Leslie Dan Faculty of Pharmacy

Permanent URI for this communityhttps://hdl.handle.net/1807/68860

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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1 Assessment of a Standardized Discharge Prescription Implemented to Prevent Excess Opioid Use Post-Surgery: An Opioid Stewardship Strategy
(2021) El Refaei, Sama
Background Excessive prescribing of postoperative opioids is a recognized contributor to opioid misuse and related harms. As part of an Ontario provincial initiative to address the issue, a standardized discharge prescription was implemented for patients undergoing day surgery. The discharge prescription consisted of 20 hydromorphone tablets prescribed as two part-fills of 10 tablets, to be dispensed 3 days apart. Objective(s) Primary: To evaluate the impact of reducing the quantity of opioids prescribed and determine the effect of using part-fills on pain control. Secondary: To assess the feasibility of implementing follow-up calls on the clinical pharmacy technician’s (CT) daily workflow. Methods Prior to the implementation of this quality improvement (QI) initiative, it was standard of care for nurses to call patients 24 hours post-surgery. In the new process, CTs made an additional follow-up call to patients who received the prescription on day 7 using a standardized questionnaire. Outcomes included number of hydromorphone tablets consumed, number of patients who filled the second part-fill, pain score on day 7 assessed with a 5-point scale (0-no pain, 5-difficult to manage pain), and average time required to conduct the calls per day. Results Between November 2019 and March 2020, 47 patients received a CT-led follow-up call. Of these 47 patients, 38 received the standardized discharge prescription without alterations by prescribers. At day 7 post-surgery, 29% of 970 hydromorphone tablets were consumed with an average of 6 tablets consumed per patient. Eighteen-percent of patients filled the second part-fill, 9% consumed all hydromorphone prescribed and 34% did not consume any hydromorphone tablets. Patients reported an average pain score of 1.6 on a 5-point scale. The average time for the CT follow up call was 29 minutes per day (0.01 Full-Time Equivalent of CT per day). Conclusion(s) Reducing the quantity of opioids prescribed and using part-fills in a standardized post-surgery discharge prescription reduced the availability of opioids in the community without compromising pain relief. Follow-up calls were also feasible to incorporate into the daily workflow of CTs.
Accuracy of Best Possible Medication Histories Collected by Nurses in Pre-Surgical Screening of Elective Surgery Patients
(2019-03-22) Wagner, Brittany; Methot, Linda
Rationale: Obtaining an accurate Best Possible Medication History (BPMH) is the foundation of Medication Reconciliation (MedRec), a practice that reduces medication errors and patient harm. At Kingston Health Sciences Centre (KHSC), nurses obtain BPMH for elective surgery patients during a Pre-Surgical Screening (PSS) appointment. The PSS BPMH is used by surgeons to generate orders for home medications at the time of admission. The accuracy of PSS BPMHs has not been studied and could be affected by the adequacy of training provided to nurses and purposeful changes to medications made between the time of PSS and surgery. Methods: A prospective, non-randomized comparison was used to determine the accuracy of PSS BPMHs. A pharmacy resident obtained BPMHs during the post-operative period for a convenience sample of 60 elective surgery patients. For each patient, the PSS BPMH was retrieved and compared with the pharmacy-obtained BPMH. Discrepancies between medication regimens were recorded and classified by type and risk of patient harm. Results: 31% of medication regimens contained discrepancies between the PSS and pharmacy-obtained BPMHs, with an average of 2.55 discrepancies per patient. Of these, 4.6% were judged to carry risk of moderate harm to the patient and 95.6% carried little to no risk of harm. No discrepancies which posed a risk of severe harm were identified. 60% of discrepancies were related to non-prescription medications. 21% of discrepancies resulted from a purposeful medication change during the time between PSS and surgery. Conclusion: While the rate of discrepancies between BPMHs was high, the majority of discrepancies carried little to no risk of harm. Elective surgery patients are unlikely to experience clinically important medication errors secondary to use of the nursing-obtained PSS BPMHs in the current model of MedRec at KHSC.
