Dr Sarira El-Den MPS and Emeritus Professor Philip Boyce
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[post_content] => It was World Patient Safety Day on 17 September, with this year’s theme around improving diagnosis for patient safety.
Australian Pharmacist examines three health conditions where diagnosis is commonly delayed, incorrect, or missed – and pharmacists’ important role in ensuring an accurate and timely diagnosis to improve treatment outcomes.
COPD is significantly underdiagnosed
Around 50% of people living with Chronic Obstructive Pulmonary Disorder (COPD) are estimated to be undiagnosed.
While patient symptoms and a physical examination can support diagnosis, full spirometry is required to diagnose the condition correctly, said Advanced Practice Pharmacist Associate Professor Debbie Rigby FPS, head of PSA’s Respiratory Care Community of Specialty Interest.
[caption id="attachment_25619" align="alignright" width="270"]
Associate Professor Debbie Rigby FPS[/caption]
‘There are many other respiratory conditions that can present as symptoms of COPD such as wheeze, shortness of breath, chest tightness, chronic cough and poor exercise intolerance – including asthma,’ she said.
An additional layer of complexity is the stigma associated with COPD, which is commonly perceived as a disease solely caused by cigarette smoking.
‘However, we know that around 30% of people diagnosed with COPD have never smoked a cigarette,’ said A/Prof Rigby. ‘There are many other factors, including genetic [predisposition] and environmental exposures that can lead to COPD.’
Because of the high rate of underdiagnosis of COPD, the condition is often undertreated.
‘It’s important to appropriately treat COPD, because although it can’t be cured, we can slow the progression in decline in lung function with medications as well as non-pharmacological treatments such as pulmonary rehab,’ she said.
The Lung Foundation Australia’s Lung Health Checklist can help pharmacists identify people who are at risk for COPD, looking at factors such as:
Nicolette Ellis MPS[/caption]
‘The National Pain Report 2024 highlights that while it takes an average of 3 years to diagnose a chronic pain condition, endometriosis typically takes 7–9 years to diagnose,’ she said.
‘This delay is largely due to a lack of education, awareness, and the fact that it can only be definitively diagnosed through invasive laparoscopy.’
However, timely diagnosis is crucial for managing pain and preventing its escalation.
‘Early detection improves outcomes, reducing the physical and emotional toll on patients,’ said Ms Ellis. ‘Delayed diagnosis often leads to feelings of dismissal, with many told the pain is "all in their head," further worsening the vicious cycle of chronic pain.’
Pharmacists should be aware that endometriosis can present with a wide range of symptoms, including:
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[post_content] => Case scenario
Carmen, 54 years old, presents to the pharmacy reporting sleep difficulties. She reports poor sleep quality and daytime exhaustion that started about 6 months ago.
[caption id="attachment_27236" align="alignright" width="297"]
A national education program for pharmacists funded by the Australian Government under the Quality Use of Diagnostics, Therapeutics and Pathology program.[/caption]
She has no history of medicine use for sleep but would like information on the different medicines that are available. You ask Carmen about the specific sleep symptoms that she is experiencing, including her sleep patterns and symptoms of sleep disorders. She is not on any regular medicines.
After reading this article, pharmacists should be able to:
|
Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.
Insomnia and obstructive sleep apnoea (OSA) are the two most prevalent sleep disorders and frequently co-exist.1 Comorbid insomnia and sleep apnoea (COMISA) is a prevalent and debilitating condition in Australia.2 This article presents information on evidence-based assessment tools, pharmacological and non-pharmacological management, and referral options for patients with COMISA.
Insomnia is defined as self-reported difficulties falling asleep, maintaining sleep, and/or early morning awakenings from sleep on at least three nights per week, with associated daytime impairment.1,3 It is estimated that 10–15% of adults at any given time have chronic insomnia (≥3 month duration).4,5 Insomnia is associated with reduced quality of life and an increased risk of depression.6 When occurring in the presence of other mental and physical health conditions, insomnia should be viewed as a ‘comorbid’ disorder that requires targeted assessment and management.7
OSA is characterised by frequent narrowing and/or closure of the upper airway during sleep, resulting in hypoxemia, hypercapnia and awakenings from sleep.1,3,8 Approximately 10% of the general population experience moderate-to-severe OSA at any given time.9 OSA is more prevalent in males than females, however some studies indicate that this equalises around the time of menopause.10 OSA is also associated with daytime impairments, risk of sleepiness-related accidents, and risk of cardiovascular disease, cognitive impairment and depression.8,10,11
Both these disorders can occur separately, but if they co-occur, this is termed COMISA. Approximately 30–50% of people with OSA have comorbid insomnia, and 30–40% of people with chronic insomnia have comorbid OSA.9,12 A recent population-based study reported that 11% of Australian adults report symptoms of COMISA.13
Some models of insomnia suggest that insomnia results from14:
In people with chronic insomnia, a state of ‘conditioned insomnia’ can develop, whereby the bed or bedroom environment becomes a conditioned stimuli for a state of alertness/worry/wakefulness.15 Short-term insomnia can initially result from different mental and physical stressors (i.e. the precipitant), however insomnia can rapidly develop functional independence of these precipitating triggers and become maintained by specific psycho-behavioural processes (perpetuating factors and a state of conditioned insomnia).16
The most consistent risk factors for OSA are increasing age, overweight/obesity, male sex,11 cranio-facial abnormality and adenotonsillar hypertrophy.
Pharmacists should avoid viewing insomnia as a ‘secondary symptom’ of other mental and physical health conditions.1 In the context of COMISA, insomnia symptoms may initially result from untreated OSA, however insomnia can quickly develop functional independence of the OSA and become maintained by insomnia-specific perpetuating factors.1
People with COMISA experience impaired sleep, daytime functioning, mental health, physical health and quality of life, compared to people with neither condition. COMISA is often associated with greater impairment across these domains, compared to people with either disorder alone.1,17,18 COMISA is associated with a 50–70% increased risk of all-cause mortality compared over 10–20 years of follow-up, potentially due to mental and physical health consequences or misdiagnosis and reduced treatment acceptance.2,18–21
People with COMISA may present with a general complaint of sleep dissatisfaction, specific insomnia symptoms, obvious manifestations of OSA (e.g. witnessed breathing pauses, choking awakenings, loud snoring), or daytime impairment (e.g. fatigue, lethargy, irritability).
Many people with insomnia symptoms attempt self-management approaches before presenting to health professionals (e.g. simple ‘sleep hygiene’ techniques; complementary/alternative medicines; consuming different foods/beverages promoted on social media to improve sleep; relaxation breathing exercises).22,23 A state of learned helplessness can develop in people that experience persistent insomnia despite using a large range of remedies that are not effective over the long term.
Many people with long-term insomnia may present with a history of sedative-hypnotic medicine use, and many people with OSA and COMISA may present with a history of previous/current use of continuous positive airway pressure (CPAP) therapy.
It is important for pharmacists to be aware of presenting symptoms of insomnia and OSA, and evidence-based screening, assessment and diagnostic tools for each condition (Table 1). OSA symptoms should be assessed in people with insomnia symptoms, and insomnia symptoms should be assessed in people with suspected or confirmed OSA.24
The ‘gold standard’ measure of OSA presence and severity is an overnight sleep study (Table 1).25 The most common single metric to determine OSA presence and severity is the apnoea-hypopnoea index (AHI), representing the average number of airway narrowing and closure events occurring per hour of sleep.24 Identifying the most appropriate management approaches for OSA also requires consideration of lifestyle factors, symptoms and consequences, occupation, chronic conditions, and other sleep conditions. Self-report questionnaires may be used to screen for a high-risk of OSA and identify patients suitable for referral and consideration of overnight sleep study assessment (Table 1).24
Insomnia, sleep apnoea and COMISA may co-occur with other sleep disorders such as restless legs syndrome and shift work sleep disorder. Circadian misalignment may be a factor in some patients with COMISA.26
Successful management of COMISA can be more difficult than management of either disorder alone, and requires a tailored management approach.20
Pharmacological management
Sedative and hypnotic medicines (e.g. benzodiazepines, non-benzodiazepine hypnotics, off-label antidepressant medicines) are often used in the management of insomnia.28 Although hypnotics provide rapid therapeutic relief from insomnia via increasing sleep duration, they are not the recommended first-line insomnia treatment, and are not recommended for long-term use.29 This is because hypnotics do not target or treat the underlying psycho-behavioural factors that maintain insomnia. Most medicines used for insomnia are associated with adverse effects and risks of adverse events, including psychomotor impairment, falls/fractures, and next-day sedation.29–31 Over time, patterns of short-term therapeutic benefit are often replaced by patterns such as tolerance, long-term dependence and withdrawal symptoms in attempts to reduce use.32 Upon discontinuation of hypnotics, patients may experience insomnia relapse.32 Some sedatives that are used in the management of insomnia may also exacerbate apnoea events in specific patients with OSA.30
Although evidence-based guidelines unanimously recommend avoiding long-term use of hypnotics, they are indicated for a minority of patients that present with severe acute insomnia that is causing significant psychological distress or functional impairment.29 Most people who experience short-term insomnia symptoms (1–2 weeks) can be reassured that sleep will return to ‘normal’ after the underlying precipitant has subsided, without targeted treatment (i.e. hypnotic medicines).29,33 For those who experience persistent insomnia, cognitive behavioural therapy for insomnia (CBTi) is the first-line treatment. Pharmacotherapy may be considered in patients with severe insomnia that is causing significant impairment or distress (e.g. times of acute work/exam stress, bereavement).34
Non-pharmacological management
CBTi is the recommended first-line treatment for insomnia.35 It is effective in people with both acute and chronic insomnia.29,36 CBTi is a multi-component treatment that aims to identify and gradually treat the underlying precipitating triggers and perpetuating factors of long-term insomnia. For this reason, CBTi is often associated with moderate-to-large improvements in insomnia, daytime function and mental health that are sustained long after treatment cessation.37 A recent systematic review and meta-analysis reported that CBTi is an effective treatment for insomnia in the presence of comorbid OSA.38 CBTi is associated with increased daytime sleepiness during the initial stages of bedtime restriction therapy (a core therapeutic component of CBTi), and patients should be warned of feelings of sleepiness while driving or performing other tasks that require sustained attention, and monitored closely.39,40
Although CBTi improves insomnia symptoms in the presence of comorbid OSA,38 depression, anxiety and pain, it is only accessed by approximately 1% of Australian adults with insomnia.28 Access to CBTi may be further reduced in people with COMISA if the OSA is viewed as the ‘primary disorder’ that should be managed before treatment of insomnia, or if there is reservation about referring patients with untreated OSA for sleep restriction therapy (one component of CBTi that aims to temporarily reduce time spent in bed).41
CBTi delivered by a suitably trained and experienced ‘sleep’ psychologist is the ‘gold standard’ form of this treatment.24 Insomnia is an eligible condition for a GP referral to a psychologist, with a mental health treatment plan.42 Evidence-based self-guided digital CBTi programs may also be appropriate for patients with COMISA that are receiving treatment for OSA (e.g. well-controlled on CPAP therapy), with close oversight from a specialist sleep/respiratory clinician.41,43
CPAP therapy is the most effective treatment for OSA.24,44 In a minority of patients with COMISA, CPAP therapy is accepted and improves symptoms of both the insomnia and OSA.9 However, on average, patients with comorbid insomnia are less likely to initially accept a trial of CPAP therapy, and use CPAP therapy for fewer hours per night compared to patients with OSA alone.2,45 Some randomised trials indicate that initial management with CBTi may improve CPAP acceptance and use in patients with COMISA, however this finding is not consistent across all studies.17
Tailored recommendations for non-CPAP therapies may also be provided to patients with different levels of OSA severity and presenting features.17 For example, weight management advice where indicated, positional devices (in the presence of supine-predominant OSA), mandibular advancement splints (in patients with mild-to-moderate OSA), and upper airway surgery are effective treatments that may be tailored to each individual patient.24
Patients with suspected COMISA should be referred to a medical practitioner for further assessment and management.34 After initial assessment, some patients may be initially managed in the primary care setting. The GP may also refer the patient to a specialist sleep and respiratory physician and/or ‘sleep’ psychologist. The Australasian Sleep Association’s Primary Care Sleep Health Resources website lists criteria a GP may use for specialist referral for insomnia and OSA.
Pharmacists should be aware that insomnia and obstructive sleep apnoea (OSA) are the two most prevalent sleep disorders and frequently co-occur.
