The prevalence and perceived effectiveness of using a medication-swallowing lubricant in aged care facilities across Australia.

Objective: To explore the extent of use and perceived effectiveness of using a medication lubricant that is specifically designed to help people who struggle to swallow their solid medications whole. Method: Health care workers of varying professional levels in aged care facilities (ACFs) across Australia who are involved in medication administration were invited to participate in a structured online survey. Results: Of the 355 health care workers who completed the survey, 48% had used the medication lubricant to aid administration of whole and/or crushed solid oral dosage forms, and of these 89% agreed with the statement that "it is effective method to facilitate medication swallowing in residents." The main benefits of using the medication lubricant were considered to be easier medication administration to residents (49%), reduction in need for crushing of medications (34%), and better adherence with medications (33%). Conclusions: This study showed that using a medication lubricant for aged care residents may facilitate the process of medication administration for health care workers, which they perceive to improve residents' adherence with medications. Serious complications associated with solid dosage form modification may also be decreased by using a medication lubricant, as the need for modifying medications is reduced. Therapeutic Goods Administration (TGA)-approved medication lubricants could therefore be a valuable tool to aid the medication administration for patients who have difficulties swallowing medications. Future research may consider the clinical efficacy and acceptability of medication lubricants specifically for people with swallowing difficulties.

Perceived Usability of Tablet Crushers: Comparison of Devices by People with and without Limited Hand Functions.

Tablet crushing is a common practice used by patients and their carers, mainly to facilitate swallowing. Various tablet-crushing devices with different designs are currently available on the market. This study aimed to compare the usability of different tablet-crushing devices in people with and without limited hand functions. The hand function of 100 adults recruited from the general community (40 of whom self-reported a limited hand function) was assessed using the hand and finger function subscale of the Arthritis Impact Measurement Scale version 2. The hand strength was measured using a dynamometer. Participants crushed tablets using 11 crushing devices and completed a Rapid Assessment of Product Usability and Universal Design questionnaire for each device. Hand-held twist-action crushers with an ergonomic grip received the highest usability scores among both groups, irrespective of the cost (p < 0.05). Crushers with bags were scored lower by those with limited hand functions, although the score improved if the device was automatic. Preferences regarding electronic crushers significantly changed once the cost was revealed. Economical twist-action crushers with ergonomic grips and without bags or cups were the most favoured crushers.

Identification of drug-related problems followed by clinical pharmacist interventions in an outpatient pharmacotherapy clinic.

WHAT IS KNOWN AND OBJECTIVE: Pharmacotherapy is an essential strategy for the treatment of many medical conditions especially chronic disease and often involves multiple medications being used simultaneously. Increasing the use of medications may pose some challenges to safe and effective drug therapy and if not identified and prevented by the pharmacists eventually can lead to drug-related problems (DRPs). The present study aimed to examine the incidence of DRPs in Iranian patients and to evaluate patients' adherence to the clinical pharmacist interventions as well as the physicians' acceptance of these recommendations. METHODS: This study was conducted in a university-affiliated outpatient pharmacotherapy clinic over a 22-month period. Patients aged 18 years and older with at least one chronic disease receiving at least four medications were included in the study. The patients were interviewed by a clinical pharmacist for comprehensive medication review. DRPs were identified using the DOCUMENT classification system. Recommendations were provided by the clinical pharmacist including interventions involving patient and/or physician to resolve DRPs. The patients were followed up after 2 weeks to evaluate their compliance and physician acceptance of clinical pharmacist recommendations. RESULTS AND DISCUSSION: Two hundred patients were included in this study. Overall, 875 DRPs were identified with an average of 4.37 per patient. The most prevalent DRPs were related to patient education or information (22.8%), undertreated indications (17.4%) and patient compliance (17.2%). The most common drugs associated with DRPs were alimentary and metabolism (22.2% of DRPs) followed by the cardiovascular system (19.2%) and nervous system (9.6%) medications. The DRP incidence correlated with gender only and was higher in females (p = 0.019). The clinical pharmacist provided 912 interventions with an average of 4.56 and 1.04 interventions per patient and per DRPs respectively. Patient education (41.3%), medication initiation or discontinuation (24.5%), and non-pharmacological interventions (12.9%) were the most common clinical pharmacist interventions. Out of 912 interventions, 665 were followed up, out of which 427 were patient dependent and 228 involved physicians. The patient's compliance with clinical pharmacist recommendations was 81.2%. The physician acceptance rate of the recommendations was 44.1%. WHAT IS NEW AND CONCLUSION: The study shows that especially designed services such as pharmacotherapy clinics running by clinical pharmacists are necessary to detect and resolve DRPs in an effective way. The high compliance rate of the patients indicates patients' confidence in the clinical pharmacist services provided in the pharmacotherapy clinic. The low acceptance rate of the physicians highlights the need to improve interprofessional collaboration between clinical pharmacists and physicians in an outpatient setting.

