David J Maxwell

A quality improvement initiative to improve adherence to national guidelines for empiric management of community-acquired pneumonia in emergency departments

OBJECTIVE The objective of this study was to improve the concordance of community-acquired pneumonia management in Australian emergency departments with national guidelines through a quality improvement initiative promoting concordant antibiotic use and use of a pneumonia severity assessment tool, the pneumonia severity index (PSI). DESIGN and INTERVENTIONS Drug use evaluation, a quality improvement methodology involving data collection, evaluation, feedback and education, was undertaken. Educational interventions included academic detailing, group feedback presentations and prescribing prompts. SETTING AND PARTICIPANTS Data were collected on 20 consecutive adult community-acquired pneumonia emergency department presentations by each hospital for each of three audits. MAIN OUTCOME MEASURES Two process indicators measured the impact of the interventions: documented PSI use and concordance of antibiotic prescribing with guidelines. Comparisons were performed using a Chi-squared test. RESULTS Thirty-seven hospitals, including public, private, rural and metropolitan institutions, participated. Twenty-six hospitals completed the full study (range: 462-518 patients), incorporating two intervention phases and subsequent follow-up audits. The baseline audit of community-acquired pneumonia management demonstrated that practice was varied and mostly discordant with guidelines. Documented PSI use subsequently improved from 30/518 (6%, 95% confidence interval [CI] 4-8) at baseline to 125/503 (25%, 95% CI 21-29; P < 0.0001) and 102/462 (22%, 95% CI 18-26; P < 0.0001) in audits two and three, respectively, while concordant antibiotic prescribing improved from 101/518 (20%, 95% CI 16-23) to 132/462 (30%, 95% CI 26-34; P < 0.0001) and 132/462 (29%, 95% CI 24-33; P < 0.001), respectively. CONCLUSIONS Improved uptake of guideline recommendations for community-acquired pneumonia management in emergency departments was documented following a multi-faceted education intervention.

SHPA Standards of Practice for Drug Use Evaluation in Australian Hospitals: SHPA Committee of Specialty Practice in Drug Use Evaluation

INTRODUCTION Drug use evaluation (DUE) is a systematic quality improvement activity. The purpose of DUE is to improve the quality and cost-effectiveness of drug (medicine) use, and thereby improve patient care. DUE may be applied to a drug, therapeutic class, disease state or condition, a drug use process or specific outcomes.1 It may be applied in various practice settings, including hospitals, other health facilities, and community practice environments.2 DUE is an essential component of pharmacy service provision, clinical pharmacy practice and pharmacy quality assurance and management programs. These standards supersede the previously published SHP A Standards of Practice for DUE in Australian hospitals. 3

Evaluation Of Mycophenolate For Unregistered Indications.

Aim: To describe the use of mycophenolate mofetil for unregistered indications at St Vincents Hospital, Sydney and to assess the financial impact.

Role of Therapeutic Drug Monitoring in HIV Therapy

Background: Therapeutic drug monitoring (TDM) is increasingly becoming part of the management of antiretroviral therapy for the treatment of HIV.

Community-Acquired Pneumonia

Background: The National Prescribing Service is funding a project to improve patient outcomes through implementation of national guidelines for management of community‐acquired pneumonia (CAP). There is evidence that knowledge of and adherence to the CAP guidelines in the Therapeutic Guidelines: Antibiotic in Australian hospitals is suboptimal. These guidelines incorporate a pneumonia severity index (PSI) and all antibiotic recommendations are based on the PSI score.

Improving and Learning from Practice

David Maxwell, BPharm, DipHospPharm, DUE Program Coordinator, NSW TAG, Darlinghurst, New South Wales Address for correspondence: David Maxwell, NSW TAG, PO Box 766, Darlinghurst NSW 2010, Australia E-mail: djmaxwell@stvincents.com.au CONFERENCE OVERVIEW The 23rd International Society for Quality in Health Care (ISQua) conference was held in London, UK in October 2006 with the theme ‘Improving healthcare: the challenge of continuous change’. The conference is an annual international meeting that engages interest from across the healthcare system and participants included health professionals, policy makers, administrators, researchers, educators and consumers. I presented the ‘Community-acquired pneumonia: towards improving outcomes nationally’ (CAPTION) project in the Clinical stream that also included papers on patient safety, medication reconciliation, medication safety and disease state management. It was an ideal opportunity to meet other pharmacists working in the area of quality improvement, with a particular interest in medication use. There was also opportunity to visit the National Patient Safety Agency (NPSA) through the two-day ISQua mentoring program. NPSA is a Special Health Authority within the National Health Service (NHS) in the UK. It was created in July 2001 to coordinate national efforts to report and learn from mistakes and problems that affect patient safety. The national system for reporting patient incidents in the healthcare system was a key topic within the two-day mentoring program. This report includes a summary of lessons learned relevant to the CAPTION project and improving practice, as well as an overview of two reporting systems designed to assist in learning from practice.

Infliximab in refractory Behcet's disease

Objective: To describe the use of infliximab in a patient with refractory Behcets disease (BD).