1. Medicines Use in Australia

Medication issues in AustraliaJane BoothJune 2014

A typical Australian hospital

3 facilities - 1 health serviceAustin Hospital - founded 1880

Heidelberg RepatriationHospital - founded 1941

Royal Talbot Rehabilitation Centre - founded 1907

Catchment area• Primary catchment area

• Banyule and Darebin

• Population >260,000 people (expected to grow by 2.1% by 2016)

• Culturally diverse, ¼ of Darebin residents born in a non-English speaking country

• Significant Aboriginal community

• Areas of social disadvantage

• Extended catchment area• Population 1.2 million people

1. 980 beds across the 3 campuses (including day beds)2. 8,000 staff3. 91,661 inpatient admissions and 176,426 outpatient attendances in 2012-

134. 71,391 ED presentations in 2012-13 (4.8% increase from 2011-12)5. Statewide services are based at Austin Health:

• Victorian Spinal Cord Service• Victorian Respiratory Support Services• Victorian Liver Transplant Unit• Acquired Brain Injury Unit/Brain Disorders Unit (Royal Talbot Rehabilitation)• Child Mental Health Inpatient Unit• Victorian Toxicology Service & Poisons Centre• Psychological Trauma Recovery Service (including Veterans Psychiatry)

An overview of Austin Health

6. Other specialty units Psychiatry (inc. Child, Adolescent & Adult inpatient units, Secure Extended

Care Unit, Parent & Infant Service, Body Image/Eating Disorders Service, Psychological Trauma Recovery Service/Veterans Psychiatry, Drug Dependency Clinic)

Emergency Department Paediatrics and Paediatric Surgery Intensive Care Unit, Anaesthetics & Pain Services General Medicine Aged Care Rehabilitation (including Brain Disorders, Acute Brain Injury, Amputee) Spinal (including Spinal Surgery) Gastroenterology, Liver Transplant Unit Infectious Diseases


6. Other specialty units Renal (including transplant) Oncology, Haematology, Radiation Oncology, Palliative Care Respiratory (inc VRSS), Sleep Laboratory and Thoracic Surgery Cardiology and Cardiac Surgery Neurology, Acute Stroke Unit and Neurosurgery Endocrinology Rheumatology Vascular Surgery Toxicology Oral and Maxillofacial Surgery, Ear Nose and Throat Surgery, Head and Neck

Surgery, Ophthalmology Orthopaedic Surgery Various other surgical units


1. Pharmacists• 80 Pharmacists (approx. 60 FTE) work in the Pharmacy Department• 4.5 FTE (Pharmacists & Toxicologists) work in Poisons Information• 3 FTE Pharmacists work in Clinical Informatics• 2 Pharmacists work for chronic disease management (Outreach)• 1 FTE Pharmacist works in nuclear medicine (Radiopharmacy)• 0.5 FTE Infectious Diseases consultant for Antimicrobial Stewardship

2. Technicians and support staff• 23 Pharmacy Technicians• 10 Pharmacy Store staff

3. Intern pharmacists• 7 Intern Pharmacists

Pharmacy Department Statistics

• The Pharmacy Department manages a 42 million dollar of drug expenditure a year.

• On an average day, we:—dispense 220 outpatient prescriptions—dispense 600 discharge prescriptions—dispense 80 methadone doses—provide 540 non-imprest inpatient items —prepare 45 sterile and non-sterile preparations—compound 70 cytotoxic sterile preparations—process 20 clinical trials

• 66% of pharmacists have a higher qualification, i.e. Graduate Certificate of Pharmacy or above.

• 28% of pharmacists have a Masters or Doctorate.

Pharmacy Department Statistics

Australia’s first small bowel transplant in 2010.Small bowel (intestinal transplant). For this patient,the liver, pancreas, bile ducts, duodenum & small intestine were transplanted, patient retained stomach and stoma site.

Austin Health is now the Australian referral hospitalfor other potential small bowel transplant candidatese.g. patients on long term home TPN


Olivia Newton-John Cancer & Wellness Centre• Outpatient services, day oncology and specialist clinics opened in December 2012 and the inpatient wards opened in July 2013.

• The Centre offers care for all aspects of cancer treatment including:— Outpatient/Specialist Clinics— Day Oncology & Apheresis— Radiation Oncology— Palliative Care—Clinical Genetics Service

•Wellness is central to the Centre's philosophy, expressed through the evidence-based complementary therapies offered in the Wellness Centre

•Austin Health's Medical Oncology Unit is run jointly with leading international cancer research organisation the Ludwig Institute for Cancer Research, allowing patients to benefit quickly from the latest scientific discoveries.

A typical day for a ward pharmacist

Hospital Pharmacy Practice in Australia

What do Austin ward pharmacists do in a day?

