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As digitisation continues to increase across Australian health services, the nursing profession has focused on analysing and measuring the way care is provided to the patients. Focus on optimising nursing workflows and improved care delivery has presented challenges but this is now demonstrating improvements in patient care outcomes and time for care.

Introduction and Aims Nicotine replacement therapy (NRT) is recommended as a smoking cessation aid for hospitalised smokers. We examined factors associated with NRT use during hospitalisation and after discharge, and NRT uptake when systematically offered free of cost. Design and Methods A nested analysis was conducted using data from a clinical trial that evaluated the effectiveness of a pharmacist-led smoking cessation intervention in 600 hospitalised smokers. Results NRT was used at least once by 285 (48%) participants during hospitalisation and by 287 (48%) participants during the 12 months post-discharge. Heavy smokers and those who expressed interest in using NRT for their next quit attempt at baseline interview were more likely to use NRT during hospitalisation [odds ratio (OR) 1.94, 95% confidence interval (CI) 1.38, 2.74; OR 2.09, 95% CI 1.48, 2.95] and after discharge (OR 1.70, 95% CI 1.20, 2.41; OR 1.97, 95% CI 1.39, 2.79). Those using six or more medications were more likely to use NRT during hospitalisation (OR 1.65, 95% CI 1.05, 2.61). Post-discharge NRT users were more likely to have been initially admitted for a respiratory or cardiac problem (OR 1.51, 95% CI 1.05, 2.18). When NRT was offered free of cost to a subset of patients (n = 300), 157 (52%) used NRT during hospitalisation. Nicotine dependence and interest in using NRT predicted its use (OR 2.26, 95% CI 1.38, 3.70; OR 2.58, 95% CI 1.58, 4.20). Discussion and Conclusions Targeting heavy smokers, those with cardio-respiratory conditions and those interested in using NRT regardless of regimen complexity could improve NRT uptake.

This study evaluates the clinical efficacy and safety of NovoRapid (insulin aspart) compared to Actrapid™ (human neutral insulin) for diabetic ketoacidosis (DKA). In this retrospective study involving 40 patients, no statistically significant differences were observed between biochemical variables, infusion duration or complications in patients treated with insulin aspart or human neutral insulin. These results support the use of insulin aspart as an effective and safe alternative to human neutral insulin in DKA.

This work was supported by Cancer Research UK (EHW, TJ: C42738/A24868); National Institute of Health Research Cambridge Biomedical Research Centre (HE); National Institute of Health Research UK Academic Clinical Fellowship (CMC); and National Institutes of Health USA Cancer Center support grant (TJ: 5P30CA045508-31). Important oncological management decisions rely on kidney function assessed by serum creatinine-based estimated glomerular filtration rate (eGFR). However, no large-scale multicentre comparison of methods to determine eGFR in patients with cancer are available. To compare the performance of formulas for eGFR based on routine clinical parameters and serum creatinine not calibrated with isotope dilution mass spectrometry (non-IDMS), we studied 3,620 patients with cancer and 166 without cancer who had their GFR measured with an exogenous nuclear tracer at one of seven clinical centres. The mean measured GFR was 86 ml/min. Accuracy of all models was centre-dependent, reflecting inter-centre variability of non-IDMS creatinine measurements. CamGFR was the most accurate model for eGFR (root-mean-squared-error (RMSE) 17.3 ml/min) followed by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) model (RMSE 18.2 ml/min).Important oncological management decisions rely on kidney function assessed by serum creatinine-based estimated glomerular filtration rate (eGFR). However, no large-scale multicentre comparison of methods to determine eGFR in patients with cancer are available. To compare the performance of formulas for eGFR based on routine clinical parameters and serum creatinine not calibrated with isotope dilution mass spectrometry (non-IDMS), we studied 3,620 patients with cancer and 166 without cancer who had their GFR measured with an exogenous nuclear tracer at one of seven clinical centres. The mean measured GFR was 86 ml/min. Accuracy of all models was centre-dependent, reflecting inter-centre variability of non-IDMS creatinine measurements. CamGFR was the most accurate model for eGFR (root-mean-squared-error (RMSE) 17.3 ml/min) followed by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) model (RMSE 18.2 ml/min).Important oncological management decisions rely on kidney function assessed by serum creatinine–based estimated glomerular filtration rate (eGFR). However, no large-scale multicenter comparisons of methods to determine eGFR in patients with cancer are available. To compare the performance of formulas for eGFR based on routine clinical parameters and serum creatinine not calibrated with isotope dilution mass spectrometry, we studied 3620 patients with cancer and 166 without cancer who had their glomerular filtration rate (GFR) measured with an exogenous nuclear tracer at one of seven clinical centers. The mean measured GFR was 86 mL/min. Accuracy of all models was center dependent, reflecting intercenter variability of isotope dilution mass spectrometry–creatinine measurements. CamGFR was the most accurate model for eGFR (root-mean-squared error 17.3 mL/min) followed by the Chronic Kidney Disease Epidemiology Collaboration model (root-mean-squared error 18.2 mL/min). Publisher PDF

