Exploring the impact of attending an online CPPE return to prescribing (RTP) programme

Introduction

Within the Interim NHS people plan, pharmacist prescribers are described as a central part of the multi professional team across primary care networks.1 Non-medical prescribers (NMP) constitute a small proportion of the pharmacy workforce and a proportion of NMPs do not use their qualification.2 CPPE has designed a series of three online workshops to support return to prescribing by improving NMP’s knowledge of law and ethics, improve confidence and discuss barriers and solutions with peers in a safe supportive environment. We routinely evaluate all of our programmes and used this data to inform this study.

Aim

To explore the learner’s feedback following attendance at the online CPPE RTP series of workshops by asking for their views on: the impact of the course on their knowledge of the topic, how exploring the barriers and solutions influenced their prescribing practice and the usefulness of the programme and resources.

Methods

Between March 2020 and July 2022, 119 people attended the CPPE RTP online workshops. Using online post workshop evaluation surveys sent to all attendees, participants were asked to share feedback on their experience of the programme via a course specific survey adapted from the CPPE standard post workshop evaluation. In July 2022 there were 59 responses. The data was analysed using thematic analysis3 to highlight common themes from the free text survey comments. This evaluation considered the intentions of learners at the sessions, follow up surveys would permit the exploration of the impact on sustained practice change. Ethical approval was not required as this was a course evaluation

Results

98% of participants felt that the workshops increased their knowledge of the topic and 97% of participants felt the workshops were thought provoking. Barriers to prescribing were identified included: no defined role (26%), no support (32%), no personal confidence (26%), lack of understanding of prescribing role from GP colleagues (10%), prescribing not in job description, therefore not covered by indemnity (6%). After attending the RTP workshops 70% of pharmacists were using their prescribing qualification and 40% were prescribing more often. The programme evaluation showed 56% of participants felt that sharing and listening to others experiences gave them confidence and support to consider starting to prescribe, 21% of participants found the knowledge and enthusiasm of the CPPE tutors supportive and 16% found discussion of the case studies to be useful. 7% of participants found sign posting to resources helpful.

Discussion/Conclusion

This evaluation demonstrated that the RTP programme helped pharmacists to identify barriers to prescribing and facilitated peer discussion of solutions and of sharing best practice. The course was shown to increase the confidence of participants and facilitate their journey to start prescribing again. Increasing the number of pharmacist prescribers using their qualification has a positive impact on patient care.1 Our research shows that participating in the CPPE return to prescribing workshop series enables pharmacists to return to or start prescribing in practice.

References

1. Interim NHS People plan: the future pharmacy workforce. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/05/Interim-NHS-People-Plan_June2019.pdf (accessed 19/7/22)

2. Graham-Clarke E, Rushton A, Noblet T, Marriott J (2018) Facilitators and barriers to nonmedical prescribing – A systematic review and thematic synthesis. PLoS ONE 13(4): e0196471. https://doi.org/10.1371/journal.pone.019647tics (accessed 19/7/22)

3. Braun, V. & Clarke, V. (2013). Successful qualitative research a practical guide for beginners. London: SAGE publishers Ltd.

The National COVID Cohort Collaborative (N3C): Rationale, design, infrastructure, and deployment

Objective

Coronavirus disease 2019 (COVID-19) poses societal challenges that require expeditious data and knowledge sharing. Though organizational clinical data are abundant, these are largely inaccessible to outside researchers. Statistical, machine learning, and causal analyses are most successful with large-scale data beyond what is available in any given organization. Here, we introduce the National COVID Cohort Collaborative (N3C), an open science community focused on analyzing patient-level data from many centers.

Materials and Methods

The Clinical and Translational Science Award Program and scientific community created N3C to overcome technical, regulatory, policy, and governance barriers to sharing and harmonizing individual-level clinical data. We developed solutions to extract, aggregate, and harmonize data across organizations and data models, and created a secure data enclave to enable efficient, transparent, and reproducible collaborative analytics.

