CSHP Professional Practice Conference 2018: Poster Abstracts /
Conférence sur la pratique professionnelle 2018 de la SCPH : résumés des affiches
Facilitated Poster Sessions: Discussions of original research and
pharmacy practice projects
Séance animée de présentations par affiches : Discussions sur des
projets de recherche originale et des projets dans le domaine de la
pratique pharmaceutique
Sunday, February 4, 2018 ● Dimanche 4 février 2018
Infectious Diseases / Antimicrobial Stewardship
1. Falsely Elevated Vancomycin Concentrations in a Patient Not Receiving
Vancomycin
2. A Case of Vancomycin-Induced Thrombocytopenia
3. Successful Treatment of Chronic Spinal Osteomyelitis Caused by Multidrug
Resistant Pseudomonas aeruginosa with Ceftolozane-Tazobactam and
Surgical Intervention
4. Clinical Burden of Antibiotic Resistance Following Implementation of a
Multidisciplinary Antimicrobial Stewardship Initiative in a Major Tertiary
Care Center: A Controlled Interrupted Time Series Analysis Over 14 Years
5. Antibiotic Utilization Feedback Reports on General Medicine: A Qualitative
Assessment
Pharmacy Practice / Patient-Centred Care / Pharmacy Education #1
1. A Descriptive Analysis of an Alternate-Level-of-Care Patient Cohort:
Comprehensive Medication Overview
2. Pharmacist Actual and Perceived Priority Interventions in the Emergency
Department: An Observational Study and Survey Questionnaire
3. Patient Preferences for Atrial Fibrillation Stroke Prevention Therapy Using
an Individualized Risks and Preferences-Based Decision Aid
4. Optimizing Patient Education of Oncology Medications: A Patient
Perspective (award—see page 55)
5. Informing Patients and Families about Storage and Disposal of Opioids
Medication Utilization, Effectiveness, and Safety
1. Pan-Canadian Trends in the Prescribing of Opioids, 2012 to 2016
2. Cardiac Arrest after Acute on Chronic Colchicine Toxicity
3. Mandatory Quality Related Events Reporting in Canada: A Province-wide
Review over 7 Years
4. Analysis of Smart Pump Continuous Quality Improvement Data across
Multiple Organizations
5. Comparison of Weight-Based versus Fixed-Dose Norepinephrine Dosing
in Patients with Septic Shock
Drug Stability, Drug Shortages, Pharmacokinetics, and Occupational
Exposure
1. Varying Ammonia Levels with Two Formulations of Sodium Phenylbutyrate
2. Stability of 8.4% Injectable Sodium Bicarbonate When Stored at Room
Temperature
3. Stability of Ropivacaine 2.7 mg/mL, Morphine 0.091 mg/mL and Ketorolac
0.27 mg/mL in Polyvinyl Chloride Bags at 4°C
4. Étude descriptive de la contamination urinaire de travailleurs exposés au
cyclophosphamide, à l’ifosfamide, au méthotrexate et au fluorouracile
5. Stability of 10, 40 and 200 mcg/mL Hydromorphone Solutions Stored in
Syringes at Room Temperature (23°C)
56
Medication Utilization, Effectiveness, and Safety / Drug Stability and
Shortages
1. A Literature-Based Algorithm for the Assessment, Management and
Monitoring of Drug-Induced QTc Prolongation in the Psychiatric Population
2. Provincial Smart Pump Program Improves Patient Safety
3. A Multi-Incident Analysis on Medication Incidents Associated with Patient
Harm
4. Insourcing High-Risk Sterile Compounded Injectables: Development of
In-House Capacity to Produce High-Quality Injectables during the Sodium
Bicarbonate Shortage
5. Coordinating a Response to a Critical Drug Shortage: Experience with
Sodium Bicarbonate
Monday, February 5, 2018 ● Lundi 5 février 2018
Infectious Diseases / Antimicrobial Stewardship
1. Development and Implementation of a Mobile Antimicrobial Handbook
App at a Tertiary Teaching Hospital
2. Retrospective Multicentre Cohort Study Comparing Safety and Efficacy
Outcomes with Intermittent Infusion versus Continuous Infusion
Vancomycin
3. Evaluation of Dosing Strategies with Meropenem using Monte Carlo
Simulations against Bacteria with Raised MIC
4. Development of an HIV National Clinical Observership Program for
Pharmacists
5. An Innovative In-House Developed Access® Database to Capture and
