Implications of differences between point-of-care blood gas analyser and laboratory analyser potassium results on hyperkalaemia diagnosis & treatment.

BACKGROUND: Hyperkalaemia is managed in the emergency department (ED) following measurement of potassium results by blood gas analysers (BGA) or laboratory analysers (LAB). AIMS: To determine the prevalence of clinically significant differences between BGA and LAB potassium results and the impact on ED hyperkalaemia management. METHODS: Retrospective analysis of time-matched ED BGA and LAB potassium samples from 2019 to 2020 (taken within 15 min, one or both results ≥6.0 mmol/L). Mean differences and 95% limits of agreement (LoA) were determined for pairs with one or both results ≥6.0 mmol/L and a separate 500 consecutive sample pairs. RESULTS: Four hundred eighty-eight matched BGA and LAB samples met the inclusion criteria. Of these, 201 (41.2%) differed by ≤0.5 mmol/L, 169 (34.6%) included a haemolysed LAB sample, and 12 (2.5%) had an unreportable BGA sample. One hundred six (21.7%) pairs differed by >0.5 mmol/L, and 60/106 (57%) had normal LAB potassium results, but BGA indicated moderate/severe hyperkalaemia (two of these pairs received hyperkalaemia treatment). Of patients with a haemolysed LAB sample, or where pairs differed by >0.5 mmol, 48 were treated with insulin and five (10.4%) experienced hypoglycaemia. Mean differences and LoA for pairs with LAB results <6.0 mmol/L but BGA ≥6.0 mmol/L demonstrated unacceptable agreement, with 18 (25.7%) BGA results exceeding 8.0 mmol/L. CONCLUSIONS: Potentially significant discordance may occur between BGA and LAB potassium results. Clinicians need to be aware of factors impacting both analytical methods' accuracy (such as poor venepuncture or sample handling, (K) EDTA interference) and undetectable haemolysis with BGA measurements. We recommend BGA hyperkalaemia be confirmed with LAB results using a non-haemolysed sample where time permits.

Accuracy of medication histories derived from an Australian cloud-based repository of prescribed and dispensed medication records.

BACKGROUND: Obtaining accurate medication histories at transitions of care is challenging, but important for patient safety. Prescription exchange services (PES) securely transfer electronic prescription and dispensing records between prescribers and pharmacies, which is potentially useful data for determining medication histories. AIM: To evaluate the accuracy of PES-derived medication histories. METHODS: Prospective observational study, at two Australian tertiary-referral health services. A convenience sample of adult inpatients was recruited. The main outcome measure was: proportion of patients with ≥1 errors in their PES-derived pre-admission medication histories, compared with gold-standard best-possible medication histories, including prescribed and non-prescribed medications, obtained by pharmacists using multiple sources including patient/carer interview. RESULTS: Of 154 patients (median age 76 years; interquartile range (IQR) 64-84 years; median 10.0 pre-admission medications; IQR 6.0-14.0), 153 (99.4%) had ≥1 errors in their PES-derived medication history (median 6.0 errors per patient; IQR 4.0-9.0). Excluding when-required medications, 146 (94.8%) patients had >1 errors (median 4.0 errors per patient; IQR 2.0-6.0). Omission was the most common error, affecting 549 (33.3%) of 1648 current medications (median 3.0; IQR 1.0-5.0 per patient); 396 (72.1%) omissions were over-the-counter medicines. Dose-regimen errors affected 276 (25.1%) of 1099 current medications captured in PES-derived medication histories (median 1.0 error per patient; IQR 0.0-3.0). Commission errors (medications in PES-derived histories that were not current) affected 224 (16.9%) of 1323 medications (median 1.0 error per patient; IQR 1.0-2.0). CONCLUSIONS: Medication histories derived solely from a cloud-based medication record repository had a high error rate compared with patients' actual medication use. Like all medication history sources, data from cloud-based repositories need to be verified with additional sources including the patient and/or their carer.

