Accuracy of patient self-administered medication history forms in the emergency department.

OBJECTIVES: The primary objective of this study was to determine the proportion of patients with medication discrepancies when using a self-administered medication history form in the emergency department (ED). The secondary objectives were to identify predictors of medication discrepancies and determine the proportion of patients with a high-risk medication discrepancy. METHODS: This was a cross-sectional study conducted in an urban ED in Australia. Patients completed a self-administered medication history form while waiting to be seen by a physician. Subsequently, a best possible medication history was taken by a pharmacist to determine accuracy of the self-reported medication lists for patients with planned admissions. Discrepancies between the two medication lists were reported descriptively. A Poisson regression analysis was conducted to identify predictors of the rate of discrepancies. Associations were reported as incident rate ratios (IRR). RESULTS: A total of 138 patients were included in the study. The total number of discrepancies was as follows: 0 (25%, n = 34), 1 (34%, n = 47), 2 (11%, n = 15), and ≥3 (30%, n = 42). The number of medications (IRR 1.11, 95% CI 1.09 to 1.14, p < 0.001), female (IRR 1.51, 95% CI 1.18 to 1.92, p = 0.001), and missing community pharmacy information (IRR 2.10, 95% CI 1.64 to 2.68, p < 0.001) were significantly associated with rate of discrepancies. Overall, 20% (n = 28) of patients had one or more high-risk medication discrepancies. CONCLUSION: Patient self-administered medication history forms have a high rate of discrepancies and should be verified by a best possible medication history.

Patient completion of self-administered medication history forms in the emergency department.

BACKGROUND: A self-administered patient medication history form may improve efficiency of workflow in the emergency department. The objective of this study was to evaluate the patient perspective of completing a self-administered medication history form in the emergency department. METHODS: This was a cross-sectional survey of patients who presented to an urban emergency department in Australia. Face and content validity of the survey was established via an iterative process that included pharmacists and patients. After completing a self-administered medication history form, patients were surveyed regard their perspective of this approach. The results of each survey question were evaluated descriptively. RESULTS: A total of 113 completed the survey. The mean age was 59±19 years, and 52% were male. Most patients (87%, n=98) did not think there were any problems completing a self-administered list while waiting to be seen by a physician or pharmacist in the emergency department. Some patients preferred other modalities for clinicians to obtain the list due to their lack of recollection or confusion (4%, n=4), preferred that clinicians utilised existing lists or evaluated medications brought with them (2%, n=2), preferred the convenience of answering questions rather than writing (1%, n=1), or did not list a reason (1%, n=1). CONCLUSION: Most patients who present to the emergency department view a self-administered medication history form positively.

Management of acute coronary syndromes at hospital discharge: do targeted educational interventions improve practice quality?

Evidence-based guidelines exist for the management of patients with acute coronary syndromes (ACS), yet adherence is suboptimal. The Discharge Management of Acute Coronary Syndrome project used a quality improvement approach, with targeted intervention strategies to optimize: prescription of guideline-recommended medications; education regarding lifestyle modifications, including cardiac rehabilitation (CR); and communication between hospital staff, patients, and general practitioners. Hospitals across Australia participated in a quality improvement cycle of audit, feedback, intervention, and reaudit. Interventions involved educational meetings, academic detailing and point-of-care reminders, and feedback of baseline audit results. Outcome measures included prescription of guideline-recommended medications, referral to CR, and documentation and communication of management plan. At baseline, 49 hospitals recruited 1,545 patients, and postintervention, 45 hospitals remained active in the project and recruited 1,589 patients. Three thousand and thirty-four hospital staff attended group education or academic detailing sessions. Postintervention, there was a significant increase in the prescription of all four guideline-recommended medications (69% vs. 57%; p<.0001); short-acting nitrates (68% vs. 56%; p<.0001); and documented referral to CR (68% vs. 57%; p<.0001). There were significant increases in documented discharge medication counselling, smoking cessation counselling, and communication of management plans. Targeted educational interventions used as part of a quality improvement cycle can enhance adherence to evidence-based guidelines for the management of patients with ACS.

Implementation and evaluation of a multisite drug usage evaluation program across Australian hospitals - a quality improvement initiative.