Rationale, aim and objective In Australia and New Zealand, there are no established standards for the final presentations of prepared intravenous medications in Intensive Care Units (ICUs). Variability has the potential to contribute to deficiencies in safety, efficiency and cost effectiveness. This study aimed to examine the variability in the preparation of intravenous medications in ICUs. Methods An electronic survey was distributed to critical care pharmacists in Australia and New Zealand via an established email group. The preparation of vasopressors, inotropes, sedation, analgesia, heparin, insulin and neuromuscular blockers were examined. Respondents were asked about initial presentation, final concentration prepared, who prepared and current safety practices used. Questions also addressed opinions and attitudes to safety practices and responsibility for leading change. Results Forty responses to the survey were received, representing 17% of ICUs in Australia and New Zealand. Significant variation in final concentration was observed for all infusions except insulin and esmolol. The final volumes varied significantly for all drugs. The majority of infusions were prepared by nursing staff with only a small number of pre-prepared presentations currently in use. Labelling was usually hand-written with some colour-coding. Most respondents identified safety and efficiency but not cost effectiveness as likely to be improved by the use of pre-prepared infusions. Most respondents felt ‘government’ or peak clinical bodies should lead practice standardization. Conclusion Significant variation exists in the preparation of intravenous medications across ICUs in Australia and New Zealand. Nationally or regionally coordinated rationalization and standardization could improve safety and efficiency and potentially reduce the barrier of cost.

There has been limited assessment of the impact that automated medication dispensing machines have on the medication administration process, particularly in Australian emergency departments. The aim of this study is to examine the change in medication retrieval times, number of medications retrieved and staff perceptions before and after the installation of automated dispensing machines in an Australian emergency and trauma centre.A time and motion method recorded the time taken and number of medications retrieved from the medication room by emergency department staff, before and after the installation of two automated dispensing machines. Surveys were administered to staff members to elicit the perceived impact on clinical practice, utilising 5-point Likert scales.A total of 954 medication retrievals (1030 medications) were recorded in the pre-implementation period and 842 (991 medications) in the post-implementation period. The mean time taken to retrieve any medication was significantly longer in the post-implementation period (+5.7s; p0.01). For schedules 2, 3, 4 or unscheduled medications, the mean time increased by 26.9s (p0.01), but decreased by 36.1s (p0.01) for schedule 8 or 11 medications. The mean number of medications per retrieval increased slightly in the post implementation period (+0.10; p0.01). Staff perceptions were that automated dispensing machines improve knowledge of medications on imprest (p=0.03) and reduced medication retrieval time (p0.01).This study found that the medication retrieval process was slower with automated dispensing machines for Schedules 2, 3, 4 and unscheduled medications, but quicker for Schedule 8 and 11 medications in an Australian emergency and trauma centre. Although retrieving medications took slightly longer overall, staff believed automated dispensing machines save time.

Introduction ED overcrowding has been associated with increased mortality, morbidity and delays to essential treatment. It was hypothesised that hospital-wide reforms designed to improve patient access and flow, in addition to improving ED overcrowding, would impact on clinically important processes within the ED, such as timely delivery of antibiotics. Methods A single pre-implementation and post-implementation prospective cohort study was conducted prior to and after a hospital-wide reform (Timely Quality Care (TQC)). Among patients who had intravenous antibiotics prescribed in the ED, data were prospectively collected on times of presentation, prescription and administration of antibiotics. Demographics and discharge diagnoses were retrospectively extracted. Results There were 380 cases included with 179 cases prior to introduction of the TQC model and 201 cases after its introduction. Time from presentation to administration of antibiotics improved significantly from 192 (99–320) min to 142 (81–209) min (P

The purpose of this study was to define the pulmonary and systemic pharmacokinetics of colistin methanesulfonate (CMS) and formed colistin following intravenous (i.v.) and inhaled administration in cystic fibrosis (CF) patients. Six CF subjects were administered nebulized CMS doses of 2 and 4 million IU and an i.v. CMS infusion of 150 mg of colistin base activity. Blood plasma, sputum, and urine samples were collected for 12 to 24 h postdose. To assess the tolerability of the drug, lung function tests, blood serum creatinine concentrations, and adverse effect reports were recorded. All doses were well tolerated in the subjects. The pharmacokinetic parameters for CMS following i.v. delivery were consistent with previously reported values. Sputum concentrations of formed colistin were maintained at

Background Oncology clinicians are now routinely provided with an estimated glomerular filtration rate on pathology reports whenever serum creatinine is requested. The utility of using this for the dose determination of renally excreted drugs compared with other existing methods is needed to inform practice. Patients and methods Renal function was determined by [Tc99m]DTPA clearance in adult patients presenting for chemotherapy. Renal function was calculated using the 4-variable Modification of Diet in Renal Disease (4v-MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), Cockcroft and Gault (CG), Wright and Martin formulae. Doses for renal excreted cytotoxic drugs, including carboplatin, were calculated. Results The concordance of the renal function estimates according to the CKD classification with measured Tc99mDPTA clearance in 455 adults (median age 64.0 years: range 17–87 years) for the 4v-MDRD, CKD-EPI, CG, Martin and Wright formulae was 47.7%, 56.3%, 46.2%, 56.5% and 60.2%, respectively. Concordance for chemotherapy dose for these formulae was 89.0%, 89.5%, 85.1%, 89.9% and 89.9%, respectively. Concordance for carboplatin dose specifically was 66.4%, 71.4%, 64.0%, 73.8% and 73.2%. Conclusion All bedside formulae provide similar levels of concordance in dosage selection for the renal excreted chemotherapy drugs when compared with the use of a direct measure of renal function.