Relationship between amikacin pharmacokinetics and biological parameters associated with organ dysfunction: a case series study of critically ill patients with intra-abdominal sepsis.

OBJECTIVES: This study aimed to evaluate the relationship between amikacin pharmacokinetics and the biomarkers associated with organ dysfunction in critically ill patients with intra-abdominal sepsis. METHODS: A case series involving critically ill patients with intra-abdominal sepsis who received an amikacin loading dose of 20-25 mg/kg intravenous infusion was studied. The 1-, 2-, 4-, 6- and 24-hour amikacin serum concentrations were measured to calculate the pharmacokinetic parameters. The Sequential Organ Failure Assessment (SOFA) score, white blood cells, neutrophil to lymphocyte ratio, platelet count, serum creatinine, creatinine clearance, bilirubin, partial pressure of oxygen to fraction of inspired oxygen ratio, serum albumin, procalcitonin, lactate level, erythrocyte sedimentation rate (ESR) and C-reactive protein were recorded. A linear regression analysis was performed to examine the relationship between the amikacin pharmacokinetics and the biological parameters. RESULTS: Twenty-one patients were studied. A significant correlation was found between the volume of distribution and ESR (p<0.05, r=0.844). Moreover, drug clearance had a significant inverse correlation with serum lactate (p<0.05, r=-0.603). No other significant correlations were found. CONCLUSIONS: ESR and serum lactate were identified as useful predictors of amikacin pharmacokinetics in critically ill patients with intra-abdominal sepsis and may help guide the selection of appropriate empirical dosing.

Antibiotic therapy in sepsis: No next time for a second chance!

WHAT IS KNOWN AND OBJECTIVE: Sepsis is a life-threatening organ dysfunction associated with a high rate of morbidity and mortality. Appropriate antibiotic therapy remains the cornerstone of sepsis and septic shock management. COMMENT: Although the early initiation of antimicrobial agents in the treatment of sepsis is widely acknowledged, the selection and adjustment to optimal dosage can be equally important. Since significant pathophysiological changes in the critically ill patients lead to altered pharmacokinetics of antibiotics, early consideration of pharmacokinetic/pharmacodynamic (PK/PD) properties is necessary for optimal antibiotic dosing in sepsis and should be integrated in practice. WHAT IS NEW AND CONCLUSION: Where possible, an individualized antibiotic dosing approach through the application of therapeutic drug monitoring (TDM) service should replace the conventional dosing in critically ill patients with sepsis. Finally, antimicrobial stewardship can help improve clinical outcomes.

A Difficult Pill to Swallow: An Investigation of the Factors Associated with Medication Swallowing Difficulties.

