Hospital at home: A systematic review of how medication management is conceptualised, described and implemented in practice-A study protocol.

INTRODUCTION: Hospital at Home (H@H) is a method of healthcare delivery, where hospital level interventions are conducted in the patient's usual place of residence, offering an alternative to hospital admission. This often includes the ability to perform point of care diagnostics and treat conditions using a range of treatments traditionally associated with hospital admission, including intravenous medicines and oxygen. H@H services have been established worldwide but there is a wide variation in definition and delivery models and currently no documented evidence supporting the delivery of medicines and medicines management within the H@H model. Therefore, this study aims to 1) describe how medication management in H@H is conceptulised, 2) describe and identify key components of medication management in H@H and 3) describe and identify variability in the implementation of medication management services within H@H models. METHODS AND ANALYSIS: We will search a range of databases (PubMed, Medline, Embase, CINAHL), publicly accessible documents and expert recommendations. Studies, reports and policy documents published between 1st January 2000 and 31st January 2022 will be included. Two independent reviewers will 1) screen and select studies based on a priori inclusion/exclusion, 2) conduct quality assessment using the Mixed Methods Appraisal Tool on included studies and 3) extract data. Inductive thematic analysis (objectives 1 and 2), the SEIPS 2.0 model (objective 2) and the Consolidated Framework for Implementation Research (objective 3) will be used to synthesise data. ETHICS AND DISSEMINATION: This systematic review will use secondary data sources from published documents, and as such research ethical approval was not required. We will disseminate the findings of this study in a peer-reviewed journal and national/international conference(s). TRIAL REGISTRATION: PROSPERO registration number: CRD42022300691. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022300691.

Fijian Veterinarian and Para-Veterinarians' Behavior, Attitude and Knowledge Toward Antimicrobial Use and Antimicrobial Resistance: A Qualitative Study.

Antimicrobial resistance (AMR) is a global health issue affecting humans and livestock. Reduction in antimicrobial use (AMU) and appropriate use of antimicrobials in livestock production systems have been encouraged. Lack of access to qualified veterinarians, policies regulating AMU and knowledge of AMU and AMR have been identified as drivers of inappropriate AMU behavior in developing countries. Hence, para-veterinarians take a lead role in providing veterinary services to livestock farmers in developing countries. Our previous work found Fijian farmers lack knowledge and understanding of AMU and AMR. However, the attitude, knowledge, and behavior of Fijian veterinary professionals toward AMU and AMR is currently unknown. Therefore, this qualitative study used face-to-face, semi-structured interviews to explore and understand Fijian veterinarian and para-veterinarians' attitude, knowledge, and behavior toward AMU and AMR. A sample of at least ten participants was targeted and recruited from the Central and Western divisions of Viti Levu, Fiji. The Theory of Planned Behavior (TPB) informed the development of the semi-structured interview guide. The interviews were audio-recorded and analyzed using reflexive thematic analysis and deductively using the TPB framework. Our analysis generated three key themes: 1) Antimicrobials prescribed and used based on availability and cost rather than clinical need, 2) Para-veterinarians awareness and knowledge of AMR influence treatment decisions, and 3) Limited resources impede effective consultation and veterinary service delivery. This study demonstrated para-veterinarians (not veterinarians) lacked knowledge and understanding of AMU and AMR. The availability and cost of antimicrobials rather than clinical justification drove antimicrobial prescribing amongst the para-veterinarians. Veterinarians did not visit farms to provide veterinary services; therefore, para-veterinarians provided the veterinary services to the livestock farmers. Lack of human resources, antimicrobials, and physical resources incapacitated veterinary service delivery, where services to farmers' were delayed or not provided at all. Terms of reference for veterinary service delivery and para-veterinarian training framework targeting prescribing, dispensing, use of antimicrobials and risks associated with inappropriate AMU are recommended as part of antimicrobial stewardship (AMS) programmes. Allocation of physical and human resources to Fijian veterinary services should be considered part of AMS programmes to improve veterinary service delivery to livestock farmers and optimize the AMU at the country level.

Fijian Farmers' Attitude and Knowledge Towards Antimicrobial Use and Antimicrobial Resistance in Livestock Production Systems-A Qualitative Study.