Patients having undergone allogeneic stem cell transplantation (SCT) require complex medication regimens. To ensure the safe and effective management of this patient group, specialised care in a centre with a dedicated and experienced healthcare team is essential. The aim of this study was to evaluate the effectiveness of a specialty clinical pharmacist working in an ambulatory SCT clinic. A prospective cohort study was conducted on patients post SCT and discharged to the ambulatory setting. Patients were reviewed by a clinical pharmacist weekly for six visits. At these visits a medication review was undertaken. Interventions from these reviews were recorded. Interventions were then assigned a risk rating by a multidisciplinary panel. Adherence was also assessed by a Morisky questionnaire and review of dose administration aids. Comparison of data over the six-visit period was undertaken. In total 23 patients were enrolled in the study. All six visits were completed in 17 patients and 161 interventions were recorded at an average of 1.4 interventions per patient visit. The panel rated 40 % of interventions as high risk, 46 % as medium risk and 14 % as low risk. At all visit points high- and medium-risk interventions constituted >80 % of the total. Morisky scores improved by an average of 1.53 (p

Background: Falls are a leading cause of preventable hospitalizations from long-term care facilities (LTCFs). Polypharmacy and falls-risk medications are potentially modifiable risk factors for falling. Objective: This study investigated whether polypharmacy and falls-risk medications are associated with fall-related hospital admissions from LTCFs compared with hospital admissions for other causes. Methods: This was a hospital-based, case–control study of patients aged ≥65 years hospitalized from LTCFs. Cases were patients with falls and fall-related injuries, and controls were patients admitted for infections. Conditional logistic regression was used to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between polypharmacy (defined as the use of nine or more regular pre-admission medications) and falls-risk medications (categorized as psychotropic medications and those that can cause orthostatic hypotension) with fall-related hospital admissions. Results: There was no association between polypharmacy and fall-related hospital admissions (adjusted OR 0.97, 95% CI 0.63–1.48); however, the adjusted odds of fall-related hospital admissions increased by 16% (95% CI 3–30%) for each additional falls-risk medication. Medications that can cause orthostatic hypotension (adjusted OR 1.25, 95% CI 1.06–1.46), but not psychotropic falls-risk medications (adjusted OR 1.02, 95% CI 0.88–1.18) were associated with fall-related hospital admissions. The association between medications that can cause orthostatic hypotension and fall-related hospital admissions was strongest among residents with polypharmacy (adjusted OR 1.44, 95% CI 1.08–1.92). Conclusion: Polypharmacy was not an independent risk factor for fall-related hospital admissions; however, medications that can cause orthostatic hypotension were associated with fall-related hospital admissions, particularly among residents with polypharmacy. Falls-risk should be considered when prescribing medications that can cause orthostatic hypotension. Refereed/Peer-reviewed

The practice of naturopathy and Western herbal medicine (WHM) was built on traditional evidence but may be undergoing change with the advent of scientific evidence. The aims of this research were to provide a better understanding of practitioners' attitudes towards evidence, information sources, professional regulation and their knowledge about the evidence of commonly used complementary medicines (CMs).Naturopaths and WHM practitioners were invited to participate in an anonymous, self-administered, on-line survey. Participants were recruited using the mailing lists and websites of CM manufacturers and professional associations.Four hundred and seventy nine practitioners participated; 95% currently in practice. The majority (99%) thought well documented traditional evidence was essential or important, 97% patient reports and feedback, 97% personal experience, 94% controlled randomised trials and 89% published case reports. Significantly more recent graduates (less than 5 years) rated randomised trials as essential compared to others. Most (82%) respondents want information sources containing both traditional and scientific evidence. They currently use several resources; 74% CM textbooks, 67% conferences/seminars, 57% CM journals, 48% databases and 40% manufacturers' information. The mean knowledge score was 61.5% with no significant differences between respondents with diploma or degree level education or by graduating year. Eighty-five percent of practitioners strongly agreed or agreed that practitioners should be formally registered to safeguard the public, 8% were unsure and 8% disagreed or strongly disagreed.Naturopaths and WHM practitioners accept the importance of scientific evidence whilst maintaining the importance and use of traditional evidence. The majority are in favour of professional registration.

