Older people in the emergency department (ED) often pose complex medical challenges, with a significant prevalence of polypharmacy and potentially inappropriate medicines (PIMs) in Australia. A retrospective analysis of 200 consecutive patients aged over 65 years admitted to the emergency short stay unit (ESSU) aimed to identify polypharmacy (five or more regular medications), assess PIM prevalence, and explore the link between pre-admission PIMs and ESSU admissions. STOPP/START version 2 criteria were used for the PIM assessment, with an expert panel categorizing associated risks. Polypharmacy was observed in 161 patients (80.5%), who were older (mean age 82 versus 76 years) and took more regular medications (median 9 versus 3). One hundred and eighty-five (92.5%) patients had at least one PIM, 81 patients (40.5%) had STOPP PIMs, and 177 patients (88.5%) had START omissions. Polypharmacy significantly correlated with STOPP PIM (OR 4.8; 95%CI: 1.90–12.1), and for each additional medication the adjusted odds of having a STOPP PIM increased by 1.20 (95%CI: 1.11–1.28). Nineteen admissions (9.5%) were attributed to one or more PIMs (total 21 PIMs). Of these PIMs, the expert panel rated eight (38%) as high risk, five (24%) as moderate risk, and eight (38%) as low risk for causing hospital admission. The most common PIMs were benzodiazepines, accounting for 14 cases (73.6%). Older ESSU-admitted patients commonly presented with polypharmacy and PIMs, potentially contributing to their admission.

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

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

ABSTRACT Background Increasing life expectancy has seen a continual rise in older patients who present to hospital with acute decompensation. Pharmacists are well equipped to make medication recommendations in these settings to meet patient care needs, promote harm minimisation, and improve workflow efficiency. The Partnered Pharmacist Medication Charting (PPMC) model enables pharmacists to chart regular medications for patients admitted to the General Medicine Unit (GMU) in collaboration with treating clinicians. The model was expanded to assess the safety of pharmacists additionally charting newly initiated medications. Aim The aim of this study was to assess the safety of the expanded PPMC model through the number of medication errors. Method This prospective observational study was conducted at a tertiary hospital. Patients admitted to the GMU and received PPMC were included. Pharmacists were able to chart any new medications as well as the patients' pre‐admission medications. The primary outcome was the number of medication errors charted on admission. Medication errors were defined as medications charted outside of the specific recommendations documented in the medication management plan written by the PPMC pharmacist and co‐signed by the admitting medical officer. Results A total of 8093 medications were charted by a credentialed pharmacist, with 10% ( n = 816) planned newly initiated medications. Eight (0.98%) medication charting errors were identified in the PPMC model, which included five planned medications omitted. Of the 811 newly charted medications, 87 (10.7%) were amended within 24 h, with the majority being due to change in diagnosis or driven by changes in clinical status or investigative results becoming available. Conclusion The expansion of the PPMC model of care to enable pharmacist charting of new medications was found to be safe. The adoption of the model may aid in reducing medication errors, thereby improving patient care and safety.

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

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

Objective To test the administration of intravenous (i.v.) propofol at a procedural sedation dose compared to standard therapy for initial management of migraine in the ED. Methods This was an open label, randomised controlled pilot trial. Eligible patients were adults with a diagnosis of migraine and planned for treatment with i.v. medications. Patients were randomised to propofol or standard therapy groups. The primary outcome variable was time to discharge (TTD) defined as time from intervention to discharge from the ED. Secondary outcomes were safety of propofol administration and change in pain scores. A reduction of pain by >= 50% or discharge from the ED was defined as favourable. All analyses were performed on an intention-to-treat basis. Results Data from 29 patients were analysed, with 15 patients in the propofol group and 14 patients in the standard therapy group. TTD was significantly lower in the propofol group with median of 290 (interquartile range 162-500) min compared to 554.5 (interquartile range 534-639) min in the standard therapy group (P= 0.021). The hazard ratio for the defined favourable outcome of reduction of pain scores or discharge from the ED was 1.54 (95% CI 0.69-3.41). Conclusions Initial management of migraine with i.v. propofol at procedural sedation doses significantly reduced TTD compared to standard therapy. We did not detect any significant safety concerns although the study was not adequately powered to detect safety of the intervention and requires validation.

The role of clinical pharmacists in the care of hospitalised general medicine patients is evolving from a reactive model of care to a model with an emphasis on interdisciplinary care and more advanced models of care. The purpose of this review was to evaluate the published literature on the effects of roles of clinical pharmacists that extend beyond those activities considered to be standard clinical practice in Australia, on clinical outcomes in hospitalised general medicine patients. A search of English-language publications in six databases was conducted. Peer-reviewed, English-language articles were identified across the date range January 2000 to June 2020. Studies were included if they evaluated an inpatient pharmacy service in a general medicine population and the article included a study design with a clear comparator and outcomes such as medication errors or medication appropriateness. Studies evaluating pharmacists’ activities that are considered standard clinical practice for pharmacists in Australia, such as participation on ward rounds, medication reconciliation and patient education were excluded. Twelve studies met the inclusion criteria: four evaluating pharmacist-led anticoagulation or thromboprophylaxis management, one evaluating pharmacist-led vaccination, three evaluating a pharmacist charting model, two evaluating pharmacist-led de-escalation of therapy, one evaluating a pharmacist intervention in patients with chronic kidney disease and one evaluating pharmacist-led glycaemic control. The addition of advanced clinical pharmacist services in the care of general medicine inpatients generally resulted in improved care, with no evidence of harm. Future studies should include multiple sites, larger sample sizes, reproducible interventions and identification of patient-specific factors that lead to improved outcomes.

