Facing uncertainty - Pilot testing of a palliative prognostic index training with hospital aged care assessment teams.

BACKGROUND: Prognostic avoidance can delay discussions about older hospital patients' life expectancy. This pilot study examined the effects of a prognostic training program on hospital clinicians' knowledge and confidence in identifying older patients at risk of dying. METHODS: Fifty-seven clinicians from aged care assessment teams at two Australian hospitals were introduced to the Palliative Prognostic Index, a 5-item checklist indicating prognoses between 3 and 6 weeks. Mixed-methods training evaluation included pre-post-training surveys and semi-structured interviews, conducted three months post-training. RESULTS: Clinicians used a combination of experience, knowledge, and intuition as strategies to generate prognoses. Allied health staff relied on intuition more often than medical and nursing staff. Prognostic tools were rarely used. Pre-post-training comparisons showed significant improvements in clinicians' knowledge and confidence in identifying signs of dying, particularly amongst allied health. Follow-up interviews highlighted advantages and challenges of using prognostic tools. Recommendations are made for addressing these.

Challenges and barriers associated with medication management for home nursing clients in Australia: a qualitative study combining the perspectives of community nurses, community pharmacists and GPs.

BACKGROUND: Increasing numbers of older people are receiving home nursing support for medication management to enable them to remain living at home. Home nursing clients frequently experience medication errors and adverse medication events. There has been little study of how medication management processes and interdisciplinary teamwork impact on medication management in the home nursing setting. OBJECTIVE: To explore medication management processes and describe barriers and challenges from the perspective of community nurses, community pharmacists and GPs involved in the provision of medication management services for home nursing clients. METHODS: Focus groups, in-depth interviews and stakeholder consultations were conducted with a convenience sample of community nurses, community pharmacists and GPs. Data were analysed using the framework approach (a deductive thematic analysis) to identify issues affecting the delivery of medication management services. RESULTS: Ten focus groups, 12 in-depth interviews and 5 stakeholder consultation meetings were conducted with 86 health practitioners (55 community nurses, 17 GPs, 10 community pharmacists and 4 nurse managers). Participants highlighted a range of barriers and challenges associated with medication management for home nursing clients, including deficiencies in interdisciplinary communication; problems related to organizational or workplace policies, processes and systems; and ineffective team function. The negative impacts of these were recognized as compromised client safety, reduced workforce efficiency and productivity and compromised interprofessional relationships. CONCLUSION: Barriers and challenges with medication management for home nursing clients and associated negative impacts were identified. Strategies are needed to improve interdisciplinary medication management and medication safety in the home nursing setting.

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.

Medicines Management, Medication Errors and Adverse Medication Events in Older People Referred to a Community Nursing Service: A Retrospective Observational Study.

BACKGROUND: Increasing numbers of older people are receiving support with medicines management from community nursing services (CNSs) to enable them to live in their own homes. Little is known about these people and the support they receive. OBJECTIVES: To explore the characteristics of older people referred for medicines management support, type of support provided, medication errors and adverse medication events (AMEs). METHODS: A retrospective observational study of a random sample of 100 older people referred to a large non-profit CNS for medicines management support over a 3-month period was conducted. Measures were: demographics, referral source, current medical problems, medicines, medication aids, types of medication authorisations used by nurses, frequency of nurse visits and type of support provided, medication errors, AMEs and interdisciplinary teamwork among community nurses, general practitioners and pharmacists. RESULTS: Older people (median 80 years) were referred for medicines support most often by hospitals (39 %). Other referrals were from families/carers, case-managers, palliative care services and general practitioners. Multiple health conditions (median 5) and medicines (median 10) were common; 66 % used ≥5 medicines; 48 % used ≥1 high-risk medicines-most commonly opiates, anticoagulants and insulin. Medication aids were frequently used, mostly multi-compartment dose administration aids (47 %). Most people received regular community nurse visits (≥4 per week) to administer medicines or monitor medicine-taking. Only 16 % had a medication administration chart; for other clients nurses used medicine lists or letters from doctors for medication authorisation. Medication errors occurred in 41 % of people and 13 % had ≥1 AME requiring medical consultation or hospitalisation; 9/13 (64 %) AMEs were potentially preventable. There was little evidence of interdisciplinary teamwork or medication review. CONCLUSION: CNS clients had multiple risk-factors for medication misadventure. Deficiencies in medicines management were identified, including low use of medication charts and interdisciplinary medication review. Strategies are needed to improve medicines management in the home-care setting.