Pharmacists can use brief evidence-based self-report screening tools to support the identification and referral of patients with suspected insomnia and/or OSA.
If a patient has COMISA, it is important to consider assessment and management/referral options for both conditions. Treatment approaches for OSA can be tailored to each individual’s presenting features. The most effective and recommended ‘first-line’ treatment for insomnia is cognitive behavioural therapy for insomnia (CBTi).
Comorbid insomnia and sleep apnoea (COMISA) is a prevalent and debilitating condition in the Australian population that requires nuanced assessment and management approaches. Pharmacists can play an important role in supporting the identification, assessment, initial management and referral of patients with COMISA, by using brief screening tools and providing information about evidence-based treatment options.
Case scenario continuedYou discuss Carmen’s symptoms further and offer her a 7-item Insomnia Severity Index and the 4-item OSA50 questionnaire to fill in. The results indicate likely long-term symptoms of insomnia and a high risk of undiagnosed OSA. Carmen reports daytime fatigue but no daytime sleepiness. You refer her to a GP for further assessment and explain that the GP may provide a further referral for an overnight sleep study, consultation with a sleep and respiratory physician and a psychologist for CBTi. You explain that CBTi is most effective for treatment of insomnia. Carmen is encouraged that there are non-pharmacological options available and is looking forward to discussing this with her GP. |
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Dr Alexander Sweetman (he/him) PhD
Senior Program Manager, and chair of the psychologist education subcommittee at the Australasian Sleep Association.
Associate Professor Sutapa Mukherjee (she/her) MBBS, FRACP, PhD
Respiratory and sleep physician, Associate Professor of Respiratory and Sleep Medicine at Flinders University and past President of the Australasian Sleep Association.
Professor Garun Hamilton (he/him) MBBS, FRACP, PhD
Respiratory and sleep physician, clinical professor at Monash Health and Monash University and President of the Australasian Sleep Association.
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While Australians are taking fewer antibiotics overall, there are concerns that antimicrobial prescribing is steadily increasing in aged care.
Each year, the Australian Commission on Safety and Quality in Health Care’s Antimicrobial use in the community (AURA) report analyses antimicrobials supplied under the Pharmaceutical Benefits Scheme (PBS) and Repatriation PBS (RPBS) – featuring both antimicrobial use in aged care and by local area.
The latest report, AURA 2023 found that although there has been a small increase of 1.3% in overall antimicrobial use in the community from 2022 to 2023, use is still 24.4% lower than in 2015.
Alarmingly, there has been a stark 11.1% increase in antimicrobial use in residents of aged care homes from 2022 to 2023.
Antimicrobial use is also considerably higher for older Australians who reside in aged care homes than for those living in the community. While just over a third of Australians had at least one antimicrobial dispensed, almost three-quarters of residential aged care facility (RACF) residents received at least one antimicrobial prescription last year.
Australian Pharmacist looks at which antibiotics are most commonly prescribed in aged care, the impacts of high antimicrobial use, and what pharmacists can do to help.
Why is antibiotic prescribing in aged care so high?
There are several reasons why RACF antimicrobial prescribing is higher than in the rest of the community.
[caption id="attachment_24236" align="alignright" width="216"]
Professor John Turnidge AO[/caption]
According to infectious diseases physician and microbiologist Professor John Turnidge AO, Senior Medical Advisor, Australian Commission on Safety and Quality in Health Care, these include:
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[post_content] => Melatonin is a naturally occurring hormone responsible for regulating the body’s circadian rhythm. Secretion of melatonin declines during adulthood. Supplemental melatonin can help to reinforce the circadian rhythm, making it useful for treatment of insomnia and jet lag.1
How can pharmacists meet their legal and professional obligations when prescribing melatonin for insomnia?
When prescribing melatonin as a Pharmacist Only medicine, you must establish therapeutic need, determine the medicine is safe for the patient and comply with restrictions of the Schedule 3 listing. This includes that the patient is aged 55 or over and it is for short-term treatment. Routine recording of patient name, address and date of birth supports appropriate provision and is the best way for pharmacists to demonstrate they have met legal and professional obligations.
How long is 'short-term'?
While there is evidence to support the safety and efficacy of melatonin up to 13 weeks,3 patients should be referred to a medical practitioner for review if they require treatment for more than 3 weeks.⁴ Three weeks is consistent with evidence from the pivotal efficacy study noted by the Therapeutic Goods Administration in the final decision to amend melatonin scheduling to Schedule 3.⁵
A patient who has been prescribed melatonin MR 2 mg nightly for 3 months by a medical practitioner presents to the pharmacy seeking a supply as they have run out. What can a pharmacist prescribe?
This pattern of use is not short term, so a pharmacist would not be able to prescribe melatonin within Schedule 3. Other options may apply, such as using emergency supply provisions relating to Schedule 4 medicines. The criteria for emergency supply by a pharmacist, and quantity of medicine able to be supplied, depends on the state or territory in which the pharmacist is practising.
What options are available to pharmacists to treat jet lag?
Despite the inclusion of immediate-release melatonin for jet lag in Schedule 3 of the Poisons Standard, at the time of writing, there is no commercially available immediate-release product in Australia which can be prescribed as a Pharmacist Only medicine. Pharmacists may compound an immediate-release preparation that contains 5 mg or less of melatonin when a particular person requests this medicine. If a commercial product becomes available, compounding would no longer be appropriate. Patients should be advised to avoid purchasing melatonin via the internet because the melatonin content may be unreliable.6
Poisons Standard Schedule 3 entry for melatonin7
MELATONIN in:
(a) modified release tablets containing 2 mg or less of melatonin for monotherapy for the short-term treatment of primary insomnia characterised by poor quality of sleep for adults aged 55 or over, in packs containing not more than 30 tablets; or
(b) immediate release preparations containing 5 mg or less of melatonin for the treatment of jet lag in adults 18 years and over, in a primary pack containing no more than 10 dosage units.
References
1. Goldstein, CA. Overview of circadian rhythm sleep-wake disorders. UpToDate [updated Dec 2023]. At: https://sso.uptodate.com/contents/overview-of-circadian-rhythm-sleep-wake-disorders?search=melatonin&source=search_result&selectedTitle=3%7E113&usage_type=default&display_rank=3
2. Insomnia in adults. Therapeutic guidelines [updated Mar 2021]. At: https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Psychotropic&topicfile=insomnia-adults
3. Treatment guidelines for pharmacists: insomnia. In: Sansom LN, ed. Australian pharmaceutical formulary and handbook. 26th edn. Canberra: Pharmaceutical Society of Australia; 2024.
4. Therapeutic Goods Administration. Notice of final decision to amend the current Poisons Standard in relation to melatonin. 2020. At: www.tga.gov.au/resources/publication/scheduling-decisions-final/notice-final-decision-amend-current-poisons-standard-relation-melatonin
5. Pharmacy Board of Australia. FAQ – For pharmacists on the compounding of medicines. At: www.pharmacyboard.gov.au/documents/default.aspx?record=WD15%2f16635&dbid=AP&chksum=rE0qmZcEafURzzXc3NBiuA%3d%3d
6. Therapeutic Goods Administration. Notice of interim decision to amend (or not amend) the current Poisons Standard. 2023. At: www.tga.gov.au/sites/default/files/2023-10/notice-interim-decisions-amend-not-amend-the-current-poisons-standard.pdf
7. Therapeutic Goods (Poisons Standard – June 2024) Instrument 2024. At: www.legislation.gov.au/F2024L00589/latest/text (edited)
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[post_content] => Sleep is a hot topic for Anousheh Page MPS, Director of Pharmacy at Brisbane’s only 24-hour pharmacy.
Why did you choose pharmacy?
Becoming a pharmacist was actually one of three options on my university application. At the time, all I really knew was that I enjoyed science-based subjects at school and also helping people (natural Virgo at heart, of course!). When it came to the pros and cons list, pharmacy felt like the best option. And I don’t have any regrets.
I absolutely love being a pharmacist. I completed a Bachelor of Pharmacy at the University of Sydney and can honestly say my university experience was the best of all time, which reinforced my choice to become a pharmacist.
What led you to your current role?
I knew whilst completing my pharmacy degree that I always wanted to work within a hospital environment. My pharmacy career in hospital began after completing my internship at the Children’s Hospital, Westmead, in Sydney. In 2007, I was moving back from a hospital role on the South Coast of New South Wales when I saw a Pharmacist In Charge role advertised for Kareena Private Hospital (God’s country, aka the Sutherland Shire in southern Sydney). I was fortunate enough to be offered the role. Working within any Ramsay Health Care facility never feels like work. The hospital staff become your adopted family and you work within a well-supported multidisciplinary team. I gained experience within multiple Ramsay Hospitals and eventually landed Director of Pharmacy at Greenslopes Private Hospital.
How do you and your staff cope with the late-night and overnight hours?
In general, staff cope very well and have an amazing ability to adapt to the various hours. There is a good balance of work which flows through the hospital inpatient stream but is also complemented by the variety of community patients that come through. I personally would sleep a few hours before a shift if I knew I had to cover an overnight. Like most, I would stay awake and try and get back to a normal sleep routine for the next shift.
What are common requests from patients who visit in the wee small hours?
Patients do often come in for sleep issues at night, however what stands out the most are patients who request salbutamol inhalers. Every night can be different depending on the day of the week, but the most consistent request is salbutamol. We have had patients coming from areas like the Gold Coast or even Mount Barney (130 kilometres south-east of Brisbane, population less than 50). This really highlights the opportunity pharmacists have to be able to deliver full-scope activities such as improved asthma management – including developing an asthma action plan – particularly outside standard business hours. The second-most common would be the management of acute illnesses to treat gastroenteritis or flu-like symptoms. We have many local public facilities surrounding Greenslopes, including our own emergency department, so we service lots of patients requiring after-hours medicines.
What are your strategies to deal with barriers to overnight care?
In most scenarios we would just use our experience and clinical judgment when helping patients. Working an overnight shift is similar to working a weekend shift in some respects, so we are very accustomed to managing or referring when necessary. We are also fortunate to work in an area with late-opening medical centres and local emergency centres. This allows us to refer patients who require further review. QScript (Queensland’s real-time prescription monitoring system) has also been a game changer in helping provide better support and clinical judgement for dispensing high-risk medicines; this had often been a challenge when working outside normal hours in pharmacy.
If you could change anything about your 24-hour pharmacy, what would it be?
Coffee is the gift that keeps on giving. A barista-made coffee on hand at any hour wouldn’t be too much to ask, would it?
What’s your advice for ECPs?
It’s important to work in an environment you love. Surrounded by the right team and environment can absolutely make the difference on how you approach work. If you dread work or feel anxious before the work week, you’re not in the right job.
A day in the life of Anousheh Page MPS, Director of Pharmacy, Greenslopes Private Hospital, QLD
| 4.30 am |
Up and at it Never in my life did I think I would be one of those early morning risers to hit the gym, but the pandemic forced a change and that schedule gets me mentally prepared for the day. |
| 7.30 am |
Handover time A double-shot of cappuccino in hand, my day begins with a handover between the 24-hour retail pharmacy and hospital dispensary team. Urgent action might be needed on alteplase orders to replace stock used overnight for a stroke patient in ED, or ensuring discharge medicines that were completed are given to that ward’s pharmacist for patient counselling. |
| 8.30 am |
Hospital bed managers’ meeting Meeting daily with the ward and other multidisciplinary hospital team managers helps me reallocate pharmacy staff to areas that need support i.e. for timely discharges or immediate communication if a regular pharmacy staff member is on leave. On Thank You Thursdays, meetings end by nominating a team member deserving of recognition, who later receives a card and lunch voucher from the hospital executive team. |
| 9.30 am |
Current shortages Next meeting addresses state shortages – this time its fluids. This entails direct contact with other Ramsay Queensland hospitals via the state procurement manager who organises a consistent supply of fluids, such as saline. |
| 10 am – 4 pm |
Daily challenges Every work day is different. Overseeing a 24-hour pharmacy that never closes requires being prepared for anything, and problem-solving is a strong skill set in my role. If I have multiple staff on leave with the spread of colds and flu, I actively help cover an area, (which has helped me be a better manager with greater knowledge of what shifts entail or how wards operate). Urgent deliveries of home IV antibiotics for patients and expensive IV anti-fungals at short notice are part of it. |
| 4.00 pm |
Home time I start my second job, which could ideally be a paid Uber driver, but is actually driving my children to their various daily extracurricular activities. At least I’m off my feet! |
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[post_content] => It was World Patient Safety Day on 17 September, with this year’s theme around improving diagnosis for patient safety.
