What is impacting clinical pharmacists' participation in an interprofessional ward round: a thematic analysis of a national survey.

The ward round (WR) is an important opportunity for interprofessional interaction and communication enabling optimal patient care. Pharmacists' participation in the interprofessional WR can reduce adverse drug events and improve medication appropriateness and communication. WR participation by clinical pharmacists in Australia is currently limited. This study aims to explore what is impacting clinical pharmacists' participation in WRs in Australian hospitals. A self-administered, anonymous national survey of Australian clinical pharmacists was conducted. This study describes the outcomes from qualitative questions which were analyzed thematically in NVivo-2020 according to Braun and Clarke's techniques. Five themes were constructed: "Clinical pharmacy service structure", "Ward round structure", "Pharmacist's capabilities", "Culture" and "Value". A culture supportive of pharmacist's contribution with a consistent WR structure and flexible delivery of clinical pharmacy services enabled pharmacists' participation in WR. Being physically "absent" from the WR due to workload, workflow, and self-perception of the need for extensive clinical knowledge can limit opportunities for pharmacists to proactively contribute to medicines decision-making with physicians to improve patient care outcomes. Bidirectional communication between the interprofessional team and the pharmacist, where there is a co-construction of each individual's role in the WR facilitates consistent and inter-dependent collaborations for effective medication management.

Hospital admission as a deprescribing triage point for patients discharged to Residential Aged Care Facilities.

BACKGROUND: Deprescribing may benefit older frail patients experiencing polypharmacy. We investigated the scope for deprescribing in acutely hospitalised patients and the long-term implications of continuation of medications that could potentially be deprescribed. METHODS: Acutely hospitalised patients (n = 170) discharged to Residential Aged Care Facilities, ≥75 years and receiving ≥5 regular medications were assessed during admission to determine eligibility for deprescribing of key drug classes, along with the actual incidence of deprescribing. The impact of continuation of nominated drug classes (anticoagulants, antidiabetics, antiplatelets, antipsychotics, benzodiazepines, proton pump inhibitors (PPIs), statins) on a combined endpoint (death/readmission) was determined. RESULTS: Hyperpolypharmacy (>10 regular medications) was common (49.4%) at admission. Varying rates of deprescribing occurred during hospitalisation for the nominated drug classes (8-53%), with considerable potential for further deprescribing (34-90%). PPI use was prevalent (56%) and 89.5% of these had no clear indication. Of the drug classes studied, only continued PPI use at discharge was associated with increased mortality/readmission at 1 year (hazard ratio 1.54, 95% confidence interval (1.06-2.26), P = 0.025), driven largely by readmission. CONCLUSION: There is considerable scope for acute hospitalisation to act as a triage point for deprescribing in older patients. PPIs in particular appeared overprescribed in this susceptible patient group, and this was associated with earlier readmission. Polypharmacy in older hospitalised patients should be targeted for possible deprescribing during hospitalisation, especially PPIs.

Exploration of 'micro' level factors that affect the involvement of clinical pharmacists in interprofessional ward rounds in hospitals: Through the lens of social cognitive theory.

BACKGROUND: Macro and meso level factors that influence the participation by clinical pharmacists in ward rounds include pharmacy management culture, commitment to ward rounds and adequate time for ward rounds being included in workload models. The 'micro' level factors that affect the involvement of clinical pharmacists in ward rounds have not been widely explored. OBJECTIVE: Explore 'micro' level factors to gain insight into clinical pharmacists' participation in interprofessional ward rounds in inpatient settings through the lens of social cognitive theory. METHOD: A qualitative focused ethnographic study with five clinical pharmacists, four medical practitioners, one allied health professional and one nurse was conducted in three metropolitan hospitals in Southern Australia. Seven hours of semi-structured interview (n = 11) and 76-h of observations (n = 5) were conducted. A qualitative descriptive analysis was conducted (guided by Spradley) followed by reflexive thematic-analysis (according to Braun and Clarke's technique). RESULTS: Three micro level factors influencing clinical pharmacist participation in ward rounds are: (1) Cognitive mindset of clinical pharmacists, (2) Behavioural conduct of clinical pharmacists, and (3) Social rules of the ward. Clinical pharmacists that did not participate in ward round reconciled their moral distress by transferring information without clinical judgement or interpretation of the patient scenario to medical practitioners. Clinical pharmacists that did participate in ward rounds demonstrated credibility by making relevant recommendations with a holistic lens. This enabled clinical pharmacists to be perceived as trustworthy by medical practitioners. Positive experiences of participating in ward rounds contributed to their cognitive upward spiral of thoughts and emotions, fostering continued participation. CONCLUSION: Clinical pharmacists participate in ward rounds when they develop a positive mindset about ward round participation and perceive ward rounds as an enabler to the establishment of trusted professional relationships with medical practitioners. This trusted relationship creates an environment where the pharmacist develops confidence in making relevant recommendations.

