Leslie Dan Faculty of Pharmacy

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The Leslie Dan Faculty of Pharmacy is Canada’s largest pharmacy school and has a world class reputation in education and research. Educational programming is at the heart of the Leslie Dan Faculty of Pharmacy and it currently offers a number of cutting-edge educational programs.

The research conducted by students, faculty, research associates and postdoctoral fellows at the Leslie Dan Faculty of Pharmacy focuses on drugs and medications. The results of this research have a profound impact in drug therapy on both the molecular level and on entire populations.

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A LEAN Approach to Intravenous Antibiotic Distribution in a Tertiary Care Academic Hospital
(2016) Leavitt, Jessica A.; McKenna, Susan
Background: LEAN is a quality improvement methodology that identifies and eliminates waste in processes. LEAN principles, such as value stream mapping, may be applied to the hospital IV antimicrobial distribution process to increase resource use efficiency while ensuring patient safety. Objectives: Primarily to define the current IV antibiotic distribution process at Kingston General Hospital (KGH) and to identify opportunities for improvement in resource use efficiency. Secondarily to reduce waste, categorized as non-value-added time from a patient perspective or by cost of unusable product, in the IV antibiotic distribution process. Methods: A stakeholder group of pharmacy personnel and a patient experience advisor was formed. Current state value stream maps (VSMs) were constructed with direct observation for time estimates for each of the three, not previously defined, distribution streams: (1) central intravenous admixture service (CIVAS) preparation, (2) CIVAS-prepared minibags stocked in automated dispensing cabinet (ADC), and (3) vial stock in ADC used with point-of-care activation device. Each process step was categorized into ‘value-added’, ‘non-value-added’ (pure waste), and ‘non-value-added, but essential’. Opportunities for process improvement were identified, and education of staff regarding IV antibiotic order entry into the pharmacy information system was chosen for implementation using a Plan-Do-Study-Act (PDSA) cycle. Representative product waste and adherence to standardized order entry procedures were assessed before and after education. Results: Current state VSMs of ampicillin, cefazolin and piperacillin-tazobactam distribution were constructed, representing distributions streams 1, 2 and 3, respectively. Value added time was found to be the highest with stream 3, piperacillin-tazobactam at 26% (16 min), followed by stream 1 at 21% (14 min), then stream 2 at 14% (12 min). Stream 2 had the highest proportion of non-value-added (pure waste) with 74% (62 min), followed by Stream 1 at 67% (45 min), then Stream 3 at 64% (40 min). No statistically significant difference was observed in resource waste or policy adherence before and after staff education on IV order entry processes (waste, $1804 versus $1840; adherence, 49% versus 46%, NS). Conclusions: Using LEAN methodology, the IV distribution stream associated with the most efficient resource use is ADC vial stock intended for use with point-of-care activation device, but resource waste is still substantial. A PDSA intervention focused on PIS order entry in all 3 streams failed to demonstrate waste reduction. Exploration of further opportunities identified should be undertaken.
A Drug Use Evaluation of Alteplase 2 mg Vials at Kingston General Hospital
(2016) Schiavi, Alexandra
Background: Alteplase, a recombinant tissue plasminogen activator, is a high alert medication with many indications. In Fiscal 2015, the expenditure of alteplase 2 mg vials increased by 64% at Kingston General Hospital (KGH), despite formulary restrictions and no change in acquisition cost. Applicable restrictions include: catheter occlusion, transcatheter thrombolysis, provocative mesenteric angiography, and intrapleural fibrinolysis. KGH Pharmacy Services is responsible for the drug budget to ensure expenditures are evidence-based and reflect value for money. Objective: To assess appropriateness of the use of alteplase 2 mg vials at KGH because of the high and increasing expenditure. Methods: A prospective, observational, drug use evaluation of alteplase was conducted over 52 days between October and December 2015, including all adult patients dispensed alteplase 2 mg vials during their hospital or renal unit visit. Patient demographics, adherence to KGH restrictions and evidence-based use, completeness of documentation, and wastage were analyzed. Results: A total of 100 courses of therapy (50 renal unit, 50 non-renal unit) were included. Overall, 48% adhered to restrictions, 4% renal unit and 92% non-renal unit. Ninety-four percent of orders outside restrictions were evidence-based. Occluded central venous catheter (87%) and dialysis lock (88%) were the most common indications in non-renal unit and renal unit patients, respectively. Electronic and written orders were correct 54% of the time (90% renal unit and 12% non-renal unit); the most frequent discrepancies included incorrect route and not following hospital policy or standards. No wastage was identified for 88% of renal unit orders. Wastage was unclear in 32% of non-renal unit patients as documentation was inconsistent, with 16% of orders having no documentation of administration. Conclusion: The results support implementation of additional physician order sets for alteplase, revising KGH restrictions to reflect evidence-based practice, and preparing 10 mg doses of alteplase in the pharmacy to improve medication prescribing, documentation, patient safety, and minimize cost. Key words: alteplase, cost, safety, drug use evaluation, evidence-based Word Count: 306
A Retrospective Comparison of the Safety and Efficacy of 3 months vs. 6 months Valganciclovir for Cytomegalovirus Prophylaxis in Renal Transplant Recipients
(2016) Masys, Ashley; Dalton, Alyssa; Deschênes, Marie-Josée; Fairhead, Dr. Todd; Giguere, Pierre