Analyze Antimicrobial Stewardship Interventions
Pharmacy Practice / Patient-Centred Care / Pharmacy Education
1. Performance of an Innovative Patient Decision Aid for Atrial Fibrillation
Stroke Prevention Therapy
2. Novel Student-Preceptor Models in Pharmacy Education: A Qualitative
Analysis of the PharmD Student Experience
3. Evaluation of Physical Assessment Education for Practicing Pharmacists:
A Cross-Sectional Study
4. International Normalized Ratio Point of Care Testing in an Outpatient
Anticoagulation Clinic and the Impact on the Patient Experience: A Quality
Improvement Study
Medication Utilization, Effectiveness, and Safety #1
1. Case Report: Fatal Arrhythmia in a Patient Receiving an Aconite Herbal
Product
2. A Survey of the Use of Cannabis in Children at a Tertiary Teaching Hospital
3. Current Identification and Management Practices of Steroid-Induced
Hyperglycemia in Brain and Spinal Tumour Patients on a Neurosurgical
Unit
4. Clonidine for Sedation in Critically Ill Adults: A Retrospective Chart
Review
5. The Effect of Preoperative Cannabis Use on Opioid Consumption
Following Surgery: A Cohort Analysis
Pharmacy Practice / Patient-Centred Care / Pharmacy Education #2
1. Atrial Fibrillation Patient Knowledge Gaps: A Systematic Review
2. A Feasibility Study: Implementing a Medication Adherence Contract in
Kidney Transplant Recipients Followed by an Outpatient Transplant Clinic
3. An Emerging Challenge: Pharmacists’ Ability to Counsel a Growing
Immigrant Population
4. Toxicology Education Needs of Emergency Department Pharmacists
5. Implementation of an Overnight Pharmacist Mode
Drug Stability, Drug Shortages, Pharmacokinetics, and Occupational
Exposure
1. Stability of Extemporaneously-Compounded Temozolomide 10 mg/mL
Suspension in Oral Mix SF in Glass and Plastic Bottles and Plastic Syringes
2. Stability of 20, 40 and 50 mcg/mL Fentanyl Solutions Stored in Syringes at
Room Temperature (23°C)
3. Stability of Generic Formulations of Bortezomib 1.0 and 2.5 mg/mL in
Vials and Syringes Stored 4°C and Room Temperature (23°C)
4. Stability of 4 and 10 mcg/mL Remifentanil Solutions Stored in Syringes
at Room Temperature (23°C)
5. Satisfaction des établissements de santé suite à la mise en place d’une
plateforme web de surveillance environnementale
CJHP – Vol. 71, No. 1 – January–February 2018
JCPH – Vol. 71, no 1 – janvier–février 2018
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
Medication Utilization, Effectiveness, and Safety #2
1. Medication Fluids in the Intensive Care Unit
2. Drug Use Evaluation of Oxycodone at a Canadian Teaching Hospital
3. Inpatient Insulin Stewardship Program: A Baseline Needs Assessment
4. Long-Term Beta-Blockers after Myocardial Infarction in the Contemporary
Era: A Systematic Review
5. Clinical Guide for Pharmacists to Evaluate Risks and Manage QTc
Prolongation Drug-Drug Interactions
Infectious Diseases / Antimicrobial Stewardship/ Pharmacy Practice
1. Trickle-Down Antimicrobial Stewardship: Reduction in Long-Term Care
Resistance Rates Following Implementation of a Prospective Audit and
Feedback Intervention in the Adjacent Acute Care Hospital
2. Enhancing Mental Health Services through Hospital Outpatient Pharmacy
and Assertive Community Treatment Team Collaboration
3. Vancomycin Every 4 hours in Paediatric Patients: A Case Series
4. Comparison of Clinical Pharmacy Services in General Medicine and Surgery
Patients: A Workload Measurement Study
Tuesday, February 6, 2018 ● Mardi 6 février 2018
Infectious Diseases / Antimicrobial Stewardship
1. Validation of a Screening Tool to Assist in the Early Identification of
Bloodstream Infection in Older Patients
2. Patterns of Antimicrobial Use in an Outpatient Hemodialysis Unit
3. Impact of an Antimicrobial Stewardship Bloodstream Infection Surveillance
Program in Hospitalized Patients
4. Epidemiology of Carbapenemase-Producing Enterobacteriaceae Bacteremia
and Evaluation of Antimicrobial Prescribing Practices in a Community .
