A tale of 2 digital hospitals: A qualitative study of antimicrobial stewardship teams.

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.

'We are somehow fixated on this being a diabetes drug': a qualitative study exploring the views of cardiologists and nephrologists about sodium-glucose cotransporter 2 inhibitor initiation.

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.

Strategies used to detect and mitigate system-related errors over time: A qualitative study in an Australian health district.

BACKGROUND: Electronic medical record (EMR) systems provide timely access to clinical information and have been shown to improve medication safety. However, EMRs can also create opportunities for error, including system-related errors or errors that were unlikely or not possible with the use of paper medication charts. This study aimed to determine the detection and mitigation strategies adopted by a health district in Australia to target system-related errors and to explore stakeholder views on strategies needed to curb future system-related errors from emerging. METHODS: A qualitative descriptive study design was used comprising semi-structured interviews. Data were collected from three hospitals within a health district in Sydney, Australia, between September 2020 and May 2021. Interviews were conducted with EMR users and other key stakeholders (e.g. clinical informatics team members). Participants were asked to reflect on how system-related errors changed over time, and to describe approaches taken by their organisation to detect and mitigate these errors. Thematic analysis was conducted iteratively using a general inductive approach, where codes were assigned as themes emerged from the data. RESULTS: Interviews were conducted with 25 stakeholders. Participants reported that most system-related errors were detected by front-line clinicians. Following error detection, clinicians either reported system-related errors directly to the clinical informatics team or submitted reports to the incident information management system. System-related errors were also reported to be detected via reports run within the EMR, or during organisational processes such as incident investigations or system enhancement projects. EMR redesign was the main approach described by participants for mitigating system-related errors, however other strategies, like regular user education and minimising the use of hybrid systems, were also reported. CONCLUSIONS: Initial detection of system-related errors relies heavily on front-line clinicians, however other organisational strategies that are proactive and layered can improve the systemic detection, investigation, and management of errors. Together with EMR design changes, complementary error mitigation strategies, including targeted staff education, can support safe EMR use and development.

Is evidence of effectiveness a driver for clinical decision support selection? A qualitative descriptive study of senior hospital staff.

Limited research has focused on understanding if and how evidence of health information technology (HIT) effectiveness drives the selection and implementation of technologies in practice. This study aimed to explore the views of senior hospital staff on the role evidence plays in the selection and implementation of HIT, with a particular focus on clinical decision support (CDS) alerts in electronic medication management systems. A qualitative descriptive design was used. Twenty senior hospital staff from six Australian hospitals in New South Wales and Queensland took part in a semistructured interview. Interviews were audio-recorded and transcribed, and a general inductive content analysis approach was used to identify themes. Participants acknowledged the importance of an evidence base, but reported that selection of CDS alerts, and HIT more broadly, was rarely underpinned by evidence that technologies improve patient care. Instead, investments in technologies were guided by the expectation that benefits will be achieved, bolstered by vendor assurances, and a perception that implementation of HIT is unavoidable. Postponing implementation of a technology until an evidence base is available was not always feasible. Although some technologies were seen as not requiring an evidence base, stakeholders viewed evidence as extremely valuable for informing decisions about selection of CDS alerts. In the absence of evidence, evaluation or monitoring of technologies postimplementation is critical, particularly to identify new errors or risks associated with HIT implementation and use. Increased transparency from vendors, with technology evaluation outcomes made directly available to healthcare organizations, may result in less reliance on logic, intuition, and vendor assertions and more evidence-based selection of HIT.

The impact of digital interventions on antimicrobial stewardship in hospitals: a qualitative synthesis of systematic reviews.

BACKGROUND: Antimicrobial stewardship (AMS) programmes in hospitals support optimal antimicrobial use by utilizing strategies such as restriction policies and education. Several systematic reviews on digital interventions supporting AMS have been conducted but they have focused on specific interventions and outcomes. OBJECTIVES: To provide a systematic overview and synthesis of evidence on the effectiveness of digital interventions to improve antimicrobial prescribing and monitoring in hospitals. METHODS: Multiple databases were searched from 2010 onwards. Review papers were eligible if they included studies that examined the effectiveness of AMS digital interventions in an inpatient hospital setting. Papers were excluded if they were not systematic reviews, were limited to a paediatric setting, or were not in English. RESULTS: Eight systematic reviews were included for data extraction. A large number of digital interventions were evaluated, with a strong focus on clinical decision support. Due to the heterogeneity of the interventions and outcome measures, a meta-analysis could not be performed. The majority of reviews reported that digital interventions reduced antimicrobial use and improved antimicrobial appropriateness. The impact of digital interventions on clinical outcomes was inconsistent. CONCLUSIONS: Digital interventions reduce antimicrobial use and improve antimicrobial appropriateness in hospitals, but no firm conclusions can be drawn about the degree to which different types of digital interventions achieve these outcomes. Evaluation of sociotechnical aspects of digital intervention implementation is limited, despite the critical role that user acceptance, uptake and feasibility play in ensuring improvements in AMS are achieved with digital health.