Antimicrobial resistance (AMR) is a global health issue affecting humans and livestock. To mitigate AMR risks, responsible use of antimicrobials in livestock production systems have been advocated. Studies have reported patterns of antimicrobial use (AMU) in livestock production systems; however, there is limited information on the drivers of AMU and AMR. Therefore, this study aimed to explore and understand the attitude and knowledge of Fijian livestock farmers on AMU and AMR. Livestock farmers and managers from the Central and Western divisions of Viti Levu, Fiji were recruited using purposive and snowball sampling methods. Face-to-face one-to-one semi-structured qualitative interviews were conducted. Interview questions were informed by the Theory of Planned Behavior (TPB). Interview transcripts were analyzed inductively using reflexive thematic analysis and deductively using the TPB framework. A total of 19 cattle and poultry farmers took part. Our analysis generated four themes: (1) Uninformed use of antimicrobials and unaware of AMR, (2) Safeguarding livestock and generating income source as primary motivators for using antimicrobials (3) Medicine shortage results in hoarding and self-prescribing, and (4) Farm decisions on AMU and livestock management influenced by foreign farmers and veterinarians. Livestock farmers used medicines in livestock production; however, they could not differentiate amongst different types of medicine, including antimicrobials. Antimicrobials were used to prevent diseases in livestock and promote production of food and financial security but without any awareness of the risks of AMR. Additionally, farmers hoarded and self-prescribed medicines. Farmers rationed antimicrobials by not completing the entire course of antibiotics to save them for future use. Based on past experiences, farmers expressed dissatisfaction with the veterinary services provided by the government. They sought help online and from foreign farmers and veterinarians. We propose the need for antimicrobial stewardship (AMS) programmes focused on promoting rational use of antimicrobials and awareness of AMR amongst farmers in the Fijian livestock production systems. These programmes need to consider the anthropological, socio-cultural, economic, and environmental factors driving AMU. Future studies are underway to explore the attitude and knowledge of Fijian veterinarians, para-veterinarians and pharmacists on AMU and AMR to gain a broader systems knowledge to inform the design of AMS programmes.

Modelling the use of variable rate intravenous insulin infusions in hospitals by comparing Work as Done with Work as Imagined.

BACKGROUND: Variable rate intravenous insulin infusions (VRIIIs) are widely used to treat elevated blood glucose (BG) in adult inpatients who are severely ill and/or will miss more than one meal. VRIIIs can cause serious harm to the patient if used incorrectly. Recent safety initiatives have embraced the Resilient Health Care (RHC) approach to safety by understanding how VRIIIs are expected to be used (Work as Imagined, 'WAI') and how it is actually used in everyday clinical care (Work as Done, 'WAD'). OBJECTIVES: To systematically compare WAI and WAD and analyse adaptations used in situ to develop a model explaining VRIII use. METHODS: A qualitative observational study video-recording healthcare practitioners using VRIII. The video data were transcribed and inductively coded to develop a hierarchical task analysis (HTA) to represent WAD. This HTA was compared with a HTA previously developed to represent WAI. The comparison output was used to develop a model of VRIII use. RESULTS: While many of the tasks in the WAD HTA were aligned with the tasks presented in the WAI HTA, some important ones did not. When misalignment was observed, permanent adaptations (e.g. signing as a witness for a changed VRIII's rate without independently verifying whether the new rate was appropriate) and temporary workarounds (e.g. not administering intermediate-acting insulin analogues although the intermediate-acting insulin prescription was not suspended) were the most frequently observed adaptations. The comparison between WAI and WAD assisted in developing a model of VRIII use. The model shed light on strategies used to imagine everyday work (e.g. incident reports, VRIII guidelines), how everyday work was accomplished (e.g. context-dependent adaptations) and how these contributed to both successful and unsuccessful outcomes. CONCLUSIONS: This study provided in-depth understanding of the tasks required while using VRIIIs, and responses and adaptations needed to achieve safer care in a complex environment.

How do people with dementia make sense of their medications? An Interpretative Phenomenological Analysis study.