Abstract Background: Antiviral prophylaxis has been shown to be effective in reducing the risk of CMV disease in renal transplant recipients and reducing all-cause mortality in solid organ transplant recipients. Extending valganciclovir prophylaxis from 100 to 200 days was associated with a further reduction of CMV disease post-renal transplant. Longer valganciclovir prophylaxis can induce leukopenia, increase risk of other infections, and lead to alteration in immunosuppression, which may lead to rejection. It is currently unknown how the extension from 3 to 6-month prophylaxis with valganciclovir has impacted outcomes in our institution. Methods: A retrospective chart review was conducted from January 1st 2010 to May 31st 2014 (followed until May 31st 2015). Patients were included if they had received a renal transplant and were prescribed 3 months (group 1; from January 2010 to December 2011) or 6 months (group 2; from January 2012 to May 2014) of valganciclovir and were at least 18 years of age at time of transplant. Results: Both groups experienced high rates of leukopenia; 78% in 3-month prophylaxis group compared to 85% in 6-month prophylaxis group (P = 0.284). There is a statistically insignificant increase in patients who developed CMV viremia in 6-month prophylaxis group (19.8%) compared to the 3-month group (14.3%). There was one patient in 3-month prophylaxis group (2.0%) and three patients in 6-month prophylaxis group (3.5%) (P=0.633) who experienced acute rejection. Conclusion: The change of TOH Renal Transplant Protocol to extend duration of CMV prophylaxis from 3 to 6 months for high-risk recipients did not result in statistically significant change in incidence of leukopenia; CMV viremia; or rates of graft rejection.
Hemodynamic Consequences of Continuing Angiotensin Inhibitors in a NonCardiac Surgical Population
(2016) Kolshuk, Sarah; Celetti, Steven; Asaadd, Ihab
BACKGROUND: Despite widespread use of angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists (ACEI/ARBs), controversy exists on the optimal perioperative management of these agents due to their association with post-induction hypotension during non-cardiac surgery. Additionally, it is unknown if elderly patients taking ACEI/ARBs are at increased risk of this adverse event compared to younger surgical patients. OBJECTIVES: To determine if ACEI/ARBs should be continued or held on the morning of non-cardiac surgery. Primary outcome was post-induction hypotension rates within 30 minutes taken at 5 minute intervals. Secondary outcomes were vasopressor use at 0-15 or 16-30 minutes and death by any cause, cardiac events, or stroke occurring during surgery or until time of hospital discharge. Outcomes for patients less than 65 years were compared to patients 65 years of age or older. METHODS: A retrospective chart review was performed at Trillium Health Partners – Credit Valley Hospital from October 2014 to June 2015. Adult patients taking chronic ACEI/ARBs therapy and undergoing elective surgery with post-surgical admission to an inpatient ward were included. RESULTS: A total of 395 patients were included. Hypotension rates in patients who received ACEI/ARBs prior to surgery were 34.8% compared to 26.7%, in patients who had their ACEI/ARB held prior to surgery (P=0.068). Continuation of ACEI/ARBs on the morning of surgery was not associated with increased vasopressor use (P= 0.151), cardiac events, stroke, or death (P=0.268). There were no differences in primary or secondary outcomes based on patient age. Previously published hypotension rates were higher than collected rates suggesting the study was underpowered to detect statistically significant differences in outcomes. Vasopressor use increased when systolic blood pressure was less than 90 mmHg. CONCLUSION: In patients who continued ACEI/ARBs on the morning of surgery, there was a non- significant trend towards an increased risk of post-induction hypotension. With continued data collection, this study has the potential to optimize perioperative management of ACEI/ARBs and prevent adverse outcomes.
Applying LEAN Six Sigma Strategies to Manage Missing Medications in a Tertiary Acute Care Hospital
(2016-08-26) Marchese, Maria
Background: Despite implementation of automated dispensing cabinets (ADCs) at Kingston General Hospital (KGH), there continues to be reports of medications unavailable at administration time (missing medications). This can result in a significant barrier to providing optimal patient care. Objectives: To determine the root causes of missing medications at KGH. To apply LEAN Six Sigma strategies to implement and measure an opportunity for improvement related to inpatient drug distribution. Methods: We investigated 83 medications reported missing to pharmacy in December 2015. Analyses of these findings were utilized to select a pharmacy process change expected to improve availability of medications at the point of care. A pilot intervention was tested on three patient care units with a descriptive and quantitative determination of missing medications compared pre and post-change. Results: The leading reason for missing medications was “nurse was unable to locate” (medication was actually on the Nursing Unit) accounting for 27.70% (n=23). Of medications that were truly missing, one-third were related to ADC patient-specific bins (n=20). After implementation of a software configuration and key inventory changes to ADCs, the proportion of missing medications from the three pilot wards relative to the entire hospital decreased significantly, from 23.93% to 12.36% (p=0.0357). Analyses were limited by small sample size. Conclusion: Missing medications are part of a complex drug distribution and storage system in hospitals with decentralized dispensing models. Using a LEAN Six Sigma approach to select and implement a process change was successful in resolving the targeted cause of missing medications. Effective expansion of this initiative would require further investment of pharmacy resources and continuous re-evaluation by involved staff.
