant in 42% of courses with 34% lower than recommended. Only 14% of TDM samples were trough vancomycin concentrations. Dose was not adjusted for 60% (21/35) of subtherapeutic and 43% (18/42) of supratherapeutic trough vancomycin concentrations, respectively. Interview participants reported that patient characteristics (including renal function), vancomycin concentrations, guidelines and expert advice influenced vancomycin prescribing decisions. Despite referring to guidelines when completing simulated prescribing scenarios, only 37% of prescribing decisions aligned with guideline recommendations. Conclusion: Poor compliance with institutional vancomycin guidelines was observed, despite prescriber awareness of available guidelines. Multifaceted strategies to support prescriber decision‐making are required to improve vancomycin dosing and monitoring. [ABSTRACT FROM AUTHOR]

Background: Deprescribing, the supervised withdrawal of inappropriate medications, intends to manage polypharmacy, which is prevalent in older patients. Aims: To examine general practitioner (GP) perceptions of communication processes between clinicians in hospital and GP in the community about deprescribing decisions made in hospital. Methods: Focus groups and interviews were held with 15 GP, exploring deprescribing in hospitals, communication of deprescribing information and the format of communications. Sessions were audiotaped, transcribed and analysed using an inductive approach. Results: GP stated that they should be involved in deprescribing decisions, especially for older complex patients, because of their good knowledge of their patients. Barriers to effective communication included the acute nature of hospital stays and lack of time. Facilitators included long‐term relationships of GP with their patients and engaged patients. GP preferred communication of deprescribing decisions to be over the telephone while the patient was still in hospital, and with a concise, electronic discharge summary at the time of discharge. GP indicated that rationale for medication changes and recommended follow‐up actions were crucial in a discharge summary to enable care post‐discharge. Conclusions: GP welcome increased communication with hospital clinicians regarding deprescribing decisions made while patients are in hospital. Communication needs to be timely, transparent, succinct and accessible. Lack of time and difficulties contacting hospital clinicians challenge this process. [ABSTRACT FROM AUTHOR]

The article discusses the results of a survey of Australian hospital outpatient pharmacy managers conducted from December 2020 to March 2021 aimed to identify how their services were adapted during the 2020 COVID-19 lockdowns. Topics covered include the use telepharmacy services during the pandemic, the adaptations that were made to reduce patient contact in face-to-face services, and manager's perception on the services preferred by patients.

Objective: To measure the direct and indirect out‐of‐pocket (OOP) costs borne by Australians with gout. Methods: A cross‐sectional, Australia‐wide, web‐based survey was conducted over 12 months between May 2017 and April 2018. Participants were recruited via advertisements in doctors' clinics and healthcare organizations' websites, and social media platforms such as Facebook and Twitter. Survey questions collected information about participants' OOP spending on direct medical and non‐medical gout‐related healthcare costs. Participant demographics, gout status, healthcare sought, workdays lost to due gout and health‐related quality of life were also collected. Results: Seventy‐nine patients with gout completed the survey; 70 (89%) were male, and on average were 56 (SD 16) years of age and had gout for 14 (SD 12) years. For this cohort, the median total OOP direct medical cost was AU$200 per year (interquartile range [IQR]: AU$60‐AU$570). Sixty (76%) people with gout reported being affected by gout during work; however, only 0.25 (IQR: 0‐3) days of work (approximately $60) were lost due to gout in a year. Nine percent (n = 7) of participants experienced cost‐related treatment attrition and 33% reported economic hardship (n = 26). Participants who experienced economic hardship or cost‐related treatment attrition had higher median total gout‐related direct costs than those who did not. Conclusion: In Australia, gout has an OOP financial cost and reduces work productivity. The presence of cost‐related treatment attrition among people with gout indicates that financial costs may be a significant barrier to seeking treatment for a subset of patients with gout. [ABSTRACT FROM AUTHOR]