Proton pump inhibitors (PPI) are extensively prescribed internationally and in Australia. However, minimal information is available on the appropriateness of PPI use in the general medical population. This study determined the proportion of general medical unit (GMU) inpatients taking a PPI on admission and evaluated the appropriateness of these PPI prescriptions. A single-centre prospective observational study was conducted from 6 June to 11 July 2016. Consecutive patients were screened, and those taking a PPI prior to admission were included, whereas those not taking a PPI formed the control cohort. Appropriateness of PPI use was evaluated by: (1) reviewing for concordance with the Australian Therapeutic Guidelines and National Prescribing Service Guidelines on PPI use in gastro-oesophageal reflux disease; (2) assessment of indication, dose and treatment duration by an expert panel consisting of two general physicians and one senior pharmacist. Among 440 consecutive GMU patients, 198 (45.0%) were taking a PPI on admission. Of these, 66.2% had an inappropriate indication, dose or treatment duration. The largest category of inappropriate PPI use was excessive treatment duration (43.4%). In terms of comorbid conditions, PPI users had a higher prevalence of osteoporosis and/or history of fracture (42.9% vs 27.2%; p < 0.001) and hypomagnesaemia (10.6% vs 3.4%; p = 0.003). Inappropriate PPI use is highly prevalent among GMU inpatients. Given the potential for adverse effects, unnecessary health expenditure and pill burden, strategies should be developed to aid clinicians to consistently consider the utility of continuing long-term PPI prescriptions in each patient's situation.

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

Patients admitted to General Medical Units (GMU) and Emergency Short Stay Units (ESSU) are often elderly with multiple comorbidities and the majority are considered to be at high risk of complications from influenza. The aim of this study was to assess the practice of including a pharmacist assessment of appropriateness and charting of influenza vaccination in a partnered pharmacist charting model in a GMU and ESSU. As part of a partnered pharmacist charting model, the pharmacist assessed each patient for suitability of receiving the influenza vaccination at admission. If it was deemed appropriate by the pharmacist and medical officer, the pharmacist charted the influenza vaccination for administration as an inpatient and this was documented in the discharge summary to the general practitioner. There were 6595 patients admitted to the two units during the study period, of which 316 patients had partnered pharmacist charting. Among these, 52 patients were eligible for vaccination, of which 31 patients (59.6%) had their influenza vaccination charted by a pharmacist. Among the 6279 patients who had their medication charted by a medical officer only, there were no cases of influenza vaccination prescription (p < 0.01). We identified that initiation of the influenza vaccination as part of the partnered pharmacist charting model is feasible and effective in increasing the rates of vaccination among ESSU and GMU patients.

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

Objectives: To evaluate whether pharmacists completing the medication management plan in the medical discharge summary reduced the rate of medication errors in these summaries.Design: Unblinded, cluster randomised, controlled investigation of medication management plans for patients discharged after an inpatient stay in a general medical unit.Setting: The Alfred Hospital, an adult major referral hospital in metropolitan Melbourne, with an annual emergency department attendance of about 60 000 patients.Participants: The evaluation included patients' discharge summaries for the period 16 March 2015 - 27 July 2015.Interventions: Patients randomised to the intervention arm received medication management plans completed by a pharmacist (intervention); those in the control arm received standard medical discharge summaries (control).Main outcome measures: The primary outcome variable was a discharge summary including a medication error identified by an independent assessor.Results: At least one medication error was identified in the summaries of 265 of 431 patients (61.5%) in the control arm, compared with 60 of 401 patients (15%) in the intervention arm (P < 0.01). The absolute risk reduction was 46.5% (95% CI, 40.7-52.3%); the number needed to treat (NNT) to avoid one error was 2.2 (95% CI, 1.9-2.5). The absolute risk reduction for a high or extreme risk error was 9.6% (95% CI, 6.4-12.8%), with an NNT of 10.4 (95% CI, 7.8-15.5).Conclusions: Pharmacists completing medication management plans in the discharge summary significantly reduced the rate of medication errors (including errors of high and extreme risk) in medication summaries for general medical patients.

Valproate is commonly prescribed as part of combination therapy in antiepileptic or mood stabilising regimens. Although generally well tolerated, valproate has potential to cause serious adverse effects, one of which is valproate-induced hyperammonaemic encephalopathy (VHE). The risk of developing VHE is rare; however, this can increase when valproate is used in conjunction with other medications. This report aims to highlight the importance of early diagnosis of VHE and emphasise the potential deleterious effects of polypharmacy and certain hazardous drug combinations. A 58-year-old woman with a 1-week history of increasing lethargy, confusion and drowsiness presented to the emergency department. Blood tests showed a raised ammonia level and liver function test (LFT) derangement. She had been on a long-term antiepileptic regimen which included sodium valproate. The only recent change to her medications was the introduction of atorvastatin. A diagnosis of VHE was made and valproate was discontinued. Atorvastatin was also stopped on account of its likely role in LFT derangement. After discontinuation of both agents attributed to her presentation, serum ammonia and LFTs returned to within normal range. The patient also gradually resumed her usual level of alertness and functional state. This report describes a case of VHE and emphasises the detrimental role of polypharmacy associated with this presentation. This illustrates the potentially complex pharmacy issues that must be considered in the management of a patient on chronic valproate therapy.

An 82-year-old man sustained an unwitnessed mechanical fall within his residential care facility, after which he developed lower back pain and intermittent dizziness. On review by his general practitioner 3 days later, he was found to have extensive bruising of his back, buttocks and thighs. Pathology tests 6 days after the fall showed a haemoglobin level of 69 g/L (reference interval [RI], 122–170 g/L). On arrival at the Alfred Hospital emergency department, he had mild abdominal pain, appeared lethargic and displayed clinical signs of anaemia.