Judith Coombes

Towards best practice in acute stroke care in Ghana: A survey of hospital services

BackgroundStroke and other non-communicable diseases are important emerging public health concerns in sub-Saharan Africa where stroke-related mortality and morbidity are higher compared to other parts of the world. Despite the availability of evidence-based acute stroke interventions globally, uptake in low-middle income countries (LMIC) such as Ghana is uncertain. This study aimed to identify and evaluate available acute stroke services in Ghana and the extent to which these services align with global best practice.MethodsA multi-site, hospital-based survey was conducted in 11 major referral hospitals (regional and tertiary - teaching hospitals) in Ghana from November 2015 to April 2016. Respondents included neurologists, physician specialists and medical officers (general physicians). A pre-tested, structured questionnaire was used to gather data on available hospital-based acute stroke services in the study sites, using The World Stroke Organisation Global Stroke Services Guideline as a reference for global standards.ResultsAvailability of evidence-based services for acute stroke care in the study hospitals were varied and limited. The results showed one tertiary-teaching hospital had a stroke unit. However, thrombolytic therapy (thrombolysis) using recombinant tissue plasminogen activator for acute ischemic stroke care was not available in any of the study hospitals. Aspirin therapy was administered in all the 11 study hospitals. Although eight study sites reported having a brain computed tomographic (CT) scan, only 7 (63.6%) were functional at the time of the study. Magnetic resonance imaging (MRI scan) services were also limited to only 4 (36.4%) hospitals (only functional in three). Acute stroke care by specialists, especially neurologists, was found in 36.4% (4) of the study hospitals whilst none of the study hospitals had an occupational or a speech pathologist to support in the provision of acute stroke care.ConclusionThis study confirms previous reports of limited and variable provision of evidence based stroke services and the low priority for stroke care in resource poor settings. Health policy initiatives to enhance uptake of evidence-based acute stroke services is required to reduce stroke-related mortality and morbidity in countries such as Ghana.

The Queensland experience of participation in a national drug use evaluation project, Community-acquired pneumonia – towards improving outcomes nationally (CAPTION)

BackgroundMulticentre drug use evaluations are described in the literature infrequently and usually publish only the results. The purpose of this paper is to describe the experience of Queensland hospitals participating in the Community-Acquired Pneumonia Towards Improving Outcomes Nationally (CAPTION) project, specifically evaluating the implementation of this project, detailing benefits and drawbacks of involvement in a national drug use evaluation program.MethodsEmergency departments from nine hospitals in Queensland, Australia, participated in CAPTION, a national quality improvement project, conducted in 37 Australian hospitals. CAPTION was aimed at optimising prescribing in the management of Community-Acquired Pneumonia according to the recommendations of the Australian Therapeutic Guidelines: Antibiotic 12th edition. The project involved data collection, and evaluation, feedback of results and a suite of targeted educational interventions including audit and feedback, group presentations and academic detailing.A baseline audit and two drug use evaluation cycles were conducted during the 2-year project. The implementation of the project was evaluated using feedback forms after each phase of the project (audit or intervention). At completion a group meeting with the hospital coordinators identified positive and negative elements of the project.ResultsEvaluation by hospitals of their participation in CAPTION demonstrated both benefits and drawbacks. The benefits were grouped into the impact on the hospital dynamic such as; improved interdisciplinary working relationships (e.g. between pharmacist and doctor), recognition of the educational/academic role of the pharmacist, creation of ED Pharmacist positions and enhanced involvement with the National Prescribing Service, and personal benefits. Personal benefits included academic detailing training for participants, improved communication skills and opportunities to present at conferences. The principal drawback of participation was the extra burden on already busy staff members.ConclusionA national multicentre drug use evaluation project such as CAPTION allows hospitals which would otherwise not undertake such projects the opportunity to participate. The Queensland arm of CAPTION demonstrated benefits to both the individual participants and their hospitals, highlighting the additional value of participating in a multicentre project of this type.

Piloting an Objective Structured Clinical Examination to Evaluate the Clinical Competency of Pre‐Registration Pharmacists

Objectives: The primary aim of the study was to pilot the Objective Structured Clinical Examination (OSCE) as a method of evaluating the clinical competency of pre‐registration pharmacists trained in Brisbane and nearby hospitals. A secondary aim was to demonstrate that this model of assessment is transferable when used to evaluate preregistration pharmacists from the UK.