Tumour lysis syndrome (TLS) is a life-threatening oncological emergency characterized by hyperuricaemia, hyperkalaemia, hyperphosphataemia, and hypocalcaemia [1, 2] due to the rapid lysis of malignant cells, following the initiation of anticancer therapies [3]. Traditionally, therapy for TLS involved intensive hydration, urinary alkalinization and administration of allopurinol [4–6]. Newer guidelines now include rasburicase, with monitoring of electrolytes, white blood cell counts (WCC) and lactate dehydrogenase (LDH) concentrations [1, 7, 8]. Rasburicase, a recombinant urate oxidase enzyme, effectively decreases existing serum uric acid (UA) by oxidizing it to allantoin which is readily soluble and excretable [3]. Although the recommended dose is 0.2 mg kg−1 day−1 for 5–7 days [9], studies have shown the efficacious use of reduced doses for shorter periods of time and subsequent cost savings [5, 6, 10–17]. Expert guidelines by Coieffer et al. [7] in 2008 and Cairo et al. in 2010 [1] on the management of TLS recommend a rasburicase dose of 0.1–0.2 mg kg−1 on the first day, then repeated for up to 7 days [1] or as necessary [7]. We present an analysis of a fixed 3 mg dose of rasburicase administered to adult patients, treated at a tertiary referral centre. The study was approved by the Alfred Health Human Research Ethics Committee and the Monash University Human Research Ethics Committee. Demographic data were collected. Biochemical parameters (serum creatinine, serum UA, phosphate and LDH concentrations), at baseline, 24 h and 72 h after initial administration of rasburicase were recorded and compared. The institution guideline indicates rasburicase to be given before the first dose of chemotherapy in patients considered high risk for TLS. This includes a diagnosis of Burkitt's lymphoma, acute lymhoblastic leukaemia, bulky non-Hodgkin's lymphoma, lymphoblastic lymphoma or acute myeloid leukaemia with one or more of the following: serum UA>0.46 mmol l−1, white cell count (WCC) >50 × 109 l−1 or LDH >two times normal. Patients who were at an ongoing risk of TLS (i.e. elevated UA or LDH or multiple days of aggressive cytoreductive chemotherapy) were allowed a repeat dose of rasburicase 3 mg. Adherence to the guideline was measured. Forty-one patients received 42 courses of rasburicase over a 40 month period (Figure 1A). Diagnosis, demographic and baseline biochemical data are presented in Table 1. Figure 1 Summaryof rasburicase courses and uric acid concentrations. A) Summary of rasburicase courses administered. B) Median uric acid concentrations over time stratified by presentation a baseline. ♦, normal; ▪, hyperuricaemic; ▴, all ... Table 1 Patientcharacteristics Rasburicase was administered as per institution guidelines in 40 (95%) of the patients. Median serum UA concentrations were within normal range at 72 h in all groups; in those who presented with hyperuricaemia, in those who presented with normal baseline serum UA concentrations and overall (Figure 1B). The majority of patients received one dose of rasburicase 3 mg (Figure 1A). In 34 patient episodes requiring one dose only, there was a decline in the median (range) UA concentration from 0.44 mmol l−1 (0.13–1.15) at baseline to 0.22 mmol l−1 (0.02–0.66) at 24 h. This decrease was maintained at 72 h (P < 0.0001) with a median of 0.21 mmol l−1 (0.02–0.52). Serum creatinine concentrations were within normal range (60–105 μmol l−1) at baseline in 74% of patients, with 82% having a normal creatinine at 72 h. Hyperphosphataemia was present in 29% of patients at baseline and increased to 44% at 72 h. Eight patient episodes required more than one dose due to the ongoing risk of TLS. In these patients the median (range) baseline UA was 0.50 mmol l−1 (0.02–2.0), 0.33 mmol l−1 (0.02−1.10) at 24 h and 0.24 mmol l−1 (0.02−1.10) at 72 h (P < 0.0001). Of these patients only 52% had a normal creatinine at baseline, increasing to 83% at 72 h. Mean phosphate concentrations decreased over time but all patients remained hyperphosphataemic at 72 h. No hypersensitivity reactions were noted, no patients required haemodialysis and no deaths were related to the administration of rasburicase. Our results demonstrate that a single fixed dose of rasburicase 3 mg, repeated if required, should be the standard regimen in the management of TLS. Recent studies and published guidelines have shown cumulative support for the safe and efficacious use of off-label dosing regimens of rasburicase [1, 5–8, 10, 11, 16, 17]. A quarter of our patients presented with a baseline WCC>100 × 109 l−1 (Table 1), which is considered a high risk for developing TLS [1, 7]. The Product Information recommends rasburicase 0.1–0.2 mg kg−1 day−1 for 1–7 days [9]. We successfully used a fixed 3 mg dose for these patients. Our data support that presented by Trifilio et al. [11] in a recent study of 287 episodes, the largest published series at this time, of raised UA concentrations successfully treated with a single 3 mg dose of rasburicase, repeated if required. In our cohort, which was smaller in size, a single 3 mg dose was equally effective in both patients who had a normal baseline UA and those with hyperuracaemia. This differed from that published by Trifilio et al., where the single dose was more successful in patients with a lower baseline UA concentration. Our patient cohort also had a higher median LDH. Suboptimal management of hyperphosphatemia was identified in our cohort. More stringent monitoring of patient phosphate concentrations may be warranted in the future to minimize the risk of renal impairment. Serum creatinine, showing a gradual decrease with time, was used as a surrogate maker to indicate an improvement in renal function. Rasburicase was used in conjunction with allopurinol, urinary alkalinazation and intravenous hydration. This strategy is also supported by recent studies and recommendations [1, 11, 16], although the benefit of administering alkalinization with rasburicase needs further investigation [1, 7]. A single fixed 3 mg dose of rasburicase, in the setting of an institution guideline, was efficacious in the management of TLS.