Results

Organized in inclusive workstreams, we created legal agreements and governance for organizations and researchers; data extraction scripts to identify and ingest positive, negative, and possible COVID-19 cases; a data quality assurance and harmonization pipeline to create a single harmonized dataset; population of the secure data enclave with data, machine learning, and statistical analytics tools; dissemination mechanisms; and a synthetic data pilot to democratize data access.

Conclusions

The N3C has demonstrated that a multisite collaborative learning health network can overcome barriers to rapidly build a scalable infrastructure incorporating multiorganizational clinical data for COVID-19 analytics. We expect this effort to save lives by enabling rapid collaboration among clinicians, researchers, and data scientists to identify treatments and specialized care and thereby reduce the immediate and long-term impacts of COVID-19.

Emergence from general anaesthesia and evolution of delirium signs in the post-anaesthesia care unit

BACKGROUND

Emergence from anaesthesia is often accompanied by signs of delirium, including fluctuating mental status and inattention. The evolution of these signs of delirium requires investigation since delirium in the post-anaesthesia care unit (PACU) may be associated with worse outcomes.

METHODS

Adult patients emerging from anaesthesia were assessed for agitated emergence in the operating room using the Richmond Agitation-Sedation Scale (RASS). The Confusion Assessment Method for the Intensive Care Unit was then used to evaluate delirium signs at PACU admission and during PACU stay at 30 min, 1 h, and discharge. Signs consistent with delirium were classified as hyperactive vs hypoactive based upon a positive CAM-ICU assessment and the concomitant RASS score. Multivariable logistic regression was utilized to assess potential risk factors for delirium during PACU stay including age, American Society of Anesthesiologists classification, and opioid and benzodiazepine exposure.

RESULTS

Among 400 patients enrolled, 19% had agitated emergence. Delirium signs were present at PACU admission, 30 min, 1 h, and PACU discharge in 124 (31%), 59 (15%), 32 (8%), and 15 (4%) patients, respectively. In patients with delirium signs, hypoactive signs were present in 56% at PACU admission and in 92% during PACU stay. Perioperative opioids were associated with delirium signs during PACU stay (P=0.02).

CONCLUSIONS

A significant proportion of patients develop delirium signs in the immediate postoperative period, primarily manifesting with a hypoactive subtype. These signs often persist to PACU discharge, suggesting the need for structured delirium monitoring in the PACU to identify patients potentially at risk for worse outcomes in the postoperative period.

Avoidable maternal deaths: three ways to help now

The current paper examines the realities of women delivering in resource-poor settings, and recommends cost-effective, scalable strategies for making these deliveries safer. Ninety-five percent of maternal deaths occur in poor settings, and the largest proportion of these deaths are women who deliver at home, far away from health care facilities, and without financial access to skilled providers. This situation will improve only when policymakers and programme planners refocus their attention on service delivery and financing interventions, with the potential to reach the largest portion of women living in places where mortality is the highest. We suggest three feasible interventions that can potentially minimise both demand and supply side problems of safe delivery: (1) misoprostol to treat postpartum haemorrhage, an easy to use and heat stable technology to reduce the leading cause of maternal deaths; (2) alternative providers, such as clinical officers, trained to offer emergency obstetric care services; (3) financing safe delivery through vouchers or other mechanisms that can be implemented in poor settings and made attractive to the donor community through output-based assistance (OBA).

Computerized medical records in the Department of Veterans Affairs

The VA Medical Center in Washington, DC, was the nexus for a number of computerization projects that were initiated by the Department of Veterans Affairs. The culmination of these initiatives is a software package that presents the complete electronic patient record in an easy-to-use graphic user interface. This record combines text data from the legacy data base, diagnostic images from patient procedures, electrocardiograms from a commercial server, an Internet connection, and a hospital web site with pertinent reference information. The information is available in over 1000 places in the hospital and can be accessed remotely using a remote access server. The computerization of the medical record has improved hospital efficiency, has made physician access to patient information more reliable, has opened new opportunities for patient education, and has given healthcare providers more time to care for patients.