The Prevalence and Nature of Medication Errors and Adverse Events Related to Preadmission Medications When Patients Are Admitted to an Orthopedic Inpatient Unit: An Observational Study.

BACKGROUND: Medication errors commonly occur when patients move from the community into hospital. Whereas medication reconciliation by pharmacists can detect errors, delays in undertaking this can increase the risk that patients receive incorrect admission medication regimens. Orthopedic patients are an at-risk group because they are often elderly and use multiple medications. OBJECTIVE: To evaluate the prevalence and nature of medication errors when patients are admitted to an orthopedic unit where pharmacists routinely undertake postprescribing medication reconciliation. METHODS: A 10-week retrospective observational study was conducted at a major metropolitan hospital in Australia. Medication records of orthopedic inpatients were evaluated to determine the number of prescribing and administration errors associated with patients' preadmission medications and the number of related adverse events that occurred within 72 hours of admission. RESULTS: Preadmission, 198 patients were taking at least 1 regular medication, of whom 176 (88.9%) experienced at least 1 medication error. The median number of errors per patient was 6 (interquartile range 3-10). Unintended omission of a preadmission medication was the most common prescribing error (87.4%). There were 17 adverse events involving 24 medications in 16 (8.1%) patients that were potentially related to medication errors; 6 events were deemed moderate consequence (moderate injury or harm, increased length of stay, or cancelled/delayed treatment), and the remainder were minor. Conclusion and Relevance: Medication errors were common when orthopedic patients were admitted to hospital, despite postprescribing pharmacist medication reconciliation. Some of these errors led to patient harm. Interventions that ensure that medications are prescribed correctly at admission are required.

Midazolam-Droperidol, Droperidol, or Olanzapine for Acute Agitation: A Randomized Clinical Trial.

STUDY OBJECTIVE: We aim to determine the most efficacious of 3 common medication regimens for the sedation of acutely agitated emergency department (ED) patients. METHODS: We undertook a randomized, controlled, double-blind, triple-dummy, clinical trial in 2 metropolitan EDs between October 2014 and August 2015. Patients aged 18 to 65 years and requiring intravenous medication sedation for acute agitation were enrolled and randomized to an intravenous bolus of midazolam 5 mg-droperidol 5 mg, droperidol 10 mg, or olanzapine 10 mg. Two additional doses were administered, if required: midazolam 5 mg, droperidol 5 mg, or olanzapine 5 mg. The primary outcome was the proportion of patients adequately sedated at 10 minutes. RESULTS: Three hundred forty-nine patients were randomized to the 3 groups. Baseline characteristics were similar across the groups. Ten minutes after the first dose, significantly more patients in the midazolam-droperidol group were adequately sedated compared with the droperidol and olanzapine groups: differences in proportions 25.0% (95% confidence interval [CI] 12.0% to 38.1%) and 25.4% (95% CI 12.7% to 38.3%), respectively. For times to sedation, the differences in medians between the midazolam-droperidol group and the droperidol and olanzapine groups were 6 (95% CI 3 to 8) and 6 (95% CI 3 to 7) minutes, respectively. Patients in the midazolam-droperidol group required fewer additional doses or alternative drugs to achieve adequate sedation. The 3 groups' adverse event rates and lengths of stay did not differ. CONCLUSION: Midazolam-droperidol combination therapy is superior, in the doses studied, to either droperidol or olanzapine monotherapy for intravenous sedation of the acutely agitated ED patient.

Accuracy of general practitioner medication histories for patients presenting to the emergency department.