The Impact of Delayed Medication Reconciliation for Patients Admitted to the General Internal Medicine Service at St. Joseph’s Healthcare Hamilton - A Retrospective Study
(2016-09-30) Pileggi, Holly
Medication reconciliation is an accreditation standard that identifies discrepancies between a patient’s home and admission medications. Completing medication reconciliation within 48 hours of admission is a policy at St. Joseph Healthcare Hamilton (SJHH). Prioritization is given to General Internal Medicine (GIM) patients over age 65 and the target completion rate is 100%. The aim of this study was to assess GIM medication reconciliation performance at SJHH and to evaluate the impact of delaying medication reconciliation. The objective is to determine the number of medication reconciliations completed within 48 hours of admission for General Internal Medicine (GIM) patients over the age of 65 at a large academic teaching hospital in Ontario. Secondary objectives included an assessment of the number of medication discrepancies and determination of the clinical importance. Eligible patients included those admitted to the GIM service at SJHH over the age of 65. Charts were reviewed for a medication reconciliation form and the time from admission to completion of the form was documented. The medication discrepancies were recorded, and two independent reviewers assessed their clinical importance using the National Coordinating Council for Medication Error Reporting and Prevention algorithm. 153 eligible patients admitted from January-April 2016 were included. 93 (61%) had medication reconciliation completed, with 36 (37%) completed within 48 hours of admission. The timing of medication reconciliation did not affect the number of medication discrepancies identified (IRR=1.18, p=0.49) or clinically important medication discrepancies identified (IRR=1.48, p=0.29). However, the number of medications per patient significantly affected both outcomes respectively (IRR=1.10 p<0.001, IRR=1.11 p=0.001). In conclusion, the current medication reconciliation program at SJHH is only reaching 61% of a priority group of GIM seniors, with only 37% reached within 48 hours of admission. Timing was not associated with the number of discrepancies found. To achieve 100% completion of medication reconciliation, a new process and additional resources would be required.
Effect of an educational intervention on surgical house staff’s medication reconciliation knowledge and practices
(2016-10-28) Young, Leslie; Ralph, Bonnie
Background: Medication reconciliation is recognized as an important medication safety initiative. It is acknowledged that a comprehensive education program incorporating new staff training and ongoing instruction is a key success factor for medication reconciliation programs. Despite this, the impact of education on medication reconciliation practices is not well described. Currently, formal medication reconciliation training for physicians at Kingston General Hospital (KGH) is comprised of only a brief overview for new medical house staff during hospital orientation. Objectives: To develop and deliver a medication reconciliation educational intervention within the surgical services at KGH and to evaluate the effect on medication reconciliation compliance, quality, and knowledge. Methods: An educational intervention was developed and delivered to 24 general surgery, orthopaedic surgery, and urology residents. Medical records data were used to measure compliance. Patient charts with a documented Best Possible Medication History (BPMH) by both a pharmacist and a physician who attended the educational intervention were used to measure quality. A total of 20 charts pre-education and 20 charts post-education were randomly selected to evaluate the mean number of discrepancies/number of medications/patient, and their potential clinical significance. Pre-education and post-education tests were administered to measure knowledge. Results: Post-education medication reconciliation compliance significantly increased from 53.8% to 69.8% (P < 0.001). The mean number of BPMH discrepancies/number of medications/patient was significantly reduced (0.72 pre-education versus 0.52 post-education, P < 0.001). There was no difference in the relative distribution of discrepancy clinical significance classes (P = 0.191). No difference in test scores was noted among residents who completed the knowledge tests (57.8% pre-education versus 64.4% post-education, P = 0.317). Conclusion: A medication reconciliation educational intervention delivered to KGH surgical house staff significantly improved compliance with and quality of medication reconciliation documentation. This supports implementation of hospital-wide formal physician education due to the potential patient safety implications.