In vitro susceptibilities of bacterial ocular isolates to fluoroquinolones

PURPOSE

To evaluate and compare the in vitro antimicrobial activity of levofloxacin versus ciprofloxacin and ofloxacin against ocular isolates from patients with bacterial conjunctivitis.

METHODS

The in vitro antimicrobial susceptibilities of ocular isolates to levofloxacin, ofloxacin, and ciprofloxacin were determined using both the agar disk diffusion and broth dilution methods.

RESULTS

Disk diffusion susceptibility testing disclosed that 99% (100 of 101 isolates) of gram-negative isolates and 98% (127 of 129 isolates) of gram-positive isolates were susceptible to levofloxacin; 96% (97 of 101 isolates) of gram-negative isolates and 78% (100 of 129 isolates) of gram-positive isolates were susceptible to ofloxacin; and 94% (95 of 101 isolates) of gram-negative isolates and 61% (79 of 129 isolates) of gram-positive isolates were susceptible to ciprofloxacin. Broth dilution testing disclosed that 99% (72 of 73 isolates) of gram-negative isolates and 98% (111 of 113 isolates) of gram-positive isolates were susceptible to levofloxacin; 96% (70 of 73 isolates) of gram-negative isolates and 92% (104 of 113 isolates) of gram-positive isolates were susceptible to ofloxacin; and 95% (69 of 73 isolates) of gram-negative isolates and 82% (93 of 113 isolates) of gram-positive isolates were susceptible to ciprofloxacin.

CONCLUSIONS

In this study, levofloxacin demonstrated superior in vitro activity against human bacterial conjunctival isolates compared with either ofloxacin or ciprofloxacin (levofloxacin > ofloxacin > ciprofloxacin).

Muscle and nerve imaging techniques in neuromuscular diseases

Imaging of muscle and nerve has become increasingly useful and of promising value in the evaluation of patients with various neuromuscular disorders. These techniques include ultrasonography, radionuclide scanning, computed tomography, and magnetic resonance imaging. They have different applications, advantages. and disadvantages. This review assesses these imaging modalities and describes the findings in pathologic conditions. The usefulness of these methods in the evaluation of various neuromuscular diseases is discussed.

Delivery of superoxide dismutase to pulmonary epithelium via pH-sensitive liposomes

Respiratory insufficiency, when treated with oxygen supplementation, or exposure to diverse pulmonary toxins can cause lung damage as a result of increased oxygen radical production. Enzymes such as superoxide dismutase (SOD) may attenuate this pathological process, but the intracellular delivery and antioxidant action of SOD is impeded by its inability to cross cellular membranes. One approach for facilitating intracellular delivery of macromolecules is to entrap SOD into liposomes. The delivery of SOD to lung cells was accomplished using pH-sensitive liposomes, made with 1,2-dioleoyl-sn-glycero-3-phosphoethanolamine (DOPE) and 1-oleoyl-2-oleoyl-sn-glycero-3-succinate (DOSG), added to cultured fetal rat lung distal epithelial (FRLE) cells. FRLE cells, obtained from fetuses at day 19 gestation, expressed a high-affinity receptor for surfactant protein A (SP-A) with an apparent dissociation constant (Kd) = 3.6 +/- 0.2 micrograms/ml (5.5 x 10(-9) M) and a capacity of 130 +/- 3 ng/10(6) cells (125,000 +/- 3,000 binding sites/cell). This receptor was utilized for targeting liposomes to cells, after incorporating SP-A during liposome membrane formation. Liposomes were uniformly small (180 +/- 77 nm; mean +/- SD) and stable at 4 degrees C for 1 wk, entrapping 10 +/- 4% of initially added SOD. After incubation of pH-sensitive liposomes containing entrapped SOD with cultured FRLE cells, cell-associated SOD activity was increased 5.1-fold from 7.8 +/- 2.5 to 40.1 +/- 3.3 U SOD/mg cell protein. Incorporation of SP-A into liposomes increased by 6.2-fold the delivery of liposomal SOD to cells.(ABSTRACT TRUNCATED AT 250 WORDS)

