Quality of Prescribing for Elderly Inpatients at Nine Hospitals in Victoria, Australia

Paracetamol dosing in hospital and on discharge for older people who are frail or have low body weight

Aims

To describe paracetamol dosing and liver function test (LFT) monitoring in older hospital inpatients who are frail or have low body weight.

Methods

Retrospective observational study, at a 790‐bed metropolitan public health service in Australia. Patients aged ≥70 years, with body weight <50 kg or frailty index based on laboratory data (FI‐Lab) score ≥0.3, who were administered paracetamol during an admission with length‐of‐stay >72 hours, were included. Data were extracted from electronic medical records. Paracetamol doses administered in hospital, and doses prescribed on discharge, were compared against consensus guidelines that recommended ≤60 mg/kg/d for older people weighing <50 kg, and ≤3000 mg/d for frail older people.

Results

In total, 240 admissions (n = 229 patients, mean age 84.7 years) were analysed. During 150 (62.5%) admissions, higher than recommended paracetamol doses were prescribed. On 138 (57.5%) occasions, patients were prescribed paracetamol on discharge, and 112/138 (81.2%) doses were higher than recommended. Most discharge prescriptions (97/138, 70.3%) were for regular administration. The median daily dose on discharge for patients <50 kg was 83.7 mg/kg (interquartile range 73.6–90.9 mg/kg). For frail patients ≥50 kg, the median daily discharge dose was 3990 mg (interquartile range 3000–4000 mg). LFTs were measured in hospital for 151/200 (75.5%) and 93/166 (56.0%) patients who received paracetamol for >48 hours and >5 days, respectively.

Conclusion

Majority of paracetamol doses prescribed for frail or low‐weight older patients in hospital and on discharge were higher than recommended in consensus guidelines. LFTs were not measured for 44% patients who received paracetamol regularly for >5 days. Further studies are needed to explore long‐term outcomes of this practice.

Variables associated with completeness of medical record documentation in the emergency department

OBJECTIVE

The completeness of ED medical record documentation is often suboptimal. We aimed to determine the variables associated with documentation completeness in a large, tertiary referral ED.

METHODS

We audited 1200 randomly selected medical records of patients who presented with either abdominal pain, cardiac chest pain, shortness of breath or headache between May-July 2013 and May-July 2016. Data were collected on patient and treating doctor variables. Documentation completeness was assessed using a 0-10 point scoring tool designed for the study. A maximum score was achieved if each of 10 pre-determined important items, specific to the presenting complaint, were documented (five medical history items, five physical examination items). Data were analysed using multivariate regression.

RESULTS

The presenting year, day and time, patient age and gender, preferred language, interpreter requirement, discharge destination and doctor gender were not associated with documentation completeness (P > 0.05). Patients with triage category 3 or pain score of 6-7 had higher documentation scores (P < 0.05). Compared to interns, registrars (effect size -0.72, 95% CI -1.02 to -0.42, P < 0.01) and consultants (-1.62, 95% CI -1.95 to -1.29, P < 0.01) scored significantly less. The headache patient subgroup scored significantly less than the other patient subgroups (-0.35, 95% CI -0.63 to -0.08, P = 0.01). For all presenting complaint subgroups, examination findings were less well documented than history items (P < 0.001).

CONCLUSION

Documentation completeness is less among senior doctors, headache patients and for examination findings. Research should determine if the supervision responsibilities of senior doctors affects documentation and if medico-legal and patient care implications exist.

First do no harm: a real need to deprescribe in older patients

Inappropriate polypharmacy in older patients imposes a significant burden of decreased physical functioning, increased risk of falls, delirium and other geriatric syndromes, hospital admissions and death. The single most important predictor of inappropriate prescribing and risk of adverse drug events in older patients is the number of prescribed medications. Deprescribing is the process of tapering or stopping drugs, with the goal of minimising polypharmacy and improving outcomes. Barriers to deprescribing include underappreciation of the scale of polypharmacy-related harm by both patients and prescribers; multiple incentives to overprescribe; a narrow focus on lists of potentially inappropriate medications; reluctance of prescribers and patients to discontinue medication for fear of unfavourable sequelae; and uncertainty about effectiveness of strategies to reduce polypharmacy. Ways of countering such barriers comprise reframing the issue to one of highest quality patient-centred care; openly discussing benefit-harm trade-offs with patients and assessing their willingness to consider deprescribing; targeting patients according to highest risk of adverse drug events; targeting drugs more likely to be non-beneficial; accessing field-tested discontinuation regimens for specific drugs; fostering shared education and training in deprescribing among all members of the health care team; and undertaking deprescribing over an extended time frame under the supervision of a single generalist clinician.