Australian Pharmacist examines three health conditions where diagnosis is commonly delayed, incorrect, or missed – and pharmacists’ important role in ensuring an accurate and timely diagnosis to improve treatment outcomes.
COPD is significantly underdiagnosed
Around 50% of people living with Chronic Obstructive Pulmonary Disorder (COPD) are estimated to be undiagnosed.
While patient symptoms and a physical examination can support diagnosis, full spirometry is required to diagnose the condition correctly, said Advanced Practice Pharmacist Associate Professor Debbie Rigby FPS, head of PSA’s Respiratory Care Community of Specialty Interest.
[caption id="attachment_25619" align="alignright" width="270"] Associate Professor Debbie Rigby FPS[/caption]
‘There are many other respiratory conditions that can present as symptoms of COPD such as wheeze, shortness of breath, chest tightness, chronic cough and poor exercise intolerance – including asthma,’ she said.
An additional layer of complexity is the stigma associated with COPD, which is commonly perceived as a disease solely caused by cigarette smoking.
‘However, we know that around 30% of people diagnosed with COPD have never smoked a cigarette,’ said A/Prof Rigby. ‘There are many other factors, including genetic [predisposition] and environmental exposures that can lead to COPD.’
Because of the high rate of underdiagnosis of COPD, the condition is often undertreated.
‘It’s important to appropriately treat COPD, because although it can’t be cured, we can slow the progression in decline in lung function with medications as well as non-pharmacological treatments such as pulmonary rehab,’ she said.
The Lung Foundation Australia’s Lung Health Checklist can help pharmacists identify people who are at risk for COPD, looking at factors such as:
Nicolette Ellis MPS[/caption]
‘The National Pain Report 2024 highlights that while it takes an average of 3 years to diagnose a chronic pain condition, endometriosis typically takes 7–9 years to diagnose,’ she said.
‘This delay is largely due to a lack of education, awareness, and the fact that it can only be definitively diagnosed through invasive laparoscopy.’
However, timely diagnosis is crucial for managing pain and preventing its escalation.
‘Early detection improves outcomes, reducing the physical and emotional toll on patients,’ said Ms Ellis. ‘Delayed diagnosis often leads to feelings of dismissal, with many told the pain is "all in their head," further worsening the vicious cycle of chronic pain.’
Pharmacists should be aware that endometriosis can present with a wide range of symptoms, including:
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[post_content] => Case scenario
Carmen, 54 years old, presents to the pharmacy reporting sleep difficulties. She reports poor sleep quality and daytime exhaustion that started about 6 months ago.
[caption id="attachment_27236" align="alignright" width="297"] A national education program for pharmacists funded by the Australian Government under the Quality Use of Diagnostics, Therapeutics and Pathology program.[/caption]
She has no history of medicine use for sleep but would like information on the different medicines that are available. You ask Carmen about the specific sleep symptoms that she is experiencing, including her sleep patterns and symptoms of sleep disorders. She is not on any regular medicines.
After reading this article, pharmacists should be able to:
|
Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.
Insomnia and obstructive sleep apnoea (OSA) are the two most prevalent sleep disorders and frequently co-exist.1 Comorbid insomnia and sleep apnoea (COMISA) is a prevalent and debilitating condition in Australia.2 This article presents information on evidence-based assessment tools, pharmacological and non-pharmacological management, and referral options for patients with COMISA.
Insomnia is defined as self-reported difficulties falling asleep, maintaining sleep, and/or early morning awakenings from sleep on at least three nights per week, with associated daytime impairment.1,3 It is estimated that 10–15% of adults at any given time have chronic insomnia (≥3 month duration).4,5 Insomnia is associated with reduced quality of life and an increased risk of depression.6 When occurring in the presence of other mental and physical health conditions, insomnia should be viewed as a ‘comorbid’ disorder that requires targeted assessment and management.7
OSA is characterised by frequent narrowing and/or closure of the upper airway during sleep, resulting in hypoxemia, hypercapnia and awakenings from sleep.1,3,8 Approximately 10% of the general population experience moderate-to-severe OSA at any given time.9 OSA is more prevalent in males than females, however some studies indicate that this equalises around the time of menopause.10 OSA is also associated with daytime impairments, risk of sleepiness-related accidents, and risk of cardiovascular disease, cognitive impairment and depression.8,10,11
Both these disorders can occur separately, but if they co-occur, this is termed COMISA. Approximately 30–50% of people with OSA have comorbid insomnia, and 30–40% of people with chronic insomnia have comorbid OSA.9,12 A recent population-based study reported that 11% of Australian adults report symptoms of COMISA.13
Some models of insomnia suggest that insomnia results from14:
In people with chronic insomnia, a state of ‘conditioned insomnia’ can develop, whereby the bed or bedroom environment becomes a conditioned stimuli for a state of alertness/worry/wakefulness.15 Short-term insomnia can initially result from different mental and physical stressors (i.e. the precipitant), however insomnia can rapidly develop functional independence of these precipitating triggers and become maintained by specific psycho-behavioural processes (perpetuating factors and a state of conditioned insomnia).16
The most consistent risk factors for OSA are increasing age, overweight/obesity, male sex,11 cranio-facial abnormality and adenotonsillar hypertrophy.
Pharmacists should avoid viewing insomnia as a ‘secondary symptom’ of other mental and physical health conditions.1 In the context of COMISA, insomnia symptoms may initially result from untreated OSA, however insomnia can quickly develop functional independence of the OSA and become maintained by insomnia-specific perpetuating factors.1
People with COMISA experience impaired sleep, daytime functioning, mental health, physical health and quality of life, compared to people with neither condition. COMISA is often associated with greater impairment across these domains, compared to people with either disorder alone.1,17,18 COMISA is associated with a 50–70% increased risk of all-cause mortality compared over 10–20 years of follow-up, potentially due to mental and physical health consequences or misdiagnosis and reduced treatment acceptance.2,18–21
People with COMISA may present with a general complaint of sleep dissatisfaction, specific insomnia symptoms, obvious manifestations of OSA (e.g. witnessed breathing pauses, choking awakenings, loud snoring), or daytime impairment (e.g. fatigue, lethargy, irritability).
Many people with insomnia symptoms attempt self-management approaches before presenting to health professionals (e.g. simple ‘sleep hygiene’ techniques; complementary/alternative medicines; consuming different foods/beverages promoted on social media to improve sleep; relaxation breathing exercises).22,23 A state of learned helplessness can develop in people that experience persistent insomnia despite using a large range of remedies that are not effective over the long term.
Many people with long-term insomnia may present with a history of sedative-hypnotic medicine use, and many people with OSA and COMISA may present with a history of previous/current use of continuous positive airway pressure (CPAP) therapy.
It is important for pharmacists to be aware of presenting symptoms of insomnia and OSA, and evidence-based screening, assessment and diagnostic tools for each condition (Table 1). OSA symptoms should be assessed in people with insomnia symptoms, and insomnia symptoms should be assessed in people with suspected or confirmed OSA.24
The ‘gold standard’ measure of OSA presence and severity is an overnight sleep study (Table 1).25 The most common single metric to determine OSA presence and severity is the apnoea-hypopnoea index (AHI), representing the average number of airway narrowing and closure events occurring per hour of sleep.24 Identifying the most appropriate management approaches for OSA also requires consideration of lifestyle factors, symptoms and consequences, occupation, chronic conditions, and other sleep conditions. Self-report questionnaires may be used to screen for a high-risk of OSA and identify patients suitable for referral and consideration of overnight sleep study assessment (Table 1).24
Insomnia, sleep apnoea and COMISA may co-occur with other sleep disorders such as restless legs syndrome and shift work sleep disorder. Circadian misalignment may be a factor in some patients with COMISA.26
Successful management of COMISA can be more difficult than management of either disorder alone, and requires a tailored management approach.20
Pharmacological management
Sedative and hypnotic medicines (e.g. benzodiazepines, non-benzodiazepine hypnotics, off-label antidepressant medicines) are often used in the management of insomnia.28 Although hypnotics provide rapid therapeutic relief from insomnia via increasing sleep duration, they are not the recommended first-line insomnia treatment, and are not recommended for long-term use.29 This is because hypnotics do not target or treat the underlying psycho-behavioural factors that maintain insomnia. Most medicines used for insomnia are associated with adverse effects and risks of adverse events, including psychomotor impairment, falls/fractures, and next-day sedation.29–31 Over time, patterns of short-term therapeutic benefit are often replaced by patterns such as tolerance, long-term dependence and withdrawal symptoms in attempts to reduce use.32 Upon discontinuation of hypnotics, patients may experience insomnia relapse.32 Some sedatives that are used in the management of insomnia may also exacerbate apnoea events in specific patients with OSA.30
Although evidence-based guidelines unanimously recommend avoiding long-term use of hypnotics, they are indicated for a minority of patients that present with severe acute insomnia that is causing significant psychological distress or functional impairment.29 Most people who experience short-term insomnia symptoms (1–2 weeks) can be reassured that sleep will return to ‘normal’ after the underlying precipitant has subsided, without targeted treatment (i.e. hypnotic medicines).29,33 For those who experience persistent insomnia, cognitive behavioural therapy for insomnia (CBTi) is the first-line treatment. Pharmacotherapy may be considered in patients with severe insomnia that is causing significant impairment or distress (e.g. times of acute work/exam stress, bereavement).34
Non-pharmacological management
CBTi is the recommended first-line treatment for insomnia.35 It is effective in people with both acute and chronic insomnia.29,36 CBTi is a multi-component treatment that aims to identify and gradually treat the underlying precipitating triggers and perpetuating factors of long-term insomnia. For this reason, CBTi is often associated with moderate-to-large improvements in insomnia, daytime function and mental health that are sustained long after treatment cessation.37 A recent systematic review and meta-analysis reported that CBTi is an effective treatment for insomnia in the presence of comorbid OSA.38 CBTi is associated with increased daytime sleepiness during the initial stages of bedtime restriction therapy (a core therapeutic component of CBTi), and patients should be warned of feelings of sleepiness while driving or performing other tasks that require sustained attention, and monitored closely.39,40
Although CBTi improves insomnia symptoms in the presence of comorbid OSA,38 depression, anxiety and pain, it is only accessed by approximately 1% of Australian adults with insomnia.28 Access to CBTi may be further reduced in people with COMISA if the OSA is viewed as the ‘primary disorder’ that should be managed before treatment of insomnia, or if there is reservation about referring patients with untreated OSA for sleep restriction therapy (one component of CBTi that aims to temporarily reduce time spent in bed).41
CBTi delivered by a suitably trained and experienced ‘sleep’ psychologist is the ‘gold standard’ form of this treatment.24 Insomnia is an eligible condition for a GP referral to a psychologist, with a mental health treatment plan.42 Evidence-based self-guided digital CBTi programs may also be appropriate for patients with COMISA that are receiving treatment for OSA (e.g. well-controlled on CPAP therapy), with close oversight from a specialist sleep/respiratory clinician.41,43
CPAP therapy is the most effective treatment for OSA.24,44 In a minority of patients with COMISA, CPAP therapy is accepted and improves symptoms of both the insomnia and OSA.9 However, on average, patients with comorbid insomnia are less likely to initially accept a trial of CPAP therapy, and use CPAP therapy for fewer hours per night compared to patients with OSA alone.2,45 Some randomised trials indicate that initial management with CBTi may improve CPAP acceptance and use in patients with COMISA, however this finding is not consistent across all studies.17
Tailored recommendations for non-CPAP therapies may also be provided to patients with different levels of OSA severity and presenting features.17 For example, weight management advice where indicated, positional devices (in the presence of supine-predominant OSA), mandibular advancement splints (in patients with mild-to-moderate OSA), and upper airway surgery are effective treatments that may be tailored to each individual patient.24
Patients with suspected COMISA should be referred to a medical practitioner for further assessment and management.34 After initial assessment, some patients may be initially managed in the primary care setting. The GP may also refer the patient to a specialist sleep and respiratory physician and/or ‘sleep’ psychologist. The Australasian Sleep Association’s Primary Care Sleep Health Resources website lists criteria a GP may use for specialist referral for insomnia and OSA.
Pharmacists should be aware that insomnia and obstructive sleep apnoea (OSA) are the two most prevalent sleep disorders and frequently co-occur.
