The effect of a residential care pharmacist on medication administration practices in aged care: A controlled trial

Systematic review of types of safety incidents and the processes and systems used for safety incident reporting in care homes

AIMS

To identify the safety incident reporting systems and processes used within care homes to capture staff reports of safety incidents, and the types and characteristics of safety incidents captured by safety incident reporting systems.

DESIGN

Systematic review following PRISMA reporting guidelines.

METHODS

Databases were searched January 2023 for studies published after year 2000, written in English, focus on care homes and incident reporting systems. Data were extracted using a bespoke data extraction tool, and quality was assessed. Data were analysed descriptively and using narrative synthesis, with types and characteristics of incidents analysed using the International Classification for Patient Safety.

DATA SOURCES

Databases were CINAHL, MEDLINE, PsycINFO, EMBASE, HMIC, ASSISA, Nursing and Allied Health Database, MedNar and OpenGrey.

RESULTS

We identified 8150 papers with 106 studies eligible for inclusion, all conducted in high-income countries. Numerous incident reporting processes and systems were identified. Using modalities, typical incident reporting systems captured all types of incidents via electronic computerized reporting, with reports made by nursing staff and captured information about patient demographics, the incident and post-incident actions, whilst some reporting systems included medication- and falls-specific information. Reports were most often used to summarize data and identify trends. Incidents categories most often were patient behaviour, clinical process/procedure, documentation, medication/intravenous fluids and falls. Various contributing and mitigating factors and actions to reduce risk were identified. The most reported action to reduce risk was to improve safety culture. Individual outcomes were often reported, but social/economic impact of incidents and organizational outcomes were rarely reported.

CONCLUSIONS

This review has demonstrated a complex picture of incident reporting in care homes with evidence limited to high-income countries, highlighting a significant knowledge gap. The findings emphasize the central role of nursing staff in reporting safety incidents and the lack of standardized reporting systems and processes.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The findings from this study can inform the development or adaptation of safety incident reporting systems in care home settings, which is of relevance for nurses, care home managers, commissioners and regulators. This can help to improve patient care by identifying common safety issues across various types of care home and inform learning responses, which require further research.

IMPACT

This study addresses a gap in the literature on the systems and processes used to report safety incidents in care homes across many countries, and provides a comprehensive overview of safety issues identified via incident reporting.

REPORTING METHOD

PRISMA.

PATIENT OR PUBLIC CONTRIBUTION

A member of the research team is a patient and public representative, involved from study conception.

Optimization of solid oral dosage form administration to patients with swallowing difficulties: An integrative review

AIM

To appraise and synthesize research investigating optimizing the administration of solid oral dosage forms (SODFs) to adults with swallowing difficulties.

DESIGN

An integrative review.

METHODS

An electronic search was conducted on Medical Literature Analysis and Retrieval System Online (Public Medline interface), Elsevier SciVerse Scopus and Scientific Electronic Library Online (updated February 2023). Restriction regarding the publication date was not considered for the inclusion of records. Studies addressing risks, general aspects, recommendations about patient postural adjustments, swallowing techniques, swallowing aids and aspects of concealment of SODFs were included.

RESULTS

Fifty-three records published between 2002 and 2021 were included. The main administration risks were aspiration, asphyxia and solid oral dosage form-induced oral/oesophageal mucosal lesions. The most frequent general aspect reported was administering one oral dosage form at a time. The sitting position was the most patient postural adjustment mentioned. The most frequently reported solid oral dosage form swallowing technique was the lean-forward method for capsules. Solid oral dosage form swallowing aids cited: tongue and throat lubricant and solid oral dosage form coating device, swallowing cup and swallowing straw.

CONCLUSION

The literature data on administering SODFs for adults with swallowing difficulties were appraised and synthesized. Some aspects, for example, not administering SODFs simultaneously, can make swallowing safer. Postural adjustments and solid oral dosage form swallowing aids are important to avoid administration risks. Swallowing SODFs can be easier if learned by techniques. Liquid and food are helpful as vehicles, and several of these have been listed.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

By optimizing the contributing factors of administering oral pharmacotherapy, the nurse can use appropriate practices to improve patient safety. Additionally, knowing and establishing the administration aspects are reasonable steps for standardizing care for patients with swallowing oral dosage form difficulties.

IMPACT

This study addressed administering SODFs to adult patients with swallowing difficulties. The administration of SODFs to adult patients with swallowing difficulties can be optimized if only one oral dosage form at a time is administrated and if patient postural adjustments, swallowing techniques and swallowing aids are used. This investigation will impact the care of patients with swallowing difficulties.

REPORTING METHOD

The authors declare they adhered to the relevant EQUATOR guidelines and report following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 Statement.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Embedded on-site aged care pharmacists in Australia: Insights from early adopters of a new workforce model

OBJECTIVE

To explore the roles of early adopters of Australia's embedded on-site pharmacist model in supporting quality use of medications in residential aged care facilities (RACFs).

METHODS

Qualitative semistructured interviews were conducted with 15 pharmacists working as embedded on-site pharmacists, or beyond the scope of traditional consultant pharmacist roles in Australian RACFs. Interviews were audio-recorded, transcribed and thematically analysed independently by two investigators using an inductive approach. Deductive analysis was also undertaken using a knowledge broker framework: knowledge manager, linkage agent and capacity builder.

RESULTS

Dominant themes were roles and benefits of embedded pharmacists, factors associated with success and challenges. Roles and benefits included (1) resident-level interventions and an enhanced ability to provide collaborative outcome-focussed resident-centred care, including timely input and follow-up, and improved relationships with residents, family and interdisciplinary team; and (2) system-level interventions such as contributing to clinical governance and quality improvement. Factors associated with success included personal capabilities and approach of the pharmacist, and organisational culture and sector-wide support. Challenges included pharmacist workforce shortages, perceived lack of pharmacist readiness and difficulty determining an appropriate service model. Deductive coding demonstrated roles of embedded pharmacists were consistent with all three activities of a knowledge broker.

CONCLUSIONS

This study highlights the resident- and system-level roles and benefits of embedded on-site pharmacists, and provides a framework for defining this emerging workforce model in Australian RACFs.

Implementing a medication lubricant for pill dysphagia on an acute care ward using Plan-Do-Study-Act cycles

BACKGROUND

Pill dysphagia, the difficulty in swallowing solid oral medications, is a common problem that can affect medication adherence and increase pill modifications. Current practices of crushing medications or using food vehicles have limitations and potential risks. This report describes the implementation of a medication lubricant, Gloup, for pill dysphagia on an acute care ward using Plan-Do-Study-Act cycles.

OBJECTIVE

The objective of this project was to evaluate the implementation of Gloup in the acute care ward setting and assess its acceptability and uptake by patients and ward nurses during medication administration.