Electronic Prescribing and Medication Management at a Residential Aged Care Facility: Uptake by General Practitioners and Qualitative Evaluation of the Benefits and Barriers.

BACKGROUND: A cloud-based mobile electronic prescribing and medication management system (ePMMS), in which prescribers' orders directly populate residential aged care facility (RACF) medication administration records (MARs) and are communicated electronically to the RACF's pharmacy, may create efficiencies and improve patient safety when compared to the paper-based and hybrid paper-electronic medication management systems used in most Australian RACFs. Little is known about general-practitioners' (GPs'), nurses' and pharmacists' acceptance of, or experiences with, ePMMS. OBJECTIVES: To explore the uptake of an ePMMS by GPs, and the experiences and perceptions of GPs, nurses and pharmacists, at a 90-bed RACF that tested a beta-version ePMMS. METHODS: Retrospective audit to determine the proportion of medicines ordered by GPs via the ePMMS over a three-month period. Focus groups conducted three-to-four months after implementation: one with GPs (n=5), one with nurses (n=12); in-depth interview/survey of pharmacists (n=2). Qualitative data were analysed thematically. RESULTS: Three of seven GPs used the ePMMS to order medicines; 53/205(25.9%) medicines were ordered via the ePMMS by GPs. Two broad themes were identified: benefits of the ePMMS, and barriers/limitations. Benefits related to patient safety and workforce efficiency, and included GPs' ability to access and modify residents' MARs remotely, no need for nurses to fax orders to the pharmacy, and no need for pharmacy transcription of GPs' handwritten orders to create electronic MARs. Barriers and limitations related to inefficiency, low GP uptake and training/support, and included slower prescribing compared to written orders, the need for GP-signed paper copies of the MAR, lack of integration with GP clinic software, and low GP motivation to use the system, especially GPs with few patients at the RACF. CONCLUSIONS: GPs, nurses and pharmacists felt the ePMMS improved medication-safety and workforce-efficiency, however a number of barriers were identified that contributed to low GP-uptake and limited the benefits.

Evaluation of a hybrid paper-electronic medication management system at a residential aged care facility.

Objectives The aims of the study were to investigate discrepancies between general practitioners' paper medication orders and pharmacy-prepared electronic medication administration charts, back-up paper charts and dose-administration aids, as well as delays between prescribing, charting and administration, at a 90-bed residential aged care facility that used a hybrid paper-electronic medication management system. Methods A cross-sectional audit of medication orders, medication charts and dose-administration aids was performed to identify discrepancies. In addition, a retrospective audit was performed of delays between prescribing and availability of an updated electronic medication administration chart. Medication administration records were reviewed retrospectively to determine whether discrepancies and delays led to medication administration errors. Results Medication records for 88 residents (mean age 86 years) were audited. Residents were prescribed a median of eight regular medicines (interquartile range 5-12). One hundred and twenty-five discrepancies were identified. Forty-seven discrepancies, affecting 21 (24%) residents, led to a medication administration error. The most common discrepancies were medicine omission (44.0%) and extra medicine (19.2%). Delays from when medicines were prescribed to when they appeared on the electronic medication administration chart ranged from 18min to 98h. On nine occasions (for 10% of residents) the delay contributed to missed doses, usually antibiotics. Conclusion Medication discrepancies and delays were common. Improved systems for managing medication orders and charts are needed. What is known about the topic? Hybrid paper-electronic medication management systems, in which prescribers' orders are transcribed into an electronic system by pharmacy technicians and pharmacists to create medication administration charts, are increasingly replacing paper-based medication management systems in Australian residential aged care facilities. The accuracy and safety of these systems has not been studied. What does this paper add? The present study identified discrepancies between general practitioners' orders and pharmacy-prepared electronic medication administration charts, back-up paper medication charts and dose-administration aids, as well as delays between ordering, charting and administering medicines. Discrepancies and delays sometimes led to medication administration errors. What are the implications for practitioners? Facilities that use hybrid systems need to implement robust systems for communicating medication changes to their pharmacy and reconciling prescribers' orders against pharmacy-generated medication charts and dose-administration aids. Fully integrated, paperless medication management systems, in which prescribers' electronic medication orders directly populate an electronic medication administration chart and are automatically communicated to the facility's pharmacy, could improve patient safety.