Pharmacists can use brief evidence-based self-report screening tools to support the identification and referral of patients with suspected insomnia and/or OSA.
If a patient has COMISA, it is important to consider assessment and management/referral options for both conditions. Treatment approaches for OSA can be tailored to each individual’s presenting features. The most effective and recommended ‘first-line’ treatment for insomnia is cognitive behavioural therapy for insomnia (CBTi).
Comorbid insomnia and sleep apnoea (COMISA) is a prevalent and debilitating condition in the Australian population that requires nuanced assessment and management approaches. Pharmacists can play an important role in supporting the identification, assessment, initial management and referral of patients with COMISA, by using brief screening tools and providing information about evidence-based treatment options.
Case scenario continuedYou discuss Carmen’s symptoms further and offer her a 7-item Insomnia Severity Index and the 4-item OSA50 questionnaire to fill in. The results indicate likely long-term symptoms of insomnia and a high risk of undiagnosed OSA. Carmen reports daytime fatigue but no daytime sleepiness. You refer her to a GP for further assessment and explain that the GP may provide a further referral for an overnight sleep study, consultation with a sleep and respiratory physician and a psychologist for CBTi. You explain that CBTi is most effective for treatment of insomnia. Carmen is encouraged that there are non-pharmacological options available and is looking forward to discussing this with her GP. |
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Dr Alexander Sweetman (he/him) PhD
Senior Program Manager, and chair of the psychologist education subcommittee at the Australasian Sleep Association.
Associate Professor Sutapa Mukherjee (she/her) MBBS, FRACP, PhD
Respiratory and sleep physician, Associate Professor of Respiratory and Sleep Medicine at Flinders University and past President of the Australasian Sleep Association.
Professor Garun Hamilton (he/him) MBBS, FRACP, PhD
Respiratory and sleep physician, clinical professor at Monash Health and Monash University and President of the Australasian Sleep Association.
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While Australians are taking fewer antibiotics overall, there are concerns that antimicrobial prescribing is steadily increasing in aged care.
Each year, the Australian Commission on Safety and Quality in Health Care’s Antimicrobial use in the community (AURA) report analyses antimicrobials supplied under the Pharmaceutical Benefits Scheme (PBS) and Repatriation PBS (RPBS) – featuring both antimicrobial use in aged care and by local area.
The latest report, AURA 2023 found that although there has been a small increase of 1.3% in overall antimicrobial use in the community from 2022 to 2023, use is still 24.4% lower than in 2015.
Alarmingly, there has been a stark 11.1% increase in antimicrobial use in residents of aged care homes from 2022 to 2023.
Antimicrobial use is also considerably higher for older Australians who reside in aged care homes than for those living in the community. While just over a third of Australians had at least one antimicrobial dispensed, almost three-quarters of residential aged care facility (RACF) residents received at least one antimicrobial prescription last year.
Australian Pharmacist looks at which antibiotics are most commonly prescribed in aged care, the impacts of high antimicrobial use, and what pharmacists can do to help.
Why is antibiotic prescribing in aged care so high?
There are several reasons why RACF antimicrobial prescribing is higher than in the rest of the community.
[caption id="attachment_24236" align="alignright" width="216"] Professor John Turnidge AO[/caption]
According to infectious diseases physician and microbiologist Professor John Turnidge AO, Senior Medical Advisor, Australian Commission on Safety and Quality in Health Care, these include:
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[post_content] => Melatonin is a naturally occurring hormone responsible for regulating the body’s circadian rhythm. Secretion of melatonin declines during adulthood. Supplemental melatonin can help to reinforce the circadian rhythm, making it useful for treatment of insomnia and jet lag.1
How can pharmacists meet their legal and professional obligations when prescribing melatonin for insomnia?
When prescribing melatonin as a Pharmacist Only medicine, you must establish therapeutic need, determine the medicine is safe for the patient and comply with restrictions of the Schedule 3 listing. This includes that the patient is aged 55 or over and it is for short-term treatment. Routine recording of patient name, address and date of birth supports appropriate provision and is the best way for pharmacists to demonstrate they have met legal and professional obligations.
How long is 'short-term'?
While there is evidence to support the safety and efficacy of melatonin up to 13 weeks,3 patients should be referred to a medical practitioner for review if they require treatment for more than 3 weeks.⁴ Three weeks is consistent with evidence from the pivotal efficacy study noted by the Therapeutic Goods Administration in the final decision to amend melatonin scheduling to Schedule 3.⁵
A patient who has been prescribed melatonin MR 2 mg nightly for 3 months by a medical practitioner presents to the pharmacy seeking a supply as they have run out. What can a pharmacist prescribe?
This pattern of use is not short term, so a pharmacist would not be able to prescribe melatonin within Schedule 3. Other options may apply, such as using emergency supply provisions relating to Schedule 4 medicines. The criteria for emergency supply by a pharmacist, and quantity of medicine able to be supplied, depends on the state or territory in which the pharmacist is practising.
What options are available to pharmacists to treat jet lag?
Despite the inclusion of immediate-release melatonin for jet lag in Schedule 3 of the Poisons Standard, at the time of writing, there is no commercially available immediate-release product in Australia which can be prescribed as a Pharmacist Only medicine. Pharmacists may compound an immediate-release preparation that contains 5 mg or less of melatonin when a particular person requests this medicine. If a commercial product becomes available, compounding would no longer be appropriate. Patients should be advised to avoid purchasing melatonin via the internet because the melatonin content may be unreliable.6
Poisons Standard Schedule 3 entry for melatonin7
MELATONIN in:
(a) modified release tablets containing 2 mg or less of melatonin for monotherapy for the short-term treatment of primary insomnia characterised by poor quality of sleep for adults aged 55 or over, in packs containing not more than 30 tablets; or
(b) immediate release preparations containing 5 mg or less of melatonin for the treatment of jet lag in adults 18 years and over, in a primary pack containing no more than 10 dosage units.
References
1. Goldstein, CA. Overview of circadian rhythm sleep-wake disorders. UpToDate [updated Dec 2023]. At: https://sso.uptodate.com/contents/overview-of-circadian-rhythm-sleep-wake-disorders?search=melatonin&source=search_result&selectedTitle=3%7E113&usage_type=default&display_rank=3
2. Insomnia in adults. Therapeutic guidelines [updated Mar 2021]. At: https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Psychotropic&topicfile=insomnia-adults
3. Treatment guidelines for pharmacists: insomnia. In: Sansom LN, ed. Australian pharmaceutical formulary and handbook. 26th edn. Canberra: Pharmaceutical Society of Australia; 2024.
4. Therapeutic Goods Administration. Notice of final decision to amend the current Poisons Standard in relation to melatonin. 2020. At: www.tga.gov.au/resources/publication/scheduling-decisions-final/notice-final-decision-amend-current-poisons-standard-relation-melatonin
5. Pharmacy Board of Australia. FAQ – For pharmacists on the compounding of medicines. At: www.pharmacyboard.gov.au/documents/default.aspx?record=WD15%2f16635&dbid=AP&chksum=rE0qmZcEafURzzXc3NBiuA%3d%3d
6. Therapeutic Goods Administration. Notice of interim decision to amend (or not amend) the current Poisons Standard. 2023. At: www.tga.gov.au/sites/default/files/2023-10/notice-interim-decisions-amend-not-amend-the-current-poisons-standard.pdf
7. Therapeutic Goods (Poisons Standard – June 2024) Instrument 2024. At: www.legislation.gov.au/F2024L00589/latest/text (edited)
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[post_content] => Sleep is a hot topic for Anousheh Page MPS, Director of Pharmacy at Brisbane’s only 24-hour pharmacy.
Why did you choose pharmacy?
Becoming a pharmacist was actually one of three options on my university application. At the time, all I really knew was that I enjoyed science-based subjects at school and also helping people (natural Virgo at heart, of course!). When it came to the pros and cons list, pharmacy felt like the best option. And I don’t have any regrets.
I absolutely love being a pharmacist. I completed a Bachelor of Pharmacy at the University of Sydney and can honestly say my university experience was the best of all time, which reinforced my choice to become a pharmacist.
What led you to your current role?
I knew whilst completing my pharmacy degree that I always wanted to work within a hospital environment. My pharmacy career in hospital began after completing my internship at the Children’s Hospital, Westmead, in Sydney. In 2007, I was moving back from a hospital role on the South Coast of New South Wales when I saw a Pharmacist In Charge role advertised for Kareena Private Hospital (God’s country, aka the Sutherland Shire in southern Sydney). I was fortunate enough to be offered the role. Working within any Ramsay Health Care facility never feels like work. The hospital staff become your adopted family and you work within a well-supported multidisciplinary team. I gained experience within multiple Ramsay Hospitals and eventually landed Director of Pharmacy at Greenslopes Private Hospital.
How do you and your staff cope with the late-night and overnight hours?
In general, staff cope very well and have an amazing ability to adapt to the various hours. There is a good balance of work which flows through the hospital inpatient stream but is also complemented by the variety of community patients that come through. I personally would sleep a few hours before a shift if I knew I had to cover an overnight. Like most, I would stay awake and try and get back to a normal sleep routine for the next shift.
What are common requests from patients who visit in the wee small hours?
Patients do often come in for sleep issues at night, however what stands out the most are patients who request salbutamol inhalers. Every night can be different depending on the day of the week, but the most consistent request is salbutamol. We have had patients coming from areas like the Gold Coast or even Mount Barney (130 kilometres south-east of Brisbane, population less than 50). This really highlights the opportunity pharmacists have to be able to deliver full-scope activities such as improved asthma management – including developing an asthma action plan – particularly outside standard business hours. The second-most common would be the management of acute illnesses to treat gastroenteritis or flu-like symptoms. We have many local public facilities surrounding Greenslopes, including our own emergency department, so we service lots of patients requiring after-hours medicines.
What are your strategies to deal with barriers to overnight care?
In most scenarios we would just use our experience and clinical judgment when helping patients. Working an overnight shift is similar to working a weekend shift in some respects, so we are very accustomed to managing or referring when necessary. We are also fortunate to work in an area with late-opening medical centres and local emergency centres. This allows us to refer patients who require further review. QScript (Queensland’s real-time prescription monitoring system) has also been a game changer in helping provide better support and clinical judgement for dispensing high-risk medicines; this had often been a challenge when working outside normal hours in pharmacy.
If you could change anything about your 24-hour pharmacy, what would it be?
Coffee is the gift that keeps on giving. A barista-made coffee on hand at any hour wouldn’t be too much to ask, would it?
What’s your advice for ECPs?
It’s important to work in an environment you love. Surrounded by the right team and environment can absolutely make the difference on how you approach work. If you dread work or feel anxious before the work week, you’re not in the right job.
A day in the life of Anousheh Page MPS, Director of Pharmacy, Greenslopes Private Hospital, QLD
| 4.30 am |
Up and at it Never in my life did I think I would be one of those early morning risers to hit the gym, but the pandemic forced a change and that schedule gets me mentally prepared for the day. |
| 7.30 am |
Handover time A double-shot of cappuccino in hand, my day begins with a handover between the 24-hour retail pharmacy and hospital dispensary team. Urgent action might be needed on alteplase orders to replace stock used overnight for a stroke patient in ED, or ensuring discharge medicines that were completed are given to that ward’s pharmacist for patient counselling. |
| 8.30 am |
Hospital bed managers’ meeting Meeting daily with the ward and other multidisciplinary hospital team managers helps me reallocate pharmacy staff to areas that need support i.e. for timely discharges or immediate communication if a regular pharmacy staff member is on leave. On Thank You Thursdays, meetings end by nominating a team member deserving of recognition, who later receives a card and lunch voucher from the hospital executive team. |
| 9.30 am |
Current shortages Next meeting addresses state shortages – this time its fluids. This entails direct contact with other Ramsay Queensland hospitals via the state procurement manager who organises a consistent supply of fluids, such as saline. |
| 10 am – 4 pm |
Daily challenges Every work day is different. Overseeing a 24-hour pharmacy that never closes requires being prepared for anything, and problem-solving is a strong skill set in my role. If I have multiple staff on leave with the spread of colds and flu, I actively help cover an area, (which has helped me be a better manager with greater knowledge of what shifts entail or how wards operate). Urgent deliveries of home IV antibiotics for patients and expensive IV anti-fungals at short notice are part of it. |
| 4.00 pm |
Home time I start my second job, which could ideally be a paid Uber driver, but is actually driving my children to their various daily extracurricular activities. At least I’m off my feet! |
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[post_content] => It was World Patient Safety Day on 17 September, with this year’s theme around improving diagnosis for patient safety.