Aims: Dose‐prediction software can optimise vancomycin therapy, improving therapeutic drug monitoring processes and reducing drug toxicity. Success of software in hospitals may be dependent on prescriber uptake of software recommendations. This study aimed to identify the perceived psychosocial and environmental barriers and facilitators to prescriber acceptance of dose‐prediction software. Methods: Semi‐structured interviews, incorporating prescribing scenarios, were undertaken with 17 prescribers. Participants were asked to prescribe the next maintenance dose of vancomycin for a scenario(s) and then asked if they would accept a recommendation provided by a dose‐prediction software. Interviews further explored opinions of dose‐prediction software. Interview transcripts were analysed using an inductive approach to identify themes and the Theoretical Domains Framework was used to synthesise barriers and facilitators to software acceptance. Results: When presented with software recommendations, half of the participants were comfortable with accepting the recommendation. Key barriers to acceptance of software recommendations aligned with 2 Theoretical Domains Framework domains: Knowledge (uncertainty of software capability) and Beliefs about Consequences (perceived impact of software on clinical outcomes and workload). Key facilitators aligned with 2 domains: Beliefs about Consequences (improved efficiency) and Social Influences (influence of peers). A novel domain, Trust, was identified as influential. Conclusion: Prescribers reported barriers to acceptance of dose‐prediction software aligned with limited understanding of, and scepticism about, software capabilities, as well as concerns about clinical outcomes. Identification of key barriers and facilitators to acceptance provides essential information to design of implementation strategies to support the introduction of this intervention into the workplace. [ABSTRACT FROM AUTHOR]

Objective: To identify individual and organisational factors associated with the prevalence, type and impact of unprofessional behaviours among hospital employees. Design, setting, participants: Staff in seven metropolitan tertiary hospitals operated by one health care provider in three states were surveyed (Dec 2017 – Nov 2018) about their experience of unprofessional behaviours — 21 classified as incivility or bullying and five as extreme unprofessional behaviour (eg, sexual or physical assault) — and their perceived impact on personal wellbeing, teamwork and care quality, as well as about their speaking‐up skills. Main outcome measures: Frequency of experiencing 26 unprofessional behaviours during the preceding 12 months; factors associated with experiencing unprofessional behaviour and its impact, including self‐reported speaking‐up skills. Results: Valid surveys (more than 60% of questions answered) were submitted by 5178 of an estimated 15 213 staff members (response rate, 34.0%). 4846 respondents (93.6%; 95% CI, 92.9–94.2%) reported experiencing at least one unprofessional behaviour during the preceding year, including 2009 (38.8%; 95% CI, 37.5–40.1%) who reported weekly or more frequent incivility or bullying; 753 (14.5%; 95% CI, 13.6–15.5%) reported extreme unprofessional behaviour. Nurses and non‐clinical staff members aged 25–34 years reported incivility/bullying and extreme behaviour more often than other staff and age groups respectively. Staff with self‐reported speaking‐up skills experienced less incivility/bullying (odds ratio [OR], 0.53; 95% CI, 0.46–0.61) and extreme behaviour (OR, 0.80; 95% CI, 0.67–0.97), and also less frequently an impact on their personal wellbeing (OR, 0.44; 95% CI, 0.38–0.51). Conclusions: Unprofessional behaviour is common among hospital workers. Tolerance for low level poor behaviour may be an enabler for more serious misbehaviour that endangers staff wellbeing and patient safety. Training staff about speaking up is required, together with organisational processes for effectively eliminating unprofessional behaviour. [ABSTRACT FROM AUTHOR]

Background: Vancomycin is the primary treatment for methicillin‐resistant Staphylococcus aureus infections. Hospital audits have showed that dosing and therapeutic drug monitoring practices for vancomycin are suboptimal. Limited studies have examined the current educational resources used to support vancomycin use. Aims: To explore and compare the perceptions of health educators and recipients of education on the methods currently used to educate health professionals about vancomycin and to identify ideal methods of education. Methods: Semi‐structured interviews were conducted with health educators around Australia and with recipients of education (doctors and nurses). Interview questions explored previous experiences of education and perceptions of ideal methods of education. Interviews were audio‐taped, transcribed and thematically analysed. Results: Health educators explained that current vancomycin education comprises large‐scale presentations, but they perceived these to be ineffective. The recipients of vancomycin education reported a lack of formal education on vancomycin. Despite this, both educators and recipients agreed on the ideal methods of education: nurses are reported to be protocol driven, and education for nurses should be through in‐services or e‐learning modules, while doctors require an evidenced‐based approach. Senior doctors initially require convincing that education is needed. Once convinced, they respond well to brief emails and case‐based and one‐on‐one education strategies. Technology‐based strategies and problem‐based learning were observed to be effective methods for junior doctors. Conclusions: Vancomycin dosing and therapeutic drug monitoring involves multiple health professionals, but current education strategies do not take this into account. Ideal education strategies need to be multimodal and targeted to specific health profession groups. [ABSTRACT FROM AUTHOR]