METHODS

The project involved chart audits of medication administration records, collection of patient feedback, and staff feedback through meetings. Patient characteristics and medication administration practices were documented. The implementation process included education and training sessions for staff, development of a medication chart sticker for evaluation data collection and small-scale testing of Gloup with patients before ward-level implementation.

RESULTS

The implementation of Gloup on the acute care ward showed high uptake and acceptability. The majority of patients using Gloup had crushed medications, and the use of Gloup varied based on patient needs.

CONCLUSION

The implementation of Gloup as a medication lubricant for pill dysphagia on an acute care ward was successful and well received by patients and staff. The use of Gloup appeared to improve medication administration practices and reduce the need for crushing medications or using food vehicles. This project highlights the importance of addressing pill dysphagia in acute care settings and provides insights for other wards considering similar interventions.

The RESPECT-brochure: Development of a tool to inform and empower residents and informal caregivers on the medicines' pathway in nursing homes

Objective

To develop and evaluate a tool to inform and empower nursing home (NH) residents and informal caregivers regarding the medicines' pathway.

Methods

Feedback on the tool's text, drafted by the research team, was collected from a professional organization; the lay-out was designed by an illustrator. The tool was pilot tested in NHs, focusing on feasibility, appropriateness, and meaningfulness. Semi-structured interviews and focus groups with residents, informal caregivers, and healthcare professionals were performed, as well as document analysis. Qualitative data were analyzed inductively.

Results

The RESPECT-brochure was developed and described each process of the medicines' pathway. Piloting showed that the tool was well perceived among residents and informal caregivers and offered opportunities to discuss medication-related questions and concerns, but that skills to tailor the conversation, especially given the changing NH population, a matching vision and local champion are required for the tool's uptake.

Conclusion

An informative and empowering tool has been successfully developed and pilot tested in NHs. Future research should investigate which strategies for implementation work best and can explore the impact of the tool's use in daily practice.

Innovation

The tool is the first in its kind and grants nursing home staff a new strategy to promote person-centered care.

Medication delivery errors in outpatients with percutaneous endoscopic gastrostomy: effect on tube feeding replacement

Patients with enteral access usually receive oral drugs via feeding tubes and correct drug administration remains a challenge. The aim of this study was to identify common medication delivery errors (MDEs) in outpatients with percutaneous endoscopic gastrostomy (PEG) and evaluate their association with the need for tube replacement due to deterioration or clogging. A 2-year retrospective study that comprised adult outpatients with a placed/replaced PEG tube and whose electronic medical record included home medication was carried out. Treatment with medication that should not be crushed and administered through an enteral feeding tube was considered an MDE. We included 269 patients and 213 MDEs (20% of oral prescriptions) were detected in 159. Ninety-two percent of the medications associated with MDEs could be substituted by appropriate formulations. Tube replacement due to obstruction was needed in 85 patients. MDEs were associated with increased risk for tube replacement (OR 2.17; 95% CI 1.10-4.27). Omeprazole enteric-coated capsules were associated with the greatest risk (OR 2.24; 95% CI 1.01-4.93). PEG outpatients are highly exposed to MDEs, leading to a significant increase in the odds of tube replacement, mainly when treated with omeprazole. The use of appropriate alternative therapies would prevent unnecessary adverse events.

Exploring medication safety structures and processes in nursing homes: a cross-sectional study

BACKGROUND

Medication safety is important to limit adverse events for nursing home residents. Several factors, such as interprofessional collaboration with pharmacists and medication reviews, have been shown in the literature to influence medication safety processes.

AIM

This study had three main objectives: (1) To assess how facility- and unit-level organization and infrastructure are related to medication use processes; (2) To determine the extent of medication safety-relevant processes; and (3) To explore pharmacies' and pharmacists' involvement in nursing homes' medication-related processes.

METHOD

Cross-sectional multicenter survey data (2018-2019) from a convenience sample of 118 Swiss nursing homes were used. Data were collected on facility and unit characteristics, pharmacy services, as well as medication safety-related structures and processes. Descriptive statistics were used.

RESULTS

Most of the participating nursing homes (93.2%) had electronic resident health record systems that supported medication safety in various ways (e.g., medication lists, interaction checks). Electronic data exchanges with outside partners such as pharmacies or physicians were available for fewer than half (10.2-46.3%, depending on the partner). Pharmacists collaborating with nursing homes were mainly involved in logistical support. Medication reviews were reportedly conducted regularly in two-thirds of facilities.

CONCLUSION

A high proportion of Swiss nursing homes have implemented diverse processes and structures that support medication use and safety for residents; however, their collaboration with pharmacists remains relatively limited.

Assessing implementation fidelity of an on-site pharmacist intervention within Australian residential aged care facilities: A mixed methods study

BACKGROUND

An on-site pharmacist (OSP) intervention was implemented which sought to improve medication management within residential aged care facilities (RACFs) in the Australian Capital Territory, Australia. The objectives of this mixed methods study were to evaluate the implementation fidelity of the OSP intervention and to determine the moderating factors which influenced delivery of this intervention.

METHODS

This convergent parallel mixed methods study was underpinned by Hasson's conceptual framework for implementation fidelity. Implementation fidelity for seven intervention RACFs was quantitatively assessed using three quantitative data sets: (1) range of OSP intervention activities delivered; (2) random sample of 10% of medication reviews assessed for quality; (3) proportion of residents who received at least one medication review. Semi-structured interviews (n = 14) with managers and OSPs across the intervention RACFs were conducted to identify moderating factors which may have influenced OSP intervention delivery.

RESULTS

The OSP intervention was generally delivered as intended with overall medium levels of implementation fidelity. This delivery was supported by a range of facilitation strategies with most participants perceiving that the intervention was delivered to a high standard. RACF managers and OSPs were mostly well engaged and responsive. A number of potential barriers (including the part-time OSP role, COVID-19 pandemic, RACFs spread out over a large area with significant distance between resident dwellings) and facilitators (including the pharmacist support meetings, OSPs who took time to establish relationships, RACF managers who actively supported OSPs and worked with them) for OSP intervention delivery were identified which have potential implications for the roll out of OSPs within Australian RACFs.

CONCLUSION

In this study, the implementation fidelity of OSP intervention delivery was assessed with overall medium levels of fidelity found across the intervention RACFs. This suggested that the OSP intervention can generally be delivered as intended in real world RACFs. OSP intervention delivery was influenced by a range of moderating factors, some of which posed barriers and others which facilitated the OSP intervention being delivered as intended.