Evaluation of the Impact of Pharmacist-Led Communication of the Clinical Pulmonary Infection Score (CPIS) on Antibiotic Prescribing in the Intensive Care Unit – A Pilot Study
(2017) Tran, Lanny; Wright, Angela; Wallace, Christine; Lee, Jennifer; Stankus, Vida
Abstract Background: Overprescribing of antibiotics for nosocomial pneumonia in the intensive care unit (ICU) is a prevalent issue for antimicrobial stewardship programs (ASP). Discontinuation of antibiotics based on a low Clinical Pulmonary Infection Score (CPIS) on day 3 of therapy is associated with decreased antibiotic days and antimicrobial resistance. However, the impact of a pharmacist-led CPIS initiative is unknown. Objectives: The primary objective was to assess feasibility of a pharmacist-led CPIS initiative. Secondary objectives included determining impact on antibiotic prescribing and patient-important outcomes, and discerning prescriber rationale for antibiotic continuation in patients eligible for discontinuation. Methods: This was a prospective, interventional pilot study of ICU patients treated for nosocomial pneumonia over eight weeks. Pharmacists suggested antibiotic discontinuation on Day 3 of treatment for patients with CPIS ≤6 on Days 1 and 3 of therapy. Physician rationale for continuing antibiotics beyond Day 3 for these patients was recorded. Comparisons were drawn between the study period and data collected previously under auspices of ASP, without pharmacist intervention. Results: During this study period, eleven patients met the inclusion criteria, with six patients eligible for discontinuation. Data was collected from 12 patients during the ASP period. Two discontinuations occurred during the study period, in comparison with none during ASP data collection. There were significantly fewer mean ICU antibiotic days during the study period (11.17 days; 95% CI 4.41-17.93) than the ASP period (22.67 days; 95% CI 19.03-26.31). Physician rationale for antibiotic continuation included positive sputum cultures and extra-pulmonary infections. Barriers identified during the study included prescriber unfamiliarity with the CPIS and pharmacist unavailability on weekends. Conclusions: The pilot study demonstrated feasibility of a pharmacist-led CPIS intervention and identified barriers that may have affected its impact. Pharmacist intervention was associated with significant reduction in mean antibiotic days. Larger studies would provide further insight into potential impacts of pharmacist-led CPIS interventions.
Characterizing Opioid Use at an Academic Family Health Team
(2017) Prete, Brittani; Kwan, Debbie; Marr, Patricia; Papoushek, Christine; Mizdrak, Nikolina
Background: The escalating use of opioids and related mortality is highly publicized in the media. Clinical practice guidelines have sought to provide direction on the judicious use of opioids; however, primary care providers continue to struggle with how to manage patients on opioid therapy. Objective: The objective of this study was to characterize chronic opioid prescribing patterns for non-cancer pain at an academic family health team and its concordance with the Canadian guideline and the Centers for Disease Control and Prevention guideline. Methods: Electronic medical records for adult patients with non-cancer pain prescribed chronic opioid therapy between January 1, 2015 and November 30, 2016 were retrospectively reviewed. Descriptive statistics assessed concordance to guidelines. Results: One hundred sixty adult patients (< 1% of total population) received chronic (i.e. > 3 months) opioids for non-cancer pain. Fifty-three percent of patients were female; mean age 61 years. The most common pain diagnoses were back pain (45%), osteoarthritis (33%) and chronic pain (24%). Risk factors for opioid overdose or misuse were found in 82% of cases. The following rates of concordance with guideline recommendations were found: 1) total daily doses < 90 mg morphine equivalents (73%), 2) presence of drug contract (42%), 3) follow-up at least four times per year (33%) and 4) annual urine drug screening (3%). Conclusions: The family health team infrequently prescribed chronic opioids. Most prescribed doses were below the recommended watchful dose of morphine equivalents. The respective frequencies of guideline-concordant monitoring processes demonstrate modest adherence to current practice guidelines. However, the data is comparable to similar studies. Opportunities to improve current opioid monitoring practices include more frequent urine drug screening, follow-up, and documentation of opioid treatment agreements. Future interventions should target system-level documentation in order to improve guideline-concordant care of patients on opioid therapy.
Patterns of Antimicrobial Use in an Outpatient Hemodialysis Unit
(2017) Sivarajahkumar, Sylvia; So, Miranda; Morris, Andrew; Bell, Chaim; Battistella, Marisa
Background: Hemodialysis (HD) patients are at high risk for infections, including those caused by multi-drug resistant organisms (MDROs). Since antimicrobial exposure is the main risk factor for the emergence of MDROs, minimizing inappropriate antimicrobial use is imperative. Objectives: To optimize antimicrobial use, it is first important to understand patterns of antimicrobial prescribing in this setting. The objectives of this study were to: (1) measure antimicrobial use, and (2) describe antimicrobial prescribing patterns, among patients receiving outpatient HD at the University Health Network. Methods: A retrospective observational cohort study was performed in an outpatient HD unit at an academic centre from February 1 – April 30, 2017. Eligible patients included adults who were prescribed at least one oral or intravenous (IV) antimicrobial by a hospital or community prescriber. Data were retrieved from the HD unit infection control database and analyzed using descriptive statistics. The primary outcome was total antimicrobial days of therapy (DOT) per 1000 patient-days. Secondary outcomes were antimicrobial prescriptions characterized by type of antimicrobial, purpose, indication, route, and prescriber type. Results: A total of 53 patients were eligible for inclusion and 75 antimicrobial prescriptions were included for analysis. Over the 3-month study period, antimicrobial use was 27.5 DOTs/1000 patient-days. Antimicrobial use occurred in 53 (16%) of 330 total outpatient HD patients. The most common indication for antimicrobial therapy was skin and soft tissue infection, followed by bloodstream infection and respiratory tract infection. Fluoroquinolones were the most frequently prescribed antimicrobials, accounting for 23% of prescriptions, while the second most prescribed were first-generation cephalosporins (21%). Conclusion: Overall, this study indicates that antimicrobial use was common, with 1 in 6 HD patients receiving antimicrobials during the 3-month study period. We believe this is the first Canadian study to describe prescribing patterns for both oral and IV antimicrobials in an outpatient HD population.