Aim: To assess the effectiveness of a pharmacist anticoagulant dosing service in an ambulatory care program at an Australian hospital. Method: A pre- and post-intervention study method was used. The pre-intervention group consisted of patients admitted for anticoagulation to the Hospital-in-the-Home program from September 2009 to January 2010, where warfarin was managed by doctors from the treating unit. The post-intervention group consisted of patients enrolled in the pharmacist dosing service from February 2010 to October 2010. Eligibility criteria for enrolment in the pharmacy dosing service included: admission to the Hospital-in-the-Home program for anticoagulation; warfarin dosing initiated in line with the existing hospital anticoagulation guidelines (modified to accommodate a pharmacist dosing service); medical unit consent for patient inclusion; and patients able to undergo daily INR blood tests. Results: The mean number of days for a patient to achieve 2 consecutive therapeutic international normalised ratios was 8.8 days for the pharmacist dosing service (n = 35) and 11.8 days for the pre-intervention group (n = 53) (p = 0.002). There was no difference in the mean number of international normalised ratios measured between the two groups. Conclusion: A pharmacist anticoagulant dosing service effectively managed warfarin dosing in patients admitted to an ambulatory care program.

BACKGROUND: Therapeutic drug monitoring is usually required for safe and effective administration of vancomycin. However, dosing recommendations from published guidelines are not suitable in achieving therapeutic vancomycin concentrations in a timely manner in patients with normal renal function. OBJECTIVE: To audit vancomycin dosing and concentrations at our institution and evaluate the predictive accuracy of a pharmacokinetic simulation program, with a view to implementing a pharmacy-based pharmacokinetic service for vancomycin monitoring. METHODS: Patients receiving vancomycin were identified prospectively through the therapeutic drug monitoring archives. Patient information was obtained from medication charts and medical records that were located on wards. Data were entered into the MM-USC*Pack program (Jelliffe R, University of Southern California, 2008, version 12.10). This software was used to predict initial and subsequent concentrations of vancomycin based on patient parameters. The predictive accuracy of this software was evaluated by comparing the predicted concentrations to the observed concentrations. RESULTS: During a 6-week period, 204 concentrations were measured in 77 patients. The most common dosing regimen was 1 g every 12 hours. Overall, initial trough concentrations were subtherapeutic (35 kg/m2) and in patients with unstable renal function. CONCLUSIONS: A delay in attaining target trough concentrations was observed in a significant proportion of patients. Pharmacokinetic modeling software is a potential tool to improve the timeliness of achieving adequate dosing by allowing concentrations to be determined prior to steady-state. The program was able to predict vancomycin concentrations across a heterogeneous patient population with little systematic bias, but only moderate precision.

Aim: To determine the impact of a pharmacist intervention on patient–guided diuretic dose adjustment in ambulatory patients with heart failure. Method: Patients with heart failure were randomised to usual care or usual care plus pharmacist intervention and followed for 3 months. Pharmacist intervention focused on patients improving self-care, recognising symptoms of fluid retention, measuring weight daily and self-adjusting diuretic dose using frusemide. The primary outcome was the number of appropriate weight-titrated frusemide dose adjustments. Secondary outcomes included the number of patients who correctly selfadjusted their frusemide dose, hospital readmissions due to fluid overload, heart failure-related knowledge and understanding, and quality of life (using validated tools). Results: 70 patients were recruited: 35 usual care (control) and 35 usual care plus pharmacist intervention. The average number of appropriate weight-titrated frusemide dose adjustments per patient per month in the control group was 0.32 ± 0.08 and in the intervention group was 0.85 ± 0.13 (p = 0.006). Hospital readmissions due to fluid overload was 31% in the control and 14% in the intervention groups (p = 0.04). There were significant differences between the groups regarding appropriate self-adjusted frusemide doses, heart failure-related knowledge and understanding, and quality of life. Conclusion: A pharmacist intervention improved the ability of heart failure patients to self-adjust their diuretic dose by using a flexible dosing regimen based on weight, resulting in quality of life improvement and a decrease in hospital readmissions due to fluid overload. J Pharm Pract Res 2011; 41: 126-31.