Would they trust it? An exploration of psychosocial and environmental factors affecting prescriber acceptance of computerised dose-recommendation software.

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.

Accuracy of documented administration times for intravenous antimicrobial drugs and impact on dosing decisions.

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.

Are vancomycin dosing guidelines followed? A mixed methods study of vancomycin prescribing practices.

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.

The prevalence and impact of unprofessional behaviour among hospital workers: a survey in seven Australian hospitals.

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.

Communicating deprescribing decisions made in hospital with general practitioners in the community.

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.

Effectiveness of a coordinated support system linking public hospitals to a health coaching service compared with usual care at discharge for patients with chronic low back pain: protocol for a randomised controlled trial.

BACKGROUND: Although many people with chronic low back pain (LBP) improve following conservative treatment, one in five will experience worsening symptoms after discharge from treatment and seek health care again. The current LBP clinical care pathway in many health services lacks a well-integrated, systematic approach to support patients to remain physically active and self-manage their symptoms following discharge from treatment. Health coaching can support people to improve physical activity levels and may potentially reduce health care utilisation for LBP. The primary aim of this study is to evaluate the effect of introducing a coordinated support system (linking hospital outpatient physiotherapy services to a public health coaching service) at discharge from LBP treatment, on the future use of hospital, medical, and health services for LBP, compared with usual care provided at discharge. METHODS: Three hundred and seventy-four adults with chronic non-specific LBP will be recruited from the outpatient physiotherapy departments of public hospitals in New South Wales, Australia. Participants will be individually randomised to a support system (n = 187) or usual care group (n = 187). All participants will receive usual care provided at discharge from treatment. Participants allocated to the support system will also receive up to 10 telephone-based health coaching sessions, delivered by the Get Healthy Service®, over a 6-month period. Health coaches will monitor and support participants to improve physical activity levels and achieve personal health-related goals. The primary outcome is the total number of encounters with hospital, medical, and health services for LBP, at 12 months from baseline. A within-trial economic evaluation will quantify the incremental costs and benefits of the support system from a health system perspective, to support reimbursement decision making. DISCUSSION: This study will establish the effect of a coordinated support system, introduced at discharge from treatment, on the future use of hospital, medical, and health services for LBP and various health outcomes. CONCLUSION: Innovative community-driven solutions to support people with chronic LBP after discharge from treatment are urgently needed. Study findings will help inform health care policy and clinical practice in Australia. TRIAL REGISTRATION: Prospectively registered on the Australian New Zealand Clinical Trials Registry ( ACTRN12620000889954 ) on 10/09/2020.

Supporting deprescribing in hospitalised patients: formative usability testing of a computerised decision support tool.

BACKGROUND: Despite growing evidence that deprescribing can improve clinical outcomes, quality of life and reduce the likelihood of adverse drug events, the practice is not widespread, particularly in hospital settings. Clinical risk assessment tools, like the Drug Burden Index (DBI), can help prioritise patients for medication review and prioritise medications to deprescribe, but are not integrated within routine care. The aim of this study was to conduct formative usability testing of a computerised decision support (CDS) tool, based on DBI, to identify modifications required to the tool prior to trialling in practice. METHODS: Our CDS tool comprised a DBI MPage in the electronic medical record (clinical workspace) that facilitated review of a patient's DBI and medication list, access to deprescribing resources, and the ability to deprescribe. Two rounds of scenario-based formative usability testing with think-aloud protocol were used. Seventeen end-users participated in the testing, including junior and senior doctors, and pharmacists. RESULTS: Participants expressed positive views about the DBI CDS tool but testing revealed a number of clear areas for improvement. These primarily related to terminology used (i.e. what is a DBI and how is it calculated?), and consistency of functionality and display. A key finding was that users wanted the CDS tool to look and function in a similar way to other decision support tools in the electronic medical record. Modifications were made to the CDS tool in response to user feedback. CONCLUSION: Usability testing proved extremely useful for identifying components of our CDS tool that were confusing, difficult to locate or to understand. We recommend usability testing be adopted prior to implementation of any digital health intervention. We hope our revised CDS tool equips clinicians with the knowledge and confidence to consider discontinuation of inappropriate medications in routine care of hospitalised patients. In the next phase of our project, we plan to pilot test the tool in practice to evaluate its uptake and effectiveness in supporting deprescribing in routine hospital care.