The Cognitive Abilities Screening Instrument (CASI): a practical test for cross-cultural epidemiological studies of dementia

The Cognitive Abilities Screening Instrument (CASI) has a score range of 0 to 100 and provides quantitative assessment on attention, concentration, orientation, short-term memory, long-term memory, language abilities, visual construction, list-generating fluency, abstraction, and judgment. Scores of the Mini-Mental State Examination, the Modified Mini-Mental State Test, and the Hasegawa Dementia Screening Scale can also be estimated from subsets of the CASI items. Pilot testing conducted in Japan and in the United States has demonstrated its cross-cultural applicability and its usefulness in screening for dementia, in monitoring disease progression, and in providing profiles of cognitive impairment. Typical administration time is 15 to 20 minutes. Record form, manual, videotape of test administration, and quizzes to qualify potential users on the administration and scoring of the CASI are available upon request.

Reformulation and Drop Size of Apraclonidine Hydrochloride

We performed a prospective, double-masked, placebo-controlled, six-period, cross-over study in which normal subjects were randomly assigned to treatment and compared three different formulations of apraclonidine hydrochloride (the present commercially available formulation, and formulations with hydroxypropylmethylcellulose or lysolecithin). We also evaluated the efficacy of a 16-microliters and 30-microliters drop size. The magnitude and duration of decrease in intraocular pressure was comparable for all formulations. Most subjects tolerated all formulations well with only a few reporting any side effects. The best-tolerated formulation was 0.5% apraclonidine hydrochloride delivered with a 16-microliters drop size. Dry mouth developed frequently with the commercially available 1% apraclonidine solution. Blurred vision complicated the use of the formulation containing hydroxypropylmethylcellulose. Both dry mouth (P less than .05) and blurred vision (P = .004) were statistically significant side effects.

The effect of topical antiglaucoma drugs on the results of high-pass resolution perimetry

We conducted a randomly assigned, double-masked, crossover study of the effects of betaxolol, epinephrine, pilocarpine, and timolol on the high-pass resolution perimetry results in normal subjects. The influence of topical administration of these intraocular pressure-reducing drugs was negligible, which confirmed the reliability of high-pass resolution perimetry results. The method seems appropriate for the diagnosis of glaucoma and the follow-up of patients with glaucoma.

Daptomycin versus vancomycin treatment for Staphylococcus aureus bacteremia in a murine model

Daptomycin (LY 146032), a new lipopeptide antimicrobial agent with activity against gram-positive bacteria, was compared to vancomycin in the treatment of staphylococcal bacteremia in a murine model. Two hundred and ninety-nine mice were inoculated with 1 x 10(8) bacteria by the tail vein, and treatment was begun 3 days later. Two dosage regimens of each drug were used: 10 mg/kg and 5 mg/kg administered every 12 h for 14 days. A control group received no therapy. Survival was determined 31 days after inoculation. There was no significant difference in survival in any of the four treatment groups. The survival in all treatment groups was significantly greater than in the control group. Serum levels of daptomycin remained longer in the therapeutic range than serum levels of vancomycin. In the murine model of staphylococcal disease, daptomycin treatment was as effective as treatment with vancomycin.

Reliability of children's reports of depressive symptomatology

The use of self-report measures for the assessment of depression in children has gained wide popularity as a component in the evaluation of children's mental health and well-being. However, the extent to which children are reliable and consistent reporters of their depressive symptoms is sometimes called into question. This study examined the test-retest reliability of children's reports of depressive symptomatology on the Reynolds Child Depression Scale (RCDS; Reynolds, 1989a). The sample consisted of 220 children, in grades 3 through 6, representing a cross-section of ethnic groups. Children were tested twice, with a 4-week interval between testings. Results showed a high degree of stability in children's responses to the RCDS, with a test-retest reliability coefficient of .85 for the total sample, and a mean difference between testings of less than 2 points. Test-retest reliability coefficients were also computed for males and females, for each grade, and for white, black, Hispanic, and Asian children. Overall, the results lend strong support for the reliability and stability of children's self-reported depressive symptomatology as assessed by the RCDS.