Quality of drug prescribing in older patients: is there a problem and can we improve it?

Older patients are at high risk of suboptimal prescribing (overuse, underuse and misuse of drugs), which can lead to serious adverse drug reactions (ADR). About one in four patients admitted to hospital are prescribed at least one inappropriate medication and up to 20% of all inpatient deaths are attributed to potentially preventable ADR. Lists of drugs to avoid (unnecessary or where risks outweigh benefits) and drugs not to be omitted (strong indications if there are no contraindications) can assist in identifying suboptimal prescribing although, to date, no trials have established the ability of such screening, by itself, to improve prescribing quality. Remedial strategies proven to be effective in randomized trials include detailed appraisal of medication lists by multidisciplinary teams, which involve geriatricians and close liaison with specialist clinical pharmacists. A multifaceted quality improvement strategy is proposed that includes an aspirational target of no more than five different drugs be regularly prescribed to vulnerable older patients. Achieving this target involves prioritizing drug selection on the basis of strength of indication which may run counter to current disease-specific clinical guideline recommendations based on trials that have excluded most older patients. Such a strategy is worthy of further evaluation in a multicentre randomized trial.

Inappropriate medication use and prescribing indicators in elderly Australians: development of a prescribing indicators tool

BACKGROUND

Evidence-practice gaps, adverse medication-related incidents and unplanned medical admissions to hospital are common in elderly Australians. Many prescribing indicator tools designed to address some of these problems have been reported in the literature, the most common of which is the Beers list of inappropriate medications in the elderly. However, many of these tools are not appropriate for the Australian healthcare environment without modification and validation, and there appears to be a need for a tool based on Australian data.

OBJECTIVE

To develop a list of prescribing indicators for elderly (aged >65 years) Australians based on the most frequent medications prescribed to Australians, and the most frequent medical conditions for which elderly Australians consult medical practitioners.

METHOD

The most common reasons for elderly Australians to seek or receive healthcare were cross-referenced with the 50 highest-volume Pharmaceutical Benefits Scheme medications prescribed to Australians in 2006 to develop prescribing indicators in the elderly using Australian medication and medical condition information resources.

RESULTS

Forty-eight prescribing indicators were identified, consisting mainly of optimum as well as inappropriate medication choices for a large number of common medical conditions in the elderly.

CONCLUSION

A prescribing indicators tool was developed. This tool is envisaged as forming an important part of the medication review process, which is aimed at addressing the common problem of adverse medication-related events in elderly Australians.

Atención farmacéutica en un centro socio-sanitario

OBJECTIVE

To reflect the activity of the pharmacy department within the nursing home s multidisciplinary team, and to assess care improvements received by residents, including a better use of drugs.

METHOD

In addition to pharmacotherapeutical guidelines and a standardized work procedure listing generic and therapeutic replacements to be implemented, selected procedures were specified in order to ensure a rational use of drugs and to increase the quality of care received by residents in our center. Such procedures will be performed by the center s multidisciplinary team and will focus on caring the caring for so-called geriatric syndromes.

RESULTS

After an assessment of treatments for 125 patients and a 3-month follow-up, 10 interventions per patient were performed, out of which 4.74 were pharmacist interventions and 5.26 were to increase quality of care.

CONCLUSIONS

The presence of the pharmacy department within the multidisciplinary team ensures a better use of drugs and a safe delivery system. Its activity contributes to improve quality of care, most notably procedures regarding nutritional status, and the prevention and treatment of pressure ulcers.