Health professionals’ views on the barriers and enablers to evidence-based practice for acute stroke care: a systematic review

BackgroundAdoption of contemporary evidence-based guidelines for acute stroke management is often delayed due to a range of key enablers and barriers. Recent reviews on such barriers focus mainly on specific acute stroke therapies or generalised stroke care guidelines. This review examined the overall barriers and enablers, as perceived by health professionals which affect how evidence-based practice guidelines (stroke unit care, thrombolysis administration, aspirin usage and decompressive surgery) for acute stroke care are adopted in hospital settings.MethodologyA systematic search of databases was conducted using MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PsycINFO, Cochrane Library and AMED (Allied and Complementary Medicine Database from 1990 to 2016. The population of interest included health professionals working clinically or in roles responsible for acute stroke care. There were no restrictions to the study designs. A quality appraisal tool for qualitative studies by the Joanna Briggs Institute and another for quantitative studies by the Centre for Evidence-Based Management were used in the present study. A recent checklist to classify barriers and enablers to health professionals’ adherence to evidence-based practice was also used.ResultsTen studies met the inclusion criteria out of a total of 9832 search results. The main barriers or enablers identified included poor organisational or institutional level support, health professionals’ limited skills or competence to use a particular therapy, low level of awareness, familiarity or confidence in the effectiveness of a particular evidence-based therapy, limited medical facilities to support evidence uptake, inadequate peer support among health professionals’, complex nature of some stroke care therapies or guidelines and patient level barriers.ConclusionsDespite considerable evidence supporting various specific therapies for stroke care, uptake of these therapies is compromised by barriers across organisational, patients, guideline interventions and health professionals’ domains. As a result, we recommend that future interventions and health policy directions should be informed by these findings in order to optimise uptake of best practice acute stroke care. Further studies from low- to middle-income countries are needed to understand the barriers and enablers in such settings.Trial registrationThe review protocol was registered in the international prospective register of systematic reviews, PROSPERO 2015 (Registration Number: CRD42015023481)

Quality use of medicine experiential placements for fourth year pharmacy students

The educational principles that underpin undergraduate experiential placements include self-directed student learning, contextual and workplace learning, progression towards life-long learning (beyond undergraduate academia), multi-professional learning, reflective practices, peer teaching and learning. To support this approach to teaching and learning, the School of Pharmacy, University of Queensland, Australia, has instigated fourth year experiential placements at which the student completes a “Quality Use of Medicine” (QUM) project in conjunction with the placement on-site preceptor. The placements are self-selected by the students with the proviso that the placement is centred on QUM. The 4-week placements take place twice a year across the world, and it is not necessary for the preceptor to be a pharmacist. Over the course of eight university semesters, 871 QUM placements have been successfully completed. Feedback from students and preceptors has indicated the worth of these placements in the undergraduate pharmacy course.

Acceptance and attitudes of healthcare staff towards the introduction of clinical pharmacy service: a descriptive cross-sectional study from a tertiary care hospital in Sri Lanka

BackgroundMultidisciplinary patient management including a clinical pharmacist shows an improvement in patient quality use of medicine. Implementation of a clinical pharmacy service represents a significant novel change in practice in Sri Lanka. Although attitudes of doctors and nurses are an important determinant of successful implementation, there is no Sri Lankan data about staff attitudes to such changes in clinical practice. This study determines the level of acceptance and attitudes of doctors and nurses towards the introduction of a ward-based clinical pharmacy service in Sri Lanka.MethodsThis is a descriptive cross-sectional sub-study which determines the acceptance and attitudes of healthcare staff about the introduction of a clinical pharmacy service to a tertiary care hospital in Sri Lanka. The level of acceptance of pharmacist’s recommendations regarding drug-related problems (DRPs) was measured. Data regarding attitudes were collected through a pre-tested self-administered questionnaires distributed to doctors (baseline, N =13, post-intervention period, N = 12) and nurses (12) worked in professorial medical unit at baseline and post-intervention period.ResultsA total of 274 (272 to doctors and 2 to nurses) recommendations regarding DRPs were made. Eighty three percent (225/272) and 100% (2/2) of the recommendations were accepted by doctors and nurses, respectively. The rate of implementation of pharmacist’s recommendations by doctors was 73.5% (200/272) (95% CI 67.9 – 78.7%; P < 0.001). The response rate of doctors was higher at the post-intervention period (92.3%; 12/13) compared to the baseline (66.7%; 8/12). At the post-intervention survey 91.6% of doctors were happy to work with competent clinical pharmacists and accepted the necessity of this service to improve standards of care. The nurses’ rate of response at baseline and post-intervention surveys were 80.0 and 0.0% respectively. Their perceptions on the role of clinical pharmacist were negative at baseline survey.ConclusionsThere was high acceptance and implementation of clinical pharmacist’s recommendations regarding DRPs by the healthcare team. The doctors’ views and attitudes were positive regarding the inclusion of a ward-based pharmacist to the healthcare team. However there is a need to improve liaison between clinical pharmacist and nursing staff.Trial registrationSri Lanka Clinical Trials Registry SLCTR/2013/029 Date: 13 September 2013; retrospectively registered.