1. Identify new patients and order any non-imprest stock– Will be dispensed in one of the Satellite Pharmacies

2. Find out who is going home and begin reviewing discharge scripts– Might be dispensed by the Satellite Pharmacies– Supply medication list, warfarin discharge plan, RACF chart prn

3. Take discharge medications back to the ward and provide bedside counselling4. “Admit” new patients

– Medication Reconciliation5. Review all patients drug charts6. Respond to queries / requests etc7. Attend ward handover with allied health and discharge coordinators8. Perhaps attend ward rounds

Current issues of medicines use in Australia

Current medication issues in Australia• Australian Commission for Quality and Safety in Healthcare:

– National Standards Accreditation – National Inpatient Medication Chart– Medication reconciliation– High Risk Medications– Naming, labelling and packaging of medicines– VTE Prevention– Electronic prescribing / eHealth






– National Standards Accreditation – National Inpatient Medication Chart– Medication reconciliation– High Risk Medications– Naming, labeling and packaging of medicines– VTE Prevention– Electronic prescribing / eHealth

High risk medicines• Anti-infectives

• Potassium and other electrolytes

• Insulin

• Narcotics

• Chemotherapeutic agents

• Heparin and other anticoagulants

• Systems

• P

• I

• N

• C

• H

High risk medicines• Systems:

– Infusion pumps– Patient controlled analgesia– Liquid medicines and wrong route errors– Patient handover



Naming, labelling and packaging of medicines• Tall Man Lettering:

– cefEPIME– cefOTAXIME– cefOXITIN– cefTAZIDIME– cefTRIAXONE– cefALOTIN– cephaLEXin– cephaZOLin



The National Healthcare Standards

• From January 1st 2013, all Australian health services will be accredited against the new national standards (10 in total)

• Against each standard:– core (critical) actions – developmental (aspirational) actions

• Total of 256 actions across the ten national standards

• Assessment based on a three point rating scale (not met, satisfactorily met, met with merit)

Background – National Standards

Standard Core Actions Developmental Actions

Governance for Safety and Quality in Health Service Organisations

44 9

Partnering with Consumers 4 11

Preventing and Controlling Healthcare Associated Infections 39 2

Medication Safety 31 6

Patient Identification and Procedure Matching 9 0

Clinical Handover 9 2

Blood and Blood Products 20 3

Preventing and Managing Pressure Injuries 20 4

Recognising and responding to Clinical Deterioration in Acute Health Care

15 8

Preventing Falls and Harm from Falls 18 2

209 47

Requirement for each standard:Do we have a governance structure in place?

Do staff access policies and procedures? … and are these compliant with best practice?

Do we monitor when things go wrong?Do staff have access to tools and processes?

… and are these compliant with best practice?Do we provide education and training for our staff?

Do we audit what we are doing?Do we appropriately involve consumers?

Structure of Each Standard

“The intention of this (Medication Safety) Standard is to ensure competent clinicians safely prescribe, dispense and administer appropriate medicines to informed patients and carers”

Standard 4 – Medication Safety• Governance and systems for medication safety

– Health service organisations have mechanisms for the safe prescribing, dispensing, supplying, administering, storing, manufacturing, compounding and monitoring of the effects of medicines.

• Documentation of patient information– The clinical workforce accurately records a patient’s medication history and this history

is available throughout the episode of care.

• Medication management processes – The clinical workforce is supported for the prescribing, dispensing, administering, storing,

manufacturing, compounding and monitoring of medicines.

• Continuity of medication management– The clinician provides a complete list of a patient’s medicines to the receiving clinician and

patient when handing over care or changing medicines.

• Communicating with patients and carers– The clinical workforce informs patients about their options, risks and responsibilities for

an agreed medication management plan.

Electronic prescribing

Electronic Patient RecordSince 2011 Austin Health has implemented a clinical system for patient care (Cerner)

• Inpatient Medication ordering and administration (MAR)

• Ordering of Prescriptions

• Ordering of Pathology and Radiology

• Electronic recording of specimen collection

• Electronic Discharge Summary

• Fluid Balance Chart

• Allied Health Referrals

• Patient care orders

• Results reporting and acknowledgement

• Documentation of some clinical information e.g. allergies, diagnoses, alerts, past history and procedures are recorded on Cerner

Improvements for pharmacists

• Each pharmacist has a personal laptop to carry out their daily functions in the system

• PharmNet software: – Includes a ‘monitor’ screen that shows the

pharmacist all new and modified orders for patients in their specific ward(s)

– Enables review of medication charts and generating dispensing labels remotely

– Integrates with the dispensing system to prevent dual data entry

• Streamlined medication supply to the ward as system knows when resupply of medications due

No more looking around for missing drug charts!