Australian Pharmacist examines three health conditions where diagnosis is commonly delayed, incorrect, or missed – and pharmacists’ important role in ensuring an accurate and timely diagnosis to improve treatment outcomes.
COPD is significantly underdiagnosed
Around 50% of people living with Chronic Obstructive Pulmonary Disorder (COPD) are estimated to be undiagnosed.
While patient symptoms and a physical examination can support diagnosis, full spirometry is required to diagnose the condition correctly, said Advanced Practice Pharmacist Associate Professor Debbie Rigby FPS, head of PSA’s Respiratory Care Community of Specialty Interest.
[caption id="attachment_25619" align="alignright" width="270"] Associate Professor Debbie Rigby FPS[/caption]
‘There are many other respiratory conditions that can present as symptoms of COPD such as wheeze, shortness of breath, chest tightness, chronic cough and poor exercise intolerance – including asthma,’ she said.
An additional layer of complexity is the stigma associated with COPD, which is commonly perceived as a disease solely caused by cigarette smoking.
‘However, we know that around 30% of people diagnosed with COPD have never smoked a cigarette,’ said A/Prof Rigby. ‘There are many other factors, including genetic [predisposition] and environmental exposures that can lead to COPD.’
Because of the high rate of underdiagnosis of COPD, the condition is often undertreated.
‘It’s important to appropriately treat COPD, because although it can’t be cured, we can slow the progression in decline in lung function with medications as well as non-pharmacological treatments such as pulmonary rehab,’ she said.
The Lung Foundation Australia’s Lung Health Checklist can help pharmacists identify people who are at risk for COPD, looking at factors such as:
Nicolette Ellis MPS[/caption]
‘The National Pain Report 2024 highlights that while it takes an average of 3 years to diagnose a chronic pain condition, endometriosis typically takes 7–9 years to diagnose,’ she said.
‘This delay is largely due to a lack of education, awareness, and the fact that it can only be definitively diagnosed through invasive laparoscopy.’
However, timely diagnosis is crucial for managing pain and preventing its escalation.
‘Early detection improves outcomes, reducing the physical and emotional toll on patients,’ said Ms Ellis. ‘Delayed diagnosis often leads to feelings of dismissal, with many told the pain is "all in their head," further worsening the vicious cycle of chronic pain.’
Pharmacists should be aware that endometriosis can present with a wide range of symptoms, including:
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[post_content] => Case scenario
Carmen, 54 years old, presents to the pharmacy reporting sleep difficulties. She reports poor sleep quality and daytime exhaustion that started about 6 months ago.
[caption id="attachment_27236" align="alignright" width="297"] A national education program for pharmacists funded by the Australian Government under the Quality Use of Diagnostics, Therapeutics and Pathology program.[/caption]
She has no history of medicine use for sleep but would like information on the different medicines that are available. You ask Carmen about the specific sleep symptoms that she is experiencing, including her sleep patterns and symptoms of sleep disorders. She is not on any regular medicines.
After reading this article, pharmacists should be able to:
|
Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.
Insomnia and obstructive sleep apnoea (OSA) are the two most prevalent sleep disorders and frequently co-exist.1 Comorbid insomnia and sleep apnoea (COMISA) is a prevalent and debilitating condition in Australia.2 This article presents information on evidence-based assessment tools, pharmacological and non-pharmacological management, and referral options for patients with COMISA.
Insomnia is defined as self-reported difficulties falling asleep, maintaining sleep, and/or early morning awakenings from sleep on at least three nights per week, with associated daytime impairment.1,3 It is estimated that 10–15% of adults at any given time have chronic insomnia (≥3 month duration).4,5 Insomnia is associated with reduced quality of life and an increased risk of depression.6 When occurring in the presence of other mental and physical health conditions, insomnia should be viewed as a ‘comorbid’ disorder that requires targeted assessment and management.7
OSA is characterised by frequent narrowing and/or closure of the upper airway during sleep, resulting in hypoxemia, hypercapnia and awakenings from sleep.1,3,8 Approximately 10% of the general population experience moderate-to-severe OSA at any given time.9 OSA is more prevalent in males than females, however some studies indicate that this equalises around the time of menopause.10 OSA is also associated with daytime impairments, risk of sleepiness-related accidents, and risk of cardiovascular disease, cognitive impairment and depression.8,10,11
Both these disorders can occur separately, but if they co-occur, this is termed COMISA. Approximately 30–50% of people with OSA have comorbid insomnia, and 30–40% of people with chronic insomnia have comorbid OSA.9,12 A recent population-based study reported that 11% of Australian adults report symptoms of COMISA.13
Some models of insomnia suggest that insomnia results from14:
In people with chronic insomnia, a state of ‘conditioned insomnia’ can develop, whereby the bed or bedroom environment becomes a conditioned stimuli for a state of alertness/worry/wakefulness.15 Short-term insomnia can initially result from different mental and physical stressors (i.e. the precipitant), however insomnia can rapidly develop functional independence of these precipitating triggers and become maintained by specific psycho-behavioural processes (perpetuating factors and a state of conditioned insomnia).16
The most consistent risk factors for OSA are increasing age, overweight/obesity, male sex,11 cranio-facial abnormality and adenotonsillar hypertrophy.
Pharmacists should avoid viewing insomnia as a ‘secondary symptom’ of other mental and physical health conditions.1 In the context of COMISA, insomnia symptoms may initially result from untreated OSA, however insomnia can quickly develop functional independence of the OSA and become maintained by insomnia-specific perpetuating factors.1
People with COMISA experience impaired sleep, daytime functioning, mental health, physical health and quality of life, compared to people with neither condition. COMISA is often associated with greater impairment across these domains, compared to people with either disorder alone.1,17,18 COMISA is associated with a 50–70% increased risk of all-cause mortality compared over 10–20 years of follow-up, potentially due to mental and physical health consequences or misdiagnosis and reduced treatment acceptance.2,18–21
People with COMISA may present with a general complaint of sleep dissatisfaction, specific insomnia symptoms, obvious manifestations of OSA (e.g. witnessed breathing pauses, choking awakenings, loud snoring), or daytime impairment (e.g. fatigue, lethargy, irritability).
Many people with insomnia symptoms attempt self-management approaches before presenting to health professionals (e.g. simple ‘sleep hygiene’ techniques; complementary/alternative medicines; consuming different foods/beverages promoted on social media to improve sleep; relaxation breathing exercises).22,23 A state of learned helplessness can develop in people that experience persistent insomnia despite using a large range of remedies that are not effective over the long term.
Many people with long-term insomnia may present with a history of sedative-hypnotic medicine use, and many people with OSA and COMISA may present with a history of previous/current use of continuous positive airway pressure (CPAP) therapy.
It is important for pharmacists to be aware of presenting symptoms of insomnia and OSA, and evidence-based screening, assessment and diagnostic tools for each condition (Table 1). OSA symptoms should be assessed in people with insomnia symptoms, and insomnia symptoms should be assessed in people with suspected or confirmed OSA.24
The ‘gold standard’ measure of OSA presence and severity is an overnight sleep study (Table 1).25 The most common single metric to determine OSA presence and severity is the apnoea-hypopnoea index (AHI), representing the average number of airway narrowing and closure events occurring per hour of sleep.24 Identifying the most appropriate management approaches for OSA also requires consideration of lifestyle factors, symptoms and consequences, occupation, chronic conditions, and other sleep conditions. Self-report questionnaires may be used to screen for a high-risk of OSA and identify patients suitable for referral and consideration of overnight sleep study assessment (Table 1).24
Insomnia, sleep apnoea and COMISA may co-occur with other sleep disorders such as restless legs syndrome and shift work sleep disorder. Circadian misalignment may be a factor in some patients with COMISA.26
Successful management of COMISA can be more difficult than management of either disorder alone, and requires a tailored management approach.20
Pharmacological management
Sedative and hypnotic medicines (e.g. benzodiazepines, non-benzodiazepine hypnotics, off-label antidepressant medicines) are often used in the management of insomnia.28 Although hypnotics provide rapid therapeutic relief from insomnia via increasing sleep duration, they are not the recommended first-line insomnia treatment, and are not recommended for long-term use.29 This is because hypnotics do not target or treat the underlying psycho-behavioural factors that maintain insomnia. Most medicines used for insomnia are associated with adverse effects and risks of adverse events, including psychomotor impairment, falls/fractures, and next-day sedation.29–31 Over time, patterns of short-term therapeutic benefit are often replaced by patterns such as tolerance, long-term dependence and withdrawal symptoms in attempts to reduce use.32 Upon discontinuation of hypnotics, patients may experience insomnia relapse.32 Some sedatives that are used in the management of insomnia may also exacerbate apnoea events in specific patients with OSA.30
Although evidence-based guidelines unanimously recommend avoiding long-term use of hypnotics, they are indicated for a minority of patients that present with severe acute insomnia that is causing significant psychological distress or functional impairment.29 Most people who experience short-term insomnia symptoms (1–2 weeks) can be reassured that sleep will return to ‘normal’ after the underlying precipitant has subsided, without targeted treatment (i.e. hypnotic medicines).29,33 For those who experience persistent insomnia, cognitive behavioural therapy for insomnia (CBTi) is the first-line treatment. Pharmacotherapy may be considered in patients with severe insomnia that is causing significant impairment or distress (e.g. times of acute work/exam stress, bereavement).34
Non-pharmacological management
CBTi is the recommended first-line treatment for insomnia.35 It is effective in people with both acute and chronic insomnia.29,36 CBTi is a multi-component treatment that aims to identify and gradually treat the underlying precipitating triggers and perpetuating factors of long-term insomnia. For this reason, CBTi is often associated with moderate-to-large improvements in insomnia, daytime function and mental health that are sustained long after treatment cessation.37 A recent systematic review and meta-analysis reported that CBTi is an effective treatment for insomnia in the presence of comorbid OSA.38 CBTi is associated with increased daytime sleepiness during the initial stages of bedtime restriction therapy (a core therapeutic component of CBTi), and patients should be warned of feelings of sleepiness while driving or performing other tasks that require sustained attention, and monitored closely.39,40
Although CBTi improves insomnia symptoms in the presence of comorbid OSA,38 depression, anxiety and pain, it is only accessed by approximately 1% of Australian adults with insomnia.28 Access to CBTi may be further reduced in people with COMISA if the OSA is viewed as the ‘primary disorder’ that should be managed before treatment of insomnia, or if there is reservation about referring patients with untreated OSA for sleep restriction therapy (one component of CBTi that aims to temporarily reduce time spent in bed).41
CBTi delivered by a suitably trained and experienced ‘sleep’ psychologist is the ‘gold standard’ form of this treatment.24 Insomnia is an eligible condition for a GP referral to a psychologist, with a mental health treatment plan.42 Evidence-based self-guided digital CBTi programs may also be appropriate for patients with COMISA that are receiving treatment for OSA (e.g. well-controlled on CPAP therapy), with close oversight from a specialist sleep/respiratory clinician.41,43
CPAP therapy is the most effective treatment for OSA.24,44 In a minority of patients with COMISA, CPAP therapy is accepted and improves symptoms of both the insomnia and OSA.9 However, on average, patients with comorbid insomnia are less likely to initially accept a trial of CPAP therapy, and use CPAP therapy for fewer hours per night compared to patients with OSA alone.2,45 Some randomised trials indicate that initial management with CBTi may improve CPAP acceptance and use in patients with COMISA, however this finding is not consistent across all studies.17
Tailored recommendations for non-CPAP therapies may also be provided to patients with different levels of OSA severity and presenting features.17 For example, weight management advice where indicated, positional devices (in the presence of supine-predominant OSA), mandibular advancement splints (in patients with mild-to-moderate OSA), and upper airway surgery are effective treatments that may be tailored to each individual patient.24
Patients with suspected COMISA should be referred to a medical practitioner for further assessment and management.34 After initial assessment, some patients may be initially managed in the primary care setting. The GP may also refer the patient to a specialist sleep and respiratory physician and/or ‘sleep’ psychologist. The Australasian Sleep Association’s Primary Care Sleep Health Resources website lists criteria a GP may use for specialist referral for insomnia and OSA.
Pharmacists should be aware that insomnia and obstructive sleep apnoea (OSA) are the two most prevalent sleep disorders and frequently co-occur.