Education to improve vancomycin use: the perspectives of educators and education recipients.

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.

The efficiency-thoroughness trade-off after implementation of electronic medication management: a qualitative study in paediatric oncology.

OBJECTIVE: The efficiency-thoroughness trade-off (ETTO) principle proposes that people and organizations are often required to make a trade-off between being efficient and being thorough, as it is difficult to be both efficient and thorough at the same time. This study aimed to compare pre- electronic medication management system (EMMS) expectation of how an EMMS is likely to impact on efficiency and thoroughness to post-EMM experiences of an EMMS and the ETTO. DESIGN: Qualitative interview study. SETTING: A paediatric oncology cancer centre in a large paediatric tertiary teaching hospital in Sydney, Australia. PARTICIPANTS: Forty-four semi-structured interviews with doctors, nurses and pharmacists six months prior to and two years following implementation of an EMMS. RESULTS: Prior to EMM implementation, staff identified a number of areas of work where both efficiency and thoroughness were expected to improve with EMM. These included ease of accessibility of the medication record, and organization and legibility of medication information. Following EMMS implementation, staff reported improvements in these areas. However, the EMMS was perceived to drive thoroughness (safety) benefits at the expense of efficiency (time). Measures to improve safety in the EMMS enforced processes that required time, such as medication double-checking procedures. CONCLUSIONS: Overall, staff were aware of the competitive interplay between thoroughness and efficiency and reported that introduction of an EMMS had imposed processes that favoured improvements in thoroughness at the expense of efficiency.

Patients' use of mobile health applications: what general practitioners think.

BACKGROUND: Chronic disease patients are adopting self-management techniques, such as using mobile health applications (apps). As GPs are the main caregivers of chronic disease patients, obtaining GP perspectives regarding patient use of mobile health apps is vital in understanding longer term value and feasibility of these apps. OBJECTIVE: The aim was to determine GP perceptions of their current and potential roles in the use of health apps by their patients and how patient-focused apps affect patient management. METHODS: Ten GPs participated in semi-structured, face-to-face interviews, which focused on their perceptions of, and involvement in, the use of patient-focused health apps. Interviews were transcribed verbatim and thematically analysed by two independent reviewers. RESULTS: GPs found that apps complemented their role in patient management as additional sources of medical information of their patients. They perceived that patient-focused apps would be part of their future practices; however they noted that further work was required to incorporate them into their current practices. Currently, the main role of GPs was in promoting apps to patients. Suggestions for further engagement in mobile health included regularly reviewing patient data entered into health apps during consultations. CONCLUSION: GPs view patient-focused health apps positively, particularly to support them in providing patient care. Discussing information recorded in apps during consultations and frequent promotion of apps are feasible ways to integrate apps into their current work practices. Further studies involving evaluations of apps in improving health care delivery and patient communication in general practice are required.

Measuring the financial and productivity burden of paediatric hospitalisation on the wider family network.

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.

Exploring current and potential roles of Australian community pharmacists in gout management: a qualitative study.

BACKGROUND: Gout is an increasingly prevalent form of inflammatory arthritis. Although effective treatments for gout exist, current management is suboptimal due to low medication adherence rates and treatments that are non-concordant with guidelines. Medications are the mainstay and most effective form of gout management. Thus, there is potential for community pharmacists to play an important primary health care role in gout management, however their current role and their potential to improve management of gout treatment is currently unclear. The purpose of the study is to explore the views of Australian pharmacists on their roles in gout management and to identify factors influencing their involvement in gout management. METHODS: A convenience sample of community pharmacists were invited to participate using a snowballing recruitment strategy. Semi-structured, face-to-face interviews were conducted with 15 pharmacists of varying age, gender and pharmacy experience. Interviews focused on pharmacists' experiences of managing gout, interactions with people living with gout and their perceived roles and responsibilities in gout management. Interviews were transcribed verbatim and independently analysed by two reviewers to identify themes. RESULTS: The main role of pharmacists reported in gout management was providing patient education. The greatest facilitator to pharmacists involvement in gout management was identified to be pharmacists' good understanding of gout and its management. Barriers to pharmacists involvement were identified to be difficulties in monitoring adherence to gout medications, low priority given to gout in the pharmacy compared to other chronic health conditions, and lack of specific training and/or continuing education in gout prevention and management. CONCLUSIONS: Pharmacists can expand their primary health care role in gout management, particularly in the area of ongoing provision of education to people living with gout and in monitoring medication adherence in patients. However, a number of barriers need to be overcome including difficulties in monitoring patient adherence to medications, ensuring a higher priority is given to chronic gout management and providing continuing training to community pharmacists about gout. Implications for pharmacist practice include initiating conversations about medication adherence and education when dispensing medications and undertaking continuing education in gout.

