Pharmacy Residency Projects

Permanent URI for this collectionhttps://hdl.handle.net/1807/68861

This collection houses research projects completed by pharmacy residents at institutions affiliated with the University of Toronto.

Pharmacy residents have the opportunity to complete a research project during their residency training, which provides them with skills on how to conduct and manage a research project. Projects often represent an area of interest and need that has been recognized by the host institution’s pharmacy department. Projects are presented as a poster at an annual Canadian Society of Hospital Pharmacists (CSHP) Ontario Branch Residency Research Night, and many eventually go on to be published in a peer-reviewed journal.

To obtain authorization to submit your project to this collection, contact the Leslie Dan Faculty of Pharmacy, Office of Experiential Education.

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Now showing 1 - 20 of 200

CHANGE-Rx: Frailty, Falls, Polypharmacy, and Inappropriate Medication Use in a Canadian Cohort of People Aged 65 and Older Living With HIV
(2024) Hopwood-Raja, Julian; Tseng, Alice; Sheehan, Nancy; Walmsley, Sharon; Falutz, Julian; Zhabokritsky, Alice
Objective: To characterize the prevalence of polypharmacy, potentially inappropriate medication (PIMs), anticholinergic burden (ACB) and sedative burden (SB) and their association with the risk of frailty and falls in a Canadian cohort of older people with HIV. Design: CHANGE-Rx is a cross-sectional analysis of baseline data from CHANGE-HIV, a Canadian cohort of people with HIV aged 65 years and older. Methods: Information on prescription, over-the-counter/natural-health product use, comorbidities, HIV-specific factors, frailty and fall history were assessed at the baseline visit at cohort entry. Proportion of people with polypharmacy (≥5 non-antiretroviral (ARV) drugs), severe polypharmacy (≥10 non-ARV drugs), PIMs, ACB and SB were determined. Chi-square tests and multivariate regression analysis were used to assess the association between medication factors and the risk of frailty and falls. Results: 440 participants were included: median age 69 years (range: 65-89), 16.4% were classified as frail, 20.7% experienced a fall (last six months), 53.2% had polypharmacy, 14.8% had severe polypharmacy, 49.3% had ≥1 PIM. For prescribed comedications, 16.5% and 55.7% of participants had high ACB and SB, respectively. The odds ratio (OR) for frailty were 3.3, 2.6 and 2.9 among patients with high ACB, high SB and severe polypharmacy, respectively. The OR for falls were 1.9 and 1.8 for patients with high SB and ≥1 PIM, respectively. Conclusion: Polypharmacy, PIMs and high ACB and SB are common among older adults living with HIV in Canada. It remains to be determined if interventions addressing polypharmacy/PIMs would reduce falls and frailty.
Evaluating the clinical impact of targeting lower versus higher serum vancomycin trough: a retrospective study using a desirability of outcome ranking (DOOR) analysis
(2024-12-12) Shi, Zong Heng
Background: Guidelines recommend a target AUC24/MIC of 400–600 for vancomycin dosing in serious MRSA infections. However, various challenges hinder the implementation of AUC-based monitoring. Previously recommended target trough of 15–20mg/L may be associated with increased nephrotoxicity. Methods: In this single-center, retrospective study, we compared outcomes of targeting troughs of 10–15 mg/L vs 15–20 mg/L for intermittent infusion of vancomycin (IIV) in adult hospitalized patients who received ≥48 hours of IIV and had ≥1 trough measurement within recommended ranges. Local guidelines recommended target troughs of 15–20mg/L between January 2019 and December 2020 and 10–15mg/L between January 2022 and October 2023. Treatment failure, acute kidney injury (AKI) and inpatient mortality were compared using a desirability of outcome ranking (DOOR) analysis between the two time periods. The most desirable outcome was treatment success and no AKI, and the least desirable outcome was death. Results: A total of 173 IIV courses were included. The probability of obtaining a better DOOR was 57.9% (95%CI 50.5–64.9%, p = 0.0336) when targeting a lower trough. Secondary analyses demonstrated a similar trend. When analyzed separately, the lower target trough group experienced significantly less AKI (OR 0.4, p = 0.024) with no significant effect on mortality and treatment failure. Conclusion: Our study showed that targeting a trough of 10–15 mg/L for IIV was associated with a superior overall outcome compared to targeting 15-20 mg/L. In centers not using AUC-based monitoring for vancomycin dosing, a lower target trough may be preferable.