Background Insulin is a high-risk medicine which may cause significant patient harm or death when given incorrectly. A 10-fold error in administered insulin dose commonly occurs when the abbreviation ‘u’ is used for ‘units’ and subsequently misinterpreted as a ‘zero.’ Method A multidisciplinary working party was convened and mapped insulin prescribing, dispensing and administration. All inpatient orders above 25 units for short-acting insulin and 50 units for other insulin require validation by an additional source. Educational strategies to support adherence to the guideline and product-labelling alerts were developed. Results Implementation occurred in August 2008 across the three hospital sites. In 90 weeks after implementation, there were 150 patients identified in which 200 high doses of insulin were prescribed (>25 units for short-acting insulin and 50 units for other insulin). There were eight instances where high doses of insulin were prescribed in error but were detected and rectified through the new validation process. There were 12 dosing errors that occurred, including two 10-fold dosing errors. In contrast, seven major errors resulting in excessive insulin administration were identified over a 2-year period prior to the introduction of the insulin high-dose validation system. Conclusion A structured validation process was successful in reducing incorrect prescription and administration of high-dose insulin and has reduced the risk of associated fatalities or significant patient harm. Consideration should be given to adopting this process in any setting where insulin is prescribed and administered.

Allogeneic stem cell transplantation (SCT) is a complex procedure that requires specialized medication management. Providing clinical pharmacy services in the ambulatory setting is warranted, as medications are a common source of confusion for SCT patients and their carers. These patients were routinely managed via traditional ambulatory dispensary services. The successful implementation of a clinical pharmacy service to the SCT unit ambulatory clinic allowed for regular contact and review by an experienced clinical pharmacist. This new service was evaluated within the context of a research project. The clinical pharmacist's presence in the ambulatory setting resulted in the identification and rectification of many medium to high risk medication related problems. The clinical pharmacist also contributed towards improved overall adherence. Other institutions are encouraged to implement and evaluate clinical pharmacy services to their ambulatory settings for SCT and other complex chronic patients.

Benchmarking is the process of comparing the cost, cycle time, productivity, or quality of a specific process or method to that of another method that is widely considered to be an industry standard or best practice. The result is often a business case for making changes to make improvements. Benchmarking in the specialty of infusion therapy can be used to validate an infusion alliance. This article's focus is identifying the problem areas, comparing them with successful infusion alliances, and demonstrating how to collect and interpret the data for success.

2565Background: Estimation of glomerular filtration rate (GFR) is essential for carboplatin chemotherapy dosing. However, the most accurate method to estimate GFR in patients with cancer is unknown...

Thiopurine methyltransferase genotyping and thiopurine metabolite testing has been established as an adjunct to monitoring patients taking thiopurine drugs. This special report describes the clinical implications for this type of testing for patients with inflammatory bowel disease who are taking thiopurine drugs. A total of 10% of patients were found to be intermediate metabolizers and the mean dosage (in mg/kg equivalent) was lower in intermediate metabolizers than extensive metabolizers. The metabolite levels did not correlate with scores measuring clinical severity but levels of 6-methylmercaptopurine were related to the dosage of the drugs. Despite considerable study of thiopurine methyltransferase testing in the literature, it is still not widely used in many geographical areas. This study adds to the evidence about using such testing as well as expanding the role of simultaneously measuring thiopurine metabolites. Further work is planned to evaluate the uptake when such testing becomes available locally as a clinical service.

Objective Understanding smokers’ quit experiences and their preferences for a future quit attempt may aid in the development of effective cessation treatments. The aims of this study were to measure tobacco use behaviour; previous quit attempts and outcomes; methods used to assist quitting; difficulties experienced during previous attempts; the motives and preferred methods to assist quitting in a future attempt; identify the factors associated with preferences for smoking cessation. Design Face-to-face interview using a structured questionnaire. Setting Inpatient wards of three Australian public hospitals. Participants Hospitalised smokers enrolled in a smoking cessation trial. Results Of 600 enrolled patients (42.8% participation rate), 64.3% (n=386) had attempted quitting in the previous 12 months. On a scale of 1 (low) to 10 (high), current motivation to quit smoking was high (median 9; IQR 6.5–10), but confidence was modest (median 5; IQR 3–8). Among 386 participants who reported past quit attempts, 69.9% (n=270) had used at least one cessation aid to assist quitting. Nicotine replacement therapy (NRT) was most commonly stated (222, 57.5%), although the majority had used NRT for

Colony-stimulating factors are potent manipulators of the hematopoietic and immune systems. An increasing number of colony-stimulating factors with expanded indications and uses are available. To provide safe and efficacious therapy, clinicians must understand how colony-stimulating factors and other biologic response modifiers work and know about product use, patient education, and patient monitoring. This article provides an overview of the current colony-stimulating factor products, uses, indications, administration, management, and patient education.