Adherence to combination antithrombotic therapy in atrial fibrillation patients post-PCI
(2020-12-22) Poirier, Caylie; Leblanc, Kori; Carter, Aleesa; Kwan, Yvonne; Koo, Jessica; Westlund, Jill
Objective: Up to 30% of patients with atrial fibrillation (AF) also have coronary artery disease (CAD), with many undergoing percutaneous coronary intervention (PCI) for revascularization. These patients require combination antithrombotic therapy (ATT) with antiplatelet agent(s) of variable durations and an oral anticoagulant (OAC), which may require dose adjustment. The complexity of these regimens may contribute to misunderstandings for clinicians and patients alike. Any resulting non-adherence increases the risk of thrombosis and/or bleeding. This project aimed to describe patient experiences with ATT, including unplanned modifications, after discharge from University Health Network (UHN). Methods: This was an observational study with prospective follow-up. Eligible patients were those with documented AF requiring OAC who received a PCI and were discharged from UHN with a plan for combination ATT. Patients were identified from inpatient cardiology units and the coronary catheterization lab. Follow-up contact was planned at one-month, 3-months, 6-months, and 12-months post-PCI. Results: Thirty-two patients were enrolled. Follow-up one-month data was collected for 26 patients (81.3%), 3-month data for 17 patients (53.1%), and 6-month data for 10 patients (31.3%). A total of 12 patients reported at least one unplanned modification. Unplanned modifications occurred in nine patients(34.6%)at the one-month mark, six patients (35.3%) at the 3-month mark, and four patients (40%) at the 6-month mark. Nine of the 12 patients(75%)who reported modifications experienced a negative event that was either a reason for or was due to an unplanned modification to the ATT regimen. These events ranged from mild nosebleeds to ischemic stroke. Conclusion: Each patient’s experience with combination ATT is unique. Most patient-reported unplanned modifications appeared to be prescriber-driven. The risk of negative events both requiring and resulting from these modifications exists and occurred in 3 in 4patients. Understanding the patient experience is critical to improving discharge processes, transfer of information, and patient education to optimize patient outcomes.
Adverse Events Associated with Immune Checkpoint Inhibitors: Overview of Systematic Reviews
(Drugs, 2022-04-13) Morin, Sydney
Background Recognition and management of adverse events (AEs) associated with immune checkpoint inhibitor (ICI) use by cancer patients requires expertise from multiple disciplines. Greater awareness of potential AEs may result in earlier recognition, appropriate management, and better patient outcomes. Objective The primary objective of this overview of systematic reviews was to synthesize and consolidate systematic review evidence describing the incidence proportion and severity of AEs associated with various ICI therapies across different cancers. Methods A systematic literature search of four databases was conducted to identify systematic reviews that describe the incidence proportion and severity of AEs related to ICI therapy in cancer patients. A systematic review was eligible if it included adults with cancer; on ICI alone or in combination with another ICI, chemotherapy, or targeted therapy; severity (graded according to the Common Terminology Criteria for Adverse Events) and incidence proportion of AEs and whether it reported its eligibility criteria. AEs of interest were identified through an iterative ranking exercise by key stakeholders and knowledge users. Extraction of PICOTTS elements and quality indicators (AMSTAR-2) were used to manage overlap of primary studies across systematic reviews at the outcome level. Cancer subtypes were mapped to drug class and AE severity. Results Overall, 129 systematic reviews met the inclusion criteria for data mapping. Systematic reviews reported incidence proportions for more than 76 AEs, of which 34 were identified as AEs of interest. After overlap assessment, 65 systematic reviews were chosen for data extraction. The three AEs with the highest median incidence were fatigue (18.3%, interquartile range [IQR] 15.0–28.0%), diarrhea (15.3%, IQR 9.7–29.2%) and rash (14.4%, IQR 10.3–19.2%). The three AEs (high-grade) with the highest median incidence were diarrhea (1.5%, IQR 1.2–6.0%), colitis (1.3%, IQR 0.6–6.1%) and neutropenia (1.2%, IQR 0.4–3.3%). Incidence proportions of high-grade AEs were often considerably lower than all-grade AEs and combination therapy (ICI combinations or combinations of ICI with chemotherapy or targeted therapy) was responsible for some of the highest incidence proportions regardless of AE. Rare AEs and certain cancer subtypes were not well reported. Conclusions Early recognition of AEs associated with ICIs requires expertise from diverse specialists, not just oncologists. Greater awareness of potential AEs may result in earlier recognition, appropriate management, and better patient outcomes. PROSPERO Registration CRD42021231593.
Antimicrobial Management and Outcomes of Cancer Patients with Febrile Neutropenia Admitted to General Internal Medicine at Toronto General Hospital
(2020) Liu, Rachel (Xia-Ying)
Background: Febrile neutropenia (FN) is a medical emergency that can lead to significant morbidity and mortality for oncology patients. As recommended by the Infectious Diseases Society of America (IDSA) for Antimicrobial Stewardship Program (ASP) interventions, developing facility-specific guidelines for FN management in hematology-oncology patients can reduce unnecessary antibiotic use without adverse outcomes. Objective: At the University Health Network (UHN), guideline-recommended empiric antimicrobials are piperacillin/tazobactam plus aminoglycoside in higher-risk FN patients, and cefazolin plus aminoglycoside in lower-risk FN patients. Meropenem is an accepted alternative for patients with self-reported penicillin allergies. The aim of this study is to determine if patients admitted to the General Internal Medicine (GIM) service at Toronto General Hospital (TGH) for febrile neutropenia were given guideline specified empiric antimicrobials within 48 hours of admission for oncology patients admitted with febrile neutropenia. Methods: A retrospective observational study was conducted in patients admitted with FN from July 1, 2016 to June 30, 2017. Patients were classified as either low-risk or high-risk according to cancer diagnosis and chemotherapy received. The primary outcome was the proportion of patients administered guideline-specified empiric antimicrobials within 48 hours of admission to GIM. Secondary outcomes were the proportion of patients whose empiric antimicrobials were active against pathogens isolated, the rate of antimicrobial adverse events, and the 30-day readmission rate. Results: One hundred patients were included, of which 34% (34/100) were classified as low-risk FN and 66% (66/100) as high-risk FN. Antimicrobial management was guideline-concordant in 59% (59/100) of all admissions. In the low-risk group, guideline concordance was 35% (12/35), and in the high-risk group, 71% (47/66). Source of infection was identified in 50% (50/100) of cases, and empiric antimicrobials were active against 94% (17/18) of the pathogens isolated. Antimicrobial adverse events occurred in 16% (16/100) of admissions, and 30-day readmission rate was 23% (23/100). Conclusion: Guideline concordance in the antimicrobial management of FN patients was low in GIM at TGH at 59%. Future qualitative studies to identify factors influencing antimicrobial prescribing behaviours to improve knowledge translation are warranted.