BACKGROUND: Many medications are available as solid oral dosage forms such as tablets and capsules; however, some people find these medications difficult to swallow. AIM: To identify whether certain psychological, oral sensory, and oral motor characteristics contribute to medication swallowing difficulties. METHODS: A sample of healthy adults from two academic institutions in Brisbane were assessed for their experiences with swallowing solid oral dosage forms, food preferences, and food neophobia. The gag reflex, oral cavity size, fungiform papillae count, and chewing efficacy were also evaluated followed by a capsule-swallowing task. Primary outcome was the incidence of medication swallowing difficulties. Secondary outcomes were the association of medication swallowing difficulties with psychological, oral sensory, and oral motor factors. RESULTS: Of 152 subjects, 32% reported difficulty swallowing tablets or capsules whole. This group was significantly more likely to have had a memory of choking on medications compared to those without medication swallowing difficulties (OR = 7.25, p < 0.05). Current medication swallowing difficulties were significantly associated with a smaller mouth cavity size (OR = 2.98, p < 0.05), a higher density of taste receptors on the tongue (OR = 3.27, p < 0.05), and were higher among those who chewed a jelly candy to non-homogenous particle size (OR = 4.1, p < 0.05). Current medication swallowing difficulties were associated with lower confidence in swallowing large capsules (000 size: OR = 0.47, 00 size: OR = 0.39, p < 0.05). No associations were found between medication swallowing difficulties and the gag reflex or food neophobia. CONCLUSION: A combination of heightened oral perception characterized by a small oral cavity and high taste sensitivity compounded by a past choking episode on medications may be precipitating factors for medication swallowing difficulties. These factors may be helpful in identifying individuals who are more likely to experience difficulty swallowing medications.

Factors that affect health-care workers' practices of medication administration to aged care residents with swallowing difficulties: An Australia-wide survey study.

OBJECTIVES: To understand the barriers and facilitators of medication administration to aged care residents with swallowing difficulties. METHODS: Health-care workers in aged care facilities across Australia involved in medication administration to residents completed an online survey. RESULTS: Of 355 respondents, 90.9% reported 'everyday' encounters with residents with swallowing difficulties and 94.1% modified medications to facilitate administration. Time constraints (63.4%) and workload (69.0%) were common barriers. Only 39.0% believed swallowing abilities are considered at the prescribing stage. Pill size (95.8%), polypharmacy (75.2%) and lack of alternative formulations (74.9%) contributed to these challenges. Support from other health-care professionals (91.5%) and training (85.9%) were the most favoured facilitators. CONCLUSION: Health-care workers are faced with various challenges when caring for residents with swallowing difficulties. Promoting multidisciplinary collaborations, provision of training and medication review services, and improving skill mix and staffing composition in aged care facilities are needed to address these challenges.

Factors affecting Australian aged care facility workers in administering oral medication to residents with swallowing difficulties.

Swallowing difficulties are common in older people and can complicate the administration of oral medications. The aim of this study was to explore factors affecting healthcare workers in their practices of oral medication administration to aged care residents with swallowing difficulties. A purposeful sample of 17 healthcare workers composed of clinical/care managers, registered nurses (RNs), enrolled nurses (ENs), and assistants in nursing (AINs) from three aged care facilities in Queensland, Australia participated in semi-structured interviews. Leximancer was used for quantitative content analysis. The responses centered on three main factors. Participants discussed workprocess-related factors including time, workload, and stress and frustrations resulting from work processes. Medication-related factors included strategies to facilitate medication administration, uncertainties around modifying medications, availability/cost of alternatives, multidisciplinary medication management, prescribing considerations, and polypharmacy. Resident-related factors were discussed around individualized needs of residents especially those with dementia-associated swallowing difficulties. Ideas differed among the four groups of participants. Managers discussed workprocess-related factors pertaining to staff and facility. RNs focused on how clinical aspects of the medication practices were affected by work processes. ENs were task-oriented and their responses focused on work processes. AIN responses centered on reliance on RNs in performing medication tasks. The findings suggest that healthcare workers' practices of medication administration to residents with swallowing difficulties are affected by various factors associated with work processes, medications, and resident characteristics. Although these factors affect all levels of healthcare workers, the needs of each group vary depending on their level of training and responsibilities.

Appropriateness of oral dosage form modification for aged care residents: a video-recorded observational study.