Evaluation of a support worker role, within a nurse delegation and supervision model, for provision of medicines support for older people living at home: the Workforce Innovation for Safe and Effective (WISE) Medicines Care study.

BACKGROUND: Support with managing medicines at home is a common reason for older people to receive community nursing services. With population ageing and projected nurse shortages, reliance on nurses may not be sustainable. We developed and tested a new workforce model: 'Workforce Innovation for Safe and Effective (WISE) Medicines Care', which enabled nurses to delegate medicines support home visits for low-risk clients to support workers (known as community care aides [CCAs]). Primary study aims were to assess whether the model increased the number of medicines support home visits conducted by CCAs, explore nurses', CCAs' and consumers' experiences with the CCAs' expanded role, and identify enablers and barriers to delegation of medicines support. METHODS: A prospective before-after mixed-methods study was conducted within a community nursing service that employed a small number of CCAs. The CCAs' main role prior to the WISE Medicines Care model was personal care, with a very limited role in medicines support. CCAs received training in medicines support, and nurses received training in assessment, delegation and supervision. Home visit data over two three-month periods were compared. Focus groups and interviews were conducted with purposive samples of nurses (n = 27), CCAs (n = 7) and consumers (n = 28). RESULTS: Medicines support visits by CCAs increased from 43/16,863 (0.25 %) to 714/21,552 (3.3 %) (p < 0.001). Nurses reported mostly positive experiences, and high levels of trust and confidence in CCAs. They reported that delegating to CCAs sometimes eliminated the need for duplicate nurse and CCA visits (for people requiring personal care plus medicines support) and enabled them to visit people with more complex needs. CCAs enjoyed their expanded role and were accepted by clients and/or carers. Nurses and CCAs reported effective communication when medicine-related problems occurred. No medication incidents involving CCAs were reported. Barriers to implementation included the limited number of CCAs employed in the organisation and reluctance from some nurses to delegate medicines support to CCAs. Enablers included training and support, existing relationships between CCAs and nurses, and positive staff attitudes. CONCLUSIONS: Appropriately trained and supervised support workers can be used to support community nurses with providing medicines management for older people in the home care setting, particularly for those who are at low risk of adverse medication events or errors. The model was acceptable to nurses, clients and carers, and may offer a sustainable and safe and effective future workforce solution to provision of medicines support for older people in the home care setting.

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.

Exploring stakeholder perspectives on medication review services for older residents in retirement villages.

OBJECTIVE: To explore stakeholder perspectives on a government-subsidised Home Medicines Review (HMR) service and factors affecting the uptake of HMRs for older residents of retirement villages in Australia. METHODS: Thirty-two in-depth interviews and four focus groups were undertaken with a purposive sample of 32 residents of retirement villages, 10 pharmacists, nine general practitioners (GPs) and a general practice nurse. Data were transcribed verbatim and analysed using the framework approach. KEY FINDINGS: Three major themes were identified: participants' perceptions of the HMR service, barriers to the uptake of HMRs and strategies for increasing the uptake of HMR. Residents had positive, negative or mixed perceptions, whereas health professionals were generally positive about the benefits of the service. Barriers to the uptake of HMRs were related to GPs, pharmacists, patients and the healthcare system. A strategy recommended by multiple stakeholders for increasing the uptake of HMRs was to use a multi-faceted intervention targeting residents and their health professionals. CONCLUSIONS: Multiple barriers to the uptake of HMRs and multiple strategies for increasing the uptake of HMRs were identified. These findings could inform the design of interventions to improve uptake of HMRs by residents and health professionals, in turn leading to better medicine use and safety.