BACKGROUND: With the use of medicines being a broad and extensive part of health management, mechanisms to ensure quality use of medicines are essential. Drug usage evaluation (DUE) is an evidence-based quality improvement methodology, designed to improve the quality, safety and cost-effectiveness of drug use. The purpose of this paper is to describe a national DUE methodology used to improve health care delivery across the continuum through multi-faceted intervention involving audit and feedback, academic detailing and system change, and a qualitative assessment of the methodology, as illustrated by the Acute Postoperative Pain Management (APOP) project. METHODS: An established methodology, consisting of a baseline audit of inpatient medical records, structured patient interviews and general practitioner surveys, followed by an educational intervention and follow-up audit, is used. Australian hospitals, including private, public, metropolitan and regional, are invited to participate on a voluntary basis. De-identified data collected by hospitals are collated and evaluated nationally to provide descriptive comparative analyses. Hospitals benchmark their practices against state and national results to facilitate change. The educational intervention consists of academic detailing, group education, audit and feedback, point-of-prescribing prompts and system changes. A repeat data collection is undertaken to assess changes in practice.An online qualitative survey was undertaken to evaluate the APOP program. Qualitative assessment of hospitals' perceptions of the effectiveness of the overall DUE methodology and changes in procedure/prescribing/policy/clinical practice which resulted from participation were elicited. RESULTS: 62 hospitals participated in the APOP project. Among 23 respondents to the evaluation survey, 18 (78%) reported improvements in the documentation of pain scores at their hospital. 15 (65%) strongly agreed or agreed that participation in APOP directly resulted in increased prescribing of multimodal analgesia for pain relief in postoperative patients. CONCLUSIONS: This national DUE program has facilitated the engagement and participation of a number of acute health care facilities to address issues relating to quality use of medicine. This approach has been perceived to be effective in helping them achieve improvements in patient care.

A quality improvement initiative to improve adherence to national guidelines for empiric management of community-acquired pneumonia in emergency departments.

OBJECTIVE: The objective of this study was to improve the concordance of community-acquired pneumonia management in Australian emergency departments with national guidelines through a quality improvement initiative promoting concordant antibiotic use and use of a pneumonia severity assessment tool, the pneumonia severity index (PSI). DESIGN: and INTERVENTIONS: Drug use evaluation, a quality improvement methodology involving data collection, evaluation, feedback and education, was undertaken. Educational interventions included academic detailing, group feedback presentations and prescribing prompts. SETTING AND PARTICIPANTS: Data were collected on 20 consecutive adult community-acquired pneumonia emergency department presentations by each hospital for each of three audits. MAIN OUTCOME MEASURES: Two process indicators measured the impact of the interventions: documented PSI use and concordance of antibiotic prescribing with guidelines. Comparisons were performed using a Chi-squared test. RESULTS: Thirty-seven hospitals, including public, private, rural and metropolitan institutions, participated. Twenty-six hospitals completed the full study (range: 462-518 patients), incorporating two intervention phases and subsequent follow-up audits. The baseline audit of community-acquired pneumonia management demonstrated that practice was varied and mostly discordant with guidelines. Documented PSI use subsequently improved from 30/518 (6%, 95% confidence interval [CI] 4-8) at baseline to 125/503 (25%, 95% CI 21-29; P < 0.0001) and 102/462 (22%, 95% CI 18-26; P < 0.0001) in audits two and three, respectively, while concordant antibiotic prescribing improved from 101/518 (20%, 95% CI 16-23) to 132/462 (30%, 95% CI 26-34; P < 0.0001) and 132/462 (29%, 95% CI 24-33; P < 0.001), respectively. CONCLUSIONS: Improved uptake of guideline recommendations for community-acquired pneumonia management in emergency departments was documented following a multi-faceted education intervention.

Evaluating the impact of educational interventions on use of antithrombotics in Australia.

PURPOSE: The National Prescribing Service (NPS) aims to improve prescribing and use of medicines consistent with evidence-based best practice. In particular, specific educational programmes were commenced in 2003 to improve general practitioner (GP) prescribing of antithrombotics. This report assesses the impact of these multiple educational interventions in terms of changes in prescribing rates. METHODS: Monthly prescribing data (July 1996-December 2005) were obtained from a national claims database, and yearly data (2001-2006) from a GP-patient encounter database. The target group was all GPs in Australia and interventions were active (voluntary) and passive (mail-outs). Responses to the interventions were measured by changes in the mean number of antithrombotic prescriptions (for ticlopidine, clopidogrel, warfarin and dipyridamole) per 1000 consultations for each GP each month. These data were analysed using seasonally adjusted piecewise linear dynamic regression. The data from the GP-patient encounter database were reported as mean prescribing rates per 100 GP encounters. RESULTS: NPS interventions either had an effect in the expected direction or had no discernable impact. Prescribing appeared to have decreased for dipyridamole, clopidogrel and ticlopidine, although the decline was only statistically significant for dipyridamole. Prescribing of warfarin continued to rise steadily despite NPS efforts. CONCLUSIONS: The NPS antithrombotics programme appears to have had modest success, but such evaluations raise questions about whether a focus on outcomes at a national level is appropriate, given likely concealment of effects at local levels. Lessons learned should be applied in the evaluation of other programmes aimed at influencing prescribing.