Norepinephrine vs. Vasopressin for the Treatment of Hypotension among Neonates with Hypoxemic Respiratory Failure: A Retrospective Study
(2024-11-28) Shahab, Noor; Gerges, Sandra; Persad, Nishkal; Kiss, Alex; Weisz, Dany
Introduction: Norepinephrine and vasopressin are commonly used vasopressors for the treatment of systemic hypotension among preterm and term neonates with acute pulmonary hypertension and hypoxemic respiratory failure (HRF) after birth. There is uncertainty regarding which agent is more effective in improving blood pressure and clinical outcomes. This study aims to evaluate the association of norepinephrine vs. vasopressin and clinical outcomes among hypotensive neonates with HRF. Methods: We conducted a retrospective cohort study among preterm and term neonates with severe HRF and systemic hypotension, who required treatment with inhaled nitric oxide and/or had FiO2 requirements of ≥50%, and received norepinephrine or vasopressin treatment within 72 hours of birth. The primary outcome was treatment failure, defined as a composite of the need for additional vasopressor support or need to exceed the maximum conventional dose of the initial vasopressor. Secondary outcomes included mortality, necrotizing enterocolitis, severe intraventricular hemorrhage, and moderate-severe hyponatremia (defined as a serum sodium concentration ≤128 mEq/L). Multivariable logistic regression analysis was used to evaluate the association of vasopressor and clinical outcomes, adjusting for antenatal and perinatal confounders. Results: Among 63 neonates (mean gestational age 28.8±5 weeks, mean birth weight 1.39±1.00 kg) with hypotension and severe HRF, 26 neonates were treated with norepinephrine and 37 with vasopressin. Compared to norepinephrine, treatment with vasopressin was not associated with an increase in treatment failure (aOR=0.63, 95% CI 0.18-2.27, p=0.18), the need for additional vasopressor support (aOR=0.68, 95% CI 0.18-2.59, p=0.24), the need to exceed the maximum conventional dose (aOR=0.45, 95% CI 0.12-1.74, p=0.09), mortality (aOR=1.57, 95% CI 0.40-6.12, p=0.93), necrotizing enterocolitis (aOR=0.31, 95% CI 0.03-3.90, p=0.067), or severe intraventricular hemorrhage (aOR=4.20, 95% CI 0.64-27.51, p=0.93). Neonates treated with vasopressin had a higher odds of developing moderate-severe hyponatremia (aOR=5.82, 95% CI 1.51-22.38, p=0.0026). Conclusions: Among neonates with systemic hypotension and HRF, norepinephrine and vasopressin were associated with similar clinical outcomes; however, vasopressin treatment was associated with increased hyponatremia.
The clinical and economic impact of reported beta-lactam allergy in hospitalized patients with hematological malignancy
(2024-12-04) Rizzo, Jenna; Flores, Jerome; Law, Arjun; Gupta, Vikas; So, Miranda
Background: Patients with hematologic malignancies are vulnerable to developing infections during hospitalization. Up to 21% of these patients report an allergy to beta-lactam antibiotics. The clinical and economic consequences of beta-lactam allergies (BLA) in this population remain understudied. Objective: The aim of this study was to describe the healthcare resource utilization and clinical outcomes in hospitalized patients with acute leukaemia who have a reported BLA. Design: Single-centre, retrospective cohort study Setting: Tertiary cancer centre in Toronto, Ontario Patients: Adult patients hospitalized with a primary diagnosis of acute leukaemia Methods: Patients with a reported BLA were compared to those without. The primary outcome was antibiotic use and secondary outcomes included hospitalization cost, hospital length of stay (LOS), clostridium difficile infection (CDI) rate, colonization with a multidrug resistant organism and inpatient mortality rate. Antibiotic use and hospitalization cost were analysed using multivariable negative binomial regression and generalized linear models, respectively. Results: A total of 628 patients were included; 9.4% had a reported BLA. Among patients, 74.7% had acute myeloid leukaemia and 20.9% had acute lymphoblastic leukaemia. Nearly half the cohort (41.2%) received hematopoietic stem cell transplants. After adjusting for covariates, antibiotic use was 11% lower (IRR=0.89, 95% CI=0.69-1.16, p=0.395) and hospitalization cost was 7% higher (95% CI=0.85-1.34, p=0.549) in the BLA cohort. These patients also had numerically longer median LOS, lower rates of CDI and mortality, and higher rates of colonization with methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus compared to those without a BLA. Conclusions: The prevalence of BLA in this Canadian population of hospitalized patients with acute leukaemia and a self-reported BLA was lower than what is currently reported in the literature. Antibiotic use and hospitalization costs were not statistically different between groups. Future studies are needed to further evaluate these findings.