Hospital Setting
5. Development and Implementation of a Provincial Beta-Lactam Allergy
Management Initiative
Pharmacy Practice / Patient-Centred Care/ Pharmacy Education #1
1. Factors Affecting Time to Fill Antiplatelet Therapy for Patients Discharged
from Hospital
2. Evaluation of the Impact of Pharmacist-Led Penicillin Allergy Assessments
on Antibiotic Utilization in a Large Community Teaching Hospital
3. Pharmacy Technician Continuing Education Program at a Large Teaching
Hospital
4. 5 Questions to Ask about Your Medications
5. A Pharmacy-Led Interdisciplinary Teaching Model in Specialized
Pharmacotherapy: An HIV Pharmacy Rotation for Medical Residents
Medication Utilization, Effectiveness, and Safety / Drug Stability
1. Influence of Manufacturer on Cefazolin Stability
2. Opioid Selection in the Neonatal Intensive Care Unit: Morphine versus
Fentanyl: Impact on Total Opioid Exposure and Time to Enteral Feeds
3. The Prevalence of Mortality due to Rebound Toxicity after “Treat and
Release” Practices In Prehospital Opiate Overdose Care: A Systematic
Review
4. A Pan-Canadian Study on the Compounded Medicines Most in Need
of Commercialized Oral Pediatric Formulations
5. A Comparison of Intravenous Iron Dosing Regimens for Anemia
Management in Patients Undergoing Hemodialysis
Pharmacy Practice / Patient-Centred Care / Pharmacy Education #2
1. User Satisfaction Regarding Standard Assessment Tool for Field-Based
Pharmacy Training
2. Pharmacy Student-Led Best Possible Medication History Quality Audit
3. A Work-Sampling Study of Clinical Pharmacists
4. Development and Evaluation of an Anticoagulation Education Program for
Pharmacists
5. Évaluation de l’oculométrie comme outil de rétroaction en validation
pharmaceutique : étude pilote
Pharmacy Practice / Patient-Centred Care / Pharmacy Education #3
1. Qualitative Thematic Analysis of Interprofessional Perspectives on Clinical
Pharmacy Key Performance Indicators
2. Enabling Expanded Scope in Hospital Practice: Implementation of a
Pharmacist Modification Orders Protocol
3. Design, Implementation, and Evaluation of a Clinical Pharmacy Key
Performance Indicator Tracker: DIE‐cpKPI Study
4. Assessing the Perception and Implementation of Continuous Quality
Improvement in Pharmacy Professionals: A Pre-Safety IQ Initiative
5. From “Dot” to “Dot Com”: Navigating Pharmacist Handoff in a Digital
Era
The texts of poster abstracts are published exactly as submitted by the authors and have not undergone any copyediting by the Canadian Journal of Hospital Pharmacy. /
Le Journal canadien de la pharmacie hospitalière n’a pas soumis le texte des résumés des affiches à une révision linguistique et les publie ici tels que remis par les auteurs.
CJHP – Vol. 71, No. 1 – January–February 2018
JCPH – Vol. 71, no 1 – janvier–février 2018
57
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
Falsely Elevated Vancomycin Concentrations
in a Patient Not Receiving Vancomycin
Tsoi VK1, Bhayana V1,2, Bombassaro AM1,2, Tirona R1,2, Betchen D1,
Kittanakom S3,4
1
London Health Sciences Centre, London, ON
2
Western University, London, ON
3
William Osler Health System, Brampton, ON
4
University of Toronto, Toronto, ON
Background: Therapeutic drug monitoring (TDM) of vancomycin is
recommended by the Infectious Diseases Society of America for efficacy
and toxicity. Immunoassays are commonly used in diagnostic laboratories
to determine serum vancomycin concentrations. A case of falsely elevated
vancomycin serum concentrations, in a patient not receiving vancomycin
therapy, is described.
Case Description: An elderly female was prescribed vancomycin and
imipenem for a suspected septic knee. A blood sample was inadvertently
collected prior to her receiving vancomycin, and the concentration
reported as 36.10mg/L (Roche Modular P analyzer). Repeated serum
sampling over the subsequent 48 hours, despite not receiving
vancomycin, yielded similar concentrations (33.10-35.30mg/L).
Eight months later, she was again found to have an elevated vancomycin
concentration (32.9mg/L) in the absence of therapy.
Assessment of Causality: The patient sample was tested for vancomycin
using liquid chromatography-tandem mass spectrometry (LC-MS/MS)
as the gold-standard, and by four alternate commercial immunoassay
platforms. Vancomycin was undetectable by LC-MS/MS. The
immunoassays showed undetectable to high (35mg/L) concentrations.
The falsely elevated concentration observed by our Roche method was
investigated for interference by concurrent medications and endogenous
substances, such as paraproteins and human anti-mouse antibodies. Polyethylene glycol precipitation and heat inactivation resulted in the removal
of the interference responsible for the falsely elevated concentration.
Literature Review: A single case of a spuriously high vancomycin
concentration before receiving the drug, secondary to suspected endogenous interference, has been reported. However, to our knowledge, this is
the first report of falsely elevated vancomycin concentrations on the
Roche Modular P analyzer in a patient not receiving vancomycin.
Importance to Practitioners: Vancomycin immunoassays are robust
in facilitating TDM, but are susceptible to cross-reactivity. Spurious
concentrations may lead to unnecessary dose adjustments, impacting
efficacy or toxicity. Assay interference should be considered and
laboratory professionals contacted when vancomycin levels do not
correlate with clinical expectations.