Pharmacists can use brief evidence-based self-report screening tools to support the identification and referral of patients with suspected insomnia and/or OSA.
If a patient has COMISA, it is important to consider assessment and management/referral options for both conditions. Treatment approaches for OSA can be tailored to each individual’s presenting features. The most effective and recommended ‘first-line’ treatment for insomnia is cognitive behavioural therapy for insomnia (CBTi).
Comorbid insomnia and sleep apnoea (COMISA) is a prevalent and debilitating condition in the Australian population that requires nuanced assessment and management approaches. Pharmacists can play an important role in supporting the identification, assessment, initial management and referral of patients with COMISA, by using brief screening tools and providing information about evidence-based treatment options.
Case scenario continuedYou discuss Carmen’s symptoms further and offer her a 7-item Insomnia Severity Index and the 4-item OSA50 questionnaire to fill in. The results indicate likely long-term symptoms of insomnia and a high risk of undiagnosed OSA. Carmen reports daytime fatigue but no daytime sleepiness. You refer her to a GP for further assessment and explain that the GP may provide a further referral for an overnight sleep study, consultation with a sleep and respiratory physician and a psychologist for CBTi. You explain that CBTi is most effective for treatment of insomnia. Carmen is encouraged that there are non-pharmacological options available and is looking forward to discussing this with her GP. |
[cpd_submit_answer_button]
Dr Alexander Sweetman (he/him) PhD
Senior Program Manager, and chair of the psychologist education subcommittee at the Australasian Sleep Association.
Associate Professor Sutapa Mukherjee (she/her) MBBS, FRACP, PhD
Respiratory and sleep physician, Associate Professor of Respiratory and Sleep Medicine at Flinders University and past President of the Australasian Sleep Association.
Professor Garun Hamilton (he/him) MBBS, FRACP, PhD
Respiratory and sleep physician, clinical professor at Monash Health and Monash University and President of the Australasian Sleep Association.
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While Australians are taking fewer antibiotics overall, there are concerns that antimicrobial prescribing is steadily increasing in aged care.
Each year, the Australian Commission on Safety and Quality in Health Care’s Antimicrobial use in the community (AURA) report analyses antimicrobials supplied under the Pharmaceutical Benefits Scheme (PBS) and Repatriation PBS (RPBS) – featuring both antimicrobial use in aged care and by local area.
The latest report, AURA 2023 found that although there has been a small increase of 1.3% in overall antimicrobial use in the community from 2022 to 2023, use is still 24.4% lower than in 2015.
Alarmingly, there has been a stark 11.1% increase in antimicrobial use in residents of aged care homes from 2022 to 2023.
Antimicrobial use is also considerably higher for older Australians who reside in aged care homes than for those living in the community. While just over a third of Australians had at least one antimicrobial dispensed, almost three-quarters of residential aged care facility (RACF) residents received at least one antimicrobial prescription last year.
Australian Pharmacist looks at which antibiotics are most commonly prescribed in aged care, the impacts of high antimicrobial use, and what pharmacists can do to help.
Why is antibiotic prescribing in aged care so high?
There are several reasons why RACF antimicrobial prescribing is higher than in the rest of the community.
[caption id="attachment_24236" align="alignright" width="216"] Professor John Turnidge AO[/caption]
According to infectious diseases physician and microbiologist Professor John Turnidge AO, Senior Medical Advisor, Australian Commission on Safety and Quality in Health Care, these include:
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[post_content] => Melatonin is a naturally occurring hormone responsible for regulating the body’s circadian rhythm. Secretion of melatonin declines during adulthood. Supplemental melatonin can help to reinforce the circadian rhythm, making it useful for treatment of insomnia and jet lag.1
How can pharmacists meet their legal and professional obligations when prescribing melatonin for insomnia?
When prescribing melatonin as a Pharmacist Only medicine, you must establish therapeutic need, determine the medicine is safe for the patient and comply with restrictions of the Schedule 3 listing. This includes that the patient is aged 55 or over and it is for short-term treatment. Routine recording of patient name, address and date of birth supports appropriate provision and is the best way for pharmacists to demonstrate they have met legal and professional obligations.
How long is 'short-term'?
While there is evidence to support the safety and efficacy of melatonin up to 13 weeks,3 patients should be referred to a medical practitioner for review if they require treatment for more than 3 weeks.⁴ Three weeks is consistent with evidence from the pivotal efficacy study noted by the Therapeutic Goods Administration in the final decision to amend melatonin scheduling to Schedule 3.⁵
A patient who has been prescribed melatonin MR 2 mg nightly for 3 months by a medical practitioner presents to the pharmacy seeking a supply as they have run out. What can a pharmacist prescribe?
This pattern of use is not short term, so a pharmacist would not be able to prescribe melatonin within Schedule 3. Other options may apply, such as using emergency supply provisions relating to Schedule 4 medicines. The criteria for emergency supply by a pharmacist, and quantity of medicine able to be supplied, depends on the state or territory in which the pharmacist is practising.
What options are available to pharmacists to treat jet lag?
Despite the inclusion of immediate-release melatonin for jet lag in Schedule 3 of the Poisons Standard, at the time of writing, there is no commercially available immediate-release product in Australia which can be prescribed as a Pharmacist Only medicine. Pharmacists may compound an immediate-release preparation that contains 5 mg or less of melatonin when a particular person requests this medicine. If a commercial product becomes available, compounding would no longer be appropriate. Patients should be advised to avoid purchasing melatonin via the internet because the melatonin content may be unreliable.6
Poisons Standard Schedule 3 entry for melatonin7
MELATONIN in:
(a) modified release tablets containing 2 mg or less of melatonin for monotherapy for the short-term treatment of primary insomnia characterised by poor quality of sleep for adults aged 55 or over, in packs containing not more than 30 tablets; or
(b) immediate release preparations containing 5 mg or less of melatonin for the treatment of jet lag in adults 18 years and over, in a primary pack containing no more than 10 dosage units.
References
1. Goldstein, CA. Overview of circadian rhythm sleep-wake disorders. UpToDate [updated Dec 2023]. At: https://sso.uptodate.com/contents/overview-of-circadian-rhythm-sleep-wake-disorders?search=melatonin&source=search_result&selectedTitle=3%7E113&usage_type=default&display_rank=3
2. Insomnia in adults. Therapeutic guidelines [updated Mar 2021]. At: https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Psychotropic&topicfile=insomnia-adults
3. Treatment guidelines for pharmacists: insomnia. In: Sansom LN, ed. Australian pharmaceutical formulary and handbook. 26th edn. Canberra: Pharmaceutical Society of Australia; 2024.
4. Therapeutic Goods Administration. Notice of final decision to amend the current Poisons Standard in relation to melatonin. 2020. At: www.tga.gov.au/resources/publication/scheduling-decisions-final/notice-final-decision-amend-current-poisons-standard-relation-melatonin
5. Pharmacy Board of Australia. FAQ – For pharmacists on the compounding of medicines. At: www.pharmacyboard.gov.au/documents/default.aspx?record=WD15%2f16635&dbid=AP&chksum=rE0qmZcEafURzzXc3NBiuA%3d%3d
6. Therapeutic Goods Administration. Notice of interim decision to amend (or not amend) the current Poisons Standard. 2023. At: www.tga.gov.au/sites/default/files/2023-10/notice-interim-decisions-amend-not-amend-the-current-poisons-standard.pdf
7. Therapeutic Goods (Poisons Standard – June 2024) Instrument 2024. At: www.legislation.gov.au/F2024L00589/latest/text (edited)
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[post_content] => Sleep is a hot topic for Anousheh Page MPS, Director of Pharmacy at Brisbane’s only 24-hour pharmacy.
Why did you choose pharmacy?
Becoming a pharmacist was actually one of three options on my university application. At the time, all I really knew was that I enjoyed science-based subjects at school and also helping people (natural Virgo at heart, of course!). When it came to the pros and cons list, pharmacy felt like the best option. And I don’t have any regrets.
I absolutely love being a pharmacist. I completed a Bachelor of Pharmacy at the University of Sydney and can honestly say my university experience was the best of all time, which reinforced my choice to become a pharmacist.
What led you to your current role?
I knew whilst completing my pharmacy degree that I always wanted to work within a hospital environment. My pharmacy career in hospital began after completing my internship at the Children’s Hospital, Westmead, in Sydney. In 2007, I was moving back from a hospital role on the South Coast of New South Wales when I saw a Pharmacist In Charge role advertised for Kareena Private Hospital (God’s country, aka the Sutherland Shire in southern Sydney). I was fortunate enough to be offered the role. Working within any Ramsay Health Care facility never feels like work. The hospital staff become your adopted family and you work within a well-supported multidisciplinary team. I gained experience within multiple Ramsay Hospitals and eventually landed Director of Pharmacy at Greenslopes Private Hospital.
How do you and your staff cope with the late-night and overnight hours?
In general, staff cope very well and have an amazing ability to adapt to the various hours. There is a good balance of work which flows through the hospital inpatient stream but is also complemented by the variety of community patients that come through. I personally would sleep a few hours before a shift if I knew I had to cover an overnight. Like most, I would stay awake and try and get back to a normal sleep routine for the next shift.
What are common requests from patients who visit in the wee small hours?
Patients do often come in for sleep issues at night, however what stands out the most are patients who request salbutamol inhalers. Every night can be different depending on the day of the week, but the most consistent request is salbutamol. We have had patients coming from areas like the Gold Coast or even Mount Barney (130 kilometres south-east of Brisbane, population less than 50). This really highlights the opportunity pharmacists have to be able to deliver full-scope activities such as improved asthma management – including developing an asthma action plan – particularly outside standard business hours. The second-most common would be the management of acute illnesses to treat gastroenteritis or flu-like symptoms. We have many local public facilities surrounding Greenslopes, including our own emergency department, so we service lots of patients requiring after-hours medicines.
What are your strategies to deal with barriers to overnight care?
In most scenarios we would just use our experience and clinical judgment when helping patients. Working an overnight shift is similar to working a weekend shift in some respects, so we are very accustomed to managing or referring when necessary. We are also fortunate to work in an area with late-opening medical centres and local emergency centres. This allows us to refer patients who require further review. QScript (Queensland’s real-time prescription monitoring system) has also been a game changer in helping provide better support and clinical judgement for dispensing high-risk medicines; this had often been a challenge when working outside normal hours in pharmacy.
If you could change anything about your 24-hour pharmacy, what would it be?
Coffee is the gift that keeps on giving. A barista-made coffee on hand at any hour wouldn’t be too much to ask, would it?
What’s your advice for ECPs?
It’s important to work in an environment you love. Surrounded by the right team and environment can absolutely make the difference on how you approach work. If you dread work or feel anxious before the work week, you’re not in the right job.
A day in the life of Anousheh Page MPS, Director of Pharmacy, Greenslopes Private Hospital, QLD
| 4.30 am |
Up and at it Never in my life did I think I would be one of those early morning risers to hit the gym, but the pandemic forced a change and that schedule gets me mentally prepared for the day. |
| 7.30 am |
Handover time A double-shot of cappuccino in hand, my day begins with a handover between the 24-hour retail pharmacy and hospital dispensary team. Urgent action might be needed on alteplase orders to replace stock used overnight for a stroke patient in ED, or ensuring discharge medicines that were completed are given to that ward’s pharmacist for patient counselling. |
| 8.30 am |
Hospital bed managers’ meeting Meeting daily with the ward and other multidisciplinary hospital team managers helps me reallocate pharmacy staff to areas that need support i.e. for timely discharges or immediate communication if a regular pharmacy staff member is on leave. On Thank You Thursdays, meetings end by nominating a team member deserving of recognition, who later receives a card and lunch voucher from the hospital executive team. |
| 9.30 am |
Current shortages Next meeting addresses state shortages – this time its fluids. This entails direct contact with other Ramsay Queensland hospitals via the state procurement manager who organises a consistent supply of fluids, such as saline. |
| 10 am – 4 pm |
Daily challenges Every work day is different. Overseeing a 24-hour pharmacy that never closes requires being prepared for anything, and problem-solving is a strong skill set in my role. If I have multiple staff on leave with the spread of colds and flu, I actively help cover an area, (which has helped me be a better manager with greater knowledge of what shifts entail or how wards operate). Urgent deliveries of home IV antibiotics for patients and expensive IV anti-fungals at short notice are part of it. |
| 4.00 pm |
Home time I start my second job, which could ideally be a paid Uber driver, but is actually driving my children to their various daily extracurricular activities. At least I’m off my feet! |
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[post_content] => It was World Patient Safety Day on 17 September, with this year’s theme around improving diagnosis for patient safety.