Utilization of SGLT2 Inhibitors in Heart Failure Patients at Sunnybrook Health Sciences Centre
(2024-11-29) Hubscher, Melissa; Bucci, Claudia; Cohen, Eric
Abstract (258 words) Background: Early initiation of guideline-directed medical therapy for heart failure, including sodium-glucose co-transporter 2 inhibitors (SGLT2), is recommended to optimize disease control and patient outcomes. Prior to 2022, Sunnybrook Heath Sciences Centre (SHSC) restricted inpatient prescribing of SGLT2 inhibitors due to the risk of ketoacidosis. A formulary amendment now permits the initiation of SGLT2 inhibitors in hospitalized patients. Objective: To characterize the use of SGLT2 inhibitors for heart failure patients at SHSC and identify gaps in prescribing. Methods: A retrospective chart review was conducted in adult patients admitted to SHSC with a discharge diagnosis of heart failure between January 25, 2023, and May 31, 2023. SGLT2 inhibitor prescribing practices were assessed along with associated factors, including baseline characteristics, and pharmacist involvement during hospitalization. Results: A total of 147 patients were included in this study. SGLT2 inhibitors were prescribed in 49 patients (33%) at discharge and suggested as outpatient management in 17 patients (12%). SGLT2 inhibitors were prescribed more frequently in men than women (46% vs. 21%, respectively). Additionally, SGLT2 inhibitors were prescribed in a higher proportion of patients with heart failure with reduced ejection fraction (63%) compared with heart failure with preserved ejection fraction (29%). Pharmacist involvement in patient care, represented by documentation in the patient chart, was present in 49% of those prescribed SGLT2 inhibitors. Conclusions: Despite the increased uptake of SGLT2 inhibitors at SHSC, most patients are not initiated on a SGLT2 inhibitor during hospitalization. Opportunities exist to increase the prescribing of SGLT2 inhibitors in female patients and patients with heart failure with preserved ejection fraction.
Evaluation of Sedative-Hypnotic Prescribing Patterns in Hospitalized Older Adults
(2024-11) Spasik, Leona; Angle, Camille; Fan-Lun, Chris; Marchesano, Romina; Porter, Danielle
Background: Sedative-hypnotics pose significant harms for older adults yet prescribing of these medications increases with age and may have an association with recent hospitalization. Objectives: To estimate the proportion of older adults admitted to acute care units that are started on a new sedative-hypnotic and the proportion of older adults that received a sedative-hypnotic prescription at discharge. Secondary objectives included describing the prescribing and documentation practices for sedative-hypnotics. Methods: A retrospective study was conducted to identify sedative-hypnotic naïve older adults that were admitted to a medicine, surgery, or cardiology unit with a new order for a sedative-hypnotic drug and whether it was continued at discharge. A convenience sample of 100 patient encounters that received at least 1 dose of the medication were selected to characterize prescribing patterns and documentation practices of sedative-hypnotic orders. Descriptive statistics were used for analysis of all outcome variables. Results: A total of 612 patient encounters had a new sedative-hypnotic order during the study period, representing 8.1% of eligible patients admitted to acute-care floors being evaluated. Of the 612 encounters, 11.3% had the medication continued at discharge. The cardiology and cardiovascular surgery service had the highest number of orders (71%). From the random sample of 100 patients, 67% of orders were for zopiclone and 29% for lorazepam. 30% of orders for zopiclone and lorazepam had a documented indication; 100% of zopiclone orders were for sleep while 45% of lorazepam orders were for sleep, 18% for anxiety and sleep, and 18% for agitation. The mean daily dose prescribed was 5.5 mg for zopiclone and 1 mg for lorazepam. 26% of patients that received a dose of a sedative-hypnotic had the medication continued at discharge. Conclusion: Overall, approximately 1 in 12 sedative-naïve hospitalized older adults were newly ordered a sedative-hypnotic, and of those 11.3% were continued at discharge. This study highlighted high prescribing services and the associated prescribing patterns that can be targeted for interventions to reduce sedative-hypnotic prescribing.