Background Dosage forms of oral medications are frequently modified in aged care facilities by crushing/splitting tablets or opening capsules to facilitate medication administration for residents with swallowing difficulties. These practices pose safety concerns including the risk of adverse events resulting from loss of dose during transfer and alteration in the rate of absorption. Objective To identify the incidence, methods, and appropriateness of oral dosage form modification practices in aged care facilities. Setting A purposive sample of four urban and regional aged care facilities in Queensland, Australia. Method The processes of modification of oral dosage forms were observed and video-recorded using an action camera placed on medication trolleys. Each video was then reviewed and the details of the medication modification processes were recorded in a data collection form. The appropriateness of the practices of dosage form modification was evaluated against existing national guideline (Australian Don't Rush to Crush Handbook). Deviations from the instructions in the guideline were considered as inappropriate practice. Main outcome measure Incidence and characteristics of inappropriate modification of oral dosage forms. Results Oral dosage forms were modified in 25.7% of 810 observed medications. The most common methods of dosage form modification included crushing tablets with a manual crushing device (71.6%), cutting/splitting tablets (20.2%), and opening capsules (4.3%). According to the national guideline, 12.5% of the modification instances were inappropriate. Inappropriate practices were commonly associated with the suboptimal methods of medication preparation where medications were unsuitably modified, mixed, spilled, or incompletely dosed. Conclusion The modification of oral dosage forms seems a common practice in aged care facilities in Queensland. However, some of these modifications do not comply with the requirements of good practice according to existing guidelines. Healthcare workers in aged care facilities need to be supported and upskilled with effective training to promote the best and safest practices of ODF modification.

Medication Interaction and Physicians' Compliance Assessment through Medication Reconciliation Forms in a University Affiliated Hospital.

Medication interactions are associated with various unwanted adverse drug reactions. Medication Reconciliation involves a process in which a complete list of patient's previously prescribed medications are recorded and subsequently evaluated within the context of concomitantly prescribed medications and present medical condition during the hospitalization. Medical records of randomly selected 270 patients hospitalized in internal medicine, cardiovascular and infectious diseases wards were evaluated. Drug interactions were checked by LexiComp® database. Each interaction was assigned a risk rating of A, B, C, D, or X. The progression from A to X was based on increased urgency for responding to the data. Completed reconciliation forms were attached to patient charts for evaluation of physicians' compliance. Drug interactions were observed in 65.2% (176/270) of cases. The risk rating of interactions was categorized as C, D and X in 54.2%, 32.4%, and 13.4% of cases, respectively. There was a positive correlation between the number of prescribed medications and the rate of interactions (p-value < 0.001, Kendall's correlation coefficient = 0.487). Moreover, the length of hospitalization and the rate of drug interactions were significantly correlated (p-value < 0.001, Kendall's correlation coefficient = 0.350). Cardiovascular agents constituted the largest proportion of interactions (25%) followed by antibiotics (18%) and immunosuppressive agents (6%). In 59.6% of cases, no corrective action was taken by the physicians. Medication discrepancies occur commonly in hospital settings. Structured medication reconciliation may have a positive impact on prevention of medication errors.

The Rate of Physicochemical Incompatibilities, Administration Errors. Factors Correlating with Nurses' Errors.

Medication errors are commonly encountered in hospital setting. Intravenous medications pose particular risks because of their greater complexity and the multiple steps required in their preparation, administration and monitoring. We aimed to determine the rate of errors during the preparation and administration phase of intravenous medications and the correlation of these errors with the demographics of nurses involved in the process. One hundred patients who were receiving IV medications were monitored by a trained pharmacist. The researcher accompanied the nurses during the preparation and administration process of IV medications. Collected data were compared with the acceptable guidelines. A checklist was filled for each IV medication. Demographic data of the nurses were collected as well. A total of 454 IV medications were recorded. Inappropriate administration rate constituted a large proportion of errors in our study (35.3%). No significant or life threatening drug interaction was recorded during the study. Evaluating the impact of the nurses' demographic characteristics on the incidence of medication errors showed that there is a direct correlation between nurses' employment status and the rate of medication errors, while other characteristics did not show a significant impact on the rate of administration errors. Administration errors were significantly higher in temporary 1-year contract group than other groups (p-value < 0.0001). Study results show that there should be more vigilance on administration rate of IV medications to prevent negative consequences especially by pharmacists. Optimizing the working conditions of nurses may play a crucial role.