Background: Many studies have explored the effect of electronic medication management systems (EMMS) on doctors' and nurses' work, but few have focused specifically on pharmacists' work. Aim: This study examined how implementation of a commercial EMMS affected the work of pharmacists in an Australian paediatric hospital. In particular, the study investigated whether any pharmacy tasks changed or were eliminated, or whether new tasks emerged following EMMS introduction. Methods: Two rounds of semistructured interviews with pharmacists, one 4 months and the other 1 year after EMMS implementation, were conducted. In total, 17 pharmacists were interviewed, comprising inpatient, outpatient and oncology pharmacists, as well as pharmacy managers. Results: EMMS implementation eliminated a small number of tasks, changed some tasks and created many new work tasks for pharmacists. These new tasks included helping doctors and nurses to use the EMMS, duplicated data entry and the review of additional information. Pharmacists held the view that their workload had increased and that additional pharmacists were necessary to cope with the new work requirements associated with the EMMS. Some problems were perceived to be the result of implementation of a US‐designed EMMS that did not fully support Australian pharmacy workflows. Conclusion: Implementation of an EMMS in a paediatric hospital affected pharmacists' work in a variety of ways, predominately by introducing new tasks. Anticipating how workflows will change with EMMS implementation is challenging. Undertaking regular reviews of workflow and planning for an increased burden on pharmacy staff is likely to improve the transition from paper to electronic medication management. [ABSTRACT FROM AUTHOR]

Background: Electronic medication management (EMM) systems provide the capacity to enable and configure front‐end clinical decision support (CDS) tools to trigger medication‐related prescribing alerts. Aim: The aim of this study was to determine how and why alerts were selected for inclusion in inpatient EMM systems in Australian hospitals. Methods: A semistructured, cross‐sectional survey containing multiple‐choice questions, scaled responses and open‐ended questions was conducted on a purposive sample of key stakeholders from Australian hospitals who had implemented an EMM system. Results: We interviewed fifteen participants, predominantly pharmacists, representing 26 Australian hospitals that had implemented an EMM system. All hospitals had implemented drug–allergy and drug–drug alerting, and 69% (n = 18) had implemented dose range checking alerting. Implementers reported a high level of customisation of the vendor out‐of‐the box functionality in efforts to improve sensitivity and specificity of alerts and to minimise alert fatigue. For the most frequently implemented alert categories, most respondents reported that they believed there was research evidence to support the benefits of these alerts to improve prescribing behaviours and patient outcomes. Aside from drug–allergy alerts, less than 50% of EMM implementers reported that they thought alerts had improved prescriber behaviour in their hospitals. Few local evaluations of the effects of alerts had been conducted. Conclusion: The results of this survey provide implementers with new insights into the experiences of Australian hospitals to inform the design and implementation of effective medication prescribing alerts. They also highlight the urgent need for robust evaluations of prescribing alerts in Australian healthcare contexts. [ABSTRACT FROM AUTHOR]

Aim: To estimate the non-medical out-of-pocket costs for families with a child in hospital.Methods: This study was a survey of 225 parents of paediatric inpatients on nine wards of an Australian public paediatric teaching hospital on two separate days. Our primary outcomes were the costs associated with: (i) time taken off work to care for the child in hospital; (ii) time off work or contributed by family and friends to care for other dependents; and (iii) travel, meals, accommodation and incidental expenses during the child's stay. Demographic data included postcode (to assess distance, socio-economic status and remoteness), child's age, ward and whether this was their child's first admission.Results: Mean patient age was 6.5 years (standard deviation 5.2). On an average per patient day basis, parents took 1.12 days off work and spent 0.61 (standard deviation 0.53) nights away from home, with 83.8% of nights away at the child's bedside. Parents spent Australian dollars (AUD)89 per day on travel and AUD36 on meals and accommodation. Total costs (including productivity costs) were AUD589 per patient day. Higher costs per patient day were correlated with living in a more remote area (0.48) and a greater travel distance to the hospital (0.41). A higher number of days off work was correlated (0.69) with number of school days missed.Conclusion: These results demonstrate the considerable time and financial resources expended by families caring for a child in hospital and are important inputs in evaluating health-care interventions that affect risk of hospitalisation and length of stay in paediatric care. [ABSTRACT FROM AUTHOR]

The article focuses on the need for evidence-based decision support for medication management for preventing medication errors.

An introduction to the journal is presented in which the editor discusses various reports in the issue on the topics including one on gout as the common form of inflammatory arthritis in men, the other on urate-lowering therapies (ULT) and the third on improving adherence to medications in people living with gout.