Antimicrobial PK and Dosing in PIRRT: Systematic Review
(2023-01) Grewal, Arvind; Thabet, Pierre; Dubinsky, Samuel; Purkayastha, Debanjali; Wong, Kristy; Marko, Ryan; Hiremath, Swapnil; Hutton, Brian; Kanji, Salmaan
Introduction: Prolonged intermittent renal replacement therapy (PIRRT) is gaining popularity as a renal replacement modality in intensive care units but there is a relative lack of guidance regarding antimicrobial clearance and dosing when compared to other modalities. Objectives: The objectives of this systematic review were to 1) identify and describe the pharmacokinetics (PK) of relevant antimicrobials used in critically ill adults receiving PIRRT, 2) evaluate the quality of evidence supporting this data and 3) propose dosing recommendations based on the synthesis of this data. Methods: A search strategy for multiple databases was designed and executed to identify relevant published evidence describing the PK of antimicrobials used in critically ill adults receiving PIRRT. Quality assessment, evaluation of reporting and relevant data extraction was conducted in duplicate. Synthesis of PK/pharmacodynamic (PD) outcomes, dosing recommendations from study authors and physicochemical properties of included antibiotics were assessed by investigators in addition to the quality of evidence to develop dosing recommendations. Results: Thirty-nine studies enrolling 452 patients met criteria for inclusion and provided PK and/or PD data for 20 antimicrobials in critically ill adults receiving PIRRT. Nineteen studies describe both PK and PD outcomes. Vancomycin (12 studies, 171 patients), meropenem (7 studies, 84 patients) and piperacillin/tazobactam (5 studies, 56 patients) were the most frequent antimicrobials encountered. The quality of evidence was deemed strong for 7/20 antimicrobials and strong dosing recommendations were determined for 9/20 antimicrobials. Conclusions: This systematic review updates and addressed issues of quality in previous systematic reviews on this topic. Despite an overall low quality of evidence, strong recommendations were able to be made for almost half of the identified antimicrobials. Knowledge gaps persist for many antimicrobials and higher quality studies (i.e., population PK studies with assessment of PD target attainment) are needed to address these gaps.
Antipsychotic Medication Use in Pregnancy: A Survey of Patient and Physician Perspectives
(2020-12-04) Leake, Joanna
Rationale: The incidence of pregnancy is increasing among women using antipsychotics. When pregnancy occurs, a patient and her healthcare team are faced with a risk/benefit discussion. If an antipsychotic is stopped, the harm of disease relapse often outweighs the teratogenic risk. Despite this, studies report a drop in antipsychotic prescriptions filled during pregnancy. This prospective study explored patient and physician perspectives of antipsychotic use in pregnancy, specifically the perception of risk versus benefit, the nature of communication between patients/prescribers, and resources accessed regarding this topic. Methods: Two unique surveys were developed and tested for readability and content validity. Physician surveys were distributed to St. Joseph Healthcare Hamilton (SJHH) psychiatrists and psychiatry residents via email. Women over 16 years taking an antipsychotic for at least one month were informed about the survey during in-person or virtual outpatient clinic visits. All surveys were completed electronically. Results: Data from eight patient surveys suggest all patients worry that antipsychotic use may harm their unborn child, while 50% feel pregnancy may worsen their disease. Three patients initiated a discussion with a healthcare provider. All patients are likely to access their psychiatrist, family doctor, and pharmacist for information. Nineteen physician surveys were returned (25%). 79% of physicians agreed antipsychotics should not be avoided during pregnancy. Regarding communication, 78% of respondents have not or rarely discuss pregnancy with patients, yet 64% of physicians feel confident doing so. All physicians are likely to consult guidelines for information. Conclusion: These preliminary results reflect that patients are concerned about fetal harm during pregnancy. Physicians are knowledgeable of the risks/benefits of antipsychotics in pregnancy but rarely discuss this with patients. Strategies and tools to increase dialogue between patients and healthcare providers are necessary to support patients in the management of their disease and their family planning wishes.