Impact of on-site pharmacists in residential aged care facilities on the quality of medicines use: a cluster randomised controlled trial (PiRACF study)

Residents of residential aged care facilities (RACFs) have a high prevalence of use of potentially inappropriate medications (PIMs) and resultant medicines-related harm. This study investigated the effect of an on-site pharmacist model on PIMs use and other medication outcomes for residents in RACFs. A multi-facility, non-blind, cluster randomised controlled trial, with randomisation at the facility level, was conducted. Fifteen facilities enrolled and participated in the study, 7 facilities (560 residents) were allocated to the intervention arm and 8 facilities (737 residents) were allocated to the control arm. Each facility in the intervention arm employed an on-site pharmacist for 12 months to perform medication management activities as part of an interdisciplinary care team. The primary outcome was the proportion of residents taking at least one PIM according to the 2019 Beers® Criteria. Using generalised linear mixed-effects models, accounting for confounders and clustering, there was a significant reduction in the proportion of residents prescribed at least one PIM (odds ratio 0.50, 95% confidence interval, 0.335-0.750; p = 0.001) in the intervention arm. There were also significant decreases in the Anticholinergic Cognitive Burden scale and chlorpromazine equivalent daily dose of antipsychotics. The on-site pharmacist intervention significantly improved the appropriateness of medicines use in RACFs.

The role of on-site pharmacist in residential aged care facilities: findings from the PiRACF study

BACKGROUND

Residents in residential aged care facilities (RACFs) have a high number of medication-related problems. Integrating on-site pharmacists (OSPs) into this setting is a possible solution and is currently gaining traction in Australia and internationally. The Pharmacists in Residential Aged Care Facilities (PiRACF) cluster-randomised controlled trial integrated pharmacists into the RACF care team to improve medication management. The aim of this descriptive observational study is to explore the activities of OSPs when they are integrated into multidisciplinary care team in RACFs.

METHOD

An online survey tool was developed to record the activities of OSPs in RACFs using the Qualtrics© software. OSPs were asked questions about their activities in RACFs under categories that included description, time spent, outcomes where applicable and who the pharmacists communicated with to undertake the activity.

RESULTS

Six pharmacists were integrated into 7 RACFs. Overall, they recorded 4252 activities over 12 months. OSPs conducted 1022 (24.0%) clinical medication reviews; 48.8% of medication reviews identified and discussed potentially inappropriate medications with prescribers and 1025 other recommendations were made to prescribers. Overall, the prescriber accepted 51.5% of all recommendations made by OSPs. The most frequently accepted outcome was deprescribing of medications (47.5% for potentially inappropriate medications and 55.5% for other recommendations). OSPs performed facility-level activities including staff education (13.4%), clinical audits (5.8%), and quality improvement activities (9.4%). OSPs spent a large proportion of their time communicating (23.4%) extensively with prescribers, RACF's healthcare team, and residents.

CONCLUSION

OSPs successfully performed a wide range of clinical activities aimed both at improving residents' medication regimens, and organisational-level quality improvement. The OSP model presents an opportunity for pharmacists to enhance medication management in the residential aged care setting. Trial registration The trial was registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) (ACTRN: ACTRN12620000430932) on April 1, 2020.

Pharmacists as patient advocates: A series of case studies illustrating the impacts of a regular pharmacist service in residential aged care (nursing homes)

Background

Medicine-related problems are common in older people living in residential aged care facilities (RACFs). Recognising the significant medicine-related problems, the Australian government has announced a $345 million funding package to employ on-site pharmacists in RACFs starting in 2023. The new on-site pharmacists are to provide a range of clinical services to reduce medicine-related adverse events, promote quality use of medicines, and improve clinical governance and education. Underpinning these services, the authors argue that pharmacists play the critical role as resident advocates.

Objective

This study aims to demonstrate how pharmacists can enhance their advocacy responsibility within and beyond the clinical environment to not only reduce medicine-related adverse events but also improve residents' overall health and quality of life.

Methods

This study uses a case series methodology to demonstrate pharmacists' diverse roles in advocating for residents and their families. The case studies were based on participants enrolled in the Reducing Medicine-Induced Deterioration and Adverse Reactions (ReMInDAR) trial, a randomised controlled trial testing the effects of a regular pharmacist service across the Australian RACFs.

Results

Pharmacists' advocacy ranged from persistence in follow-up with a resident's general practitioner (GP) to ensure the GP was aware that a patient was experiencing bleeding and bruising while on an anticoagulant, to advocating for a new bed for a resident with peripheral oedema who had been sleeping in his chair due to fear of falling out of his current bed.

Conclusions

Our trial focussed on pharmacists serving as the residents' advocate to improve their overall health and quality of life, rather than just addressing a list of medicine-related problems. The pharmacist model used in the ReMInDAR trial supports pharmacists to work to their full scope of practice, helps guide the Australian government's new on-site pharmacist program, and serves as an exemplar pharmacist in aged care model internationally.

Factors influencing pharmacist interest and preparedness to work as on-site aged care pharmacists: Insights from qualitative analysis of free-text survey responses

BACKGROUND

High rates of suboptimal medication use exist in residential aged care facilities (RACFs). Pharmacist interventions can improve medication appropriateness. In 2023 there will be a phased implementation of pharmacists working on-site in Australian RACFs.

OBJECTIVE

To explore factors influencing Australian pharmacists' interest and perceived preparedness to work as on-site pharmacists in RACFs.

METHODS

A national cross-sectional anonymous online survey of Australian pharmacists was conducted. Pharmacists were recruited using a broad advertising strategy. The 36-question survey included three free-text questions that are the focus of this study. The questions asked participants (1) what influenced their interest in the role, (2) what influenced how prepared they felt for the role, and (3) if they had any other comments about the role. Responses were thematically analysed by two investigators using an inductive approach.

RESULTS

Most survey respondents (n=546, 84.9%) answered at least one free-text questions. Four factors influenced interest: on-site pharmacist role, aged care setting, individual pharmacist circumstances and employment model. Four factors influenced preparedness: familiarity with aged care setting, resident-level clinical skills; ability to communicate and work with a multidisciplinary team, and experience with system-level quality use of medicines activities. Four factors important for successful roll-out emerged from the 'other comments': pharmacist attributes, pharmacist workforce planning, resources and support, and RACF stakeholder engagement.

CONCLUSION

Key factors influencing pharmacist interest and preparedness to work on-site in RACFs and factors important for success were identified. These findings will support the national roll-out of the role, particularly as most identified factors are currently modifiable.

Research status and hotspots of medication safety in older adults: A bibliometric analysis

Background

Medication safety is a significant concern in healthcare. Research on medication safety for older adults has taken a broad approach, resulting in a range of proposals. At this juncture, it is necessary to identify the main contributors and establish the current developmental status of the principal research topics.

Objective

This study sets out to summarize the state-of-the-art in medication safety for older adults, identifying significant achievements, key topics, and emerging trends.