Clinical pharmacists' participation in ward rounds in hospitals: responses from a national survey.

OBJECTIVES: The inclusion of clinical pharmacists in ward rounds (WRs) can reduce adverse drug events, improve communication and enable collaborative decision-making. The aim of this study is to investigate the level of and factors that influence WR participation by clinical pharmacists in Australia. METHODS: An online administered, anonymous survey of clinical pharmacists in Australia was conducted. The survey was open to pharmacists aged ≥18 years, who had worked in an Australian hospital in a clinical role in the previous two weeks. It was distributed via The Society of Hospital Pharmacists of Australia and on pharmacist-specific social media threads. Survey questions related to the extent of WR participation and factors that influence WR participation. Cross-tabulation analysis was conducted to determine whether there was an association between WR participation and factors that influence WR participation. KEY FINDINGS: Ninety-nine responses were included. The level of WR participation by clinical pharmacists in Australian hospitals was low, with only 26/67 (39%) pharmacists who had a WR in their clinical unit actually attending the WR in the previous 2 weeks. Factors that influenced WR participation included having recognition of the role of the clinical pharmacist within the WR team, support from pharmacy management and the broader interprofessional team, and having adequate time and expectation from pharmacy management and colleagues to participate in WRs. CONCLUSIONS: This study highlights the need for ongoing interventions such as restructuring workflows and increasing the awareness of the role of a clinical pharmacist in WR to increase participation of pharmacists in this interprofessional activity.

Interventions targeting the prescribing and monitoring of vancomycin for hospitalized patients: a systematic review with meta-analysis.

PURPOSE: Vancomycin prescribing requires individualized dosing and monitoring to ensure efficacy, limit toxicity, and minimize resistance. Although there are nationally endorsed guidelines from several countries addressing the complexities of vancomycin dosing and monitoring, there is limited consideration of how to implement these recommendations effectively. METHODS: We conducted a systematic search of multiple databases to identify relevant comparative studies describing the impact of interventions of educational meetings, implementation of guidelines, and dissemination of educational material on vancomycin dosing, monitoring, and nephrotoxicity. Effect size was assessed using ORs and pooled data analyzed using forest plots to provide overall effect measures. RESULTS: Six studies were included. All studies included educational meetings. Two studies used implementation of guidance, educational meetings, and dissemination of educational materials, one used guidance and educational meetings, one educational meetings and dissemination of educational materials, and two used educational meetings solely. Effect sizes for individual studies were more likely to be significant for multifaceted interventions. In meta-analysis, the overall effect of interventions on outcome measures of vancomycin dosing was OR 2.50 (95% CI 1.29-4.84); P< 0.01. A higher proportion of sampling at steady-state concentration was seen following intervention (OR 1.95, 95% CI 1.26-3.02; P<0.01). Interventions had no effect on appropriate timing of trough sample (OR 2.02, 95% CI 0.72-5.72; P=0.18), attaining target concentration in patients (OR 1.50, 95% CI 0.49-4.63; P=0.48, or nephrotoxicity (OR 0.75, 95% CI 0.42-1.34; P=0.33). CONCLUSION: Multifaceted interventions are effective overall in improving the complex task of dosing vancomycin, as well as some vancomycin-monitoring outcome measures. However, the resulting impact of these interventions on efficacy and toxicity requires further investigation. These findings may be helpful to those charged with designing implementation strategies for vancomycin guidelines or complex prescribing processes in hospitals.

Interventions Targeting the Prescribing and Monitoring of Vancomycin for Hospitalized Patients: A Systematic Review Protocol.

INTRODUCTION: Vancomycin remains one of our essential antibiotics after fifty years of treating serious infections such as methicillin-resistant Staphylococcus aureus. Vancomycin, unlike many other antibiotic agents, requires individualized dosing and monitoring of serum drug levels to ensure it is efficacious, to minimize toxicity, and to limit the development of antibiotic resistance. These issues have led to numerous vancomycin clinical practice guidelines being published in recent years including several key national guidelines. Significant resources are invested during the development of such guidelines; however, there is often little or no information about how such guidelines or other vancomycin practice improvement initiatives should be implemented. The aim of this systematic review is to identify and evaluate the effect of interventions using education, guideline implementation, and dissemination of educational resources that have sought to improve therapeutic drug monitoring and dosing of vancomycin. METHODS: A systematic review of the literature will be conducted for RCTs and observational studies where a vancomycin guideline or practice improvement initiative has been implemented. Electronic databases to be searched are PubMed, Medline, CINAHL, EMBASE and the Cochrane Library of Systematic Reviews. The population will be patients who have had intravenous vancomycin prescribed and monitored in hospital. The interventions will be education, implementation of guidelines or protocols, dissemination of educational materials (printed or electronic) or multifaceted interventions of the above. The comparator will be patients who have had standard-care prescribing and monitoring of vancomycin. Outcomes will be changes in prescribing and ordering of vancomycin serum tests, and serum levels attained in patients as well as reported nephrotoxicity. Two reviewers will be involved in the quality assessment and extraction of data. The Scottish Intercollegiate Guidelines Network checklist for RCTs will be used. Studies that are not randomized will be assessed for quality using the validated ROBINS-I (risk of bias in non-randomized studies of interventions) tool. DISCUSSION: This systematic review will identify interventions that have been used to implement guidelines and clinical practice initiatives for vancomycin. The findings of this review may be informative to those involved with the implementation of vancomycin clinical practice guidelines. Systematic review registration: PROSPERO: CRD42016049147.