BACKGROUND: Clinical handover and obtaining best possible medication histories (BPMH) at transition points in care are key patient safety pri-orities. This study aimed to determine the accuracy of medication histories documented on general practitioner (GP) referral letters for patients referred to emergency departments. METHODS: This was a multicentre prospective observational study in eight emergency departments. Patients taking ≥1 regular medication, referred to the emergency department with a GP letter and seen by a pharmacist were included. GP medication regimens were compared with BPMH documented by the emergency department pharmacist. RESULTS: Of the GP letters (total 414), 361 (87%) had one or more discrepancies in the patients' regular medications and 62% had one or more regular medication discrepancies of moderate-high significance. Omission of medication was more prevalent in hand-written letters (P DISCUSSION: GP referral letters should not be used in isolation to determine the medication regimen taken before an emergency department presentation. Interventions are indicated to improve awareness and accuracy of medication documentation.

Systemic Occupational Health Needs of Gender-Based Violence Advocates: Findings From the Early Months of the Pandemic.

OBJECTIVE: This study explores occupational health burdens faced by domestic and sexual violence advocates, many of which intensified during the COVID-19 pandemic. It identifies key stressors and offers advocate-driven recommendations to improve their wellbeing, addressing the lack of system-level interventions in the occupational health literature. METHODS: Semistructured interviews were conducted with 22 advocacy professionals. Thematic content analysis guided transcript coding, and researchers shared initial results with participants in two member checking sessions to validate the preliminary findings. RESULTS: Advocates experienced logistical, emotional, and systemic stressors, including loss of peer support and unempathetic workplace cultures. Recommendations prioritize advocate wellbeing and call for systemic changes. CONCLUSIONS: Advocates' occupational stressors highlight the need for system-level solutions to enhance their occupational wellbeing, particularly during large-scale emergencies. Collaborative efforts among employers, funders, and staff are essential to address system deficiencies.

Implementation of a pragmatic emergency department patients' own medications (POM) procedure to improve medication safety: An interrupted time series.

BACKGROUND: Patients' Own Medications (POMs) are useful to inform clinical decision-making, best possible medication history documentation, and ensure timely medication administration. A procedure was developed for managing POMs specifically in the emergency department (ED) and short stay unit. This study evaluated the impact of this procedure on process and patient safety outcomes. METHODS: An interrupted time-series was undertaken in a metropolitan ED/short stay unit between November 2017 and September 2021. Pre-implementation and during each of four post-implementation time-periods, data were collected at unannounced times on approximately 100 patients taking medications prior to presentation. Endpoints included proportion of patients with POMs stored in green POMs bags, in standardised locations, and proportion who self-medicated without nurses knowing. RESULTS: Following procedure implementation, POMs were stored in standardised locations for 45.9 % of patients. Proportion of patients with POMs stored in green bags increased from 6.9 % to 48.2 % (difference 41.3 %, p < 0.001). Patient self-administration without nurses' knowledge declined from 10.3 % to 2.3 % (difference 8.0 %, p = 0.015). POMs were infrequently left in ED/short stay unit after discharge. CONCLUSIONS: The procedure has standardised POMs storage, but room for further improvement remains. Although POMs were not locked away and were readily available to clinicians, patient self-medication without nurses' knowledge declined.

Accuracy of medication labels on community pharmacy-prepared dose administration aids: An observational study.

Background: Hospital prescribers often use the labels on multicompartment compliance aids or monitored dosage systems, known in Australia as dose administration aids (DAAs), as a trusted source of information about patients' medication regimens taken in the community. Aim: The primary aim was to explore the prevalence and nature of labelling incidents on community pharmacy-prepared DAAs. Methods: A convenience sample of 100 adult patients admitted to a metropolitan teaching hospital who used a community pharmacy-prepared DAA at home was recruited. Patients were excluded if their DAAs were not brought to hospital. As part of usual care, a pharmacist took a best possible medication history (BPMH) using multiple information sources. This 'gold standard' BPMH was compared to the regimen listed on the DAA summary label and the DAA contents. The primary outcome was the percentage of patients whose DAA summary label(s) had one or more incidents for DAA packed medications. DAA label incident was defined as incorrect, missing or illegible/ambiguous medication name, strength, dose or dose-form when compared to the BPMH and DAA contents. Secondary outcomes were compliance with best-practice guidelines for labelling DAAs; and percentage of patients with a DAA packing error. Results: The 100 patients used 110 DAAs, packed by 75 community pharmacies. Four (4.0%) patients had no medication summary label on their DAAs. Of the 96 patients whose DAA(s) had a summary label, 82 (85.4%) had one or more summary label incidents. The most prevalent incidents were 'illegible, ambiguous or missing medication details', 'truncated medication name' and 'omission of a medication'. The most prevalent guideline non-compliance was not including generic medication names (68% DAA-packed medications). Two DAA packing errors were identified. Conclusion: A high prevalence of DAA labelling incidents was identified. Improved DAA labelling software functionality, more robust pharmacy procedures and pharmacy staff education are required.