Antipsychotic treatment and average time to discharge in patients with first-episode nonorganic psychosis and cannabis use
(2023-12-10) Gill, Karanpal (Bobby)
Objective: Cannabis-Induced Psychotic Disorder (CIPD) is a newly identified disorder that is recognized under the Diagnostic And Statistical Manual Of Mental Disorders Fifth Edition (DSM-5), but does not currently have guidelines for treatment. Evidence regarding CIPD treatment with antipsychotics is limited to case reports; thus, prescribing patterns may vary. At Trillium Health Partners (THP), some psychiatrists may initiate a scheduled antipsychotic in patients presenting with CIPD, while others may not. The primary objective of this study is to determine whether there was a difference in average time to discharge between CIPD patients who received antipsychotic treatment within five days of first psychiatry consult, compared to those who did not. Secondary objectives include percent distributions and average times to discharge for antipsychotics prescribed, and the percentage of patients discharged against medical advice. Methods: This retrospective chart review includes data from 66 charts of adult patients admitted to THP psychiatry units for a first-episode nonorganic psychosis with a positive cannabinoid urine test. Results: Current practice at THP reflects a preference for scheduled antipsychotic treatment within five days of psychiatric consult (64%) in patients presenting with CIPD. The average time to discharge in the group who received scheduled antipsychotic treatment within five days was 23 hours less than the group that did not; however, the t-score value (0.457) was smaller than the critical t-value (2.03) which suggests there is no true difference between groups for this outcome. Olanzapine was the most prescribed antipsychotic, and each antipsychotic was associated with a different average time to discharge. Conclusions: This descriptive study suggests that antipsychotic treatment within five days of first psychiatric consult may not result in a true difference in average time to discharge compared to no treatment. The findings may inform larger studies that could be better powered to identify cause-and-effect relationships and influence future CIPD treatment guidelines.
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.
Asparaginase Activity Levels and Tolerability Following Intravenous Pegaspargase in Adults with Acute Lymphoblastic Leukemia Receiving Multi-Agent Chemotherapy
(2020-02) Moreno, Maria; Wolfe, Amanda; Dara, Celina; Yee, Karen; Schuh, Andre
Background: Therapeutic drug monitoring (TDM) has emerged as an important monitoring tool for adults with acute lymphoblastic leukemia (AAL) receiving pegaspargase. For adequate asparagine depletion in leukemia cells, nadir asparaginase activity levels (AALs) are targeted to be ≥0.1 units/mL. AALs achieved following ongoing TDM and dose adjustments of pegaspargase have not yet been reported in adults. Objectives: The primary objective was to describe longitudinal TDM of AALs for patients receiving pegaspargase and the secondary objective was to describe tolerability. Methods: This was a single centre retrospective chart review including 26 patients ≥18 years who received intravenous pegaspargase as part of a chemotherapy protocol for AAL between December 2017 and November 2018. Phases of treatment included one dose of pegaspargase during induction and 7 – 10 doses every 21 days during intensification. AAL monitoring was scheduled for 15 and 22 days after each administration of pegaspargase. Results: In total, 115 doses of pegaspargase were given and 203 AALs were analyzed. Of 17 AALs (n = 17) measured during induction 22 days after pegaspargase administration, only 3 (18%) were ≥ 0.1 units/mL. During intensification, of 53 nadir AALs (n = 11), 47 (89%) were ≥ 0.1 units/mL at a variety of different individualized doses ranging from 550 to 2000 units/m2. The most common adverse effects were grade 3 and 4 elevated transaminases (38%), bilirubin increases (31%), and hypertriglyceridemia (15%). Conclusion: TDM and individualized dosing of pegaspargase given every 21 days appears feasible for adult patients to achieve and maintain target nadir AALs.
Assessing the Impact and Feasibility of Pharmacist Vancomycin Dosing and Monitoring Interventions: A Pilot Program
(2019-04) Law, Janice
BACKGROUND: The benefits of pharmacist-directed vancomycin therapeutic drug monitoring (TDM) on clinical efficacy, patient safety, and hospital cost-savings are well-described in the literature. However, there is limited data surrounding the feasibility of implementing such a program. OBJECTIVES: To evaluate the outcome of pharmacist-directed vancomycin TDM compared to standard practice and describe the feasibility of its implementation within a large community health system. METHODS: This was a dual-centre, pre-post study. A vancomycin TDM tool was developed based on current guidelines and used by pharmacists to intervene within the first 24 hours of vancomycin initiation. The primary outcomes included rate of trough target attainment, attainment of area under the curve (AUC) to minimum inhibitory concentration (MIC) ratio (AUC/MIC) targets, and the incidence of nephrotoxicity. Feasibility was assessed by measuring pharmacist intervention rates using a TDM documentation tool and identifying barriers to implementation. RESULTS: Eighty-five patient records were retrospectively reviewed during the pre-intervention period. Forty patients were enrolled during the prospective post-intervention period. Trough target attainment in the pre- and post-interventions groups were 24.7% and 32.5%, respectively (p=0.361). AUC/MIC target attainment was 76.5% in the pre-intervention group, compared to 88.9% in the post-intervention group (p=0.628). Two patients experienced nephrotoxicity; both were in the post-intervention group (p=0.095). Pharmacists intervened for 72.7% of eligible patients. The most common reasons for lack of pharmacist intervention during the post-intervention period included anticipating discontinuation of therapy within 24 hours and initiation of therapy during non-clinical hours. CONCLUSION: There was a high rate of pharmacist participation in the post-intervention period. In addition, although underpowered, there was a trend towards improved serum trough and AUC/MIC target attainment. The degree of pharmacist influence on vancomycin management during the pre-intervention period is unknown, which limits evaluation of the true impact of this intervention.