A Case of Vancomycin-Induced Thrombocytopenia
Szabolcs N1, Neilans L2, Bombassaro AM1,3, Xenocostas A1,3, Kinney J1
London Health Sciences Centre, London, ON
2
Parkwood Institute, St. Joseph's Health Care, London, ON
3
Western University, London, ON
Background: Vancomycin has been implicated in causing cytopenias.
While neutropenia is well described, vancomycin-induced thrombocytopenia is rare and may be overlooked in an initial thrombocytopenia
workup, increasing the risk of potentially life-threatening bleeding.
Case Description: A 41 year-old female underwent revision of a previous
spinal decompression surgery. Irrigation and debridement 15 days later
found complications of dural leaks, pseudomeningocele and necrotic
bone. She was empirically started on vancomycin and meropenem.
Her baseline platelet count was 349 (reference range: 150-400x109/L).
1
58
CJHP – Vol. 71, No. 1 – January–February 2018
Between days 4 and 9 from vancomycin initiation her platelets decreased
from 300 to 62, reaching a nadir of 15 on day 12. Antibiotics were
discontinued. The platelets rebounded to 68 the following day and
meropenem was resumed for a total of 6 weeks. The patient was
transferred to another institution where vancomycin was restarted on day
19 with a platelet count of 372, which decreased to 78 by the following
morning. Vancomycin was discontinued and the platelets rebounded to
120 by day 23.
Assessment of Causality: The Naranjo scale score of 10 identified
vancomycin as a definite cause of the thrombocytopenia. The reaction
resolved with drug withdrawal and recurred within 24 hours of
rechallenge. Flow cytometry testing for drug-induced thrombocytopenia
was positive with vancomycin-dependent immunoglobulin G binding
to platelets detected in the post-exposure but not in the pre-exposure
serum.
Literature Review: A retrospective review published in 2017 identified
30 case reports of vancomycin-induced thrombocytopenia. A study
investigating a case series of patients receiving vancomycin detected
vancomycin-dependent antiplatelet antibodies only in those in whom
thrombocytopenia developed.
Importance to Practitioners: Although vancomycin-induced thrombocytopenia is a rare side effect, prompt recognition and drug
discontinuation may minimize the risk of a life-threatening bleed.
At least weekly monitoring of platelets has been recommended and
patient counseling regarding risks of future exposure is important.
Successful Treatment of Chronic Spinal Osteomyelitis
Caused by Multidrug Resistant Pseudomonas
aeruginosa with Ceftolozane-Tazobactam
and Surgical Intervention
Hooper C1, Elsayed S1,2, Bombassaro AM1,2, Bailey C1,2, Bondy L1,2
London Health Sciences Centre, London, ON
2
Western University, London, ON
Background: Ceftolozane-tazobactam is a novel intravenous antibiotic
combining an anti-pseudomonal cephalosporin with a beta-lactamase
inhibitor. It is indicated for complicated intra-abdominal and urinary
tract infections. Information on the use of ceftolozane-tazobactam in
osteomyelitis is limited and is the focus of this case report.
Case Description: A 67 year-old morbidly obese female with chronic
draining wounds, refractory to multiple courses of antibiotics after spinal
deformity correction three years prior, was admitted for surgical irrigation
and debridement. Existing rods and hardware were removed and pockets
of purulent material were found throughout the spinal exposure.
Intraoperative cultures grew Streptococcus anginosus and multidrug
resistant (MDR) Pseudomonas aeruginosa sensitive only to aminoglycosides. A clinical diagnosis of chronic osteomyelitis was made. Treatment
with tobramycin and meropenem was initiated. Additional testing by
disk diffusion demonstrated susceptibility to ceftolozane-tazobactam.
Treatment with a 6 week course of ceftolozane-tazobactam 3g
intravenously every 8 hours was well tolerated.
Assessment of Causality: At days 4 and 31 after the start of ceftolozanetazobactam, intraoperative cultures were negative for the previously
identified organisms. At last follow up, 6 months after the initial surgery,
the patient’s wounds had healed completely. She was clinically well and
not receiving antibiotic therapy.
Literature Review: The 5 published case reports using ceftolozanetazobactam for osteomyelitis have involvedMDR Pseudomonas (4) and
MDR Stenotrophomonas (1). Doses varied from 750mg (adjusted for renal
impairment) to 3g intravenously every 8 hours for at least 6 weeks. Three
1
JCPH – Vol. 71, no 1 – janvier–février 2018
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
cases reported clinical success at 3 to 18 months of follow-up while two
reports did not include outcome information.
Importance to Practitioners: MDR organisms remain challenging to
treat, particularly when involving deep seated infections such as
osteomyelitis. Sharing this experience of using ceftolozane-tazobactam
combined with surgical intervention is a valuable addition to the existing
literature for clinicians faced with similar clinical scenarios.