Assessment of inter-rater reliability of screening tools to identify patients at risk of medication-related problems across the emergency department continuum of care.

BACKGROUND: Following a national multicentre study, two emergency department (ED) screening tools were developed to determine risk of medication-related problems; one for use at ED presentation and another at ED discharge to the community. This study aimed to determine the inter-rater reliability amongst ED health professionals when applying these screening tools to a series of case scenarios. METHODS: A prospective, cross-sectional study was undertaken in the ED of a major metropolitan hospital. Twelve case scenarios were developed following ED observation of a range of patients, which were incorporated into a questionnaire and distributed to 50 health professionals. Inter-rater reliabilities of each explanatory variable of the screening tools and overall assessment were calculated using Fleiss' multi-rater kappa. RESULTS: The questionnaire was completed by 15 doctors, 19 nurses and 16 pharmacists. Fleiss' kappa showed an overall inter-rater reliability for the ED presentation tool of 0.83 (95% CI 0.83-0.84), indicating near perfect agreement. Fleiss' kappa for the ED discharge tool was 0.83 (95% CI 0.83-0.85), which also showed near perfect agreement. CONCLUSIONS: The screening tools produced favourable inter-rater reliability amongst ED health professionals. These results have important implications for ensuring consistency of ED decision-making in screening patients at risk of developing medication-related problems.

Hyperkalaemia in the emergency department: Epidemiology, management and monitoring of treatment outcomes.

OBJECTIVE: To describe the epidemiology, treatment and monitoring of treatment outcomes of patients presenting to the ED with hyperkalaemia. METHODS: We undertook a retrospective observational study in a mixed adult/paediatric ED over five 3-month periods. Consecutive patients were included if they had an initial serum or blood gas potassium ≥6.0 mmol/L. Patients were excluded if their principal diagnosis was diabetic ketoacidosis, their blood sample was haemolysed or the blood gas result was inconsistent with a subsequent serum potassium. Data were extracted from electronic medical records and two senior emergency registrars independently assessed available ECGs. Moderate and severe hyperkalaemia were potassium 6.0-6.4 and ≥6.5 mmol/L, respectively. RESULTS: Overall, 392 patients were included (mean age 73.7 years, triage category 1 or 2 28.3%, admitted 91.3%). Three hundred and twenty-one (81.9%, 95% confidence interval [CI] 77.6-85.5%) patients took one or more medications that predispose to hyperkalaemia and 335 (85.5%, 95% CI 81.5-88.7%) had one or more predisposing comorbidities. Two hundred and seventy-one (69.1%, 95% CI 64.3-73.6%) patients had moderately severe and 121 (30.9%, 95% CI 26.4-35.7%) had severe hyperkalaemia. Two hundred and fifty-nine (66.1%, 95% CI 61.1-70.7%) patients were administered at least one medication in ED to lower the potassium concentration and 51 (13.0%, 95% CI 9.9-16.8%) were dialysed. One hundred and eighty-seven patients received intravenous insulin: 40 (21.4%) had documented biochemical hypoglycaemia, but 45 (24.1%) had no post-insulin blood glucose level documented. Hyperkalaemia-associated ECG changes were uncommon. CONCLUSION: Most ED patients with hyperkalaemia have identifiable clinical and medication-related risk factors. Variations in care were widespread and monitoring for iatrogenic adverse events was suboptimal.