A pharmacist-led intervention for increasing the uptake of Home Medicines Review (HMR) among residents of retirement villages (PHARMER): protocol for a cluster randomised controlled trial.

BACKGROUND: The majority of retirement village residents are at risk of medication misadventure. In a recent survey of retirement village residents in Victoria, two-thirds had at least one medication-related risk factor, and hence were eligible to receive a government-subsidised Home Medicines Review (HMR). However, only 6% of eligible residents had received a HMR in the previous 12 months. Reasons for the poor uptake of HMR, and interventions for improving HMR uptake, have been identified and developed with input from stakeholders. The trial will test the effect of Pharmacist-conducted HMR to Address the Risk of Medication-related Events in Retirement Villages (PHARMER) in improving the uptake of HMRs among retirement village residents. METHODS/DESIGN: This is a multicentre prospective cluster randomised controlled trial. Ten retirement villages in Victoria, Australia will be recruited for this trial. Retirement villages will be selected in consultation with the Residents of Retirement Villages Victoria Inc. (RRVV), based on geographical locations (e.g. northeast or southwest), size and other factors. Residents from selected villages will be recruited with the help of RRVV Resident Liaison Officers using a range of strategies. Randomisation will be by geographical location to minimise contamination. Participating villages and residents will be allocated to either Pharmacist Intervention Group (PIG) or Usual Care Group (UCG). Each group will include five retirement villages and will have at least 77 residents in total. The intervention (PHARMER) comprises educating residents regarding HMR, and using a risk assessment checklist by residents to notify their General Practitioners of their medication risk. Uptake of HMR and medication adherence will be assessed in both PIG and UCG at three and six months using telephone interviews and questionnaires. DISCUSSION: This study is the first to develop and test an intervention to improve the uptake of HMR among Australian residents in retirement villages, with a view to decreasing medication risk. A multi-faceted interventional approach will be used as suggested by stakeholders. The trial is expected to be complete by late 2011 and results will be available in 2012. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12611000109909).

Prevalence of medication-related risk factors among retirement village residents: a cross-sectional survey.

BACKGROUND: information on medication use and risk factors among older people residing in retirement villages and their uptake of medication reviews are scant. OBJECTIVES: to identify medication use issues and risk factors for medication-related problems among retirement village residents and to evaluate the uptake of government-subsidised Home Medicines Review (HMR) services in this population. DESIGN: cross-sectional, mail survey. SETTING: retirement villages in Victoria, Australia. PARTICIPANTS: members of the Residents of Retirement Villages of Victoria residing in retirement villages (2,116, aged 54-100 years). METHODS: a questionnaire was developed incorporating validated scales and items to measure medication risk, medication adherence, co-morbidity, disability, information on medication use, health and the uptake of HMR services. Questionnaires were mailed to participants for self-completion and returned using reply-paid envelopes. RESULTS: of the 2,116 respondents (70.7% response rate), 2,006 (94.8%; 95% confidence interval (CI) 93.9-95.7%) reported using prescribed medications. Three or more health conditions were present in 993 (46.9%; 95% CI 44.8-49.0%) respondents. Five or more regular medications were used by 988 (46.7%; 95% CI 44.6-48.8%) respondents. Twelve or more tablets/capsules per day were used by 229 (10.8%; 95% CI 9.5-12.1%) respondents. The use of narrow therapeutic index medications was reported by 264 (12.5%; 95% CI 11.1-13.9%) respondents. Changes to medication regimens in the previous 3 months were reported by 356 (16.8%; 95% CI 15.2-18.4%) respondents. One or more medication-related risk factors were seen in 1,374 (64.9%; 95% CI 62.9-66.9%) respondents. Of these at-risk residents, 76 (5.5%; 95% CI 4.5-6.5%) reported receiving an HMR in the previous 12 months, who were older (P < 0.001), were using more medicines (P < 0.001) and had greater disability (P = 0.002). CONCLUSIONS: reasons for the low uptake of medication reviews in retirement village residents despite the high prevalence of medication risk require further investigation.