Clinical Burden of Antibiotic Resistance Following
Implementation of a Multidisciplinary Antimicrobial
Stewardship Initiative in a Major Tertiary Care
Center: A Controlled Interrupted Time Series
Analysis Over 14 Years
Peragine C1,2, Walker SAN1,2,3,4*, Leis JA3,4,5,6,7, Simor AE3,4,5,6
1
Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON
2
Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
3
Division of Infectious Diseases, Sunnybrook Health Sciences Centre,
Toronto, ON
4
Sunnybrook Health Sciences Centre Research Institute, Sunnybrook Health
Sciences Centre, Toronto, ON
5
Faculty of Medicine, University of Toronto, Toronto, ON
6
Division of Infectious Diseases, Department of Medicine, Toronto, ON
7
Department of Infection Prevention and Control, Toronto, ON
*Senior Author; sequence determines credit approach to authorship
Background: Our institution launched a multidisciplinary prospective
audit-and-feedback (PAF) Antimicrobial Stewardship program (ASP) in
October 2009. Although reducing antimicrobial resistance (AMR) is a
major incentive for ASPs, a paucity of high quality data evaluating the
impact of ASPs on microbial outcomes remains.
Objective: The objective was to evaluate changes in institutional
AMR and antimicrobial use (AMU) in the 7 years following PAF-ASP
implementation.
Methods: Patient-level microbiologic data (clinical isolates of aerobic
gram-negative bacteria, Staphylococcus aureus, and Enterococcus spp.) and
antibiotic-use data were obtained over the 14 year study period.
Program impact was assessed by evaluating changes in institutional AMR
and AMU trends (Δ slope) between the pre- (October 2002 – September
2009) and post-intervention (October 2009 – September 2016) periods
using interrupted time-series analyses with segmented regression.
Incidence of hospital-acquired isolates resistant to at least one therapeutically active antibiotic agent per month standardized to 10,000 patient
days (PD) was assessed as the primary outcome. Change in the incidence
of antibiotic-resistant community-acquired isolates was evaluated as
an AMR control. Changes in inpatient AMU were quantified using
antibiotic days of therapy (DOT) (all patients, all antibiotic agents)/
10,000 PD per month.
Results: A significant reduction in nosocomial AMR (Δ slope =-0.7
resistant hospital-acquired isolates/10,000 PD/month, p<0.001) and
inpatient AMU (Δ slope =-36 antibiotic DOT/10,000 PD/month,
p<0.001) was found. Conversely, community-acquired AMR increased
significantly over the same period (Δ slope =+0.2 resistant communityacquired isolates/10,000PD/month, p=0.03).
Conclusions: Time series modelling revealed that implementation of a
PAF-ASP was associated with a significant reduction in nosocomial AMR
and inpatient AMU. The identified increase in community acquired
AMR further strengthens the causal inference of our findings, since an
institutional ASP would not be expected to impact community AMR
and the observed significant rise in community AMR is in keeping with
the known global crisis of rising AMR in the community.
CJHP – Vol. 71, No. 1 – January–February 2018
Antibiotic Utilization Feedback Reports on General
Medicine: A Qualitative Assessment
Rai S1,2, Elligsen M1, Lo J1, Walker SAN1,2,3,4, Peragine C1,2, Alattas N 5,
Daneman N4,5, Leis JA4,5
1
Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON
2
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
3
Division of Infectious Diseases, Sunnybrook Health Sciences Centre,
Toronto, ON
4
Sunnybrook Health Sciences Centre Research Institute, Sunnybrook Health
Sciences Centre, Toronto, ON
5
Faculty of Medicine, University of Toronto, Toronto, ON
Background: Between 30 to 50% of antibiotic prescriptions are
potentially unnecessary and these inappropriate prescriptions drive
antimicrobial resistance. Evidence suggests that despite treating similar
patient populations, antibiotic prescribing practices can vary dramatically
among prescribers. Peer comparison is an increasingly recognized behavioural intervention to improve physician prescribing practices.
Objectives: We sought to measure prescriber-level antibiotic utilization
among general internal medicine (GIM) attending physicians to provide
peer comparison reports, and assess any impact on physician practices.
Methods: Antibiotic Days of Therapy (DOT) per 1000 patient days
under the care of each GIM physician was calculated using our
antimicrobial stewardship database. We included all attending physicians
with at least 3 weeks of inpatient service during the study period (January
2nd 2015 to June 27th 2016). Readmission or death within 30 days for
patients who received at least one antibiotic was used as a balancing
measure. Anonymous, personalized feedback reports were emailed to
GIM physicians describing their antibiotic prescribing practices
compared to their peers. An electronic survey was conducted 2 months
later to assess perceptions regarding feedback and any contemplated
changes in practice as a result of the report.
Results: Among 17 GIM physicians, DOT per 1000 patient days varied
from 316 to 569. Despite these differences, there was no difference in
30 day readmission or death among patients receiving antibiotics. Of the
10 physicians that completed the feedback survey (response rate 63%),
9 prescribers (90%) found the report represented their practice while
4 (40%) contemplated changes in practice.