Methods

The Web of Science Core Collection (WOSCC) database was searched for relevant documentation over the interval 1st January 2000 to 31st December 2021. Annual outputs and citations were identified from the WOS citation reports. CiteSpace and VOSviewer were adopted for bibliometric analysis and visualization that included the distribution of countries/regions, organizations, authors and journals, and an analysis of co-cited references and keywords.

Results

A total of 1,638 documents were retrieved for bibliometric analysis, yielding 34.29 citations per document. Publications have increased over the past two decades, reaching 177 outputs in 2019. Our database encompasses 71 countries/regions, 2,347 organizations, and 7,040 authors. The United States ranks first in terms of scientific activity with 604 publications (36.87%). We have identified the University of Sydney as the most prolific organization (53 publications). J. T. Hanlon, J. H. Gurwitz, D. O'Mahony, and G. Onder are the most influential researchers in terms of publications and citations. The Journal of the American Geriatrics Society ranks first with 89 (5.43%) papers. In terms of major research directions, three topics have been identified from co-cited reference and keyword analysis: (1) estimation of the prevalence and variables associated with polypharmacy and potentially inappropriate medication; (2) analysis of interventions involving pharmacists and the associated impact; (3) patient experience and perception associated with medication use or pharmaceutical care.

Conclusion

Research on medication safety for older adults has progressed significantly over the past two decades. The United States, in particular, has made important contributions to this field. Polypharmacy and potentially inappropriate medication use, interventions involving pharmacists, patient experience and perception represent the current focus of research. Our findings suggest that these directions will continue as research hotspots in the future.

Solid Oral Dosage Forms Use in Adults with Neurological Disorders and Swallowing Difficulties: A Scoping Review

Swallowing difficulties affects the deglutition of solid oral dosage forms (SODFs) and it is a common problem among neurological disorders. Interventions may improve the use of SODFs in healthcare settings. The aim of this study was to map the available research about the interventions aiming the effective and safe use of SODFs in adults with neurological disorders and swallowing difficulties and to identify potential literature gaps in this scientific field. A scoping review was carried out based on Joanna Briggs Institute guidelines and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, in PubMed, Scopus, and SciELO databases (March 2021). Peer-reviewed observational studies assessed the effectiveness and safety of SODFs in adults with neurological disorders and swallowing difficulties in the healthcare organizations setting were included. 11 studies were included (three case reports, two mixed-methods intervention studies, and six analytic studies). The frequency of women ranged from 49 to 67%, and the age from 57 to 91 years. Most studies (n = 7) included elderly patients, Parkinson (n = 6) and dementia (n = 3). Medication review was the most frequently reported intervention, 35% (9/26). In most studies, interventions were targeted to patients during hospitalization (n = 7) and performed by physicians (n = 8). At least 20 different outcomes were evaluated in the studies. Implementing specific protocols for using SODFs aimed at the swallowing difficulties of this population is not a common practice. Additional studies on interventions aimed at optimizing SODFs are needed to support the safety and efficacy of oral therapy in this patient group.

Process evaluation for the Care Homes Independent Pharmacist Prescriber Study (CHIPPS)

Background

Medicines management in care homes requires significant improvement. CHIPPS was a cluster randomised controlled trial to determine the effectiveness of integrating pharmacist independent prescribers into care homes to assume central responsibility for medicines management. This paper reports the parallel mixed-methods process evaluation.

Method

Intervention arm consisted of 25 triads: Care homes (staff and up to 24 residents), General Practitioner (GP) and Pharmacist Independent Prescriber (PIP). Data sources were pharmaceutical care plans (PCPs), pharmacist activity logs, online questionnaires and semi-structured interviews. Quantitative data were analysed descriptively. Qualitative data were analysed thematically. Results were mapped to the process evaluation objectives following the Medical Research Council framework.

Results

PCPs and activity logs were available from 22 PIPs. Questionnaires were returned by 16 PIPs, eight GPs, and two care home managers. Interviews were completed with 14 PIPs, eight GPs, nine care home managers, six care home staff, and one resident. All stakeholders reported some benefits from PIPs having responsibility for medicine management and identified no safety concerns. PIPs reported an increase in their knowledge and identified the value of having time to engage with care home staff and residents during reviews. The research paperwork was identified as least useful by many PIPs. PIPs conducted medication reviews on residents, recording 566 clinical interventions, many involving deprescribing; 93.8% of changes were sustained at 6 months. For 284 (50.2%) residents a medicine was stopped, and for a quarter of residents, changes involved a medicine linked to increased falls risk. Qualitative data indicated participants noted increased medication safety and improved resident quality of life. Contextual barriers to implementation were apparent in the few triads where PIP was not known previously to the GP and care home before the trial. In three triads, PIPs did not deliver the intervention.

Conclusions

The intervention was generally implemented as intended, and well-received by most stakeholders. Whilst there was widespread deprescribing, contextual factors effected opportunity for PIP engagement in care homes. Implementation was most effective when communication pathways between PIP and GP had been previously well-established.

Trial registration

The definitive RCT was registered with the ISRCTN registry (registration number ISRCTN 17847169).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07062-3.

National Trends and Policy Impacts on Provision of Home Medicines Reviews and Residential Medication Management Reviews in Older Australians, 2009-2019

Comprehensive medicines reviews such as Home Medicines Review (HMR) and Residential Medication Management Review (RMMR) can resolve medicines-related problems. Changes to Australia’s longstanding HMR and RMMR programs were implemented between 2011 and 2014. This study examined trends in HMR and RMMR provision among older Australians during 2009–2019 and determined the impact of program changes on service provision. Monthly rates of general medical practitioner (GP) HMR claims per 1000 people aged ≥65 years and RMMR claims per 1000 older residents of aged care facilities were determined using publicly available data. Interrupted time series analysis was conducted to examine changes coinciding with dates of program changes. In January 2009, monthly HMR and RMMR rates were 0.80/1000 older people and 20.17/1000 older residents, respectively. Small monthly increases occurred thereafter, with 1.89 HMRs/1000 and 34.73 RMMRs/1000 provided in February 2014. In March 2014, immediate decreases of –0.32 (95%CI –0.52 to –0.11) HMRs/1000 and –12.80 (95%CI –15.22 to –10.37) RMMRs/1000 were observed. There were 1.07 HMRs/1000 and 35.36 RMMRs/1000 provided in December 2019. In conclusion, HMR and RMMR program changes in March 2014 restricted access to subsidized medicines reviews and were associated with marked decreases in service provision. The low levels of HMR and RMMR provision observed do not represent a proactive approach to medicines safety and effectiveness among older Australians.