PURPOSE Outpatient home infusion therapy is increasing; however, little data exist on the outcomes of patients receiving care. The purpose of this study was to document the natural history of central venous catheters (CVCs) used in home infusion care to determine the rate and type of catheter complications. MATERIALS AND METHODS Data from the Strategic HealthCare Programs National Database from April 1999 to September 2000 were analyzed. Primary study objectives were to identify (i) types of CVCs and principal diagnoses, (ii) type and rate of catheter complications, and (iii) outcomes in managing thrombotic catheter complications. Event rates were calculated per 1,000 catheter days; 50,470 patients representing 2.83 million catheter days met study criteria. RESULTS The rates of complications (per 1,000 catheter days) for the most common events were: catheter dysfunction (0.83 total; 0.6 nonthrombotic, 0.23 thrombotic), catheter site infections (0.26), and bloodstream infections (BSIs; 0.19). A total of 4,138 complication events were identified (event rate per 1,000 days: 1.5). The total rates of complications with each catheter type were: midline catheters (4.5), PICCs (2.0), nontunneled central catheters (1.1), tunneled catheters (1.0), and chest ports (0.52). Catheter dysfunction with loss of patency was the most common group of complications. Thrombotic occlusion was the principal cause of catheter dysfunction, occurring in 28% of patients in this group, typically within 7 days of catheter insertion. BSI was reported in 541 patients, generally more than 30 days after catheter insertion. Catheter thrombosis outcomes resulted in therapy interruption (43%), catheter replacement (29%), premature CVC removal (14%), unscheduled emergency room visits (9%), and/or hospitalizations (6%). CONCLUSION Catheter dysfunction is the most frequent complication of all CVCs in this population, almost twice that of infections. Outpatient home infusion catheter dysfunction results in delays to therapy, unscheduled hospitalizations, and need for device replacement.

Objectives The primary aim was to determine the prevalence of adverse reactions to over-the-counter complementary medicines and their severity, as described by consumers. Secondary aims were to identify consumers' reporting behaviours and understanding of the AUST L designation on product labels. Methods An anonymous, self-administered survey was completed by randomly selected pharmacy customers at 60 community pharmacy locations between August 2008 and February 2009. Key findings Of the 1121 survey participants (response rate 62%), 72% had used a complementary medicine product in the previous 12 months, and 7% of this group (n = 55) reported having experienced an adverse reaction at some time. Of these, 71% described the reaction as mild and not requiring treatment, 22% as moderate and/or requiring advice from a healthcare professional and 7% (n = 4) described it as severe and requiring hospitalisation. If they were to report the reaction, it was most commonly to a medical practitioner. Most (88%) of complementary medicine consumers had never noticed the term ‘AUST L’. Conclusions Complementary medicines are widely used by pharmacy customers. Adverse reactions to these products are under-reported to healthcare authorities. Most adverse reactions are mild and serious reactions are rare. Customers have little awareness of the designation AUST L.

Purpose: The aim of this study was to determine the correlation between body surface area (BSA) and glomerular filtration rate (GFR) measured by Tc-99m DTPA clearance in adult patients with cancer. Methods: GFR was determined by Tc-99m DTPA clearance in adult patients with cancer. Height and actual body weight were measured. Ideal body weight was calculated. BSA was calculated using the Du Bois and Du Bois linear method using both actual and ideal body weight. Results: Included in the study were 122 patients. The mean GFR measured by Tc-99m DTPA clearance was 87 ml/min (range 30–174 ml/min). The mean BSA (actual weight) was 1.76 m2 (median 1.73 m2, range 1.31–2.58 m2). The mean BSA (ideal body weight) was 1.63 m2 (median 1.63 m2, range 1.20–2.00 m2). The overall correlation between BSA (actual weight) and GFR in this adult population was r=0.24, and the 95% confidence interval was 0.06–0.4. The correlation between BSA (ideal body weight) and GFR was r=0.22. The correlation between BSA and GFR excluding patients with a BSA 2.0 m2 was 0.12. When patients with GFR 100 ml/min were excluded, the correlation with BSA was 0.07. The correlations between GFR and height, actual weight and ideal weight were 0.22, 0.21 and 0.22, respectively. Conclusions: This study demonstrated a poor correlation between GFR determined by Tc-99m DTPA clearance and BSA calculated using the Du Bois and Du Bois linear method. The 95% confidence interval for the correlation between BSA and GFR was 0.06–0.4 indicating that a strong applicable clinical correlation is very unlikely.

Objectives. To establish the incidence of adverse drug reactions (ADRs) in oncology patients hospitalised at a tertiary referral adult cancer hospital and identify areas where intervention strategies may effectively reduce their impact. Design. A prospective study was conducted in November and December 1998 at the Peter MacCallum Cancer Institute (PMCI), Melbourne, Australia. Pharmacists identified patients who had experienced an ADR contributing to the admission or occurring during the episode of care. Outcome measures. An assessment was made of causality, as definite, probably or possibly. The severity of the ADR was assessed as mild, moderate or severe. Results. Twenty-six admissions (9.6%) were related to drug therapy. One hundred and thirty-four ADRs occurred in 86 inpatient episodes of care (31.6% of admissions). One hundred and four ADRs (60.8%) were associated with active therapy for malignancy or infection. Supportive therapy, including analgesics and antiemetics, were implicated in 67 (39.2%) adverse events. Pharmacists rated the majority of reactions as definitely associated with the implicated drug and the majority of at least moderate severity. Discussion. Drug therapy contributed to 9.6% of admissions. This is higher than in other Australian studies. The majority of ADRs identified were associated with active therapy for malignancy or infection. These adverse effects are not unexpected in the setting of aggressive therapy. Other potentially preventable ADRs may be overlooked in the context of the more severe and life-threatening events occurring simultaneously. Conclusion. Approximately 37.5% of patients admitted to PMCI experienced an ADR. Many of these events may have been prevented using simple intervention strategies. There is an opportunity for clinical pharmacists to ensure preventive measures are instituted, thereby improving patient outcomes.