Evaluation of a post-discharge pharmacist opioid review following total knee arthroplasty: a pre- and post-intervention cohort study.

BACKGROUND: More than 70% of patients continue to use opioid medications 3-weeks following total knee arthroplasty. Post-discharge pharmacist reviews improve medication management, however it's effect on opioid usage is not known. AIM: This study aimed to evaluate the impact of post-discharge pharmacist review on opioid use following a total knee arthroplasty. METHOD: A pilot, cohort pre- and post-intervention study was undertaken on patients who had undergone a total knee arthroplasty and were supplied an opioid upon discharge from hospital. During the intervention, patients were contacted via telephone by a pharmacist approximately five days post-discharge to review analgesic usage, provide education and advice and communicate an opioid management plan to their general practitioner. The primary endpoint was the percentage of patients taking opioids 3-weeks post-discharge. Secondary endpoints included: percentage of patients obtaining an opioid refill; patient satisfaction with opioid supply and the pharmacist review. RESULTS: Pre- and post-intervention, 63 and 44 patients were included, respectively. The percentage of patients taking opioids 3-weeks post-discharge declined from 74.6 to 29.6% (p < 0.001) and the percentage requiring an opioid refill from their general practitioner declined from 71.4 to 36.4% (p < 0.001). More patients were satisfied with opioid supply during the intervention period (79.5% cf. 47.6%, p = 0.001). Twenty-eight (63.6%) patients could recall the post-discharge pharmacist review, and all were either satisfied or extremely satisfied with the review. CONCLUSION: Pharmacist-delivered post-discharge analgesia review reduced the percentage of patients taking opioids 3-weeks post-discharge following a total knee arthroplasty. This intervention has the potential to provide a smoother transition of care for patients supplied with opioids at the time of hospital discharge.

Qualitative exploration of Australian Muslim patients’ perceptions and experiences surrounding medication management during Ramadan.

Objective To explore Australian Muslim patients' perceptions and experiences surrounding medication management practices during Ramadan. Methods This was a qualitative exploration of the views and experiences of Muslim patients who were hospitalised during or shortly prior to Ramadan 2021. Data comprised comments obtained from a cross-sectional telephone or face-to-face questionnaire about medications and Ramadan fasting at a tertiary-referral hospital in Melbourne, Australia. A purposeful criterion sampling approach was employed for participant recruitment. Data were analysed using thematic analysis. Data were coded inductively and subthemes and themes were developed via an iterative process. Results Comments were provided by 88 patients born in a wide range of countries and with a variety of medical and surgical co-morbidities. Themes identified included interpretation of Ramadan fasting, altering medications to facilitate fasting, perceptions about healthcare professionals and health knowledge. Many patients altered their medications to facilitate Ramadan fasting and there was considerable variability in interpretation of what breaks the fast. Patients' perceptions and previous experiences with healthcare professionals determined whether they sought advice about managing their medications during Ramadan or dismissed advice and/or self-managed their medications, sometimes inappropriately. Conclusions This exploration of Australian Muslim patients found diverse views and experiences around medication practices during Ramadan - past relationships with healthcare professionals influenced this practice. As there are ramifications for physical, spiritual and family wellbeing, it is imperative that healthcare professionals partner with their Muslim patients to optimise their medication management and health outcomes for Ramadan.

Development of Screening Tools to Predict Medication-Related Problems Across the Continuum of Emergency Department Care: A Prospective, Multicenter Study.