Reducing risks associated with medicines and lifestyle in a residential care population with intellectual disabilities: evaluation of a pharmacy review initiative in England

OBJECTIVES

A collaborative service initiative involving community pharmacists and a specialist mental health pharmacist was developed to provide pharmacist reviews for care home residents with intellectual disabilities (IDs). This study aimed to characterise the medicines and lifestyle risk outcomes of the service and determine how these align with national priority issues in ID.

DESIGN

Descriptive statistical analysis of routinely collected service delivery data.

SETTING

Residential care homes in the Wirral, England for people with ID.

PARTICIPANTS

160 residents.

INTERVENTIONS

Pharmacist review of residents' medicines and lifestyle risk factors between November 2019 and May 2020.

PRIMARY AND SECONDARY OUTCOME MEASURES

Numbers of medicines prescribed, the nature of pharmacists' interventions/recommendations and general practitioner (GP)/psychiatrist acceptance.

RESULTS

The 160 residents were prescribed 1207 medicines, 74% were prescribed ≥5 medicines and 507 interventions/recommendations were made, averaging 3.3 per resident. The highest proportion (30.4%) were lifestyle risk related, while changing and stopping medicines accounted for 17.9% and 12.8%, respectively. Of the recommendations discussed with GPs/psychiatrists, 86% were accepted. Medicines with anticholinergic properties were prescribed for 115 (72%) residents, of whom 43 (37%) had a high anticholinergic burden score. Pharmacists recommended anticholinergic discontinuation or dose reduction for 28 (24%) residents. The pharmacists made interventions/recommendations about constipation management for 10% of residents and about respiratory medicines for 17 (81%) of the 21 residents with respiratory diagnoses.

CONCLUSIONS

The findings indicate considerable polypharmacy among the residents and a high level of pharmacists' interventions/recommendations about medicines and lifestyle risk, most of which were accepted by GPs/psychiatrists. This included anticholinergic burden reduction and improving respiratory disease and constipation management, which are national priority issues. Wider adoption of collaborative pharmacist review models could have similar benefits for residential populations with ID and potentially reduce pressure on other health services.

Models of provider care in long-term care: A rapid scoping review

INTRODUCTION

One of the current challenges in long-term care homes (LTCH) is to identify the optimal model of care, which may include specialty physicians, nursing staff, person support workers, among others. There is currently no consensus on the complement or scope of care delivered by these providers, nor is there a repository of studies that evaluate the various models of care. We conducted a rapid scoping review to identify and map what care provider models and interventions in LTCH have been evaluated to improve quality of life, quality of care, and health outcomes of residents.

METHODS

We conducted this review over 10-weeks of English language, peer-reviewed studies published from 2010 onward. Search strategies for databases (e.g., MEDLINE) were run on July 9, 2020. Studies that evaluated models of provider care (e.g., direct patient care), or interventions delivered to facility, staff, and residents of LTCH were included. Study selection was performed independently, in duplicate. Mapping was performed by two reviewers, and data were extracted by one reviewer, with partial verification by a second reviewer.

RESULTS

A total of 7,574 citations were screened based on the title/abstract, 836 were reviewed at full text, and 366 studies were included. Studies were classified according to two main categories: healthcare service delivery (n = 92) and implementation strategies (n = 274). The condition/ focus of the intervention was used to further classify the interventions into subcategories. The complex nature of the interventions may have led to a study being classified in more than one category/subcategory.

CONCLUSION

Many healthcare service interventions have been evaluated in the literature in the last decade. Well represented interventions (e.g., dementia care, exercise/mobility, optimal/appropriate medication) may present opportunities for future systematic reviews. Areas with less research (e.g., hearing care, vision care, foot care) have the potential to have an impact on balance, falls, subsequent acute care hospitalization.

Integrating pharmacists into aged care facilities to improve the quality use of medicine (PiRACF Study): protocol for a cluster randomised controlled trial

BACKGROUND

Medication management in residential aged care facilities is an ongoing concern. Numerous studies have reported high rates of inappropriate prescribing and medication use in aged care facilities, which contribute to residents' adverse health outcomes. There is a need for new models of care that enhance inter-disciplinary collaboration between residential aged care facility staff and healthcare professionals, to improve medication management. Pilot research has demonstrated the feasibility and benefits of integrating a pharmacist into the aged care facility team to improve the quality use of medicines. This protocol describes the design and methods for a cluster randomised controlled trial to evaluate the outcomes and conduct economic evaluation of a service model where on-site pharmacists are integrated into residential aged care facility healthcare teams to improve medication management.

METHODS

Intervention aged care facilities will employ on-site pharmacists to work as part of their healthcare teams 2 to 2.5 days per week for 12 months. On-site pharmacists, in collaboration with facility nurses, prescribers, community pharmacists, residents and families will conduct medication management activities to improve the quality use of medicines. Aged care facilities in the control group will continue usual care. The target sample size is 1188 residents from a minimum of 13 aged care facilities. The primary outcome is the appropriateness of prescribing, measured by the proportion of residents who are prescribed at least one potentially inappropriate medicine according to the 2019 Beers Criteria. Secondary outcomes include hospital and emergency department presentations, fall rates, prevalence and dose of antipsychotics and benzodiazepines, Anticholinergic Cognitive Burden Score, staff influenza vaccination rate, time spent on medication rounds, appropriateness of dose form modification and completeness of resident's allergy and adverse drug reaction documentation. A cost-consequence and cost-effectiveness analysis will be embedded in the trial.

DISCUSSION

The results of this study will provide information on clinical and economic outcomes of a model that integrates on-site pharmacists into Australian residential aged care facilities. The results will provide policymakers with recommendations relevant to further implementation of this model.

TRIAL REGISTRATION

ACTRN12620000430932 . Registered on 1 April 2020 with ANZCTR.

To crush, or not to crush? Unauthorised covert administration of medication in nursing homes

BACKGROUND AND OBJECTIVES

This study aimed to explore the experiences and perceptions of nursing home staff and residents of unauthorised covert administration of medication. Prior studies identify that covert medication administration (crushing medication to administer in food or drink) is common in nursing home settings. Still, few recognise that this practice may occur without consultation or clinical authorisation.

DESIGN

An exploratory qualitative study was conducted with nursing home staff and residents as part of a more extensive mixed-methods study on medication omissions and clinical decision-making.

METHODS

We conducted a qualitative study using focus groups and semi-structured interviews across four geographical areas in New Zealand to better understand nursing home staff and residents' experiences and perspectives on covert administration. Semi-structured interviews took place with 11 Clinical managers/leads and one senior Registered Nurse; role specific focus groups were held with Registered Nurses (n = 6), Health Care Assistants (n = 14), and Residents (n = 12). Data were analysed using thematic analysis.