A Conversation About Stroke Medications: Using Patient Perceptions to Personalise Educational Messages

Annual Conference of the Asia Pacific Stroke Organization (APSO) Combined with Stroke Society of Australasia, Brisbane, Qld, Australia, July 14-17, 2016Annual Conference of the Asia Pacific Stroke Organization (APSO) Combined with Stroke Society of Australasia, Brisbane, Qld, Australia, July 14-17, 2016

Clinical pharmacy in Sri Lanka: translating training into practice

Sri Lanka has a strong national health system, which has achieved developed world health outcomes. It has also had a sustained commitment to drug policy ranging from its innovative role in essential drug lists to the most recent iteration of national drug policy, which focuses upon quality use of medicines. Pharmacy training was introduced in the early 1950s, evolving into a diploma of pharmacy. The role of pharmacists was predominantly limited to drug procurement, distribution, dispensing and inventory. In response to the National Drug Policy that promoted the development and utilisation of local expertise in clinical pharmacology and clinical pharmacy, there has been a dramatic and rapid development in the training of pharmacists with the introduction of an undergraduate bachelor of pharmacy degrees at six universities. There has been a number of challenges, including the lack of clinical pharmacy mentors, tutors or role models to provide undergraduate training and clinical leadership. Until 2009, the BPharm programs were being taught by academics with pharmacy, medical and science backgrounds, including clinical pharmacologists, who had little experience as clinical pharmacists. Sri Lankan academics were concerned about the gaps in clinical pharmacy expertise and so approached Australian clinical pharmacists to collaborate. In 2009, two of us (IC and JC) were invited to teach at the University of Peradeniya. Over an 8-week period, we developed and piloted an undergraduate clinical pharmacy course with support from colleagues at the South Asian Clinical Toxicological Research Collaboration (SACTRC). This opportunistic request led to the growth of a collaboration between colleagues in Sri Lanka and Australia, informally known as the Collaboration of Australians and Sri Lankans for Pharmacy Education and Research (CASPER). The following year, an opportunity to build sustainability arose when a Sri Lankan team obtained a World Health Organization (WHO) grant to fund a combined program teaching BPharm students at the University of Sri Jayewardenepura (USJ) and training clinical pharmacy educators. The Australian team and the Sri Lankan staff from USJ delivered and evaluated a clinical pharmacy undergraduate course to BPharm students at USJ. In addition, a ‘Train-the-trainer’ program was undertaken to which all Sri Lankan academics delivering clinical pharmacy programs were invited. Feedback from participants confirmed that pharmacists and pharmacy educators can collaborate to improve the quality of clinical pharmacy teaching in developing countries such as Sri Lanka. The next challenge was to create a clinical pharmacy role in hospitals and provide evidence of the value of expanded pharmacy practice in order to establish a capable clinical pharmacy workforce. To address this, we were supported by SACTRC and medical colleagues in Sri Lanka to undertake local research gathering evidence while also providing Sri Lankan graduates the opportunity to become clinical pharmacists with mentoring from the Australian team. This phase commenced in 2012 with a Sri Lankan pharmacist being coached to conduct an observation study of patients in the professorial medical unit at Ragama Hospital. Training consisted of face-to-face visits and fortnightly teleconferences. The study ‘Measuring the gap in quality use of medicines in a Sri Lankan Hospital: an observational prospective cohort study’ included 478 patients and identified more than 1250 opportunities for medicine optimisation. Following this, an intervention study was conducted. The intervention study was a controlled clinical trial: ‘Impact of a ward based clinical pharmacist on improving quality use of medicines in patients with non-communicable diseases’ (SLCTR/2013/ 029); 400 patients were recruited for each arm. Results of the intervention study describe the impact on quality use of medicines and the acceptance and attitudes of medical doctors and nurses regarding integration of clinical pharmacy services into the current healthcare system in Sri Lanka. The results of this research are important as they provide an evidence base to inform policy change and alter clinical practice in Sri Lanka and other countries developing clinical pharmacy. Another research project funded by the National Research Council of Sri Lanka is underway with a clinical pharmacist in diabetic clinics at both an urban and a rural government hospital (SLCTR/ 2014/034). The research work has provided an opportunity for four BPharm graduates to gain experience as clinical pharmacists, which they are now sharing with their future colleagues. Two have been employed as lecturers and two have registered to undertake an MPhil with a local university, developing research skills along with Official Journal of the Society of Hospital Pharmacists of Australia