BACKGROUND: Managing medication is complex and multifaceted for people with dementia and their family carers. Despite efforts to support medication management, medication errors and medication-related hospital admissions still occur. This study investigated how people with dementia viewed and talked about their different medications and their medication taking. METHODS: An interpretative phenomenological analysis (IPA) qualitative research design combining photo elicitation and in-depth interviews was used. People with a diagnosis of mild or moderate dementia took photographs of anything they viewed to be related to medication, with or without the help of family carers, over any two-day period. The photographs were then used as cues for subsequent in-depth interviews, which were analysed using IPA. RESULTS: Twelve people with dementia were interviewed. Four themes encapsulated the experiences: (1) Medication as a lifeline, (2) Managing medications dominates daily lives and plans, (3) Struggling with uncertainty about the effectiveness of dementia medication and (4) Sense of 'being' and being in control. People with dementia viewed medication as a lifeline, especially donepezil, giving it preference over other daily medication they were using. Managing medications dominated the daily lives and plans of people with dementia and changed the way they viewed themselves and their life. People with dementia continually struggled with the imperceptible benefits of donepezil on their dementia, but despite such uncertainties, continued to take donepezil. CONCLUSIONS: This study provided unique insights into how people with dementia made sense of their medication. Healthcare professionals can use these insights to shape their practice around medication prescribing and advice in dementia. The findings are also useful to researchers looking to develop interventions to support medication management within the home setting.

Resilient Health Care: a systematic review of conceptualisations, study methods and factors that develop resilience.

BACKGROUND: Traditional approaches to safety management in health care have focused primarily on counting errors and understanding how things go wrong. Resilient Health Care (RHC) provides an alternative complementary perspective of learning from incidents and understanding how, most of the time, work is safe. The aim of this review was to identify how RHC is conceptualised, described and interpreted in the published literature, to describe the methods used to study RHC, and to identify factors that develop RHC. METHODS: Electronic searches of PubMed, Scopus and Cochrane databases were performed to identify relevant peer-reviewed studies, and a hand search undertaken for studies published in books that explained how RHC as a concept has been interpreted, what methods have been used to study it, and what factors have been important to its development. Studies were evaluated independently by two researchers. Data was synthesised using a thematic approach. RESULTS: Thirty-six studies were included; they shared similar descriptions of RHC which was the ability to adjust its functioning prior to, during, or following events and thereby sustain required operations under both expected and unexpected conditions. Qualitative methods were mainly used to study RHC. Two types of data sources have been used: direct (e.g. focus groups and surveys) and indirect (e.g. observations and simulations) data sources. Most of the tools for studying RHC were developed based on predefined resilient constructs and have been categorised into three categories: performance variability and Work As Done, cornerstone capabilities for resilience, and integration with other safety management paradigms. Tools for studying RHC currently exist but have yet to be fully implemented. Effective team relationships, trade-offs and health care 'resilience' training of health care professionals were factors used to develop RHC. CONCLUSIONS: Although there was consistency in the conceptualisation of RHC, methods used to study and the factors used to develop it, several questions remain to be answered before a gold standard strategy for studying RHC can confidently be identified. These include operationalising RHC assessment methods in multi-level and diverse settings and developing, testing and evaluating interventions to address the wider safety implications of RHC amidst organisational and institutional change.

Medicines management issues in dementia and coping strategies used by people living with dementia and family carers: A systematic review.

OBJECTIVES: Medicines play a key role in the lives of people with dementia, primarily to manage symptoms. Managing medicines is complex for people with dementia and their family carers and can result in multiple problems leading to harm. We conducted a systematic review to identify and model medication issues experienced and coping strategies used by people with dementia and/or family carers. METHODS: Eleven general databases and four systematic review databases were searched. Studies were quality assessed using an established framework and thematically analysed. RESULTS: Twenty-one articles were included in this study, and four domains affecting medication use were identified: cognitive, medication, social and cultural, and knowledge/educational and communication. People with dementia reported medication issues in all four domains, but few coping strategies were developed. Family carers reported issues and coping strategies related to the medication and knowledge/educational and communication domains. Common issues with regards to knowledge and communication about medicines remain unresolved. The "voices" of people with dementia appeared largely missing from the literature so were in-depth understanding of how, whether, and in which circumstances coping strategies work in managing medicines. CONCLUSIONS: Medicines management is a complex set of activities and although current coping strategies exists, these were primarily used by family carers or the person with dementia-carer dyad. Health and social care practitioners and researchers should seek to understand in-depth the "mechanisms of action" of existing coping strategies and actively involve people with dementia as co-producers of knowledge to underpin any further work on medicines management.

Work Domain Analysis for understanding medication safety in care homes in England: an exploratory study.