FINDINGS

Participants described covert administration as a practical option if a nursing home resident refused medication but recognised it was a deception that carried ethical and clinical risks, particularly when unauthorised. Participants felt that unauthorised covert administration stemmed from doubts about residents' competence and the competing demands staff face during medication administration. Staff, who typically relied on advice from their pharmacies around which medications were safe to crush, expressed a need for more education.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This study provides evidence that unauthorised covert administration of medications is an ongoing practice, using New Zealand nursing homes as an example. The results emphasise that nursing home staff and residents are aware that this practice carries ethical and clinical risks and requires a certified process to legitimise its authorised form.

Process Evaluation of the SImplification of Medications Prescribed to Long-tErm Care Residents (SIMPLER) Cluster Randomized Controlled Trial: A Mixed Methods Study

Complex medication regimens are highly prevalent, burdensome for residents and staff, and associated with poor health outcomes in residential aged care facilities (RACFs). The SIMPLER study was a non-blinded, matched-pair, cluster randomized controlled trial in eight Australian RACFs that investigated the one-off application of a structured 5-step implicit process to simplify medication regimens. The aim of this study was to explore the processes underpinning study implementation and uptake of the medication simplification intervention. A mixed methods process evaluation with an explanatory design was undertaken in parallel with the main outcome evaluation of the SIMPLER study and was guided by an established 8-domain framework. The qualitative component included a document analysis and semi-structured interviews with 25 stakeholders (residents, family, research nurses, pharmacists, RACF staff, and a general medical practitioner). Interviews were transcribed verbatim and reflexively thematically content analyzed. Descriptive statistics were used to summarize quantitative data extracted from key research documents. The SIMPLER recruitment rates at the eight RACFs ranged from 18.9% to 48.6% of eligible residents (38.4% overall). Participation decisions were influenced by altruism, opinions of trusted persons, willingness to change a medication regimen, and third-party hesitation regarding potential resident distress. Intervention delivery was generally consistent with the study protocol. Stakeholders perceived regimen simplification was beneficial and low risk if the simplification recommendations were individualized. Implementation of the simplification recommendations varied between the four intervention RACFs, with simplification implemented at 4-month follow-up for between 25% and 86% of residents for whom simplification was possible. Good working relationships between stakeholders and new remunerated models of medication management were perceived facilitators to wider implementation. In conclusion, the one-off implicit medication simplification intervention was feasible and generally delivered according to the protocol to a representative sample of residents. Despite variable implementation, recommendations to simplify complex regimens were valued by stakeholders, who also supported wider implementation of medication simplification in RACFs.

Probing pharmacists' interventions in Long-Term Care: a systematic review

PURPOSE

Long-Term Care (LTC) systems have experienced recent developments driven by changes in healthcare and demography (e.g. population ageing). As well, pharmacists are changing from traditional roles to more patient-oriented services. The present study aimed to identify and assess pharmacists' and/or pharmacy-based interventions in institutional LTC settings, also mapping relevant medications.

METHODS

The review was undertaken in general accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), using three main literature databases (PubMed, Scopus, and Web of Knowledge). A set of 16 keywords, divided into three domains (professional, type of care and type of setting), were combined into search equations. Selected studies were assessed through the Quality Assessment Tool for Quantitative Studies.

RESULTS

Twenty-six studies met the inclusion criteria, out of 794 initial hits. Most studies (12) described pharmacist/pharmacy-driven interventions assessing Medication Management Reviews' impact in different endpoints or outcomes. Other studies (3) assessed pharmacists' interventions on specific medication groups. Good Administration Practices, new pharmaceutical care models, antibiotic stewardship programs, and studies assessing other pharmacists' interventions, such as pharmacy-managed informatics and education, were addressed by 11 other papers. Six studies were classified as Strong after quality assessment.

CONCLUSION

LTC is a clinically complex type of care benefiting from interdisciplinary work. Despite the overall lower quality of the identified studies, pharmacists perform in a wide array of LTC areas. The broad implementation of pharmaceutical activities in institutional LTC settings opens opportunities to optimise medicines' use.

Impact of Medication Regimen Simplification on Medication Incidents in Residential Aged Care: SIMPLER Randomized Controlled Trial

In the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) cluster-randomized controlled trial, we investigated the impact of a structured medication regimen simplification intervention on medication incidents in residential aged care facilities (RACFs) over a 12-month follow-up. A clinical pharmacist applied the validated 5-step Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE) for 96 of the 99 participating residents in the four intervention RACFs. The 143 participating residents in the comparison RACFs received usual care. Over 12 months, medication incident rates were 95 and 66 per 100 resident-years in the intervention and comparison groups, respectively (adjusted incident rate ratio (IRR) 1.13; 95% confidence interval (CI) 0.53-2.38). The 12-month pre/post incident rate almost halved among participants in the intervention group (adjusted IRR 0.56; 95%CI 0.38-0.80). A significant reduction in 12-month pre/post incident rate was also observed in the comparison group (adjusted IRR 0.67, 95%CI 0.50-0.90). Medication incidents over 12 months were often minor in severity. Declines in 12-month pre/post incident rates were observed in both study arms; however, rates were not significantly different among residents who received and did not receive a one-off structured medication regimen simplification intervention.

Medication incident recovery and prevention utilising an Australian community pharmacy incident reporting system: the QUMwatch study

PURPOSE

To identify factors in community pharmacy that facilitate error recovery from medication incidents (MIs) and explore medication safety prevention strategies from the pharmacist perspective.

METHODS

Thirty community pharmacies in Sydney, Australia, participated in a 30-month prospective incident reporting program of MIs classified in the Advanced Incident Management System (AIMS) and the analysis triangulated with case studies. The main outcome measures were the relative frequencies and patterns in MI detection, minimisation, restorative actions and prevention recommendations of community pharmacists.

RESULTS

Participants reported 1013 incidents with 831 recovered near misses and 165 purported patient harm. MIs were mainly initiated at the prescribing (68.2%) and dispensing (22.6%) stages, and most were resolved at the pharmacy (76.9%). Detection was efficient within the first 24 h in 54.6% of MIs, but 26.1% required one month or longer; 37.2% occurred after the patient consumed the medicine. The combination of specific actions/attributes (85.5%), appropriate interventions (81.6%) and effective communication (77.7%) minimised MIs. An array of remedial actions were conducted by participants including notification, referral, advice, modification of medication regimen, risk management and documentation corrections. Recommended prevention strategies involved espousal of medication safety culture (97.8%), better application of policies/procedures (84.6%) and improvements in healthcare providers' education (79.9%).

CONCLUSION

Incident reporting provided insights on the human and organisational factors involved in the recovery of MIs in community pharmacy. Optimising existing safeguards and redesigning certain structures and processes may enhance the resilience of the medication use system in primary care.