Background: Medication-related problems (MRPs) occur across the continuum of emergency department (ED) care: they may contribute to ED presentation, occur in the ED/short-stay unit (SSU), at hospital admission, or shortly after discharge to the community. This project aimed to determine predictors for MRPs across the continuum of ED care and incorporate these into screening tools (one for use at ED presentation and one at ED/SSU discharge), to identify patients at greatest risk, who could be targeted by ED pharmacists. Methods: A prospective, observational, multicenter study was undertaken in nine EDs, between July 2016 and August 2017. Blocks of ten consecutive adult patients presenting at pre-specified times were identified. Within 1 week of ED discharge, a pharmacist interviewed patients and undertook a medical record review to determine a medication history, patient understanding of treatment, risk factors for MRPs and to manage the MRPs. Logistic regression was undertaken to determine predictor variables. Multivariable regression beta coefficients were used to develop a scoring system for the two screening tools. Results: Of 1,238 patients meeting all inclusion criteria, 904 were recruited. Characteristics predicting MRPs related to ED presentation were: patient self-administers regular medications (OR = 7.95, 95%CI = 3.79-16.65), carer assists with medication administration (OR = 15.46, 95%CI = 6.52-36.67), or health-professional administers (OR = 5.01, 95%CI = 1.77-14.19); medication-related ED presentation (OR = 9.95, 95%CI = 4.92-20.10); age ≥80 years (OR = 3.63, 95%CI = 1.96-6.71), or age 65-79 years (OR = 2.01, 95%CI = 1.17-3.46); potential medication adherence issue (OR = 2.27, 95%CI = 1.38-3.73); medical specialist seen in past 6-months (OR = 2.02, 95%CI = 1.42-2.85); pharmaceutical benefit/pension/concession cardholder (OR = 1.89, 95%CI = 1.28-2.78); inpatient in previous 4-weeks (OR = 1.60, 95%CI = 1.02-2.52); being male (OR = 1.48, 95%CI = 1.05-2.10); and difficulties reading labels (OR = 0.63, 95%CI = 0.40-0.99). Characteristics predicting MRPs related to ED discharge were: potential medication adherence issue (OR = 6.80, 95%CI = 3.97-11.64); stay in ED > 8 h (OR = 3.23, 95%CI = 1.47-7.78); difficulties reading labels (OR = 2.33, 95%CI = 1.30-4.16); and medication regimen changed in ED (OR = 3.91, 95%CI = 2.43-6.30). For ED presentation, the model had a C-statistic of 0.84 (95% CI 0.81-0.86) (sensitivity = 80%, specificity = 70%). For ED discharge, the model had a C-statistic of 0.78 (95% CI 0.73-0.83) (sensitivity = 82%, specificity = 57%). Conclusion: Predictors of MRPs are readily available at the bedside and may be used to screen for patients at greatest risk upon ED presentation and upon ED/SSU discharge to the community. These screening tools now require external validation and implementation studies to evaluate the impact of using such tools on patient care outcomes.

A Self-Administration of Medications Program to Identify and Address Potential Barriers to Adherence in Elderly Patients.

BACKGROUND: Inpatient self-administration of medications programs (SAMPs) improve the medication knowledge and adherence of elderly patients after their discharge from the hospital. They may also identify patients who will have difficulties managing their medications after discharge; however, no previous study has evaluated the value of a SAMP for detecting and addressing barriers to adherence. OBJECTIVE: To evaluate the usefulness of a SAMP for detecting and addressing barriers to adherence in functionally impaired elderly hospital inpatients, and to identify predictors of patient performance in a SAMP. METHODS: A prospective cohort study was conducted on 2 subacute aged-care wards. Patients who were intending to independently manage their medications after discharge were recruited. Medications were dispensed and labeled with full directions, and the patients were educated about their medications. Each patient was required to request the medications from nursing staff when due, then select and administer them under supervision. Patient performance was documented. Barriers to adherence and interventions used to address these barriers were recorded. Analyses were performed to identify factors associated with failing the SAMP. RESULTS: Of 62 patients who were recruited, 43 (69.4%) passed the program without requiring interventions to address adherence barriers, 7 (11.3%) passed with an intervention implemented to enable them to remain independent with medication management after discharge, and 12 (19.4%) failed and required full assistance with medication management after discharge. Overall, barriers to medication adherence (eg, inability to open containers, inability to request medications without prompting) were identified for 30.6% of patients. Mini-Mental State Examination scores and patient age were independent predictors of whether a patient would fail the SAMP. CONCLUSIONS: An inpatient SAMP effectively detected barriers to medication adherence that otherwise may not have been detected and addressed prior to a patient's discharge from the hospital.