Medication safety and errors are a major concern in care homes. In addition to the identification of incidents, there is a need for a comprehensive system description to avoid the danger of introducing interventions that have unintended consequences and are therefore unsustainable. The aim of this study was to explore the impact and uniqueness of Work Domain Analysis (WDA) to facilitate an in-depth understanding of medication safety problems within the care home system and identify the potential benefits of WDA to design safety interventions to improve medication safety. A comprehensive, systematic and contextual overview of the care home medication system was developed for the first time. The novel use of the abstraction hierarchy (AH) to analyse medication errors revealed the value of the AH to guide a comprehensive analysis of errors and generate system improvement recommendations that took into account the contextual information of the wider system. PRACTITIONER SUMMARY: It is widely acknowledged that a systems approach is necessary to improve medication safety. This study used a cognitive engineering method, Work Domain Analysis, to map the care home medication system and analyse medication errors. A macro-level view of the system was developed and this has provided a knowledge base for future interventions.

Cancer patients taking herbal medicines: A review of clinical purposes, associated factors, and perceptions of benefit or harm.

ETHNOPHARMACOLOGICAL RELEVANCE: Cancer patients in all cultures are high consumers of herbal medicines (HMs) usually as part of a regime consisting of several complementary and alternative medicine (CAM) modalities, but the type of patient, the reasons for choosing such HM-CAM regimes, and the benefits they perceive from taking them are poorly understood. There are also concerns that local information may be ignored due to language issues. This study investigates aspects of HM-CAM use in cancer patients using two different abstracting sources: Medline, which contains only peer-reviewed studies from SCI journals, and in order to explore whether further data may be available regionally, the Thai national databases of HM and CAM were searched as an example. MATERIALS AND METHODS: The international and Thai language databases were searched separately to identify relevant studies, using key words chosen to include HM use in all traditions. Analysis of these was undertaken to identify socio-demographic and clinical factors, as well as sources of information, which may inform the decision to use HMs. RESULTS: Medline yielded 5638 records, with 49 papers fitting the criteria for review. The Thai databases yielded 155, with none relevant for review. Factors associated with HM-CAM usage were: a younger age, higher education or economic status, multiple chemotherapy treatment, late stage of disease. The most common purposes for using HM-CAM cited by patients were to improve physical symptoms, support emotional health, stimulate the immune system, improve quality of life, and relieve side-effects of conventional treatment. CONCLUSIONS: Several indicators were identified for cancer patients who are most likely to take HM-CAM. However, interpreting the clinical reasons why patients decide to use HM-CAM is hampered by a lack of standard terminology and thematic coding, because patients' own descriptions are too variable and overlapping for meaningful comparison. Nevertheless, fears that the results of local studies published regionally are being missed, at least in the case of Thailand, appeared to be unfounded.

Traditional medicine use by cancer patients in Thailand.

ETHNOBOTANICAL RELEVANCE: Cancer patients commonly use traditional medicines (TM) and in Thailand these are popular for both self-medication and as prescribed by TM practitioners, and are rarely monitored. A study was conducted at Wat Khampramong, a Thai Buddhist temple herbal medicine hospice, to document some of these practices as well as the hospice regime. MATERIALS AND METHODS: Cancer patients (n = 286) were surveyed shortly after admission as to which TMs they had previously taken and perceptions of effects experienced. They were also asked to describe their current symptoms. Treatment at the hospice is built upon an 11-herb anti-cancer formula, yod-ya-mareng, prescribed for all patients, and ideally, its effects would have been evaluated. However other herbal medicines and holistic practices are integral to the regime, so instead we attempted to assess the value of the patients' stay at the hospice by measuring any change in symptom burden, as they perceived it. Surviving patients (n = 270) were therefore asked to describe their symptoms again just before leaving. RESULTS: 42% of patients (120/286; 95% CI 36.4%, 47.8%) had used herbal medicines before their arrival, with 31.7% (38/120; 95% CI 24%, 40.4%) using several at once. Mixed effects were reported for these products. After taking the herbal regime at Khampramong, 77% (208/270 95% CI; 71.7%, 81.7%) reported benefit, and a comparison of the incidence of the most common (pain, dyspepsia, abdominal or visceral pain, insomnia, fatigue) showed statistical significance (χ(2) 57.1, df 7, p < 0.001). CONCLUSIONS: A wide range of TMs is taken by cancer patients in Thailand and considered to provide more benefit than harm, and this perception extends to the temple regime. Patients reported a significant reduction in symptoms after staying at Khampramong, indicating an improvement in quality of life, the aim of hospices everywhere. Based on this evidence, it is not possible to justify the use of TM for cancer in general, but this study suggests that further research is warranted. The uncontrolled use of TMs, many of which are uncharacterised, raises concerns, and this work also highlights the fact that validated, robust methods of assessing holistic medical regimes are urgently needed.