Safety of two-hour intermittent intravenous infusions of tacrolimus in the allogeneic hematopoietic stem cell transplantation unit
(2017) Bacopoulos, Alexander J. S.; Ho, Lina; Yang, Anjie; Ng, Pamela; Dara, Celina; Loach, David; Uday, Deotare; Michelis, Fotios V.; Viswabandya, Auro; Kim, Dennis D,; Liption, Jeffrey H.; Messner, Hans A.; Thyagu, Santhosh
Background: Administering intravenous (IV) tacrolimus by 24-hour continuous IV infusion (CIV), as recommended by the product monograph, poses significant logistical challenges in the allogeneic hematopoietic stem cell transplantation (HSCT) unit because it requires a dedicated central venous catheter lumen. Consequently, at our institution, tacrolimus has been administered via two-hour intermittent IV infusions (IIV) every twelve hours in the HSCT unit. Administration by IIV is not the standard of practice and shorter infusion times are cautioned due to higher rates of nephrotoxicity, neurotoxicity and infusion-related reactions (IRRs), although there is a paucity of data to support this claim. The primary objective of this retrospective study was to evaluate the safety of a two-hour IIV of tacrolimus in an adult HSCT population. Efficacy was evaluated as a secondary endpoint. Methods and Patients: We performed a retrospective chart review of all patients who received IV tacrolimus at our institution from January 2002 – January 2016. We reviewed 104 patients who received 118 tacrolimus treatment courses by IIV (TTC) [median number of doses per TTC=22, range 1 – 158, interquartile range (IQR) = 28]. Primary outcomes collected include rates of nephrotoxicity, neurotoxicity and IRRs that occurred during TTC. The incidence of acute graft-versus-host disease (aGVHD) and disease relapse within 180 days of transplant were collected to evaluate efficacy. Results and Discussion: There were sixteen incidences (13.6%) of nephrotoxicity, defined as a doubling of serum creatinine from baseline. Nephrotoxicity resolved in all but six (5.1%) cases. Precipitating factor for nephrotoxicity unrelated to tacrolimus were identified by the physician in all six cases. There were 40 incidences (34.5%) of neurotoxicity [seizure, posterior reversible encephalopathy syndrome (PRES), tremor, paresthesia, visual disturbance], of which, eight (6.8%) were considered serious (seizure and/or PRES). All neurotoxicity reverted to baseline or resolved completely. One grade 2 infusion reaction occurred and resolved without discontinuation of tacrolimus. In the subset of patients who received tacrolimus for the prevention of aGVHD (n=41), seven patients (17.1%) developed grade II – IV aGVHD. Nine patients (8.7%) experienced relapse of their disease. Conclusions: We propose that a two-hour IIV of tacrolimus is a safe method of administration in the adult HSCT setting. Additional safety and efficacy data from other institutions will provide external validity to this conclusion.
Time to Sedation after Rapid Sequence Intubation in the Emergency Department: A Retrospective Chart Review
(2017-09) Natarajan, Sabrina; Osinga, Andrew; Kwok, Edmund; Kanji, Salmaan
Introduction: Patients requiring rapid sequence intubation in the Emergency Department will typically receive a short-acting sedative followed by a paralytic agent to facilitate endotracheal intubation. These patients are at risk of paralysis without sedation, unless further sedation is administered post-intubation in a timely manner. Objectives: To determine if there exists a delay in post-intubation sedation in the Emergency Departments at The Ottawa Hospital; to determine the predictors of delayed time to post-intubation sedation; and to determine if there exists a delay in analgesia administration in the post-intubation period. Methods: A retrospective observational study with 150 eligible patients intubated in the Emergency Departments at The Ottawa Hospital identified from April 1st, 2016 to February 1st, 2017. Data pertaining to patient demographics, administration times of peri-intubation agents, and proposed predictors of delayed sedation were collected. Results: The median time to post-intubation sedation was 10 minutes. 19.3% of patients received sedation in an inadequate timeframe. The median time to post-intubation analgesia was 75.5 minutes. Of the proposed predictors (choice of paralytic agent, pre-printed order completion, presence of trauma code or cardiac arrest, transfer shortly after intubation, designation of individual performing intubation, campus of intubation) only cardiac arrest showed a statistically significant prediction of time to sedation (p=0.002). Conclusion: A considerable proportion of Emergency Department patients received post-intubation sedation within an inadequate timeframe and was therefore at risk of paralysis without sedation. Further study is required to determine the possible barriers to initiation of timely post-intubation sedation.