Ward-based clinical pharmacists and hospital readmission: a non-randomized controlled trial in Sri Lanka.

Abstract Objective To assess if a ward-based clinical pharmacy service resolving drug-related problems improved medication appropriateness at discharge and prevented drug-related hospital readmissions. Method Between March and September 2013, we recruited patients with noncommunicable diseases in a Sri Lankan tertiary-care hospital, for a non-randomized controlled clinical trial. The intervention group received usual care and clinical pharmacy service. The intervention pharmacist made prospective medication reviews, identified drug-related problems and discussed recommendations with the health-care team and patients. At discharge, the patients received oral and written medication information. The control group received usual care. We used the medication appropriateness index to assess appropriateness of prescribing at discharge. During a six-month follow-up period, a pharmacist interviewed patients to identify drug-related hospital readmissions. Results Data from 361 patients in the intervention group and 354 patients in the control group were available for analysis. Resolutions of drug-related problems were higher in the intervention group than in the control group (57.6%; 592/1027, versus 13.2%; 161/1217; P < 0.001) and the medication was more appropriate in the intervention group. Mean score of medication appropriateness index per patient was 1.25 versus 4.3 in the control group (P < 0.001). Patients in the intervention group were less likely to be readmitted due to drug-related problems (44 patients of 311 versus 93 of 311 in the control group; P < 0.001). Conclusion A ward-based clinical pharmacy service improved appropriate prescribing, reduced drug-related problems and readmissions for patients with noncommunicable diseases. Implementation of such a service could improve health care in Sri Lanka and similar settings.

Use of a patient-centred educational exchange (PCEE) to improve patient’s self-management of medicines after a stroke: a randomised controlled trial study protocol

Introduction National and international guidelines make recommendations for secondary prevention of stroke including the use of medications. A strategy which engages patients in a conversation to personalise evidence-based educational material (patient-centred educational exchange; PCEE) may empower patients to better manage their medications. Methods and analysis This protocol outlines a non-blinded randomised controlled trial. Consenting patients admitted with a diagnosis of stroke or transient ischaemic attack will be randomised 1:1 to receive either a PCEE composed of two sessions, one at the bedside before discharge and one by telephone at least 10 days after discharge from hospital in addition to usual care (intervention) or usual care alone (control). The primary aim of this study is to determine whether a PCEE improves adherence to antithrombotic, antihypertensive and lipid-lowering medications prescribed for secondary prevention of stroke over the 3 months after discharge, measured using prescription-refill data. Secondary aims include investigation of the impact of the PCEE on adherence over 12 months using prescription-refill data, self-reported medication taking behaviour, self-reported clinical outcomes (blood pressure, cholesterol, adverse medication events and readmission), quality of life, the cost utility of the intervention and changes in beliefs towards medicines and illness. Ethics and dissemination Communication of the trial results will provide evidence to aid clinicians in conversations with patients about medication taking behaviour related to stroke prevention. The targeted audiences will be health practitioners and consumers interested in medication taking behaviour in chronic diseases and in particular those interested in secondary prevention of stroke. The trial has ethics approval from Metro South Human Research Ethics Committee (HREC/15/QPAH/531) and The University of Queensland Institutional Human Research Ethics (2015001612). Trial registration number ACTRN12615000888561; Pre-results.