Australian Pharmacist examines three health conditions where diagnosis is commonly delayed, incorrect, or missed – and pharmacists’ important role in ensuring an accurate and timely diagnosis to improve treatment outcomes.
COPD is significantly underdiagnosed
Around 50% of people living with Chronic Obstructive Pulmonary Disorder (COPD) are estimated to be undiagnosed.
While patient symptoms and a physical examination can support diagnosis, full spirometry is required to diagnose the condition correctly, said Advanced Practice Pharmacist Associate Professor Debbie Rigby FPS, head of PSA’s Respiratory Care Community of Specialty Interest.
[caption id="attachment_25619" align="alignright" width="270"] Associate Professor Debbie Rigby FPS[/caption]
‘There are many other respiratory conditions that can present as symptoms of COPD such as wheeze, shortness of breath, chest tightness, chronic cough and poor exercise intolerance – including asthma,’ she said.
An additional layer of complexity is the stigma associated with COPD, which is commonly perceived as a disease solely caused by cigarette smoking.
‘However, we know that around 30% of people diagnosed with COPD have never smoked a cigarette,’ said A/Prof Rigby. ‘There are many other factors, including genetic [predisposition] and environmental exposures that can lead to COPD.’
Because of the high rate of underdiagnosis of COPD, the condition is often undertreated.
‘It’s important to appropriately treat COPD, because although it can’t be cured, we can slow the progression in decline in lung function with medications as well as non-pharmacological treatments such as pulmonary rehab,’ she said.
The Lung Foundation Australia’s Lung Health Checklist can help pharmacists identify people who are at risk for COPD, looking at factors such as:
Nicolette Ellis MPS[/caption]
‘The National Pain Report 2024 highlights that while it takes an average of 3 years to diagnose a chronic pain condition, endometriosis typically takes 7–9 years to diagnose,’ she said.
‘This delay is largely due to a lack of education, awareness, and the fact that it can only be definitively diagnosed through invasive laparoscopy.’
However, timely diagnosis is crucial for managing pain and preventing its escalation.
‘Early detection improves outcomes, reducing the physical and emotional toll on patients,’ said Ms Ellis. ‘Delayed diagnosis often leads to feelings of dismissal, with many told the pain is "all in their head," further worsening the vicious cycle of chronic pain.’
Pharmacists should be aware that endometriosis can present with a wide range of symptoms, including:
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[post_content] => Case scenario
Carmen, 54 years old, presents to the pharmacy reporting sleep difficulties. She reports poor sleep quality and daytime exhaustion that started about 6 months ago.
[caption id="attachment_27236" align="alignright" width="297"] A national education program for pharmacists funded by the Australian Government under the Quality Use of Diagnostics, Therapeutics and Pathology program.[/caption]
She has no history of medicine use for sleep but would like information on the different medicines that are available. You ask Carmen about the specific sleep symptoms that she is experiencing, including her sleep patterns and symptoms of sleep disorders. She is not on any regular medicines.
After reading this article, pharmacists should be able to:
|
Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.
Insomnia and obstructive sleep apnoea (OSA) are the two most prevalent sleep disorders and frequently co-exist.1 Comorbid insomnia and sleep apnoea (COMISA) is a prevalent and debilitating condition in Australia.2 This article presents information on evidence-based assessment tools, pharmacological and non-pharmacological management, and referral options for patients with COMISA.
Insomnia is defined as self-reported difficulties falling asleep, maintaining sleep, and/or early morning awakenings from sleep on at least three nights per week, with associated daytime impairment.1,3 It is estimated that 10–15% of adults at any given time have chronic insomnia (≥3 month duration).4,5 Insomnia is associated with reduced quality of life and an increased risk of depression.6 When occurring in the presence of other mental and physical health conditions, insomnia should be viewed as a ‘comorbid’ disorder that requires targeted assessment and management.7
OSA is characterised by frequent narrowing and/or closure of the upper airway during sleep, resulting in hypoxemia, hypercapnia and awakenings from sleep.1,3,8 Approximately 10% of the general population experience moderate-to-severe OSA at any given time.9 OSA is more prevalent in males than females, however some studies indicate that this equalises around the time of menopause.10 OSA is also associated with daytime impairments, risk of sleepiness-related accidents, and risk of cardiovascular disease, cognitive impairment and depression.8,10,11
Both these disorders can occur separately, but if they co-occur, this is termed COMISA. Approximately 30–50% of people with OSA have comorbid insomnia, and 30–40% of people with chronic insomnia have comorbid OSA.9,12 A recent population-based study reported that 11% of Australian adults report symptoms of COMISA.13
Some models of insomnia suggest that insomnia results from14:
In people with chronic insomnia, a state of ‘conditioned insomnia’ can develop, whereby the bed or bedroom environment becomes a conditioned stimuli for a state of alertness/worry/wakefulness.15 Short-term insomnia can initially result from different mental and physical stressors (i.e. the precipitant), however insomnia can rapidly develop functional independence of these precipitating triggers and become maintained by specific psycho-behavioural processes (perpetuating factors and a state of conditioned insomnia).16
The most consistent risk factors for OSA are increasing age, overweight/obesity, male sex,11 cranio-facial abnormality and adenotonsillar hypertrophy.
Pharmacists should avoid viewing insomnia as a ‘secondary symptom’ of other mental and physical health conditions.1 In the context of COMISA, insomnia symptoms may initially result from untreated OSA, however insomnia can quickly develop functional independence of the OSA and become maintained by insomnia-specific perpetuating factors.1
People with COMISA experience impaired sleep, daytime functioning, mental health, physical health and quality of life, compared to people with neither condition. COMISA is often associated with greater impairment across these domains, compared to people with either disorder alone.1,17,18 COMISA is associated with a 50–70% increased risk of all-cause mortality compared over 10–20 years of follow-up, potentially due to mental and physical health consequences or misdiagnosis and reduced treatment acceptance.2,18–21
People with COMISA may present with a general complaint of sleep dissatisfaction, specific insomnia symptoms, obvious manifestations of OSA (e.g. witnessed breathing pauses, choking awakenings, loud snoring), or daytime impairment (e.g. fatigue, lethargy, irritability).
Many people with insomnia symptoms attempt self-management approaches before presenting to health professionals (e.g. simple ‘sleep hygiene’ techniques; complementary/alternative medicines; consuming different foods/beverages promoted on social media to improve sleep; relaxation breathing exercises).22,23 A state of learned helplessness can develop in people that experience persistent insomnia despite using a large range of remedies that are not effective over the long term.
Many people with long-term insomnia may present with a history of sedative-hypnotic medicine use, and many people with OSA and COMISA may present with a history of previous/current use of continuous positive airway pressure (CPAP) therapy.
It is important for pharmacists to be aware of presenting symptoms of insomnia and OSA, and evidence-based screening, assessment and diagnostic tools for each condition (Table 1). OSA symptoms should be assessed in people with insomnia symptoms, and insomnia symptoms should be assessed in people with suspected or confirmed OSA.24
The ‘gold standard’ measure of OSA presence and severity is an overnight sleep study (Table 1).25 The most common single metric to determine OSA presence and severity is the apnoea-hypopnoea index (AHI), representing the average number of airway narrowing and closure events occurring per hour of sleep.24 Identifying the most appropriate management approaches for OSA also requires consideration of lifestyle factors, symptoms and consequences, occupation, chronic conditions, and other sleep conditions. Self-report questionnaires may be used to screen for a high-risk of OSA and identify patients suitable for referral and consideration of overnight sleep study assessment (Table 1).24
Insomnia, sleep apnoea and COMISA may co-occur with other sleep disorders such as restless legs syndrome and shift work sleep disorder. Circadian misalignment may be a factor in some patients with COMISA.26
Successful management of COMISA can be more difficult than management of either disorder alone, and requires a tailored management approach.20
Pharmacological management
Sedative and hypnotic medicines (e.g. benzodiazepines, non-benzodiazepine hypnotics, off-label antidepressant medicines) are often used in the management of insomnia.28 Although hypnotics provide rapid therapeutic relief from insomnia via increasing sleep duration, they are not the recommended first-line insomnia treatment, and are not recommended for long-term use.29 This is because hypnotics do not target or treat the underlying psycho-behavioural factors that maintain insomnia. Most medicines used for insomnia are associated with adverse effects and risks of adverse events, including psychomotor impairment, falls/fractures, and next-day sedation.29–31 Over time, patterns of short-term therapeutic benefit are often replaced by patterns such as tolerance, long-term dependence and withdrawal symptoms in attempts to reduce use.32 Upon discontinuation of hypnotics, patients may experience insomnia relapse.32 Some sedatives that are used in the management of insomnia may also exacerbate apnoea events in specific patients with OSA.30
Although evidence-based guidelines unanimously recommend avoiding long-term use of hypnotics, they are indicated for a minority of patients that present with severe acute insomnia that is causing significant psychological distress or functional impairment.29 Most people who experience short-term insomnia symptoms (1–2 weeks) can be reassured that sleep will return to ‘normal’ after the underlying precipitant has subsided, without targeted treatment (i.e. hypnotic medicines).29,33 For those who experience persistent insomnia, cognitive behavioural therapy for insomnia (CBTi) is the first-line treatment. Pharmacotherapy may be considered in patients with severe insomnia that is causing significant impairment or distress (e.g. times of acute work/exam stress, bereavement).34
Non-pharmacological management
CBTi is the recommended first-line treatment for insomnia.35 It is effective in people with both acute and chronic insomnia.29,36 CBTi is a multi-component treatment that aims to identify and gradually treat the underlying precipitating triggers and perpetuating factors of long-term insomnia. For this reason, CBTi is often associated with moderate-to-large improvements in insomnia, daytime function and mental health that are sustained long after treatment cessation.37 A recent systematic review and meta-analysis reported that CBTi is an effective treatment for insomnia in the presence of comorbid OSA.38 CBTi is associated with increased daytime sleepiness during the initial stages of bedtime restriction therapy (a core therapeutic component of CBTi), and patients should be warned of feelings of sleepiness while driving or performing other tasks that require sustained attention, and monitored closely.39,40
Although CBTi improves insomnia symptoms in the presence of comorbid OSA,38 depression, anxiety and pain, it is only accessed by approximately 1% of Australian adults with insomnia.28 Access to CBTi may be further reduced in people with COMISA if the OSA is viewed as the ‘primary disorder’ that should be managed before treatment of insomnia, or if there is reservation about referring patients with untreated OSA for sleep restriction therapy (one component of CBTi that aims to temporarily reduce time spent in bed).41
CBTi delivered by a suitably trained and experienced ‘sleep’ psychologist is the ‘gold standard’ form of this treatment.24 Insomnia is an eligible condition for a GP referral to a psychologist, with a mental health treatment plan.42 Evidence-based self-guided digital CBTi programs may also be appropriate for patients with COMISA that are receiving treatment for OSA (e.g. well-controlled on CPAP therapy), with close oversight from a specialist sleep/respiratory clinician.41,43
CPAP therapy is the most effective treatment for OSA.24,44 In a minority of patients with COMISA, CPAP therapy is accepted and improves symptoms of both the insomnia and OSA.9 However, on average, patients with comorbid insomnia are less likely to initially accept a trial of CPAP therapy, and use CPAP therapy for fewer hours per night compared to patients with OSA alone.2,45 Some randomised trials indicate that initial management with CBTi may improve CPAP acceptance and use in patients with COMISA, however this finding is not consistent across all studies.17
Tailored recommendations for non-CPAP therapies may also be provided to patients with different levels of OSA severity and presenting features.17 For example, weight management advice where indicated, positional devices (in the presence of supine-predominant OSA), mandibular advancement splints (in patients with mild-to-moderate OSA), and upper airway surgery are effective treatments that may be tailored to each individual patient.24
Patients with suspected COMISA should be referred to a medical practitioner for further assessment and management.34 After initial assessment, some patients may be initially managed in the primary care setting. The GP may also refer the patient to a specialist sleep and respiratory physician and/or ‘sleep’ psychologist. The Australasian Sleep Association’s Primary Care Sleep Health Resources website lists criteria a GP may use for specialist referral for insomnia and OSA.
Pharmacists should be aware that insomnia and obstructive sleep apnoea (OSA) are the two most prevalent sleep disorders and frequently co-occur.