Medication administration in Australian residential aged care: A time-and-motion study

RATIONALE/AIM

Medication administration is a complex and time-consuming task in residential aged care facilities (RACFs). Understanding the time associated with each administration step may help identify opportunities to optimize medication management in RACFs. This study aimed to investigate the time taken to administer medications to residents, including those with complex care needs such as cognitive impairment and swallowing difficulties.

METHOD

A time-and-motion study was conducted in three South Australian RACFs. A representative sample of 57 scheduled medication administration rounds in 14 units were observed by a single investigator. The rounds were sampled to include different times of day, memory support units for residents living with dementia and standard units, and medication administration by registered and enrolled nurses. Medications were administered from pre-prepared medication strip packaging. The validated Work Observation Method By Activity Timing (WOMBAT) software was used to record observations.

RESULTS

Thirty nurses were observed. The average time spent on scheduled medication administration rounds was 5.2 h/unit of average 22 residents/day. The breakfast medication round had the longest duration (1.92 h/unit). Resident preparation, medication preparation and provision, documentation, transit, communication, and cleaning took an average of 5 minutes per resident per round. Medication preparation and provision comprised 60% of overall medication round time and took significantly longer in memory support than in standard units (66 vs 49 seconds per resident per round for preparation, 79 vs 58 for provision; P < .001 for both). Almost half (42%) of tablets/capsules were crushed in memory support units. The time taken for medication administration was not significantly different among registered and enrolled nurses.

CONCLUSIONS

Nurses took an average of 5 minutes to administer medications per resident per medication round. Medication administration in memory support units took an additional minute per resident per round, with almost half of tablets and capsules needing to be crushed.

Root cause analysis of fall-related hospitalisations among residents of aged care services

BACKGROUND

Fall-related hospitalisations from residential aged care services (RACS) are distressing for residents and costly to the healthcare system. Strategies to limit hospitalisations include preventing injurious falls and avoiding hospital transfers when falls occur.

AIMS

To undertake a root cause analysis (RCA) of fall-related hospitalisations from RACS and identify opportunities for fall prevention and hospital avoidance.

METHODS

An aggregated RCA of 47 consecutive fall-related hospitalisations for 40 residents over a 12-month period at six South Australian RACS was undertaken. Comprehensive data were extracted from RACS records including nursing progress notes, medical records, medication charts, hospital summaries and incident reports by a nurse clinical auditor and clinical pharmacist. Root cause identification was performed by the research team. A multidisciplinary expert panel recommended strategies for falls prevention and hospital avoidance.

RESULTS

Overall, 55.3% of fall-related hospitalisations were among residents with a history of falls. Among all fall-related hospitalisations, at least one high falls risk medication was administered regularly prior to hospitalisation. Potential root causes of falling included medication initiations and dose changes. Root causes for hospital transfers included need for timely access to subsidised medical services or radiology. Strategies identified for avoiding hospitalisations included pharmacy-generated alerts when medications associated with an increased risk of falls are initiated or changed, multidisciplinary audit and feedback of falls risk medication use and access to subsidised mobile imaging services.

CONCLUSIONS

This aggregate RCA identified a range of strategies to address resident and system-level factors to minimise fall-related hospitalisations.

Factors that affect health-care workers' practices of medication administration to aged care residents with swallowing difficulties: An Australia-wide survey study

OBJECTIVES

To understand the barriers and facilitators of medication administration to aged care residents with swallowing difficulties.

METHODS

Health-care workers in aged care facilities across Australia involved in medication administration to residents completed an online survey.

RESULTS

Of 355 respondents, 90.9% reported 'everyday' encounters with residents with swallowing difficulties and 94.1% modified medications to facilitate administration. Time constraints (63.4%) and workload (69.0%) were common barriers. Only 39.0% believed swallowing abilities are considered at the prescribing stage. Pill size (95.8%), polypharmacy (75.2%) and lack of alternative formulations (74.9%) contributed to these challenges. Support from other health-care professionals (91.5%) and training (85.9%) were the most favoured facilitators.

CONCLUSION

Health-care workers are faced with various challenges when caring for residents with swallowing difficulties. Promoting multidisciplinary collaborations, provision of training and medication review services, and improving skill mix and staffing composition in aged care facilities are needed to address these challenges.

Differences in the prescribing of potentially inappropriate medicines in older Australians: comparison of community dwelling and residential aged care residents

Potentially inappropriate medications (PIMs) can contribute to morbidity through exacerbations or progression of existing conditions among older people. In order to characterize the prevalence of PIMs according to the Beers Criteria in older Australians, three hundred and eleven participants were recruited from three residential aged care facilities (RACFs) and two hundred and twenty participants from three community pharmacies in South Australia for a retrospective audit of medication administration charts and community pharmacy dispensing histories. Although a similar number of participants were prescribed at least one PIM (P = 0.09), the average number of PIMs was significantly greater in the RACF cohort (1.96 vs 1.26, P < 0.05). Additionally, PIMs prescribed as pro re nata (PRN) in the RACF cohort had a significantly low administration rate compared to prescription rate (19.7% vs 40.7%). The mean number of PIMs within each cohort was statistically significant (RACF = 1.93 vs CDOA = 1.26, P < 0.05). RACF residents were at a slightly greater risk of being prescribed more than one PIM compared to those within the community. Routine medication reviews by pharmacists embedded in RACFs and within the community could be utilised to detect PIMs before such harm occurs.

Systematic review and narrative synthesis of pharmacist provided medicines optimisation services in care homes for older people to inform the development of a generic training or accreditation process

OBJECTIVES

To develop a training programme to enable pharmacists with prescribing rights to assume responsibility for the provision of pharmaceutical care within care homes, a systematic review and narrative synthesis was undertaken to identify reported approaches to training pharmacists and use this literature to identify potential knowledge requirements.

METHODS

A PROSPERO-registered systematic review was performed using key search terms for care homes, pharmacist, education, training and pharmaceutical care. Papers reporting primary research focussed on care of the older person within the care home setting were included. No restrictions were placed on methodology. Two researchers independently reviewed titles, abstracts and papers. Agreement on inclusion was reached through consensus. Data on titles, training and activities undertaken were extracted and knowledge requirements identified. Findings were synthesised and reported narratively.

KEY FINDINGS

Fifty-nine papers were included, most of which were uncontrolled service evaluations. Four papers reported an accreditation process for the pharmacist. Thirteen papers reported providing tools or specific training on a single topic to pharmacists. The main clinical and therapeutic areas of activity (requiring codified knowledge) were dementia, pain, antipsychotic and cardiovascular medication. Provision of pharmaceutical care, effective multidisciplinary working and care home staff training represented the main areas of practical knowledge.

CONCLUSIONS

Information regarding training and accreditation processes for care home pharmacists is limited. This study provides insight into potential codified and practical knowledge requirements for pharmacists assuming responsibility for the provision of pharmaceutical care within care homes. Further work involving stakeholders is required to identify the cultural knowledge requirements and to develop a training and accreditation process.