Assessing the Impact of a Layered Learning Practice Model on the Delivery of Clinical Pharmacy Key Performance Indicators within an Oncology Unit of a Tertiary Care Centre.
(2018-10-16) Yung, Jason; Nguyen, Tiffany; MacLean, Robert (Bob); Wentzell, Jason
Background: The layered-learning practice model (LLPM), within which a pharmacist supervises both a pharmacy resident and student, mitigates the growing demand for clinical rotations accompanying the national expansion of Doctor of Pharmacy programs. A Canadian collaborative of hospital pharmacists established consensus on eight clinical pharmacy key performance indicators (cpKPIs), activities associated with improved patient outcomes. With increased implementation of the LLPM alongside cpKPI measurement across institutions, this offers opportunities to evaluate pharmaceutical care delivery in the LLPM compared to standard practice. Objective(s): To quantify clinical productivity, as measured by the proportions of eligible patients receiving cpKPIs and the absolute number of completed cpKPIs, across scenarios during which pharmacists work with or without pharmacy learners. Methods: In this retrospective observational study, pharmacy students, pharmacy residents and pharmacists recorded completion of 7 cpKPIs for oncology inpatients over a 6-month period. Clinical productivity was described across scenarios when the following pharmacy professionals were present: i) pharmacist(s) with student(s) and a resident (‘P-R-S’); ii) pharmacist(s) with student(s) (‘P-S’); iii) pharmacist(s) alone (‘P’). Results: During the study, there were 685 recorded admissions under the inpatient oncology service. Generally, scenarios with pharmacy learners present provided cpKPIs to similar proportions of patients compared to standard practice. Standardized to 20 pharmacist work days, the total number of cpKPIs 1,2,3,5,6,7 (‘P-S’=281; ‘P-R-S’=255; ‘P’=258) and resolved drug therapy problems (DTPs) (‘P-S’=180; ‘P-R-S’=153; ‘P’=149) were similar across the scenarios. Scenario ‘P’ had fewer admitted patients per pharmacist work day (3.2) compared to Scenarios ‘P-S’ (3.4) and ‘P-R-S’ (3.7), which potentially contributed to a trend towards greater proportions of patients receiving cpKPIs in Scenario ‘P’. Conclusions: Compared to standard practice, integration of pharmacy learners within an oncology unit does not appear to impair clinical productivity, as demonstrated by the comparable proportions of patients receiving cpKPIs and total number of completed cpKPIs.
Assessing the Impact of the Pharmacist Medication Adaptation Policy on Pharmacists and Prescribers at William Osler Health System
(2024-05-28) Sahyouni, Alissa; Goel, Rakhi; Summa-Sorgini, Claudia
Background: In 2020, William Osler Health System developed the Pharmacist Medication Adaptation policy to facilitate timely access to medications for patients and prevent medication errors. Objective: To a) determine factors influencing policy implementation b) describe frequency of uptake, patient care areas where medication adaptations occurred, and common reasons for medication adaptation. Methods: Multi-method study involving a confidential, web-based survey with Likert-type and open-ended questions (distributed to 44 eligible pharmacists and 24 prescribers) and a chart review of all Pharmacist Medication Adaptation Order Sets from January 1, 2021 to February 1, 2022. Results: The pharmacist and prescriber surveys had response rates of 70% (n=31) and 42% (n=10), respectively. Timely access to medications and reduced prescriber workload were the top benefits identified. Pharmacist-reported facilitators included: self-confidence, perceived impact on patient care, and prescriber support. Prescribers reported general agreement with medication adaptations made by pharmacists and supported use of the policy. Pharmacists reported “somewhat agreement” with having adequate time to utilize the medication adaptation policy and the overall layout of the adaptation order set. Both pharmacists and prescribers supported expansion of the policy to include additional medical directives – specifically, warfarin dosing. A total of 862 medications were adapted within the first 13 months of implementation. Most medication adaptations occurred in medicine (41%), emergency (29%), and surgery (10%) patient care areas. Most common reasons for medication adaptation were renal dose adjustments (59%), dose/formulation not available or on backorder (29%), and 7% were due to a prescriber written order for the pharmacist to dose/adjust the medication. Conclusion: Overall, pharmacists and prescribers expressed positive perceptions and supported expansion of the medication adaptation policy. Strategies to facilitate more efficient use of the medication adaptation policy and increased prescriber awareness could help increase further uptake of the policy in practice.