Pharmacists can use brief evidence-based self-report screening tools to support the identification and referral of patients with suspected insomnia and/or OSA.
If a patient has COMISA, it is important to consider assessment and management/referral options for both conditions. Treatment approaches for OSA can be tailored to each individual’s presenting features. The most effective and recommended ‘first-line’ treatment for insomnia is cognitive behavioural therapy for insomnia (CBTi).
Comorbid insomnia and sleep apnoea (COMISA) is a prevalent and debilitating condition in the Australian population that requires nuanced assessment and management approaches. Pharmacists can play an important role in supporting the identification, assessment, initial management and referral of patients with COMISA, by using brief screening tools and providing information about evidence-based treatment options.
Case scenario continuedYou discuss Carmen’s symptoms further and offer her a 7-item Insomnia Severity Index and the 4-item OSA50 questionnaire to fill in. The results indicate likely long-term symptoms of insomnia and a high risk of undiagnosed OSA. Carmen reports daytime fatigue but no daytime sleepiness. You refer her to a GP for further assessment and explain that the GP may provide a further referral for an overnight sleep study, consultation with a sleep and respiratory physician and a psychologist for CBTi. You explain that CBTi is most effective for treatment of insomnia. Carmen is encouraged that there are non-pharmacological options available and is looking forward to discussing this with her GP. |
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Dr Alexander Sweetman (he/him) PhD
Senior Program Manager, and chair of the psychologist education subcommittee at the Australasian Sleep Association.
Associate Professor Sutapa Mukherjee (she/her) MBBS, FRACP, PhD
Respiratory and sleep physician, Associate Professor of Respiratory and Sleep Medicine at Flinders University and past President of the Australasian Sleep Association.
Professor Garun Hamilton (he/him) MBBS, FRACP, PhD
Respiratory and sleep physician, clinical professor at Monash Health and Monash University and President of the Australasian Sleep Association.
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While Australians are taking fewer antibiotics overall, there are concerns that antimicrobial prescribing is steadily increasing in aged care.
Each year, the Australian Commission on Safety and Quality in Health Care’s Antimicrobial use in the community (AURA) report analyses antimicrobials supplied under the Pharmaceutical Benefits Scheme (PBS) and Repatriation PBS (RPBS) – featuring both antimicrobial use in aged care and by local area.
The latest report, AURA 2023 found that although there has been a small increase of 1.3% in overall antimicrobial use in the community from 2022 to 2023, use is still 24.4% lower than in 2015.
Alarmingly, there has been a stark 11.1% increase in antimicrobial use in residents of aged care homes from 2022 to 2023.
Antimicrobial use is also considerably higher for older Australians who reside in aged care homes than for those living in the community. While just over a third of Australians had at least one antimicrobial dispensed, almost three-quarters of residential aged care facility (RACF) residents received at least one antimicrobial prescription last year.
Australian Pharmacist looks at which antibiotics are most commonly prescribed in aged care, the impacts of high antimicrobial use, and what pharmacists can do to help.
Why is antibiotic prescribing in aged care so high?
There are several reasons why RACF antimicrobial prescribing is higher than in the rest of the community.
[caption id="attachment_24236" align="alignright" width="216"] Professor John Turnidge AO[/caption]
According to infectious diseases physician and microbiologist Professor John Turnidge AO, Senior Medical Advisor, Australian Commission on Safety and Quality in Health Care, these include:
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[post_content] => Melatonin is a naturally occurring hormone responsible for regulating the body’s circadian rhythm. Secretion of melatonin declines during adulthood. Supplemental melatonin can help to reinforce the circadian rhythm, making it useful for treatment of insomnia and jet lag.1
How can pharmacists meet their legal and professional obligations when prescribing melatonin for insomnia?
When prescribing melatonin as a Pharmacist Only medicine, you must establish therapeutic need, determine the medicine is safe for the patient and comply with restrictions of the Schedule 3 listing. This includes that the patient is aged 55 or over and it is for short-term treatment. Routine recording of patient name, address and date of birth supports appropriate provision and is the best way for pharmacists to demonstrate they have met legal and professional obligations.
How long is 'short-term'?
While there is evidence to support the safety and efficacy of melatonin up to 13 weeks,3 patients should be referred to a medical practitioner for review if they require treatment for more than 3 weeks.⁴ Three weeks is consistent with evidence from the pivotal efficacy study noted by the Therapeutic Goods Administration in the final decision to amend melatonin scheduling to Schedule 3.⁵
A patient who has been prescribed melatonin MR 2 mg nightly for 3 months by a medical practitioner presents to the pharmacy seeking a supply as they have run out. What can a pharmacist prescribe?
This pattern of use is not short term, so a pharmacist would not be able to prescribe melatonin within Schedule 3. Other options may apply, such as using emergency supply provisions relating to Schedule 4 medicines. The criteria for emergency supply by a pharmacist, and quantity of medicine able to be supplied, depends on the state or territory in which the pharmacist is practising.
What options are available to pharmacists to treat jet lag?
Despite the inclusion of immediate-release melatonin for jet lag in Schedule 3 of the Poisons Standard, at the time of writing, there is no commercially available immediate-release product in Australia which can be prescribed as a Pharmacist Only medicine. Pharmacists may compound an immediate-release preparation that contains 5 mg or less of melatonin when a particular person requests this medicine. If a commercial product becomes available, compounding would no longer be appropriate. Patients should be advised to avoid purchasing melatonin via the internet because the melatonin content may be unreliable.6
Poisons Standard Schedule 3 entry for melatonin7
MELATONIN in:
(a) modified release tablets containing 2 mg or less of melatonin for monotherapy for the short-term treatment of primary insomnia characterised by poor quality of sleep for adults aged 55 or over, in packs containing not more than 30 tablets; or
(b) immediate release preparations containing 5 mg or less of melatonin for the treatment of jet lag in adults 18 years and over, in a primary pack containing no more than 10 dosage units.
References
1. Goldstein, CA. Overview of circadian rhythm sleep-wake disorders. UpToDate [updated Dec 2023]. At: https://sso.uptodate.com/contents/overview-of-circadian-rhythm-sleep-wake-disorders?search=melatonin&source=search_result&selectedTitle=3%7E113&usage_type=default&display_rank=3
2. Insomnia in adults. Therapeutic guidelines [updated Mar 2021]. At: https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Psychotropic&topicfile=insomnia-adults
3. Treatment guidelines for pharmacists: insomnia. In: Sansom LN, ed. Australian pharmaceutical formulary and handbook. 26th edn. Canberra: Pharmaceutical Society of Australia; 2024.
4. Therapeutic Goods Administration. Notice of final decision to amend the current Poisons Standard in relation to melatonin. 2020. At: www.tga.gov.au/resources/publication/scheduling-decisions-final/notice-final-decision-amend-current-poisons-standard-relation-melatonin
5. Pharmacy Board of Australia. FAQ – For pharmacists on the compounding of medicines. At: www.pharmacyboard.gov.au/documents/default.aspx?record=WD15%2f16635&dbid=AP&chksum=rE0qmZcEafURzzXc3NBiuA%3d%3d
6. Therapeutic Goods Administration. Notice of interim decision to amend (or not amend) the current Poisons Standard. 2023. At: www.tga.gov.au/sites/default/files/2023-10/notice-interim-decisions-amend-not-amend-the-current-poisons-standard.pdf
7. Therapeutic Goods (Poisons Standard – June 2024) Instrument 2024. At: www.legislation.gov.au/F2024L00589/latest/text (edited)
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[post_content] => Sleep is a hot topic for Anousheh Page MPS, Director of Pharmacy at Brisbane’s only 24-hour pharmacy.
Why did you choose pharmacy?
Becoming a pharmacist was actually one of three options on my university application. At the time, all I really knew was that I enjoyed science-based subjects at school and also helping people (natural Virgo at heart, of course!). When it came to the pros and cons list, pharmacy felt like the best option. And I don’t have any regrets.
I absolutely love being a pharmacist. I completed a Bachelor of Pharmacy at the University of Sydney and can honestly say my university experience was the best of all time, which reinforced my choice to become a pharmacist.
What led you to your current role?
I knew whilst completing my pharmacy degree that I always wanted to work within a hospital environment. My pharmacy career in hospital began after completing my internship at the Children’s Hospital, Westmead, in Sydney. In 2007, I was moving back from a hospital role on the South Coast of New South Wales when I saw a Pharmacist In Charge role advertised for Kareena Private Hospital (God’s country, aka the Sutherland Shire in southern Sydney). I was fortunate enough to be offered the role. Working within any Ramsay Health Care facility never feels like work. The hospital staff become your adopted family and you work within a well-supported multidisciplinary team. I gained experience within multiple Ramsay Hospitals and eventually landed Director of Pharmacy at Greenslopes Private Hospital.
How do you and your staff cope with the late-night and overnight hours?
In general, staff cope very well and have an amazing ability to adapt to the various hours. There is a good balance of work which flows through the hospital inpatient stream but is also complemented by the variety of community patients that come through. I personally would sleep a few hours before a shift if I knew I had to cover an overnight. Like most, I would stay awake and try and get back to a normal sleep routine for the next shift.
What are common requests from patients who visit in the wee small hours?
Patients do often come in for sleep issues at night, however what stands out the most are patients who request salbutamol inhalers. Every night can be different depending on the day of the week, but the most consistent request is salbutamol. We have had patients coming from areas like the Gold Coast or even Mount Barney (130 kilometres south-east of Brisbane, population less than 50). This really highlights the opportunity pharmacists have to be able to deliver full-scope activities such as improved asthma management – including developing an asthma action plan – particularly outside standard business hours. The second-most common would be the management of acute illnesses to treat gastroenteritis or flu-like symptoms. We have many local public facilities surrounding Greenslopes, including our own emergency department, so we service lots of patients requiring after-hours medicines.
What are your strategies to deal with barriers to overnight care?
In most scenarios we would just use our experience and clinical judgment when helping patients. Working an overnight shift is similar to working a weekend shift in some respects, so we are very accustomed to managing or referring when necessary. We are also fortunate to work in an area with late-opening medical centres and local emergency centres. This allows us to refer patients who require further review. QScript (Queensland’s real-time prescription monitoring system) has also been a game changer in helping provide better support and clinical judgement for dispensing high-risk medicines; this had often been a challenge when working outside normal hours in pharmacy.
If you could change anything about your 24-hour pharmacy, what would it be?
Coffee is the gift that keeps on giving. A barista-made coffee on hand at any hour wouldn’t be too much to ask, would it?
What’s your advice for ECPs?
It’s important to work in an environment you love. Surrounded by the right team and environment can absolutely make the difference on how you approach work. If you dread work or feel anxious before the work week, you’re not in the right job.
A day in the life of Anousheh Page MPS, Director of Pharmacy, Greenslopes Private Hospital, QLD
| 4.30 am |
Up and at it Never in my life did I think I would be one of those early morning risers to hit the gym, but the pandemic forced a change and that schedule gets me mentally prepared for the day. |
| 7.30 am |
Handover time A double-shot of cappuccino in hand, my day begins with a handover between the 24-hour retail pharmacy and hospital dispensary team. Urgent action might be needed on alteplase orders to replace stock used overnight for a stroke patient in ED, or ensuring discharge medicines that were completed are given to that ward’s pharmacist for patient counselling. |
| 8.30 am |
Hospital bed managers’ meeting Meeting daily with the ward and other multidisciplinary hospital team managers helps me reallocate pharmacy staff to areas that need support i.e. for timely discharges or immediate communication if a regular pharmacy staff member is on leave. On Thank You Thursdays, meetings end by nominating a team member deserving of recognition, who later receives a card and lunch voucher from the hospital executive team. |
| 9.30 am |
Current shortages Next meeting addresses state shortages – this time its fluids. This entails direct contact with other Ramsay Queensland hospitals via the state procurement manager who organises a consistent supply of fluids, such as saline. |
| 10 am – 4 pm |
Daily challenges Every work day is different. Overseeing a 24-hour pharmacy that never closes requires being prepared for anything, and problem-solving is a strong skill set in my role. If I have multiple staff on leave with the spread of colds and flu, I actively help cover an area, (which has helped me be a better manager with greater knowledge of what shifts entail or how wards operate). Urgent deliveries of home IV antibiotics for patients and expensive IV anti-fungals at short notice are part of it. |
| 4.00 pm |
Home time I start my second job, which could ideally be a paid Uber driver, but is actually driving my children to their various daily extracurricular activities. At least I’m off my feet! |
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