In an Australian study which explored hospital prescribers' perspectives on recording indications, a key barrier to indication documentation was identified to be prescriber knowledge of the indication: "I think that [recording indications] would be really beneficial only if the person doing it knew what they were doing. The inaccurate indication can follow the patient out of hospital (via discharge scripts, patient medication lists and medication labels), potentially resulting in confusion and misinterpretation by the patient and their healthcare providers. Keywords: electronic prescribing; indications-based prescribing; workarounds EN electronic prescribing indications-based prescribing workarounds 730 731 2 03/05/21 20210301 NES 210301 INTRODUCTION Clinicians, patients, administrators and researchers have become increasingly frustrated by the lack of indication (i.e., problem) information included in prescriptions, despite the obvious benefit this would provide to patients and other healthcare providers.1 For example, a key benefit of access to accurate indications is facilitation of medicine review and deprescribing to address polypharmacy. [Extracted from the article]

Aim: To evaluate the use of pneumonia severity scores for diagnosing community-acquired pneumonia (CAP) and to assess whether antibiotic prescribing was compliant with guidelines as determined by the calculated pneumonia severity score. Method: A retrospective chart review was undertaken of consecutive adults admitted via the emergency department with a diagnosis of CAP during a 6-month period. Charts were reviewed for symptoms and radiographic evidence of pneumonia and for recorded pneumonia severity scores. Pneumonia severity scores were calculated using CORB, CURB-65 and SMART-COP for patients with available data and used to assess compliance with the Therapeutic Guidelines: Antibiotic. Results: Of the 204 patients reviewed, 69 had radiographic evidence and symptoms of CAP. Only 1 patient had a pneumonia severity score recorded. Based on calculated CORB, CURB-65 and SMART-COP scores for the remaining 68 patients, 13 (19%), 3 (4.4%) and 1 (3.6%) patients had severe pneumonia. 93% of patients received ceftriaxone. An average of 8% of patients were prescribed antibiotics compliant with the Therapeutic Guidelines: Antibiotic. Compliance varied with the pneumonia severity scoring tool used. Conclusion: Pneumonia severity scores were rarely calculated to guide treatment and antibiotic prescribing for CAP. Compliance with the Therapeutic Guidelines: Antibiotic was poor and varied with the pneumonia severity scoring tool used. An easy-to-use pneumonia severity score to guide patient admission and choice of antibiotic is needed. [ABSTRACT FROM AUTHOR]

Background: Antibiotic stewardship programs have been shown to reduce inappropriate institutional antibiotic use. There is no consensus on the strategies, e.g. formulary restrictions, that best improve appropriate use and reduce misuse of antibiotics. Aim: To identify facilitators and barriers to compliance with an institutional antibiotic prescribing policy and to compare policymakers' perceptions about the facilitators and barriers that influence compliance with those held by prescribers. Method: 5 antimicrobial stewardship committee members (policymakers) and 15 prescribers from a large Sydney hospital participated in a semi-structured interview. To gauge prescribers' knowledge of the institutional antibiotic policy, case scenarios were included in the interviews with prescribers. Interviews were continued until data saturation was reached. Recurrent themes were analysed and interpreted in terms of a well-known conceptual framework of barriers to physician adherence to guidelines. Results: Antimicrobial stewardship committee members identified lack of knowledge as the main barrier to compliance with the antibiotic prescribing policy. Despite reporting that they were aware of and agreed with the antibiotic prescribing policy, most prescribers did not comply with the policy and referred to clinical information sources when completing the case scenarios. Organisational hierarchies were frequently reported as a barrier by both participant groups. While prescribers considered inapplicability of the antibiotic prescribing policy as an important barrier, antimicrobial stewardship committee members attributed non-compliance to the policy to prescriber autonomy and personal experience. Conclusion: We identified several barriers to compliance with the antibiotic prescribing policy, such as poor knowledge of policy specifics and medical hierarchies. Involving prescribers in policy development, giving them feedback about their prescribing, and improving existing collaboration and decision support platforms may further improve judicious antibiotic use. [ABSTRACT FROM AUTHOR]

The article describes the implementation of an electronic medication management system (eMMS) in an Australian teaching hospital. The success of eMMS is said to hinge on a positive workplace culture, acceptance of the major effect on work practices by all staff, and timely system response to user feedback. Other factors critical to a successful implementation are training and support for clinicians, a usable system, and adequate decision support.

A letter to the editor is presented in response to the article "Prevalence of error-prone abbreviations used in medication prescribing for hospitalised patients: multi-hospital evaluation," by M. J. Dooley and team from a volume 42, 2012 issue of "Internal Medicine Journal."