Assessment of a Therapeutic Drug Monitoring Strategy of Once Daily Dosing of Gentamicin/Tobramycin in Paediatric Patients
(2018-11-30) Chen, Wendy; Chung, Erin; Strzelecki, Marina; Boodhan, Sabrina; Fecteau, Annie; Seto, Winnie
Background: There is limited evidence to support the use of once daily dosing (ODD) of aminoglycosides in paediatric patients, in contrast to the adult population. In July 2014, ODD was implemented for all eligible paediatric patients at the Hospital for Sick Children. Objectives: To evaluate the ability of a once daily intravenous (IV) dose of 9 mg/kg gentamicin or tobramycin to achieve a target maximal concentration (Cmax) of 16-25 mg/L, refine optimal sampling times, assess efficacy and safety in paediatric patients and compliance to the hospital’s therapeutic drug monitoring (TDM) guideline. Methods: Pharmacokinetic parameters were calculated from serum gentamicin or tobramycin levels drawn 3 and 6 hours after the aminoglycoside infusion and summarized using descriptive statistics. Monte-Carlo simulations based on calculated pharmacokinetic parameters were used to assess optimal dosing regimens. Results: One hundred and forty children with 149 aminoglycoside courses were included. Mean pharmacokinetic parameters were: volume of distribution of 0.46±0.22 L/kg, clearance of 0.17±0.07 L/h/kg and half-life of 1.89±0.44 h. Approximately half of the courses achieved Cmax target with the initial dose. Monte-Carlo simulations showed highest Cmax target attainment with 9 mg/kg/dose IV once daily. Approximately half of the empiric courses that did not reach Cmax target stepped down to oral antibiotics. Majority (77%) of patients defervesced at the end of the course. No nephrotoxicity was identified. Almost all courses (99%) used an initial dosing of 9 mg/kg as per formulary guideline. Approximately 65% of all courses followed formulary guidelines in drawing levels for aminoglycosides, while only 34% of courses for post-operative surgical patients had levels drawn on or after post-operative day 2 as per formulary guidelines. Conclusion: An initial dose of 9 mg/kg/dose gentamicin or tobramycin IV once daily is appropriate in achieving a Cmax of 16-25 mg/L and appears to be efficacious and safe in paediatric patients. Majority of courses complied with the TDM guideline for dosing of aminoglycosides, while compliance for timing of drawing levels is lower. Future steps include analyzing additional efficacy and safety data for empiric and prophylactic courses without 3 and 6 hour levels to further assess the feasibility of minimizing levels in these patients.
Assessment of Quetiapine for Managing Delirium in Paediatric Critical Care Patients Younger than 2 Years of Age
(2024) Alder, Chelsea; Seto, Winnie; Ames, Meredith; McKinnon, Nicole; Gilfoyle, Elaine; De Souza, Claire; Nadeem, Komail; Wong, Karen; Hannah, Madelynn; Wu, Natalie; Buckley, Laura; Khafagy, Rana
Background: Delirium is a common complication of paediatric patients admitted to critical care units (CCU), leading to increased risk of morbidity and mortality. Children less than 2 years old are at a higher risk for developing delirium. For patients whose symptoms fail to improve, there is limited literature suggesting using quetiapine as an adjunct to nonpharmacological management for CCU delirium. Objectives: This study aimed to assess the effectiveness and short-term safety of quetiapine in patients less than 2 years old in the CCU at the Hospital for Sick Children. Methods: A retrospective chart review of patients less than 2 years old prescribed quetiapine in the CCU from July 2018 to November 2023 was completed to evaluate patients' characteristics, quetiapine dosing regimens, efficacy and short-term safety parameters. Results: Seventy-eight patients administered quetiapine in the CCU were included. Quetiapine use was more frequent in the Cardiac Critical Care Unit (n=62, 79.5%) compared to the Paediatric Intensive Care Unit (n=16, 20.5%). The median quetiapine course was 6 days (IQR: 2-23 days). Although Cornell Assessment of Pediatric Delirium (CAPD) scores during quetiapine therapy (mean=9.1, SD=3.86) were lower than scores before quetiapine (mean=13.0, SD=4.36), patients’ mean opioid and alpha agonist use did not differ during quetiapine therapy. Benzodiazepine use decreased during quetiapine (mean=0.22 mg of lorazepam/kg/day, SD=0.54) compared to before (mean=0.47mg of lorazepam/kg/day, SD=1.18). As benzodiazepine use is a risk factor for CCU delirium, this may have influenced patients’ CAPD scores. No adverse effects associated with quetiapine were observed. Conclusion: Patients receiving quetiapine for CCU delirium had a decrease in their CAPD scores, however, the decrease was modest and still indicative of delirium. Patients did not have changes in their opioid and alpha agonist use, but a decrease in benzodiazepine use was seen. Future research is required to standardize duration and weaning for quetiapine in this patient population and evaluate which CCU subpopulations would most benefit from quetiapine for delirium management.