Nursing Attitudes and Perceptions of Barriers that Result in Barcode Medication Administration Overrides
(2024-11-19) Xu, Nancy; Kelkar, Apoorva; Santiago, Cecilia
Background: Barcode medication administration (BCMA) enhances patient safety through electronic barcode scanning before medication administration. Overriding barcode scanning increases the risk of medication errors and indicates existing system barriers. Objective: To describe user, medication, and technology-related barriers among nursing staff leading to BCMA overrides. Methods: This two-phase study was conducted on three inpatient units at St. Michael’s Hospital: General Medicine, General Surgery, and the Trauma-Neurosurgical Intensive Care Unit. Phase 1 involved thematic analysis of BCMA data from April 1st to July 31st, 2024, collected from the Medication Administration Check (MAK) system. Phase 2 involved developing and administering a validated questionnaire to nursing staff from June 14th to July 12th, 2024, to understand their perceptions of barriers causing barcode scanning overrides. The questionnaire's face and content validity were assessed by nurses and nursing educators. Results: MAK data recorded 43,489 override occurrences in four months, with unreadable barcodes being the most common reason for overriding (39.91%). Out of 259 nurses, 125 (48%) responded to the questionnaire. Most nurses strongly agreed (SA, 62.4%) or somewhat agreed (SoA, 26.4%) that unreadable or damaged barcodes and not having a barcode available to scan (SA 56%, SoA 26.4%) were medication-related barriers. Broken scanners (SA 43.2%, SoA 28.8%) and equipment issues (SA 35.2%, SoA 30.4%) were technology-related barriers. Most nurses strongly disagreed that a lack of time (72.34%), lack of training (67.23%), or lack of familiarity with BCMA benefits (75.61%) were user-related barriers. Incomplete documentation was the most common user-related reason for overriding (35.04%). Conclusion: This study identified barcode readability, lack of barcodes, malfunctioning scanners, and incomplete documentation as key barriers to effective BCMA. The findings highlight the need for system-level interventions such as establishing barcode standards, improving barcode quality and readability, ensuring equipment maintenance, and optimizing electronic documentation workflows to mitigate these barriers and improve patient safety.
Laboratory to Bedside: An Assessment of Clinical Outcomes in Adult Patients Receiving Definitive Cefazolin Therapy in Community-Acquired Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis Bacteremia Across MIC Breakpoints
(2024-11-28) Lam, Jerry; Forrest, Russell; Li, Xena; Das, Pavani; Kan, Tiffany; Raybardhan, Sumit
Background: In 2011, Clinical and Laboratory Standards Institute revised its systemic cefazolin minimum inhibitory concentration (MIC) breakpoints to address rising antibiotic resistance. The revision was based on pharmacokinetic-pharmacodynamic analysis with limited real-world data. Institutional review anticipated a shift from susceptible to intermediate sensitivity reporting with the new MIC breakpoints. This change may result in an increased use of broad-spectrum antibiotics in situations where cefazolin therapy would have been suitable in the past. Objective: The objective was to compare the rates of treatment failure in hospitalized adult patients with community-acquired monomicrobial Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis bacteremia with cefazolin MIC of ≤ 4 versus 8 μg/mL when treated with definitive cefazolin therapy. Methods: Single-centre, retrospective chart review of patients admitted to North York General Hospital between January 1, 2015 to December 31, 2022. Multivariable logistic regression was used to model treatment failure for MIC of ≤ 4 versus 8 μg/mL. Results: 2,018 charts were screened, and 280 patients met the inclusion criteria. 11 of 280 cultures had a MIC of 8 μg/mL. Patients with a MIC of ≤ 4 μg/mL received a higher proportion of ceftriaxone as empiric therapy (61% vs 27%, p<0.05) and had Escherichia coli as the predominant organism of interest (74% vs 36%, p<0.05). There was a non-significant increase in treatment failure in patients with a MIC of 8 μg/mL (OR 1.61, 95% CI [0.14-12.63], p=0.67). Conclusions: Consistent with existing literature, a trend towards higher treatment failure rates with MIC of 8 versus ≤ 4 μg/mL was identified. Future research should validate clinical outcomes in contemporary MIC breakpoints and investigate MIC susceptibility in gram-negative bacteremias from urinary sources.