The economics of drug allergy

PURPOSE OF REVIEW

As drug allergy research aims to inform clinical practice, implementation of best practices may be influenced by financial resources required to incorporate new interventions and the resulting clinical and economic returns on those resource investments. The present review summarizes new insights into the economics of drug allergy over the past year.

RECENT FINDINGS

While considering economic implications of recent drug allergy research, many studies have addressed different contextual factors related to the setting, provider, or outcomes. Advances in technology have enabled specialized allergists to support remote settings through telemedicine consultation. Training opportunities and interdisciplinary approaches to address drug allergy challenges have enabled multiple provider types to play a role in screening, diagnosis, and management. Penicillin allergy testing has been a major focus for many institutions, with several studies focused on de-labeling strategies including confirmatory skin testing and direct oral challenges.

SUMMARY

Studies over the past year provide new opportunities for the field of drug allergy research. The focus of current research to capture direct health costs or savings associated with drug allergy interventions demonstrates opportunity for more cost-effective care delivery and opportunity to explore greater benefits to society.

Residential Aged Care Pharmacist: An Australian Pilot Trial Exploring the Impact on Quality Use of Medicines Indicators

Background: This pilot study aimed to assess whether an on-site pharmacist could influence indicators of quality use of medicines in residential aged care. Methods: A pharmacist was embedded in a residential aged care home for six months. A similar control site received usual care. Polypharmacy, drug burden index, antipsychotic and benzodiazepine use, hospital admission rates and length of stay, and emergency department presentation rates were outcomes used to indicate medication use quality. Data were extracted from participating resident health records. Results: Fifty-eight residents at the study site and 39 residents at the control site were included in the analysis. There was a reduction in the proportion of residents at the study site who had at least one hospital admission at follow-up (28% to 12%, p < 0.01), but no significant difference in other outcomes. Conclusions: This pilot study suggests that a residential care pharmacist may positively influence indicators of medication use quality in aged care; however, further research is needed to expand on these findings.

Reducing the Burden of Complex Medication Regimens: SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) Cluster Randomized Controlled Trial

OBJECTIVE

To assess the application of a structured process to consolidate the number of medication administration times for residents of aged care facilities.

DESIGN

A nonblinded, matched-pair, cluster randomized controlled trial.

SETTING AND PARTICIPANTS

Permanent residents who were English-speaking and taking at least 1 regular medication, recruited from 8 South Australian residential aged care facilities (RACFs).

METHODS

The intervention involved a clinical pharmacist applying a validated 5-step tool to identify opportunities to reduce medication complexity (eg, by administering medications at the same time or through use of longer-acting or combination formulations). Residents in the comparison group received routine care. The primary outcome at 4-month follow-up was the number of administration times per day for medications charted regularly. Resident satisfaction and quality of life were secondary outcomes. Harms included falls, medication incidents, hospitalizations, and mortality. The association between the intervention and primary outcome was estimated using linear mixed models.

RESULTS

Overall, 99 residents participated in the intervention arm and 143 in the comparison arm. At baseline, the mean resident age was 86 years, 74% were female, and medications were taken an average of 4 times daily. Medication simplification was possible for 62 (65%) residents in the intervention arm, with 57 (62%) of 92 simplification recommendations implemented at follow-up. The mean number of administration times at follow-up was reduced in the intervention arm in comparison to usual care (-0.36, 95% confidence interval -0.63 to -0.09, P = .01). No significant changes in secondary outcomes or harms were observed.

CONCLUSIONS AND IMPLICATIONS

One-off application of a structured tool to reduce regimen complexity is a low-risk intervention to reduce the burden of medication administration in RACFs and may enable staff to shift time to other resident care activities.

Recent developments and highlights in drug hypersensitivity

Drug hypersensitivity reactions (DHRs) are nowadays the third cause of allergy after rhinitis and asthma with a significant increase in prevalence in both adults and paediatric population with new drugs included as culprit. For this, DHRs represent not only a health problem but also a significant financial burden for affected individuals and health systems. Mislabelling DHRs is showing to be a relevant problem for both, false label of drug allergic and false label of nonallergic. All this reinforces the need to improve accurate diagnostic approaches that allow an appropriate management. Moreover, there is a need for training both, nonallergist stakeholders and patients to improve the reaction identification and therefore decrease the mislabelling. The use of allergy cards has shown to be relevant to avoid the induction of DHRs due to the prescription of wrong medication. Recent developments over the last 2 years and highlights about risk factors, diagnostic approaches, mechanisms involved as well as prevention actions, and management have been reviewed. In these papers, it has been outlined the need for correct diagnosis and de-labelling of patients previously false-reported as allergic, which will improve the management and treatment of patients with DHRs.

Medication Regimen Complexity In 8 Australian Residential Aged Care Facilities: Impact Of Age, Length Of Stay, Comorbidity, Frailty, And Dependence In Activities Of Daily Living

Objective

To explore variation in medication regimen complexity in residential aged care facilities (RACFs) according to resident age, length of stay, comorbidity, dementia severity, frailty, and dependence in activities of daily living (ADLs), and compare number of daily administration times and Medication Regimen Complexity Index (MRCI) as measures of regimen complexity.

Methods

This study was a cross-sectional analysis of baseline data from the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) cluster-randomized controlled trial. The SIMPLER study recruited 242 residents with at least one medication charted for regular administration from 8 RACFs in South Australia. Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Dementia severity was assessed using the Dementia Severity Rating Scale. Frailty was assessed using the FRAIL-NH scale. Dependence in ADLs was assessed using the Katz ADL scale.

Results

The median age of participants was 87 years (interquartile range 81–92). Over one-third of participants (n=86, 36%) had 5 or more daily medication administration times. The number of daily administration times and MRCI scores were positively correlated with resident length of stay (r_s=0.19; 0.27), FRAIL-NH score (r_s=0.23; 0.34) and dependence in ADLs (r_s=−0.21; −0.33) (all p<0.01). MRCI was weakly negatively correlated with CCI score (r_s=−0.16; p=0.013). Neither number of daily administration times nor MRCI score were correlated with age or dementia severity. In multivariate analysis, frailty was associated with number of daily administration times (OR: 1.13, 95% CI: 1.03–1.24) and MRCI score (OR: 1.26, 95% CI: 1.13–1.41). Dementia severity was inversely associated with both multiple medication administration times (OR: 0.97, 95% CI: 0.94–0.99) and high MRCI score (OR: 0.95, 95% CI: 0.92–0.98).

Conclusion

Residents with longer lengths of stay, more dependent in ADLs and most frail had the most complex medication regimens and, therefore, may benefit from targeted strategies to reduce medication regimen complexity.