Evaluation of the Impact of Pharmacist-Led Penicillin Allergy Assessments on Antibiotic Utilization in a Large Community Teaching Hospital
(2017-10) Saleh, Mashael
Rationale: Penicillins are the most common cause of allergic drug reactions with a prevalence of up to 20% in hospitalized patients. To date, there are limited Canadian publications describing pharmacist involvement in penicillin skin-testing. The purpose of this study is to evaluate the impact of a pharmacist-led initiative at Hôpital Montfort on de-labelling penicillin allergies and reducing the use of two broad spectrum antibiotics, meropenem and vancomycin. Objectives: To determine the proportion of patients in whom an antibiotic change was made as a result of a penicillin allergy assessment and identify barriers for not de-escalating therapy in patients deemed non penicillin allergic. Potentially drug cost savings were also examined for skin-tested patients. Methods: This is an observational cohort study conducted at Hôpital Montfort between October 1st 2016 and May 31st 2017, following the implementation of a policy allowing pharmacists to refer patients to an inpatient allergist for skin testing. Results: Pharmacists recommended a penicillin skin test (PST) for 15 of 32 identified patients (46.9%) with a penicillin allergy who were prescribed meropenem or vancomycin. Nine of 15 eligible patients (60%) underwent a PST, with five patients having their antimicrobial therapy de-escalated to a penicillin or cephalosporin antibiotic. Four patients had their therapy modified based only on the pharmacist assessment. De-escalation of therapy led to a range of cost saving between -$81.04 to $390.34 for patients switched to a penicillin or cephalosporin after PST.
National survey assessing knowledge and management of the drug interaction between dolutegravir and metformin by Canadian HIV practitioners
(2017-10-01) Dawson, Ellen; Brehaut, Jamie; Giguere, Pierre
Background: A well-described pharmacokinetic drug interaction between dolutegravir and metformin results in increased exposure to metformin. However, no conclusive management recommendations exist. This study was conducted to examine current Canadian practice. Objectives: The study objectives were to describe Canadian practitioners’ knowledge and management of the interaction, including assessment of interprofessional or regional variations, and to identify factors that influence the decision to administer metformin and dolutegravir concomitantly. Methods: The study was an online survey of Canadian physicians, nurse practitioners, and pharmacists caring for HIV-infected patients. The survey consisted of multiple choice, short answer, and case-based questions administered via SimpleSurvey. An iterative process was used to pilot the survey electronically in French and English prior to two waves of survey dissemination. Results: The survey was distributed to 179 practitioners (response rate 36 %, completion rate 83%). The majority (93%) knew the interaction increased metformin exposure; of these, 65% correctly identified the magnitude. In clinical scenarios, 67-90% of respondents administered the medications concomitantly, with some electing to decrease the metformin dose. Closer monitoring of renal function, diabetes, and metformin tolerability, including lactic acidosis, was suggested by respondents co-administering dolutegravir and metformin. Diabetes-related factors, dolutegravir dose, and renal dysfunction commonly affected co-therapy decisions. There was minimal variation by profession, though practice in Alberta may differ slightly. Conclusion: A majority of clinicians did not consider co-administration of dolutegravir and metformin to be contraindicated. However, factors such as maximum metformin dose, renal dysfunction, and diabetes-related conditions were most likely to affect decisions to continue co-therapy.
A Qualitative Descriptive Study of Admitted Homeless Patients' Perceptions of Prescribed Medications
(2017-10-16) Richler, Matthew; Yousaf, Sara; Hwang, Stephen; Dewhurst, Norman
Background: Homeless individuals experience a higher rate of emergency department visits, increased hospital lengths of stay, and increased healthcare costs compared to the general population. Medication non-adherence is one factor that has been linked to these outcomes. Although barriers to medication adherence in the homeless population have been described, patient perceptions of medications as a barrier are not well understood. Objective: To describe the perceptions, attitudes, and beliefs about prescribed medications held by hospitalized patients who are homeless. Methods: A qualitative descriptive study design using semi-structured interviews was conducted from February 27 to May 16, 2017. Interviews were conducted during patients’ admissions to the General Internal Medicine service of a tertiary care, inner city hospital. Interviews were audio-recorded and transcribed. Data were analyzed using conventional qualitative content analysis to generate data-driven codes and themes. Results: Twelve interviews were conducted (median age 48.5 years). Two-thirds of patients were living in a shelter and 11 (91.7%) patients had a mental illness. Patients were prescribed a median of four medications at the time of hospital admission and self-reported not taking prescribed medication doses on average 6.8 days in the 30 days preceding hospital stay. Four themes were identified: 1) patients acquired a new appreciation of medications during hospitalization; 2) patients perceived medications as necessary for maintaining health; 3) patients had an interest in receiving medication education; and 4) patients expressed concerns regarding medication adverse effects. Conclusion: During hospital admission, homeless patients have positive perceptions about the necessity of their medications but have concerns of medication adverse effects. Interventions to improve adherence may be successful if directed towards addressing treatment-related concerns. Future studies could explore the impact of pharmacist education on medication perceptions and adherence following hospital discharge.
