Development of a clinical pharmacy model within an Australian home nursing service using co-creation and participatory action research: the Visiting Pharmacist (ViP) study.

OBJECTIVE: To develop a collaborative, person-centred model of clinical pharmacy support for community nurses and their medication management clients. DESIGN: Co-creation and participatory action research, based on reflection, data collection, interaction and feedback from participants and other stakeholders. SETTING: A large, non-profit home nursing service in Melbourne, Australia. PARTICIPANTS: Older people referred to the home nursing service for medication management, their carers, community nurses, general practitioners (GPs) and pharmacists, a multidisciplinary stakeholder reference group (including consumer representation) and the project team. DATA COLLECTION AND ANALYSIS: Feedback and reflections from minutes, notes and transcripts from: project team meetings, clinical pharmacists' reflective diaries and interviews, meetings with community nurses, reference group meetings and interviews and focus groups with 27 older people, 18 carers, 53 nurses, 15 GPs and seven community pharmacists. RESULTS: The model was based on best practice medication management standards and designed to address key medication management issues raised by stakeholders. Pharmacist roles included direct client care and indirect care. Direct care included home visits, medication reconciliation, medication review, medication regimen simplification, preparation of medication lists for clients and nurses, liaison and information sharing with prescribers and pharmacies and patient/carer education. Indirect care included providing medicines information and education for nurses and assisting with review and implementation of organisational medication policies and procedures. The model allowed nurses to refer directly to the pharmacist, enabling timely resolution of medication issues. Direct care was provided to 84 older people over a 15-month implementation period. Ongoing feedback and consultation, in line with participatory action research principles, informed the development and refinement of the model and identification of enablers and challenges. CONCLUSIONS: A collaborative, person-centred clinical pharmacy model that addressed the needs of clients, carers, nurses and other stakeholders was successfully developed. The model is likely to have applicability to home nursing services nationally and internationally.

Infant Strangulation from an Amber Teething Necklace.

Amber teething necklaces supposedly provide analgesia for teething infants. Their use is becoming more widespread, despite lack of peer-reviewed evidence and warnings from Health Canada that they pose a strangulation and aspiration risk. To date, there have been no published reports of strangulation secondary to amber teething necklaces. In this report we present a case of non-fatal infant strangulation from the first time use of an amber teething necklace. We will also discuss the role of physicians as advocates in reporting similar cases and educating families. Finally, we will comment on the responsibility of all professionals and professional organizations that work with infants and toddlers to advocate for children by raising concerns and counselling parents.

How Prolific is Psychotropic Medicines Use in People with Dementia in Australia Within the Community Setting? A Retrospective Analysis.

BACKGROUND: When used for a therapeutic purpose such as for psychiatric illness, psychotropic drugs may enhance quality of life; however, when used to treat behaviours associated with dementia, they may have only a modest effect but lead to negative outcomes. OBJECTIVE: We undertook an analysis of community-dwelling people with dementia or cognitive impairment to ascertain how prolific psychotropic medicine use is within the Australian community setting, which psychotropic medicines are being prescribed and to whom, and whether the use of such medicines is in accordance with therapeutic guidelines. METHODS: We undertook a retrospective review of medication records, including medication charts, for 412 people with cognitive impairment, discharged from a home nursing service in Victoria, Australia, during the 6-month period between 1 January and 30 June 2013. RESULTS: Cholinesterase inhibitor use exceeded the number of individuals with a recorded diagnosis of Alzheimer's disease; in some cases, the dosage exceeded recommendations. Antidepressants were used by more than double the number of people documented with a history of depression. Antipsychotic medicines were prescribed for undocumented purposes, in some cases above maximum response levels, and multiple benzodiazepines were prescribed. CONCLUSIONS: Psychotropic medicine use was common in our study population, and use of these medicines was often not in line with therapeutic guidelines. Further research is required to ascertain reasons for the high use of psychotropic medicines in this group, and greater consideration is required by health professionals of the appropriate use and regular review of psychotropic medicines. Improved documentation of diagnoses and the indications for prescribing psychotropic medicines is needed, as is greater implementation of educational programmes to support care workers and carers.

Clinical epidemiological analysis of the mortality rate of liver transplant candidates living in rural areas.

MELD score has been used to predict 90-day mortality of subjects listed for liver transplantation (OLT). Validation of MELD score for patients on the waiting list in transplant programmes serving rural areas in North America is lacking. A retrospective cohort of patients affected by end-stage liver disease was studied to assess the mortality rate within 90 days after being listed at our transplant centre. Secondary aims were to identify differences between predicted and observed 90-days mortality using MELD and MELDNa scores at the time of listing. Among 126 patients included in this study, waiting list mortality was 35.0%. Ninety-day mortality was 21.1%, which was significantly greater than the mortality estimated by the MELD (9.1%, 95% CI: 6.6-11.5) and MELDNa (9.3%, 95%CI: 6.0-12.5). Despite this underestimation, AUC for MELD and MELDNa was 0.80 and 0.78 respectively. In our study, independent predictors of waiting list mortality were age, diagnosis of cholestatic disease and residence over 500 km from our transplant centre. MELD and MELDNa underestimated the 90-day mortality in patients with liver failure living in rural areas. Validation of these models should be performed in other transplant centres serving patients with limited access to specialized services.