The impact of a pilot continuing professional development module on hospital pharmacists' preparedness to provide contemporary advice on the clinical use of vancomycin.

BACKGROUND: Revised international clinical guidelines for the antibiotic vancomycin have changed the advice pharmacists need to provide to medical and nursing colleagues. OBJECTIVES: (1) To determine the self-reported confidence of hospital pharmacists to provide contemporary advice on vancomycin and (2) to evaluate hospital pharmacists' knowledge to provide contemporary advice on vancomycin following a pilot continuing professional development (CPD) module. METHODS: The study was a prospective two-phase design in an Australian teaching hospital. Phase one: a survey of pharmacist self-reported confidence to eight questions on providing contemporary advice on vancomycin. Responses were recorded using a Likert scales. Phase two: The provision of a pilot online CPD module on vancomycin containing knowledge-based assessment based on a clinical vignette. Likert scales recorded self-reported confidence were reported as median and interquartile range (IQR). Knowledge assessment was reported using descriptive statistics. The main outcome measure were the self-reported confidence, and knowledge of pharmacists regarding provision of contemporary advice on clinical vancomycin use. RESULTS: Response rates for surveys; confidence n = 35 (72.9 %) and knowledge n = 31 (58.5 %). Phase one: confidence was highest regarding vancomycin dosing and monitoring with 71.4-81.6 % of respondents agreeing or strongly agreeing that they were confident in these domains. Respondents agreeing or strongly agreeing were least confident regarding intravenous administration and infusion related reactions, 57.1 and 45.7 % respectively. Respondents who provided advice on vancomycin >10 times in the prior 12 months reported significantly higher confidence in; therapeutic range 1 (IQR 1-2) versus 2 (IQR 1-3) p = 0.02; amending dosage based on therapeutic drug monitoring results 2 (IQR 1-3) versus 3 (IQR 2-3) p = <0.001, and providing general advice to prescribers on vancomycin 2 (IQR 1-3) versus 2 (IQR 2-4) p = <0.009. Knowledge questions were answered correctly post CPD by >75 % of pharmacists. CONCLUSION: Pharmacists' self-reported confidence to managing vancomycin was variable but generally high. Knowledge scores were consistently high after pharmacists completed a pilot CPD module on vancomycin. These data provides impetus for a randomised controlled study across multiple sites to determine the extent to which pharmacist knowledge on vancomycin can be attributed to completion of an online CPD.

INITIAT-E.D.: Impact of timing of INITIation of Antibiotic Therapy on mortality of patients presenting to an Emergency Department with sepsis.

OBJECTIVES: To analyse the association between time from triage to administration of initial antibiotics and mortality in all patients presenting with sepsis to a tertiary hospital ED. METHODS: A retrospective review of patients presenting to the ED with sepsis from January to December 2012 was conducted at Flinders Medical Centre, South Australia. Outcome measures were: time elapsed from triage to administration of initial antibiotic therapy and in-hospital mortality. RESULTS: A total of 220 patients presented with sepsis, comprising 102 cases of uncomplicated sepsis and 118 severe sepsis. The median time to antibiotic administration was 3.5 h (interquartile range [IQR] 1.7-6.6) and in-hospital mortality was 28.6% (95% CI 22.6-34.6%). There was no association observed between delays to antibiotics and mortality in the total patient population. When stratified by presenting severity, patients with severe sepsis demonstrated a trend towards increased mortality when delays to antibiotics exceeded 6 h from triage (HR = 2.25, 95% CI 0.91-5.59, P = 0.08) in comparison with <1 h. Significant delays to antibiotic administration occurred when initial agents were charted as a 'regular medicine' (9.4 h, IQR 5.1-16.6) in comparison with a 'once only order' (3.4 h, IQR 1.7-6.7), P < 0.001. CONCLUSIONS: Early administration of antibiotics specifically in patients with severe sepsis might be beneficial. Further studies within the ED are warranted to establish the effect of delayed antibiotics in a generalised sepsis cohort.