Evaluation of Post-Stroke Medication Prescription Practices
(2017-11) Boychuk, Larissa; Tsui, Eugene; Leblanc, Kori; Cayley, Anne; Casaubon, Leanne
Background and Objectives: Toronto Western Hospital (TWH), an Ontario regional stroke centre, cares for approximately 900 stroke patients annually. The objective of this study was to determine if TWH met antithrombotic prescribing benchmarks set forth by Accreditation Canada for Distinction in Acute Stroke Services. The evaluation and treatment of modifiable risk factors, and potential practice differences between the Neurovascular Unit (NVU) and the Emergency Department (ED), were also assessed. Methods: A retrospective chart review was completed for all patients with an ischemic stroke or transient ischemic attack between July 1st and December 31st, 2016. Two hundred and sixty-three patients met inclusion criteria for analysis. Medications prescribed for secondary prevention were evaluated. The proportions of patients receiving guideline-based therapies on discharge from the NVU and ED were compared using Fisher’s exact test. Results: Antithrombotic therapy was prescribed on discharge to 88% of ED and 97% of NVU patients (p=0.003). Patients with atrial fibrillation were equally likely to receive anticoagulants on discharge (83% ED, 80% NVU; p=1.00). Antiplatelet therapy was received within 48 hours by 70% of eligible ED and 97% of eligible NVU patients (p<0.001). Antihypertensives were prescribed to 98% of ED and 85% of NVU patients diagnosed with hypertension (p=0.004). There were no significant differences in prescribing rates of statins, antihyperglycemics or smoking cessation interventions, though smoking cessation interventions were low in both groups (0% ED, 69% NVU; p=0.08). On admission, NVU patients were more frequently diagnosed with hypertension (76% vs. 54%, p<0.001) and dyslipidemia (92% vs 39%, p<0.001), and assessed for smoking status (71% vs 45%, p<0.001). Conclusions: TWH meets Accreditation Canada’s benchmark for antithrombotic prescribing. Outpatient referral for patients discharged directly from the ED may help complete the evaluation and treatment of modifiable risk factors. A future focus on assessment and prescribing of smoking cessation interventions is recommended.
A Prospective Analysis of Central Catheter Occlusions to Direct Guideline Development at Kingston Health Sciences Centre
(2017-11-20) Khuman, Hardit; Burge, Nancy
Background: Catheter occlusions are a common central line complication. Depending on the presumed cause (thrombotic or non-thrombotic), recommended management options vary. Although the incidence of nonthrombotic catheter occlusions is reported in the literature to be as high as 42%, alteplase is the only pharmacologic management option available at Kingston Health Sciences Centre (KHSC). At KHSC, the incidence of alteplase failure and the incidence of non-thrombotic catheter occlusions are unknown. Objectives: To assess the incidence of potential non-thrombotic causes of central catheter occlusions at KHSC and determine whether there is a role for adding management options in addition to alteplase to the KHSC Drug Formulary. These findings will also be used to develop KHSC Guidelines for the Management of Occluded Central Catheters. Methods: A prospective chart review of 80 subjects was conducted to assess if alteplase administration restored catheter patency. Daily reports were generated from the Pharmacy Information System to identify patients who were dispensed an alteplase 2 mg vial. The patient’s chart was assessed for documentation in regards to catheter patency restoration post-alteplase administration. The medication administration record was also reviewed for any medications, parenteral nutrition or blood products administered within the previous 24 hours to screen for potential drug incompatibilities or chemical precipitates. Results: The incidence of alteplase failure to resolve central catheter occlusions was 1.25% (1/80). Of the occlusions that resolved, patency was restored in 97.5% (77/79) following a single alteplase 2 mg dose. Nine potential occlusions secondary to drug incompatibilities were identified, however, all resolved with alteplase administration. Conclusion: The incidence of non-thrombotic central catheter occlusions is very low at KHSC and alteplase 2 mg is highly effective in restoring catheter patency. These results indicate that alteplase is being used appropriately, and that there is no need to explore alternative pharmacologic strategies for the management of occluded catheters at KHSC.