Conclusions: Provider-level antibiotic utilization at our institution
confirmed wide variation in prescribing practices without an obvious
difference in patient outcomes. The majority of physicians surveyed felt
that antibiotic prescribing feedback reports were useful, but longer
term follow up is needed to evaluate impact on antibiotic prescribing
practices.
A Descriptive Analysis of an Alternate-Level-of-Care
Patient Cohort: Comprehensive Medication Overview
Azimi M1,2, Burry L1,2,3, Duclos C1,2, Pelc J4, Upshur R4,5,6
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
2
Department of Pharmacy, Mount Sinai Hospital, Toronto, ON
3
Division of Intensive Care Unit, Mount Sinai Hospital, Toronto, ON
4
Department of Medicine, Bridgepoint Active Healthcare, Toronto, ON
5
Division of Clinical Public Health, Dalla Lana School of Public Health,
Toronto, ON
6
Department of Family and Community Medicine, Toronto, ON
Background: Alternate Level of Care (ALC) patients are hospitalized,
not receiving active medical care waiting to be transferred to another
facility. Many older patients are on complex, often inappropriate
1
JCPH – Vol. 71, no 1 – janvier–février 2018
59
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
medications. To our knowledge, there has been no analysis of ALC
medication regimens. We conducted an audit of all ALC patients within
a tertiary institution.
Objectives: (1) to analyze health-related parameters and obtain a descriptive representation of ALC patients currently admitted at our institution;
(2) to cross-reference medications to 3 existing literature references for
potentially inappropriate medications (PIMs) (Beer’s list, STOPP/
START and ISMP high alert medications); and (3) to assess the
appropriateness of medication regimens.
Methods: We conducted a cross-sectional audit of ALC patients in June
2017 as a phase I quality improvement project. Data was collected with
a standardized case report form to obtain a descriptive representation of
ALC patients. Medications were categorized and coded based on the
3 PIM lists. Data was analyzed by calculating mean, median and IQR
where appropriate.
Results: Eighty-two ALC patients were included in this study. The mean
age of patients was 75.6 (±15) years. Female patients accounted for
52.4% of our population. Patients had 6.4 (SD±3) chronic conditions,
and were prescribed 12.8 (SD±7) medications; 28.9% of patients were
prescribed ≥ 1 drug from 7 different classes of medications concurrently.
PIMs were most frequent on the Beer’s list with an average of 3.9 (SD±3)
medications/patient. One patient had zero medications flagged as PIM
from any of the 3 PIM lists.
Conclusions: ALC patients at our institution have 6 chronic conditions
managed with at least 12 medications, many of which are PIMs. This
data will inform next steps to make recommendations to simplify, reduce
or discontinue medications in which there is an unclear indication, lack
of effectiveness or evidence of potential harm.
Pharmacist Actual and Perceived Priority
Interventions in the Emergency Department:
An Observational Study and Survey Questionnaire
Dalen D1,2, Kelly J1, Zed P2,3, Gorman S1,2, Nevers W1, Slavik R1,2,
Harris D1,3
1
Pharmacy Services, Interior Health Authority, Kelowna, BC
2
Faculty of Pharmaceutical Sciences, University of British Columbia,
Vancouver, BC
3
Department of Emergency Medicine, University of British Columbia,
Vancouver, BC
Background: Emergency Department (ED) pharmacists are a finite
resource and activities with higher value should be prioritized. Literature
shows that clinical pharmacists who resolve drug therapy problems, called
pharmacist interventions (PI), improve patient outcomes and reduce
health-resource utilization. Tracking high quality PI and surveying
pharmacists to understand their perceptions of their practice will help
us establish baseline ED pharmacist practice behaviour and identify
potential gaps in ED pharmacist services delivery.
Objectives: To describe the number of PI completed by ED pharmacists
in a Canadian health authority, to describe the proportion of interventions that were priority disease PI (PD-PI) and quality indicator PI
(QI-PI), and to identify ED pharmacist perceptions of which patients
they felt they should be providing prioritized care to and which activities
they felt they should be completing.
Methods: This study consisted of two parts; a retrospective PI tracking
review and an internet-based survey. PI tracking data was captured from
three EDs with dedicated clinical pharmacist coverage over a one year
period. An electronic survey was distributed to a convenience sample
of Canadian ED pharmacists. Data was analyzed using descriptive
statistics.
60
CJHP – Vol. 71, No. 1 – January–February 2018
Results: A total of 2043 PI were completed. Of these, 1127 (54.4%)
were PD-PI and 473 (22.9%) were QI-PI. Survey participants agreed
that many priority diseases and high-value activities (QI-PI and clinical
pharmacist key performance indicators [cpKPI]) previously established
in a general medicine population should be prioritized in the ED,
but not all. Several potential new ED-specific priority diseases were
identified.