Reliability, ease of use and usefulness of I-MeDeSA for evaluating drug-drug interaction alerts in an Australian context.

BACKGROUND: Recently, attention has shifted to improving the design of computerized alerts via the incorporation of human factors design principles. The Instrument for Evaluating Human Factors Principles in Medication-Related Decision Support Alerts (I-MeDeSA) is a tool developed in the United States to guide improvements to alert design and facilitate selection of electronic systems with superior design. In this study, we aimed to determine the reliability, ease of use and usefulness of I-MeDeSA for assessing drug-drug interaction (DDI) alerts in an Australian context. METHODS: Using the I-MeDeSA, three reviewers independently evaluated DDI alert interfaces of seven electronic systems used in Australia. Inter-rater reliability was assessed and reviewers met to discuss difficulties in using I-MeDeSA and the tool's usefulness. RESULTS: Inter-rater reliability was high (Krippendorff's alpha = 0.76), however, ambiguous wording and the inclusion of conditional items impacted ease of use. A number of items were not relevant to Australian implementations and as a result, most systems achieved an I-MeDeSA score of less than 50%. CONCLUSIONS: The I-MeDeSA proved to be reliable, but item wording and structure made application difficult. Future studies should investigate potential modifications to the I-MeDeSA to improve ease of use and increase applicability to a variety of system configurations.

Medication-related calls received by a national telenursing triage and advice service in Australia: a retrospective cohort study.

BACKGROUND: Telenursing triage and advice services are increasingly being used to deliver health advice. Medication-related queries are common, however little research has explored the medication-related calls made to these services. The aim of this study was to examine the profile of medication-related calls to a national telenursing triage and advice service and the medications involved. METHODS: This was a retrospective cohort study of medication-related calls received by Australia's national helpline (healthdirect helpline) in 2014, which provides free advice from registered nurses. We examined the volume of medication-related calls over time, user profiles for patients and callers, and call characteristics and we also investigated medications involved in the calls by their generic names and therapeutic classes. RESULTS: Of 675,774 calls, 3.8% (n = 25,744) were medication-related, which was the largest category of calls. The average call length was 10 min. Over half of callers (55.4%) were advised to deliver self-care. Of 7,459 calls where the callers reported they did not know what to do prior to calling, 56.8% were advised to self-care and 3.5% were transferred to the Poisons Information Centre immediately. Of 1,277 calls where callers reported that they had originally intended to call an ambulance or attend an emergency department (ED), none were advised to do so. Advice most frequently requested was about analgesics and antipyretics, followed by non-steroidal anti-inflammatory agents. CONCLUSION: The telenursing triage and advice helpline offered quick and easily accessible advice, and provided reassurance to patients and callers with medication-related queries. The service also potentially diverted some patients from attending an ED unnecessarily.

Automation bias in electronic prescribing.

BACKGROUND: Clinical decision support (CDS) in e-prescribing can improve safety by alerting potential errors, but introduces new sources of risk. Automation bias (AB) occurs when users over-rely on CDS, reducing vigilance in information seeking and processing. Evidence of AB has been found in other clinical tasks, but has not yet been tested with e-prescribing. This study tests for the presence of AB in e-prescribing and the impact of task complexity and interruptions on AB. METHODS: One hundred and twenty students in the final two years of a medical degree prescribed medicines for nine clinical scenarios using a simulated e-prescribing system. Quality of CDS (correct, incorrect and no CDS) and task complexity (low, low + interruption and high) were varied between conditions. Omission errors (failure to detect prescribing errors) and commission errors (acceptance of false positive alerts) were measured. RESULTS: Compared to scenarios with no CDS, correct CDS reduced omission errors by 38.3% (p < .0001, n = 120), 46.6% (p < .0001, n = 70), and 39.2% (p < .0001, n = 120) for low, low + interrupt and high complexity scenarios respectively. Incorrect CDS increased omission errors by 33.3% (p < .0001, n = 120), 24.5% (p < .009, n = 82), and 26.7% (p < .0001, n = 120). Participants made commission errors, 65.8% (p < .0001, n = 120), 53.5% (p < .0001, n = 82), and 51.7% (p < .0001, n = 120). Task complexity and interruptions had no impact on AB. CONCLUSIONS: This study found evidence of AB omission and commission errors in e-prescribing. Verification of CDS alerts is key to avoiding AB errors. However, interventions focused on this have had limited success to date. Clinicians should remain vigilant to the risks of CDS failures and verify CDS.