Assessment of the Clinical Pharmacy Practice Models for Provision of Pharmaceutical Care at The Hospital for Sick Children. Phase 1: A Narrative Review of Clinical Pharmacy Practice Models
(2020-12-07) Matinnia, Cheyenne; Chung, Erin; Koo, Alicia; Lau, Elaine; Seto, Winnie
Background: Clinical pharmacy practice models (CPPMs) determine how a pharmacy department allocates resources for the provision of clinical pharmacy services by clinical pharmacists. Based on available published literature, there is a lack of consensus on CPPMs. Objective: A narrative review was performed to identify current CPPMs and inform future phases of this initiative. This narrative review aimed to provide insight for services and/or metrics included in general or service-specific clinical pharmacy practice models. Methods: Literature searches were conducted using MEDLINE, EMBASE, IPA, and Scopus by the resident and librarians independently and confirmed that there was no published consensus on CPPMs. Additional articles were identified through hand searching, article references, and grey literature. Due to limited published articles on CPPMs, a narrative review was conducted instead of a systematic review or scoping review. Articles that discussed any aspect related to allocation of pharmacy resources for pharmacy practice in an inpatient setting were included. Articles were excluded if there was no description of pharmacy model/practice, occurred in an ambulatory/emergency/telehealth/outside of hospital setting, was a survey, or no full text available. Practice model descriptors on type of services (domains) and/or clinical pharmacy key performance indicator (cpKPI) metrics (indicators) were extracted from included articles if available. A total of 701 articles were identified from the literature searches, where 112 articles received full text screening, and 24 articles met inclusion criteria. Results: Included CPPMs varied in their delivery and allocation of pharmacy practice. None of the 24 included articles fully described the domains or indicators. The domain most described was pharmaceutical care (n=20), which described various pharmacist responsibilities such as resolving drug therapy problems (DTPs), participating in rounds, medication reconciliation, and medication education. Indicators that were commonly described were direct patient care (n=4), which described pharmacists performing proactive patient chart reviews, and resolving DTPs(n=8). Overall, included articles included more descriptions of domains, and were less likely to include indicators. Conclusion: The review confirmed that published CPPMs comprised of a variety of different domains and indicators. There is no CPPM that contained entire spectrum of domains or cpKPI metrics. This narrative review was mainly limited by missing information on domains and indicators in included articles. Future studies include creating consensus metrics to evaluate CPPMs and conducting internal/external site surveys as an environmental scan of other hospital CPPMs.
Assessment of the impact of patient-completed medication questionnaires on best possible medication history completion times in admitted emergency department patients
(2020) Grant, Daniel; Riordon, Megan; Mistry, Mielen
Background: Medication errors represent one of the top medical errors that compromise patient safety. Pharmacist-led medication reconciliation (med rec) is the gold-standard and a crucial service in hospitals, which has been shown to reduce unintentional medication errors at care transitions. Studies have shown that patient medication questionnaires are reliable and compare favourably to pharmacy lists; however, there is a paucity of evidence describing the utilization of these questionnaires prior to a pharmacist’s interview as a tool to support best possible medication history (BPMH) gathering. Objective: The primary objective of this study is to determine if a patient-completed medication questionnaire available on patient interview would reduce the total time taken by the pharmacist to complete a BPMH. Secondary objectives were to determine if a reduction in time is apparent across certain patient subgroups including age, use of compliance packaging, number of medications, Canadian Triage & Acuity Scale score on admission, dispensing record available prior to interview, and admitting service. Methods: This was a prospective, non-blinded, quasi-experimental trial conducted at a single centre. Over a period of 4 weeks, eligible patients were randomized to either receive a BPMH questionnaire prior to an interview with a pharmacist or not (usual care). Data gathering, interview, and travel times were self-recorded by the completing pharmacist. Results: Nineteen patients were included in this study. None of the pre-specified endpoints met statistical significance. The median total BPMH time was 27 minutes in the control group and 50 minutes in the intervention group (p=0.089). Secondary objectives could not be evaluated due to limited sample size. Conclusion: This study does not support the use of a patient-completed medication questionnaire to improve BPMH times in emergency department patients. Extenuating circumstances prevented the capture of enough patients for meaningful analysis. Further studies are required to effectively evaluate the impact and role of questionnaires in BPMH gathering.