Conclusions: ED pharmacists in a Canadian health authority are
performing impactful, high quality interventions for patients with
priority diseases. Surveyed pharmacists identified gaps in current
definitions of priority diseases and high value pharmacist activities specific
to the ED. Our findings support the presence of unique opportunities
for ED clinical pharmacists to provide prioritized, impactful care.
Patient Preferences for Atrial Fibrillation Stroke
Prevention Therapy Using an Individualized Risks
and Preferences-Based Decision Aid
Loewen P1, Bansback N1, Andrade J1,2, Bonet B4, Deyell M1,3, Hicklin J1,
Kapanen A1, Kwan L4, Lynd L1, McLean A1, McGillivray J2, Salmasi S1
1
The University of British Columbia, Vancouver, BC
2
Vancouver Coastal Health, Vancouver, BC
3
Providence Health Care, Vancouver, BC
4
Fraser Health, Vancouver, BC
Background: Many antithrombotic therapies are effective for atrial
fibrillation (AF) stroke prevention, but choosing is complex because
patients must make trade-offs based on their values and preferences. To
address this, we have developed a decision aid (DA) that integrates AF
education, individualized stroke and bleeding risk estimates, clinical trial
evidence, a best-worst scaling discrete choice experiment (BWS-DCE),
and quantification of the alignment between therapy options and patient
preferences.
Objective: To assess the preferences of AF patients and their consequent
stroke prevention therapy choices.
Methods: Prospective observational study of patients with AF or at risk
of AF (age>50 y/o). Participants completed a pre-DA questionnaire, the
DA, and a post-DA questionnaire. The DA integrated each participant’s
stroke and major bleed risk with the results of a 9-attribute BWS-DCE
to generate individualized preference scores for each therapy option.
Participants made therapy choices based on the results presented.
Results: 38 participants (mean age 71) completed the study. 61% had
CHA2DS2-VASc score >1 and 32% had HAS-BLED score >2. 70%
were on OAC. Stroke and intracranial hemorrhage were the highest
and daily doses and cost were the lowest-weighted attributes. 54% of
participants changed their preferred treatment after using the DA. 68%
and 12% chose the highest-scored therapy option on decision 1 (no
therapy, ASA, or OAC) and decision 2 (choice of OAC), respectively.
In 54%, the direction of therapy change was to de-intensify (OAC to
ASA or ASA to no therapy). 47% of OAC users preferred a different
OAC than current.
Conclusions: Using a DA that included individualized risk estimates,
values clarification, and scoring of therapy options, most AF patients
decided they preferred a different therapy than the one currently
prescribed. The DA requires refinement for choice of OAC. Using
the DA could be a valuable facilitator of shared decision-making in AF
patients.
JCPH – Vol. 71, no 1 – janvier–février 2018
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
Informing Patients and Families about Storage
and Disposal of Opioids
Hyland B1, Fan M1, Hamilton M2, Reding R1, Trbovich P1,3
Research and Innovation, North York General Hospital, Toronto, ON
2
Institute for Safe Medication Practices Canada, Toronto, ON
3
Institute of Health Policy, Management and Evaluation, University
of Toronto, Toronto, ON
Background: Unsafe storage or disposal of medications including
opioids has resulted in accidental poisonings, inappropriate use, and theft
in patient’s homes. Increasing demand for home-based end-of-life
care underscores the opportunity to provide guidance to patients and
families.
Objectives: The project objectives were to 1) identify preferred practices
for safe home-based opioid storage and disposal, and 2) develop and
refine educational materials to support patients, families, and healthcare
providers.
Methods: Preferred practices regarding home-based opioid storage and
disposal were identified via thematic analysis of 155 out of 1285 articles
screened for inclusion and 20 multi-disciplinary stakeholder interviews.
An information card (English version below) was developed using
usability testing with research ethics board approval.
Results: Thematic analysis revealed that patient/family education was
not consistently provided by the healthcare system, nor reliably supported
with educational tools.
Complementary preferred practices were identified:
1. Homecare service providers pick up unused medications
2. Pharmacists providing in-home medication reviews pick up unused
medications
3. Patients/families return medications to a pharmacy; they can contact
the XXX to identify Canadian pharmacies participating in 'returns
programs'
Given variability in clinical practices, an information card was developed
to support preferred practice #3 above. Usability testing revealed opportunities for improvement; the information card was refined to integrate
feedback.
Conclusions: The information card can be used by healthcare providers
providing counselling to end-of-life care patients and families, including
by hospital pharmacists providing discharge counselling.
Project partners have committed to supporting its dissemination.