Aim To quantify the uptake of thiopurine methyltransferase (TPMT) phenotyping in patients on thiopurines. Method A retrospective audit was undertaken to identify all patients initiated on thiopurines from 1 August 2003 to 31 May 2006 at a tertiary referral hospital. All patients dispensed azathioprine, mercaptopurine and thioguanine were identified from computerised dispensing records. TPMT phenotype test results were obtained from the hospital's pathology service for the period 1 July 2003 to 30 June 2006. Results Of the 287 patients initiated on thiopurines, 21 (8.8%) had TPMT activity measured. Thiopurines were widely prescribed across a number of medical disciplines with the largest usage in the transplant units − 88 lung transplant recipients and 3 dual heart and lung transplant recipients. Only one transplant recipient had TPMT activity measured. In the dermatology unit, 47% of patients receiving thiopurines underwent TPMT phenotyping. Conclusion The uptake of TPMT phenotyping in patients on thiopurines was low and variable depending on the clinical unit. Further efforts to increase the uptake of TPMT phenotyping before initiation of thiopurine therapy are warranted.

Objective Identification of challenges associated with quitting and overcoming them may improve cessation outcomes. This study describes the development and initial validation of a scale for measuring challenges to stopping smoking. Methods The item pool was generated from empirical and theoretical literature and existing scales, expert opinion and interviews with smokers and ex-smokers. The questionnaire was administered to smokers and recent quitters who participated in a hospital-based smoking cessation trial. Exploratory factor analysis was performed to identify subscales in the questionnaire. Internal consistency, validity and robustness of the subscales were evaluated. Results Of a total of 182 participants with a mean age of 55 years (SD 12.8), 128 (70.3%) were current smokers and 54 (29.7%) ex-smokers. Factor analysis of the 21-item questionnaire resulted in a 2-factor solution representing items measuring intrinsic (9 items) and extrinsic (12 items) challenges. This structure was stable in various analyses and the 2 factors accounted for 50.7% of the total variance of the polychoric correlations between the items. Internal consistency (Cronbach9s α) coefficients for the intrinsic and extrinsic subscales were 0.86 and 0.82, respectively. Compared with ex-smokers, current smokers had a higher mean score (±SD) for intrinsic (24.0±6.4 vs 20.5±7.4, p=0.002) and extrinsic subscales (22.3±7.5 vs 18.6±6.0, p=0.001). Conclusions Initial evaluation suggests that the 21-item challenges to stopping smoking scale is a valid and reliable instrument that can be used in research and clinical settings to assess challenges to stopping smoking.

Background Naturopaths and Western herbal medicine (WHM) practitioners were surveyed to identify their extent, experience and roles within the community pharmacy setting and to explore their attitudes to integration of complementary medicine (CM) practitioners within the pharmacy setting. Method Practising naturopaths and WHM practitioners were invited to participate in an anonymous, self-administered, on-line survey. Participants were recruited using the mailing lists and websites of CM manufacturers and professional associations. Results 479 practitioners participated. 24% of respondents (n = 111) reported they had worked in community pharmacy, three-quarters for less than 5 years. Whilst in this role 74% conducted specialist CMs sales, 62% short customer consultations, 52% long consultations in a private room and 51% staff education. This was generally described as a positive learning experience and many appreciated the opportunity to utilise their specialist knowledge in the service of both customers and pharmacy staff. 14% (n = 15) did not enjoy the experience of working in pharmacy at all and suggested pharmacist attitude largely influenced whether the experience was positive or not. Few practitioners were satisfied with the remuneration received. 44% of the total sample provided comment on the issue of integration into pharmacy, with the main concern being the perceived incommensurate paradigms of practice between pharmacy and naturopathy. Of the total sample, 38% reported that they would consider working as a practitioner in retail pharmacy in future. Conclusions The level of integration of CM into pharmacy is extending beyond the mere stocking of supplements. Naturopaths and Western Herbalists are becoming utilised in pharmacies

Hepatitis is an inflammation of the liver that can be mild to life-threatening, based on the causative agent. Hepatitis viruses A through G are described along with potential treatments and infusion therapies. Nonviral causes of hepatitis include autoimmune, toxic, drug-induced, and alcoholic. The role of the infusion nurse is critical in prevention, patient education regarding all aspects of the condition, and administering and monitoring appropriate therapy.