Best Practices for Ordering Correctional Insulin for Acute, Non-Critically Ill Older Adults: An Expert Survey
(2021-04-13) Vu, Josephine; Molla Ghanbari, Hedieh; Romanovsky, Lindy; Coleman, Brenda; Fan-Lun, Chris
Background: Guidelines discourage correction only insulin for managing hyperglycemia in hospitalized non-critically ill adults in favour of basal-bolus-correction strategies. Older adults are at increased risk for harm from treatment but limited prospective data exists to guide practices in these patients. Appropriateness of extrapolating practices in younger adults to hospitalized older adults is unclear. Objectives: Our aims were to generate a list of best practices for ordering correctional insulin in acute, non-critically ill older adults and to evaluate the utility of a modified  order set. Methods: Seventeen institutional experts at a Canadian teaching hospital were invited to participate in an online survey to assess their agreement with statements about correctional insulin use in acute, non-critically ill older adults and proposed modifications to an existing order set. Responses were captured using a Likert-type scale and analyzed descriptively. Survey items with unanimous agreement were identified as ‘best practice statements’ or ‘endorsed modifications’. Free text responses were analyzed qualitatively to identify themes. Results: The survey response rate was 47%. Six best practice statements focused on blood glucose targets and correction scale selection were identified. Themes included lenient blood glucose targets in frail adults, individualization of treatment, and correction insulin as a bridging strategy. There were seven endorsed modifications aimed at updating terminology, increasing standardization, and providing clinical decision support. Conclusions: Available literature can be applied to acute, non-critically ill older adults when ordering correctional insulin. However, strategies to reduce hypoglycemia risk and ongoing reassessment are required to optimize treatment efficacy and safety, particularly in frail adults.
Bone Disease Post-Renal Transplant at St. Joseph’s Healthcare Hamilton – A Retrospective Chart Review
(2020-03) Baranski, Melissa
INTRODUCTION: Studies have demonstrated a rapid decrease in bone mineral density (BMD) in the first 6-12 months after renal transplantation. Bone loss after renal transplantation is primarily related to the use of glucocorticoids and persistent hyperparathyroidism. In the transplant recipient, clinical manifestations of persistent hyperparathyroidism include hypophosphatemia and hypercalcemia. KDIGO suggests treatment with vitamin D or vitamin D analogues to suppress parathyroid hormone and improve BMD. OBJECTIVES: The primary objective was to determine the effect of vitamin D and vitamin D analogues on BMD post renal transplant. Secondary objectives were to determine the effect of vitamin D and vitamin D analogues on calcium and phosphate levels, as well as, phosphate supplementation prescribed. In addition, we examined the rate of prescription of vitamin D and vitamin D analogues in patients that had a post-operative order set prompting healthcare review of vitamin D and vitamin D analogues versus patients that did not have this order set. METHODS: A retrospective chart review of inpatient and renal transplant clinic charts. RESULTS: BMD one year post-transplant appears to be similar across treatment groups. Overall, need for phosphate supplementation was reduced beyond 30 days post-transplant irrespective of vitamin D or vitamin D analogue supplementation. Treatment with vitamin D or vitamin D analogues did not appreciably raise serum calcium levels. Combination treatment with vitamin D and vitamin D analogues did not result in an observed added benefit with respect to phosphate levels, phosphate supplementation, or calcium levels. Therefore, there may be a potential cost savings with prescription of vitamin D alone. CONCLUSION: This review suggests there is no difference in median BMD one year post-transplant among patients prescribed vitamin D, vitamin D analogues or the combination of the two. There was good uptake of the vitamin D order on the renal transplant post-operative order set as an inpatient; however, there is variability in vitamin D analogue prescribing in the outpatient renal transplant clinic which does not utilize a predefined order set.
Buprenorphine/naloxone micro-induction in a tertiary care hospital: a retrospective cohort analysis
(2021-12-02) Nunn, Robert
Objectives: To describe the use of buprenorphine/naloxone micro-inductions in hospitalized patients and characterize the success rate of these inductions. Methods: We conducted a retrospective chart review of hospitalized patients receiving a buprenorphine/naloxone micro-induction for opioid use disorder in a tertiary care hospital from Jan 2020 – Dec 2020. The primary outcome was a description of the micro-induction prescribing patterns used. The secondary outcomes were a description of the demographic characteristics of patients, the estimated frequency of withdrawal symptoms experienced by patients undergoing a micro-induction, and the overall success rate of the micro-inductions defined as retention on buprenorphine/naloxone therapy with no precipitated withdrawal experienced. Results: Thirty-three patients were included in the analysis. Three main micro-induction regimens were identified, including rapid micro-inductions (8 patients), 0.5 mg SL BID initiations (6 patients), and 0.5 mg SL daily initiations (19 patients). Twenty-four patients (73%) met the criteria for a successful micro-induction, defined as being retained in buprenorphine/naloxone therapy with no precipitated withdrawal experienced. The most common reason for micro-induction failure was patient request to discontinue buprenorphine/naloxone therapy due to reported adverse effects or personal preference. Conclusion: Buprenorphine/naloxone micro-induction in hospitalized patients resulted in a majority of patients being successfully initiated on buprenorphine/naloxone therapy without requiring opioid abstinence prior to induction. Dosing regimens were variable, and the ideal regimen remains unclear.

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