1. National Medication Chart vs. Power ChartNational Medication Chart Cerner PowerChart

All orders are to be written legibly in ink All orders placed electronically. 100% of orders are legible

No erasers or “whiteout” can be used. Must be rewritten if changes occur

All changes tracked transparently in the system. Certain fields locked down on ‘Modify’

Adherence to national standards around terminology

Terminology hard-coded (via code sets). Avoids unsafe abbreviations and symbols

Essential details such as date of order, generic medication name, frequency and signature must be

present

Order Entry Format will ensure fields are present in every order which must be accompanied by an

electronic signatureAccurately portrays medication administration

requirementsTask clearly states when medication to be given as

well as contains last dose information. Tasks become ‘RED’ when overdue

Patient identification details present on ALL charts Details present at all times in Cerner in the banner bar

If more than one chart exists, it should be clearly numbered

Only one chart exists for a patient in the same location

• Electronic medication management system– Drug chart does not run out of time or space– Decision support through alerts– Closed-loop medication management– Pre-built order sentences minimise risk of order entry errors– Ability to enforce prescribing guidelines and policies

1. National Medication Chart vs. Power Chart

Pre-Built Order Sentences: cephalexin


Medication administrations instructions: Ciprofloxacin


• To promote appropriate and proper prescribing of antimicrobials

• Antimicrobial Stewardship programs aim to reduce chance of antimicrobial resistance, toxicity and unnecessary costs

• Multiple methods employed in the eMM context:– Electronic Approval System (*external to Cerner)

– Specialised Care Sets and Order sentences including time offsets and drug level reminder tasks

– Alerts– Reports

2. Antibiotic Stewardship

• Care Sets contain the ability to include prescribing guidance and information

• Ability to combine medications, pathology and radiology orders in one ordering window

• Ability to incorporate time off-sets on orders to facilitate drug level monitoring

2. Antibiotic Stewardship – Care Sets


Vancomycin: Initiation Care Sets


• Austin Health’s ‘Good Antimicrobial Prescribing Practice (GAPP)’ policy required custom build in to Cerner.

• Currently using an online approval system (IDEA3S) to generate approval numbers based on selection criteria

• On paper– Approval number is written on the drug chart– Required before administration but not always followed

• In Cerner– Creative use of Discern Alert– Cannot proceed with order unless approval number is

documented in appropriate field

2. Antibiotic Stewardship –Alerts

2. Antibiotic Stewardship –Alerts

3. Venous Thromboembolism Prophylaxis

• Venous thromboembolism remains a major cause of morbidity and mortality in hospitalised patients

• National guidelines and recommendations in place to ensure appropriate measures taken to reduce this risk

• Locally developed policy states all acute inpatient admissions should have a VTE risk assessment within 24 hours of admission and documented in the medical record

• Previous practice: Dedicated section on paper drug chart for VTE Prophylaxis prescribing. VTE Risk Assessment guideline printed on every paper drug chart


3. Venous Thromboembolism ProphylaxisPower Form for prescribers to document VTE Risk assessment


3. Venous Thromboembolism ProphylaxisPower Plan to guide ordering of medications

3. Venous Thromboembolism ProphylaxisAlert: High Risk VTE documented but no VTE Prophylaxis

4. Allergy Documentation

• Having allergy information readily available reduces the risk of patients having an adverse event

• Should be available to all those who prescribe, dispense and administer medications

• Local policy states all patients should have their allergy recorded and all clinicians are responsible

• Electronic medication management systems can warn prescribers before an order is placed through allergy interaction checking (as well as drug interactions)




95,57%

97,04%97,33%

96,28%

98,26%

97,44% 97,19% 97,30% 97,08%

97,83%

96,80% 96,84%96,51%

90,00%

91,00%

92,00%

93,00%

94,00%

95,00%

96,00%

97,00%

98,00%

99,00%

100,00%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

2013 2014

Austin Health - Allergy Audit% Patients with Allergies Recorded

4. Penicillin Allergy Alert AuditTotal number of alerts between January 2013 and March 2013 = 324- 147 instances resulted in a penicillin not being ordered- 177 instances the alert was overridden and penicillin prescribed

177 alerts

• 7 meropenem allergies• 82 cephalosporin allergies

88 alerts

• 42 cases of documentation ‘OK to proceed’

46 alerts

• 12 allergies of minor significance (e.g. nausea or diarrhoea)

34 alerts

• 24 orders cancelled (i.e. not administered)

10 alerts

• Need further investigation

4. Penicillin Allergy Alert Audit

• 10 alerts that needed further investigation to explain why a penicillin was ordered for these patients

• Out of the 10 alerts this affected 9 patients– 8 patients received a penicillin without clear documentation – 1 patient unable to ascertain if received a penicillin

• No evidence of any adverse drug reactions documented in these cases

4. Penicillin Allergy Alert Audit• Unfortunately no baseline data for comparison

• 45% of instances the alert stopped a penicillin being prescribed– 147 out of 324 alerts

• When excluding instances where it was appropriate to proceed with penicillin treatment despite the alert

– 81% of instances the alert stopped a penicillin being prescribed– 147/181 alerts

• The future: enhancing data capture and interpretation capabilities

– The more information we can get in the more powerful reporting and auditing becomes

• Potential for powerful audits:– Actual Administration Times vs. Scheduled Administration

Times» Particularly interested in antibiotics

– Number of missed doses

– Patients who have received more than 4 grams of paracetamol

– High Risk Drug audits

Moving forward

Acknowledgements• Alana Meaklim

• Anne McGrath

• Adrian Lio

Documents

1. Medicines Use in Australia