Improved uptake of guideline recommendations for community-acquired pneumonia management in emergency departments was documented following a multi-faceted education intervention.

Objectives To evaluate compliance with the Australian Pharmaceutical Advisory Council's National guidelines to achieve the continuum of quality use of medicines between hospital and community. Design Descriptive survey, based on questionnaires tilled out by general practitioners, of a sample of patients following recent discharge from public hospitals, collated with hospital record reviews for a 20% subsample of the patients. Participants and setting 357 GPs practising within the postcode boundaries of the South East Sydney Area Health Service were randomly selected to take part in the survey. Of 219 GPs who agreed to participate, 106 compiled questionnaires on 203 patients. For a subsample of 38 patients, hospital records were reviewed and compared with the GP survey data. Results For 52% (105/203) of all patients the GP was not notified of hospital admission. Medication management was documented in the discharge plan for 13% (5/38) of the subsample. Communication in both directions between GP and hospital about medications was recorded for 13% (5/38) of the subsample. Consultation with the GP about the patient's medication during the hospital stay occurred for 11% (22/203) of all patients and 24% (9/38) of the subsample. Ninety‐one per cent of patients (185/203) were discharged with sufficient medication to last until they saw their GP. Fewer than 10% of patients received all the information the Guidelines require. For 33% (66/203) of the patients, GPs considered there was at least one barrier (eg, language, cultural) to understanding the medication regimen. Conclusions Compliance with the Guidelines is not good at present, Their acceptance may be strengthened by formulating specific target indicators, A minimum indicator would be notifying the GP of three out of four matters: the patient's admission; medications on discharge; medication changes; and follow‐up arrangements.

Aim: To identify predisposing and enabling factors which influence adverse drug reaction reporting by medical, nursing and pharmacy staff in New South Wales teaching hospitals. Method: A questionnaire was distributed to all doctors, nurses and pharmacists in four New South Wales teaching hospitals. Health promotion concepts were used to provide a framework for interpreting results. Results: 4808 questionnaires were distributed and 1125 (23% response rate) were returned. Approximately 16% of respondents reported that they had reported an adverse drug reaction at least once to the Australian Adverse Drug Reactions Advisory Committee. 82% routinely asked patients about previous adverse drug reactions on admission and 95% of these respondents documented the adverse drug reaction in the medical record. Only 36% knew how to report an adverse drug reaction in their hospital. Most claimed awareness of recognised goals of adverse drug reaction reporting but many also identified erroneous goals. They were more likely to report an adverse drug reaction if it was serious or related to a new product. Predisposing factors relating to knowledge were identified as barriers to reporting by about one-third of respondents. Factors relating to attitudes and beliefs were not identified as barriers. Disabling factors included excessive workload, forms not readily available and insufficient data. Conclusion: Knowledge appears to be a greater influence on adverse drug reaction reporting than attitudes and beliefs. Simple enabling processes, such as making forms more accessible or encouraging computerised reporting, might result in more reports. Educational initiatives should target nurses and junior medical officers.

We have analysed the published literature on eptacog alfa (recombinant factor VIIa; rFVIIa) for nonhaemophiliac conditions with the aim of determining its current place in therapy. Initial surgical and/or medical management is required for any patient with life-threatening bleeding. In those with continued life-threatening bleeding (i.e. despite maximal surgical and/or medical therapy), eptacog alfa may be considered as additional therapy, in exceptional circumstances. There is good evidence from systematic reviews and randomized controlled trials (RCTs) that eptacog alfa stops bleeding in adults with intracerebral haemorrhage (ICH) if it is given within 4 hours of symptom onset. However, a recent phase III RCT suggests that it does not improve clinically relevant long-term outcomes (death and disability). There is also good evidence against prophylactic use of eptacog alfa during orthotopic liver transplantation or liver resection, and in treating variceal and nonvariceal haemorrhage in patients with cirrhosis. The evidence for the use of eptacog alfa for unexpected life-threatening bleeding in liver, cardiac or other surgery, or in blunt trauma, is not robust. In these circumstances, it should only be given as part of a clinical trial or in exceptional cases when other therapies have failed. The evidence for use of eptacog alfa in penetrating trauma is lacking. Conflicting RCT results exist for the prophylactic use of eptacog alfa in elective surgery; therefore, it cannot be recommended in this situation. There is insufficient evidence for a primary role of eptacog alfa in reversal of anticoagulation with heparin-like molecules and novel anticoagulant agents. There are effective therapies that correct all warfarin-induced factor deficiencies; thus, off-label use of eptacog alfa for reversal of warfarin should only be considered in the context of ICH. The evidence for eptacog alfa use in children is limited. The only RCT is in cardiac surgery for congenital heart disease, where eptacog alfa prophylaxis was actually associated with increased time to chest closure. It may be of potential benefit in some children with life-threatening bleeding in the context of trauma, surgery or liver disease (as additional therapy when surgical and/or medical control of bleeding has failed), but the overall benefit-risk ratio may be unfavourable if there is an underlying risk of thromboembolism (e.g. trauma, congenital heart disease, other hyperviscous or hypercoagulable states, presence of arterial or central venous catheters). Thromboembolism may be associated with eptacog alfa use. Although the magnitude of this risk and possible predisposing factors are not clearly delineated, some data suggest increased risk at higher doses. Variable effects of eptacog alfa use on mortality have been shown in a pooled analysis of RCTs. Data from some observational studies and postmarketing surveillance suggest an increased risk of thromboembolism associated with off-label uses. Further well designed studies are required to more definitively ...

Objective: To reduce pethidine prescribing in hospital emergency departments (EDs). Design: Multi-centre drug use evaluation (DUE) process. Setting and participants: Emergency departments in 23 public hospitals (22 in New South Wales, 1 in Victoria) from 1 September 2002 to 31 August 2003. Participating hospitals included seven principal referral hospitals, six major non-teaching hospitals and 10 district or community hospitals. Data for comparison were collected from 12 nonparticipating hospitals. Interventions: Hospital coordinators at each participating hospital were provided with support to implement a range of prescribing interventions in their ED in each of three DUE cycles. Interventions included educational materials (guidelines, posters, prescribing reminders), audit and feedback, and small-group discussions. Three audits of pethidine prescribing were undertaken. Prescribing was compared with evidencebased guidelines and non-concordance identified. Main outcome measures: Number of dosage units of parenteral analgesics issued to the ED from each hospital's pharmacy department was recorded monthly and aggregated in 3-month periods. Results: In the 12 months between the preintervention period and the equivalent postintervention period, pethidine use decreased by 62% in project hospitals (4669 to 1793 units) and 56% in control hospitals (1476 to 648 units). Six months after project completion there was a significantly greater reduction from baseline in participating hospitals (71%; 4669 to 1348 units) compared with non-participating hospitals (64%; 1476 to 532 units; P < 0.001). There was a concurrent increase in use of both morphine and tramadol. P