Optimizing Dexmedetomidine Dosing for Sedation in Neonates Undergoing Therapeutic Hypothermia
(2024-10-01) Lo, Terrence; Kang, Han Byul; McNair, Carol; Wilson, Diane; Bizzarri, Jennifer; Kalish, Brian; Tam, Emily; Seto, Winnie; Chung, Erin
Background: Hypoxic-ischemic encephalopathy (HIE) is one of the leading causes of neonatal death and is treated with therapeutic hypothermia (TH). Opioids are often prescribed for sedation and to suppress shivering but are associated with significant adverse effects including neurodevelopmental impairment. Recently, opioids have been replaced by dexmedetomidine due to favourable effectiveness and safety outcomes in neonatal intensive care unit (NICU) patients. However, the optimal dose of dexmedetomidine remains unclear. Objectives: To describe dosing patterns, evaluate compliance, and compare effectiveness and safety between the revised in-house dosing guideline (intervention) of dexmedetomidine 0.2µg/kg/h with titration by 0.1µg/kg/h every 30-60 minutes as needed and the original in-house dosing guideline (comparator) of dexmedetomidine 0.05µg/kg/h with titration by 0.05µg/kg/h every six hours as needed. Methods: This was a retrospective cohort study that included neonates with HIE admitted to a level IV NICU for TH who received dexmedetomidine. Dexmedetomidine doses, effectiveness endpoints (opioid/benzodiazepine exposures; Neonatal Pain, Agitation, and Sedation Scale [N-PASS] scores; and shivering), and safety endpoints (hypotension and bradycardia) were analyzed. Results: A total of 106 neonates (n=56 in intervention and n=50 in comparator groups) were included. Compliance to intervention was 69.6% for initial dexmedetomidine doses, 62.5% for dose increases, and 44.6% for dose decreases. An increased odds of opioid exposure was observed in the intervention group, but with a wide confidence interval (CI) (adjusted odds ratio: 7.13, 95% CI: 1.59-51.2, p=0.02, vs. comparator). A greater proportion of patients in the intervention group had bradycardia (21.4% vs. 4%, p=0.03). No significant differences in opioid/benzodiazepine exposures, shivering episodes, suboptimal N-PASS scores, or hypotension events were observed (p≥0.05). Conclusion: The revised dexmedetomidine dosing guideline was associated with similar effectiveness outcomes, but more bradycardia compared with the original dosing. A prospective study with population pharmacokinetic analysis is needed to individualize dexmedetomidine dosing for neonates with HIE undergoing TH.
Implementation and evaluation of a continuous infusion protocol for piperacillin-tazobactam and meropenem in critically ill adult patients with septic shock
(2024) Purkayastha, Debanjali; Thabet, Pierre; Saunders, Hannah; Kanji, Salmaan; Richler, Caitlin
Introduction: Strategies to optimize antimicrobial dosing in patients with septic shock remains a major challenge. Evidence supporting the use of prolonged infusions of beta-lactams, such as piperacillin-tazobactam and meropenem, has suggested a decrease in mortality and a higher clinical cure rate in critically ill patients with septic shock with minimal adverse events. However, the uptake of this practice in clinical settings has not been universal. The primary objective of this study was to implement a continuous infusion protocol of piperacillin-tazobactam and meropenem in a community hospital and to then evaluate the implementation of the protocol. The secondary objectives were to identify barriers to implementation and identify solutions based on data analysis. Methods: Strategies identified in a previous scoping review were used to develop and implement a protocol in the intensive care unit. These strategies included protocol approval, protocol adherence support, a multidisciplinary approach, institutional readiness assessment, education, and using a behavioural change model for successful implementation. The implementation process was then evaluated through a retrospective chart review over a 6-month period to determine the rate of protocol adherence and to identify errors in order entry, verification, and administration. Periodic reassessments were conducted to adapt implementation strategies as required. Results: There were a total of 217 orders for either piperacillin-tazobactam and/or meropenem for the 129 patients included from February 13th to August 13th, 2023. Ninety-five orders were eligible for continuous infusions. Of these orders, 43 were correctly identified and prescribed by the prescriber, 40 were correctly verified by the pharmacist, and 30 were administered as per protocol by the nursing staff. In total, 30 (28.6%) were correctly identified and appropriately prescribed, verified, and administered. Barriers to protocol adherence included lack of physician uptake and nursing administration error due to either missed bolus doses, significant time gaps between bolus and maintenance dose initiation, or incorrect rate of administration. Conclusions: This retrospective chart review provides guidance to community hospitals seeking to implement a protocol for prolonged infusions of beta-lactam antibiotics. This study does not provide information on the relative efficacy of each strategy highlighted in the scoping review, but rather emphasizes the importance of utilizing all the themes identified together. Furthermore, it identifies the importance of physician uptake and presence of physical champions to encourage the use of continuous infusions in patients who would benefit the most. Ongoing research on which key behaviour intervention functions should be targeted to direct effective practice change is crucial in understanding which strategies will have the most significant effect.
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.
Translation of a French language tool assessing the impact of pharmacist clinical interventions to the English language
(2024) Choi, Amy
Background: The CLinical, Economic, and Organizational (CLEO) tool is a French tool developed to assess the degree of impacts of clinical pharmacist interventions. However, it has not yet been formally translated into English. Objective: To translate and ensure linguistical and cultural adaptation of the French language CLEO tool into the English language in Canada. Methods: The translation was done in guidance of the International Society for Pharmacoeconomics and Outcomes Research’s Principles of Good Practice for the Translation and Cultural Adaptation Process for Patient-Reported Outcome Measures. Results: The tool was translated into the English language. There were difficulties in finding equivalent terms that are culturally relevant. The focus was to improve comprehensibility and ensure conceptual equivalence. Conclusion: This was a translation with cultural adaptation of the CLEO tool to the English language. This work will allow for expansion of the constructs, for it to be adapted to Canadian clinical pharmacy practice.