Wastage of medications supplied by hospitals to facilitate continuity of care when patients are discharged to residential care facilities in Victoria, Australia: An observational study.

OBJECTIVES: To explore wastage of hospital-supplied medications for patients discharged to residential care facilities (RCFs). METHODS: Telephone interviews with staff at 52 RCFs and nine community pharmacies after patients were discharged from three hospitals in metropolitan Victoria, Australia, with medication supplied in original packs. RESULTS: Hospital-supplied medication was used by most RCFs, for a median of 48 hours, while waiting for community pharmacies to deliver medications packed in the RCFs' preferred dose administration aid system (unit-dose or multi-dose blister packs or sachets). All RCFs reported sending unused hospital-supplied medications to their community pharmacy. Six of the nine community pharmacies (managing 83% patients) indicated they did not reuse hospital-supplied medications, with the exception of select difficult-to-source medications. CONCLUSION: There was significant wastage of hospital-supplied discharge medications. Changes to the way hospital discharge medications are funded and quantities supplied are needed to ensure continuity of medication administration while minimising financial and environmental impacts of medication wastage.

Prescription medication use by emergency department doctors to improve work and academic performance, and to manage stress and anxiety.

OBJECTIVE: To determine medications used by ED doctors to improve work and academic performance, and to manage stress and anxiety. METHODS: We undertook an online, voluntary, anonymous survey of ACEM fellows and trainees. RESULTS: One hundred and thirty-nine (46.5%) respondents used a medication under examination. Sleep aids included melatonin (19.1% of respondents) and benzodiazepines (8.7%). Medications to improve performance included modafinil (4.7%), pseudoephedrine (2.0%), melatonin (2.0%) and beta blockers (1.3%). Some medications were taken prior to shifts. Medications to manage stress and anxiety included benzodiazepines (3.0%) and beta blockers (2.0%). CONCLUSION: Medication use is common and support for some doctors may be required.

Ketamine: Is the current 200 mg product fit for purpose in the emergency department?

OBJECTIVE: To describe the magnitude of ketamine doses administered in the ED, to identify an appropriate product to minimise risk of administration errors and diversion. METHODS: Retrospective audit of patients prescribed ketamine in two mixed adult/paediatric EDs over 12 months. RESULTS: Ketamine was administered to 386 patients (722 doses). The most common dose was ≤20 mg (52.1%), followed by 21-50 mg (30.5%). Overall, 215 patients required one dose only (71 received a dose ≤20 mg), while 299 required no more than two doses. CONCLUSION: Over three-quarters of ketamine doses were ≤50 mg; therefore, 50 mg in 1 mL may be an appropriate product.

Regular medication use by active scuba divers with a declared comorbid medical condition and victims of scuba and snorkelling-related fatalities.