Novel Student-Preceptor Models in Pharmacy Education: A Qualitative Analysis of the PharmD Student Experience
(2017-11-29) McIntyre, Caitlin; Natsheh, Cindy; Leblanc, Kori; Fernandes, Olavo; Bjelajac Mejia, Aleksandra; Raman-Wilms, Lalitha; Cameron, Karen
Background: Experiential rotation requirements in the Entry-to-Practice PharmD program have increased. To accommodate significantly more pharmacy learners on-site, institutions have explored novel student-preceptor teaching models. These include peer-assisted-learning (PAL; 2 or more students of same educational level), near-peer-teaching (NPT; 1 or more junior students with 1 or more senior students), and co-preceptorship (CoP; 2 or more preceptors). Objective: To describe students’ experiences and perceptions of novel teaching models and evaluate the effectiveness of these models on students’ learning using Kirkpatrick’s levels. Methods: Pharmacy students from the class of 2015, 2016, and 2017 were invited to participate in semi-structure interviews. Interviews were transcribed, coded, and analyzed for themes. Themes were mapped according to the Kirkpatrick model for appraising educational training. Findings: Twenty semi-structured interviews were conducted with 10 pharmacy students from the class of 2017, and 5 each from the classes of 2016 and 2015. Forty-three experiences (19 CoP, 14 PAL, 10 NPT) were described from 14 institutions. Many themes overlapped between the three novel teaching models. In CoP, students described increased preceptor availability and exposure to different patient care approaches. Challenges arose when preceptors had different student expectations. Students overwhelmingly endorsed a multi-learner environment. Both PAL and NPT students felt well supported as collaboration with other learners was readily fostered. Potential challenges in PAL and NPT included student competitiveness and difficulties when personalities conflicted. All three models allowed for the development of skills including communication, collaboration, and teamwork. Because of their experiences, students reported an improvement in their approach to patient care. They also described a positive impact on their professional practice and approaches to teaching as new preceptors. Conclusion: Pharmacy students enjoyed their experiences in novel student-preceptor models. These opportunities had a positive impact on overall learning during the rotations and as new practitioners.
Evaluating the utility of a weighted-incidence syndromic combination antibiogram on time to appropriate antibiotic therapy in patients with gram-negative bacteremia
(2018) Zangari, Dan; Lee, Rebekah; Graham, Christopher; Yonadam, Lilly; Stockford, Joanne
Background: Gram-negative bacteremia (GNB) is associated with mortality rates up to 30%, with even higher rates in patients who receive inappropriate empiric antibiotic therapy. A weighted-incidence syndromic combination antibiogram (WISCA) is a novel hospital- and infection-specific tool which may aid clinicians in choosing appropriate antibiotic therapy. Objectives: The primary objective was to determine whether a WISCA improves time to appropriate antibiotic therapy in patients with GNB initially treated with inappropriate antibiotics. Secondary objectives included changes in the rates of in-hospital mortality, intensive care unit (ICU) admission, days of antibiotic therapy, consumption of antibiotics used for empiric treatment of GNB, and subsequent diagnosis of C. difficile infection (CDI). Methods: A retrospective pre- and post-implementation study was conducted across two campuses of a large Canadian community teaching hospital from December 2016 to March 2017. Adult patients with a positive blood culture for a gram-negative organism treated at either site with at least one dose of an antibiotic were included. Electronic medical records were used to collect data which was analyzed using two-sample t-tests and Chi-square tests. Results: A total of 210 GNB episodes were included in this interim analysis. Inappropriate empiric therapy was defined as not having received an antibiotic to which the organism was susceptible by release of the gram-stain. This subgroup (28.3% of patients), was analyzed in the primary objective which showed no significant difference in time to appropriate antibiotic therapy for patients in the pre-WISCA vs. post-WISCA arms (42.32 vs. 54.91 hours; p=0.25). There were no significant differences in any of the secondary objectives following implementation of the WISCA. Conclusions: Interim results do not show a significant difference in time to appropriate antibiotic therapy for patients with GNB following implementation of a WISCA. Additional data is required to make appropriate conclusions regarding the utility of this tool.
Prevalence of asymptomatic bacteriuria in inpatients at Trillium Health Partners with low urine culture colony counts
(2018) Martin, Elaine; Graham, Christopher; Yonadam, Liliana
Rationale & Objectives Most laboratories (including Trillium Health Partners (THP)) report urine cultures with colony counts >10 x 106 cfu/L. This threshold was derived from studies in young non-hospitalized women, which have limited applicability to hospitalized patients. Inpatients have an increased risk of asymptomatic bacteriuria (ASB) compared to outpatients, potentially leading to overtreatment. Our primary objective was to determine the prevalence of ASB in low colony count urine cultures (10-100 x 106 cfu/L). Our secondary objectives assessed characteristics of these cultures. Methodology A retrospective chart review of inpatients admitted to THP with urine cultures sent between April 1st 2017 to November 31st 2017 was conducted. Patients were classified as having a urinary tract infection based on modified National Healthcare Safety Network (NHSN) criteria. Charts containing no documentation of symptoms or cases where patients had an alternate source of infection were classified as ASB. To demonstrate a prevalence of ASB of >85%, a sample size of 196 inpatients was required. A prevalence of >85% was used by other institutions to implement interventions reducing prescribing for ASB. Results 95/122 (77.9%) of low urine culture colony counts represented ASB at our institution. Of these, 36 (29.5%) patients were on antibiotics for an alternate source of infection and 27 (22.1%) were prescribed antibiotics for ASB. Additionally, 7 patients (5.7%) had bacteremia secondary to a urinary source, of which 2 patients (1.6%) were asymptomatic. Finally, 10% (122/1216) of total urine cultures (any growth) sent from included wards were low growth. Conclusions Based on interim results, the prevalence of ASB for low urine culture colony counts at our institution was <85%. Additional data collection is required to meet sample size (N=196) in order to sufficiently power this outcome. A future intervention altering reporting of low growth urine cultures might reduce prescribing for ASB, and will be considered if our prevalence is >85%.

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