Continuous Heparin Infusions: Evaluation and Review of a Dosing Nomogram at Kingston Health Sciences Centre
(2024-09) Gahagan, Maddison; Tryon, Michelle
Background: KHSC uses the Heparin (Unfractionated) Standard Dose order set to titrate continuous heparin infusions using PTT monitoring. It was hypothesized that it may be failing to achieve therapeutic PTT values within 24 hours. Compared to other nomograms, KHSC uses conservative dose maximums, which may result in delays in achieving therapeutic PTT in certain patient populations. Objective: Determine if the KHSC heparin nomogram is effective at achieving a therapeutic PTT value for patients. Methods: A retrospective, cross-sectional study was completed. The primary outcome was the percentage of patients achieving a therapeutic PTT within 24 hours. Secondary outcomes included percentages of patients achieving a therapeutic PTT within 48 hours, achieving a second consecutive therapeutic PTT, unable to achieve a therapeutic PTT, median time to therapeutic PTT, and percentage of patients with supratherapeutic PTTs. Between-group analyses were conducted to identify patient-specific factors that may be associated with prolonged time to achieve therapeutic PTT or increased risk of supratherapeutic PTTs. Results: 50 patients, with 54 continuous heparin infusions, were included in the study. 53.7% and 90.7% of the patients achieved a therapeutic PTT value within 24 and 48 hours of initiating heparin, respectively. Between-group analyses determined there was a significant difference between those weighing <80 kg and ≥80 kg for the primary outcome. Conclusion: This study demonstrated that the heparin infusion nomogram is unable to achieve a therapeutic PTT for all patients within 24 hours, with patients weighing <80 kg at a higher risk. Most patients achieved a therapeutic PTT within 48 hours.
Duloxetine Administration in Intensive Care Unit Patients with Enteral Access Devices: A Retrospective Chart Review
(2024-08-20) Drolet, Jacob; Shchepanik, Kiarah; Ralph, Bonnie
Background: There is limited guidance on how to manage duloxetine therapy for patients with enteral access devices (EADs), with most resources advising not to administer due to risk of EAD occlusion. However, it is frequently administered through EADs in Kingston Health Sciences Centre’s (KHSC’s) level 3 intensive care unit (ICU). Objectives: The primary objective was to determine whether duloxetine is administered to patients with EADs in the level 3 ICU at KHSC and to quantify duloxetine therapy disruption. Methods: This retrospective chart review included patients prescribed duloxetine for administration through EADs in KHSC’s level 3 ICU. Incidences of disrupted duloxetine therapy and EAD occlusion for each treatment period were recorded. Results: Thirty-nine treatment periods were included. Duloxetine therapy was disrupted 9 times (23.1%) with no statistically significant differences in disruption with regards to types or sizes of EADs. Most disruptions were associated with one missed dose. EAD occlusion occurred in 6 treatment periods, 3 of which required EAD replacement. There were no statistically significant differences in EAD occlusion between different duloxetine doses, numbers of concomitantly administered medications, types of EADs, or sizes of EADs. Conclusions: This study demonstrated that duloxetine was often administered undisrupted in the level 3 ICU, with relatively few incidences of tube occlusion. With the unavailability of an EAD-compatible duloxetine formulation in Canada, future studies are required to investigate the clinical outcomes of this practice to determine if the benefits of avoiding duloxetine disruption outweigh the risks of EAD occlusion in the ICU.
Effectiveness and Safety of Direct Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation and Venous Thromboembolism Treatment in End-Stage Renal Disease Patients at Trillium Health Partners
(2024-08) Bardal, Viktoriya; Liao, Rose
Background/objectives: Patients with end-stage renal disease (ESRD) make up a complex population with both a higher risk of stroke and thromboembolism (VTE) and a higher risk for bleeding. Although historically managed with warfarin, evidence now suggests a potential benefit of direct oral anticoagulants (DOACs). As such, this study aimed to assess the effectiveness and safety of DOAC use in ESRD patients at Trillium Health Partners (THP), and compare this to available literature to determine if our patients are being safely and appropriately managed. Methods: Electronic records from Epic were retrospectively reviewed from October 10, 2020 to November 30, 2023 to identify patients receiving dialysis and being treated with a DOAC for the purposes of stroke prophylaxis in atrial fibrillation (AF) or treatment for VTE. Primary efficacy outcomes included recurrent stroke or VTE while receiving DOAC therapy. Safety outcomes assessed the occurrence of major and minor bleeding events. Results: A total of 52 patients were included in the study, with the majority (92.3%) receiving anticoagulation for stroke prophylaxis in AF. 92.3% received apixaban, 5.8% received edoxaban, and no patients received rivaroxaban or dabigatran. During the 3 years of follow up, 2 patients (3.8%) experienced an ischemic stroke and 1 patient (1.9%) experienced a recurrent VTE. The most common event was a bleed, with an incidence of 59.6% for any bleed, and 17.3% for major bleeds. Conclusion: Given the small population size, firm conclusions regarding the effectiveness and safety of apixaban for stroke prophylaxis could not be drawn. However, comparison to current literature suggests a similar incidence of stroke and bleeding as warfarin users in the same population. Very few patients in this study received VTE anticoagulation or used other DOACs. Although conclusions could not be made, the results of this study highlight a need for further studies in this clinical area.