INTRODUCTION: The aim of this study was to describe the nature of regular medications taken by active comorbid scuba divers (having a declared medical comorbidity) and scuba divers and snorkellers who died following a diving incident. METHODS: We undertook a retrospective, observational study from July to October, 2020. Data on 268 active comorbid divers were obtained through a 2013 survey of Divers Alert Network Asia-Pacific members. Data on 126 deceased scuba divers and 175 deceased snorkellers were obtained predominantly from 2001-2013 reports to Australian State Coronial Services. RESULTS: The active comorbid divers were significantly older, less likely to be male, and more likely to be taking one or more medications than the two deceased subject groups (P < 0.001). Cardiovascular, endocrine and psychotropic medications accounted for 53.4%, 9.9% and 6.4% of all medications taken, respectively. Almost one tenth of the deceased divers took at least one psychotropic medication, a proportion significantly greater than the other groups (P = 0.01). CONCLUSIONS: Medication use among active comorbid divers is common which likely reflects their declared medical condition. Nevertheless, they appear to be diving relatively safely, often with conditions once thought to be absolute contradictions to scuba diving. The deceased divers took significantly more psychotropic medications. It is possible that their underlying psychological/psychiatric conditions rendered them more at risk of a diving incident. Increased vigilance for psychological conditions may need to be considered during diving medical examinations.

Thunderstorm asthma medication management during an external emergency (Code Brown): An observational study of the impact of electronic prescribing and clinical documentation.

BACKGROUND: On 21 November 2016, during a thunderstorm asthma event, an external disaster was called in our Emergency Department (ED), the first since comprehensive implementation of electronic clinical documentation. This study compared medication ordering and administration documentation during surge (thunderstorm asthma) and non-surge (control) conditions. METHODS: Retrospective audit of ED patients presenting with asthma between 21 and 23 November 2016 (72-h thunderstorm asthma period) and equivalent 72-h periods of the preceding three weeks (control period). Demographic details, medical history and treatment were extracted from Cerner Millennium. RESULTS: During the thunderstorm asthma and control periods, 318 and 164 patients presented with respiratory symptoms; 302 (95.0%) and 27 (16.5%) were due to asthma, respectively. Salbutamol was ordered and administration signed on the Medication Administration Record for 122/302 (40.4%) thunderstorm asthma and 21/27 (77.8%) control patients (p<0.01). During the thunderstorm asthma period, 52/302 (17.2%) patients had no documentation on the Medication Administration Record or any ED notes of receiving salbutamol, whilst during the control periods 2/27 (7.4%) patients had no such documentation. Similar disparities with corticosteroids and ipratropium were identified. CONCLUSION: Quality of medication documentation declined during surge conditions. These data have informed policies for future surge events, when higher risk medications might be required.

Evaluation of communication to general practitioners when opioid-naïve post-surgical patients are discharged from hospital on opioids.

BACKGROUND: To address the opioid crisis, much work has focused on minimizing opioid supply to surgical patients upon hospital discharge. Research is limited regarding handover to primary care providers. The aim of this study was to evaluate the communication of post-operative opioid prescribing information provided by hospitals to general practitioners (GPs). METHODS: This study comprised two components. First, a retrospective audit of discharge summaries for opioid-naïve surgical patients supplied with an opioid on discharge was conducted to evaluate accuracy of opioid documentation and presence of an opioid management plan. Second, a survey was distributed to GPs to seek their opinions regarding adequacy of communication about hospital-initiated opioids in discharge summaries, challenges experienced in opioid management and suggestions for improvement. RESULTS: Discharge summaries for 285 patients were audited. Twenty-seven (9.5%) patients had no discharge summary completed. Of the remaining 258, 63 (24.4%) summaries had at least one discrepancy between the opioid(s) listed and the opioid(s) dispensed. Only 33 (12.8%) summaries contained an opioid management plan. From 57 GP-completed surveys, 41 (71.9%) GPs rarely or never received an opioid management plan from hospital surgical units and 34 (59.7%) were dissatisfied/very dissatisfied with information provided about opioid supply and management. Qualitative responses highlighted difficulties GPs experience managing opioid treatment for post-surgical patients after discharge, differing patient expectations and the need to improve communication at times of transition. CONCLUSION: When opioid-naive patients are discharged from hospital on opioids, communication from hospitals to GPs is poor. Future interventions should focus on strategies to improve this.