Environmental Scan of Implementation Strategies for Formulary Restrictions of Antimicrobials Across Epic Hospitals in Ontario
(2024-08-25) Qian, Aiwen; Bhojwani, Ramola; Girgis, Matthew; Graham, Christopher; Small, Lorne; Barker, Kevin
Background: The use of the electronic health record software Epic continues to expand across hospitals in Ontario with an impact on pharmacy workflows. Formulary restrictions of antimicrobials is a common antimicrobial stewardship (ASP) strategy; however, a standardized or optimal method to leverage Epic functionalities has not been identified in the literature. Aims: The primary aim of this project was to identify and compare how hospitals utilizing Epic in Ontario currently implement their formulary restrictions of antimicrobials. The secondary aims were to identify potential facilitators and barriers that should be considered when implementing formulary restrictions in the Epic system, and identify successes and setbacks from hospitals with identified formulary restriction workflows. Methods: A mixed-methods environmental scan was conducted between February and April 2024, which targeted ASP pharmacists. Phase I was a voluntary online survey that was distributed to 14 Epic hospitals in Ontario. Phase II was a semi-structured, virtual follow-up meeting with survey respondents who agreed to participate. Descriptive statistics were used to summarize background information on the hospitals and stewardship programs, as well as stewardship strategies and workflows. A subgroup analysis was performed based on the responses related to successes and setbacks, and thematic analysis was conducted for the responses from the follow-up meetings. Results: The survey had a 100% response rate (n = 14) and 50% of survey respondents participated in the follow-up meetings (n = 7). Of the 14 hospitals, 12 (85.7%) reported using formulary restrictions of antimicrobials as an ASP strategy. 11/12 (91.7%) have built them in Epic. The most frequently used Epic build for formulary restrictions of antimicrobials was an automated prompt or pop-up when the antimicrobial was selected for order. For pre-authorization, requesting providers to enter the name of the authorizing infectious diseases (ID)/ASP physician or pharmacist in the order form was the most frequently used. The subgroup analysis suggested that additional ASP funding, time since Epic go-live and size of the organization were not driving factors for success in implementing formulary restrictions in Epic. Furthermore, it appeared the more effective Epic builds prompted communication or discussion with the ID team. Enforcing formulary restrictions emerged as a separate theme from the ones pertaining to the Epic build itself. The key link in the concept map that closed the loop among the themes was communication between ASP and the Willow team. Conclusions: Most hospitals utilizing Epic in Ontario use formulary restrictions of antimicrobials as an ASP strategy and have implemented them in Epic through various builds in the system. Multiple facilitators and barriers were identified when implementing these restrictions. Future efforts should focus on optimizing resources allocated to ASPs and Willow teams to facilitate implementation of Epic builds that are tailored to each ASP’s workflow and address each hospital’s needs.
Prevalence and consequences of drug-drug interactions between high-dose methotrexate and common co-medications on an inpatient hematology unit
(2024-08-11) Chan, Wai Ying; Senneker, Tessa; Genge, Briana; Stefancsisc-Korenevsky, Patricia
Background: High-dose methotrexate (HD-MTX) is a chemotherapeutic agent that is used to treat a range of hematological cancers. Certain medications, when administered concurrently with HD-MTX, have been associated with delayed MTX clearance, which may increase the risk of adverse effects including nephrotoxicity and febrile neutropenia. The prevalence and consequences of drug-drug interactions (DDI) with HD-MTX have not previously been described at our centre. Objectives: To determine the proportion of HD-MTX cycles administered to adult hematology inpatients where at least one DDI was present. To compare the incidence of delayed MTX clearance, increased serum creatinine grade two or higher and febrile neutropenia between cycles with and without DDIs. Methods: A single-centre, retrospective cohort analysis was conducted on HD-MTX cycles administered to adult inpatients diagnosed with hematological cancer. The patient cycles were screened and allocated to the DDI and non-DDI group based on the presence of DDI during MTX clearance. The two groups were then compared. Results: From January 2020 to November 2023, DDIs were present in 53 out of 100 patient cycles. There were no statistically significant differences between the DDI and non-DDI group regarding the incidence of delayed MTX clearance, increased serum creatinine grade two or higher and febrile neutropenia. Subgroup analyses on cycles with fluoroquinolones and proton pump inhibitors co-administered also did not reveal any significant differences when compared to the non-DDI group. Conclusion: DDIs were identified in 53% of the HD-MTX cycles, but significant consequences of DDIs were not demonstrated in this study. Future larger-scale studies are required.
Implementation of a smoking cessation initiative delivered by pharmacy students on an in-patient Vascular Surgery unit: a pilot program evaluation
(2024) Nzeribe, Vanessa; Mihajlovic, Silvija; Buckner, Sarah; Kanji, Salmaan
Background: Standardized nurse-led smoking cessation programs, such as The Ottawa Model for Smoking Cessation (OMSC®), have demonstrated efficacy and feasibility in multiple healthcare settings. Pharmacy students have the potential to deliver this program in lieu of other healthcare professionals. Objectives: To evaluate the successes and challenges of a modified OMSC® program pharmacy students as smoking cessation counsellors on a Vascular Surgery inpatient unit. The primary outcome is reach; secondary outcomes are implementation and effectiveness. Methods: A pilot program was initiated with nurses systematically identifying smokers and consulting pharmacy for smoking cessation counselling. Pharmacy students completed smoking cessation consults and offered post-discharge support through the OMSC® program. Smoking prevalence and identification rates were collected from the electronic medical record and smoking quit rates at 3-months post-discharge were obtained from the OMSC® database. Results: A total of 672 patients were admitted during the program evaluation period, with 169 documented smokers and a smoking prevalence rate of 25%. Unit nurses ordered 124 smoking cessation consultations of which 102 (82%) were completed by the pharmacy student, reaching a total of 60% (102/169) of all documented smokers. Sixty-nine patients agreed to follow-up support, 37 of whom remained in the program at 3-months post-discharge. Using an intention-to-treat analysis, 28% of patients were smoke-free and 12% had reduced the amount they smoke at 3-months. Conclusions: Program feasibility was demonstrated with the pharmacy student completing a majority (82%) of ordered smoking cessation consultations and reaching a significant proportion of documented smokers. Routinization of new practices and continuous reinforcement from onsite program champions are required to ensure program sustainability and continued success.
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.
Implementation and Evaluation of Educational Modules to Prepare Pharmacists to Utilize a Medical Directive for TDM Ordering at CAMH
(2024) Kinahan, Samuel
Background: Therapeutic drug monitoring (TDM) plays a vital role in optimizing patient care and outcomes and pharmacists provide a unique skill-set to aid in TDM. A medical directive is being developed at CAMH delegating the controlled act of ordering drug concentrations of the medications clozapine, lithium, carbamazepine, & valproate to CAMH pharmacists. As per CAMH policy, educational modules must be completed prior to using new medical directives. Objective: The aim of this project is to develop & evaluate an education program that prepares pharmacists to order & take responsibility for therapeutic drug monitoring for the medications: clozapine, lithium, carbamazepine, & valproate. Methods: Two educational modules were developed focusing on key components of conducting TDM and the medications indicated in the medical directive. Modules were disseminated to CAMH staff pharmacists. Data collection involved pre and post-module RedCap surveys to assess changes in pharmacist knowledge, attitudes, confidence, and intent to use the TDM medical directive. Surveys were modelled after levels 1 & 2 of the Kirkpatrick model of educational evaluation. Data was analyzed with descriptive statistics. Results: 2 educational modules and surveys assessing knowledge, confidence and values were developed and distributed to CAMH pharmacists. 10 pharmacists completed pre-module surveys and 6 pharmacists completed post-module surveys. Pharmacist knowledge scores increased from the pre to post-module surveys (median score of 7.5/8 increased to 8/8). Confidence of pharmacists to conduct TDM on each specified medication increased by a median of 1 point on a Likert scale of 1 to 5. Pharmacist’s valued brief e-learnings, emphasizing core TDM concepts for each medication. Conclusions: This project suggests the initial knowledge base for TDM by pharmacists is high, with modest improvements in knowledge scores after completing the e-learning modules. Pharmacist’s confidence for conducting TDM was greater after completing the e-learning modules for each specified medication, the intention to engage in TDM and use the TDM medical directive was greater after completing the e-learning modules.

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