For the image that goes with this abstract, please see Abstract Appendix,
available at https://www.cjhp-online.ca/index.php/cjhp/issue/view/125/
showToc
1
Pan-Canadian Trends in the Prescribing of Opioids,
2012 to 2016
Bender M, Cheng R, Sajan P, Gaucher M
Canadian Institute for Health Information, Ottawa, ON
Background: Canada is in the midst of a worsening opioid crisis. Several
studies have identified an association between the dispensing of opioids
and opioid-related harms. The ongoing monitoring of opioid prescribing
trends is needed to support urgent public health surveillance needs to
address the crisis.
Objective: To characterize the pan-Canadian and provincial opioid
prescribing trends from 2012 to 2016.
CJHP – Vol. 71, No. 1 – January–February 2018
Methods: Opioid prescribing trends were characterized by the quantity
dispensed as measured by defined daily doses (DDDs), the number of
prescriptions dispensed and the number of people who were prescribed
opioids. Pan-Canadian aggregate drug claims data were used to examine
the number of DDDs and prescriptions dispensed. Additionally, recordlevel drug claims data from three provinces were used to determine the
number of people prescribed opioids.
Results: Between 2012 and 2016, the rate of DDDs declined by 9%
from 6,858 to 6,246 DDDs per 1,000 population; while the rate of
opioid prescriptions increased by just over 2%, from 582 to 595
prescriptions per 1,000 population. With respect to the number of people
prescribed opioids, for the three provinces included in this analysis, the
rate decreased from 132 people per 1,000 population to 125 per 1,000
population during the study period. Seniors were prescribed opioids most
often with more than 1 in 5 seniors receiving a prescription for an opioid.
Among the seniors prescribed an opioid, about 1 in 8 were prescribed a
strong opioid on a chronic basis.
Conclusions: The overall quantity of opioids dispensed in Canada
declined between 2012 and 2016 despite a steady increase in the number
of prescriptions. Moreover, the number of people prescribed an opioid
per 1,000 population steadily declined. The results of this study highlight
the importance of developing pan-Canadian strategies to reduce the
harms associated with the use of prescription opioids.
Cardiac Arrest after Acute on Chronic Colchicine
Toxicity
Keller D1, Oesch A1, Kelly L1, Slessarev M1,2
1
London Health Sciences Centre, London, ON
2
Western University, London, ON
Background: Colchicine is an antimitotic agent with a long history of
use in gout and familial Mediterranean fever. For this reason, clinicians
may overlook the potentially detrimental effects of colchicine toxicity.
Therapeutic, toxic and lethal dose are not well defined and there is no
available antidote. We report a case of colchicine use at 0.6-1.2mg/day
in a renally compromised patient which may have contributed to cardiac
arrest.
Case Description: An 80-year-old male with renal dysfunction received
colchicine 0.6mg daily as needed and in 2016, increased to twice daily
for 3 days. He decreased back to 0.6mg daily; however the prescription
was not updated. On multiple admissions to hospital over a 1 month
period, colchicine was mistakenly increased to twice daily during the
medication reconciliation process. On his last admission he presented
with diarrhea, nausea, and malaise. His leukocyte count was 0.7x109/L,
he was afebrile, and culture negative. Four days later, he was transferred
for management of elevated troponin thought to be uremic pericarditis
and consideration for intermittent hemodialysis. He was found pulseless
and unresponsive while undergoing peritoneal dialysis. Return of
spontaneous circulation was achieved after 15 minutes of downtime
and he was transferred to intensive care where he later succumbed to his
condition.
Assessment of Causality: A Naranjo score of 3 categorized this event
as a possible colchicine toxicity owing to increased colchicine dose and
subsequent sequelae such as diarrhea, nausea, leukopenia and eventual
cardiac arrest.
JCPH – Vol. 71, no 1 – janvier–février 2018
61
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
Literature Review: Documented risk factors for colchicine toxicity
include increased age, renal and/or hepatic dysfunction, chronic use,
intravenous use, loading doses, and drug interactions. Clinical stages of
toxicity including gastrointestinal, multi-organ failure and recovery phase
are also well documented.
Importance to Practitioners: Practitioners should be vigilant with
colchicine use and obtaining accurate medication histories due to unpredictable individual dose response and potentially fatal consequences.
Mandatory Quality Related Events Reporting in
Canada: A Province-wide Review over 7 Years
Boucher A1,2, Ho C 1,2, Boyle T 3, Barker J4, MacKinnon N 5, Zwicker B 6
1
Institute for Safe Medication Practices Canada, Toronto, ON
2
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
3
St. Francis Xavier University, Antigonish, NS
4
Dalhousie University, Halifax, NS
5
University of Cincinnati, Cincinnati, OH
6
Nova Scotia College of Pharmacists, Halifax, NS
Background: There has been limited research that quantitatively analyzes
quality related events (QREs) in pharmacies. Recognizing the importance
of quality improvement and management to patient safety, several
Canadian provinces have moved towards mandatory reporting of QREs
in pharmacies to an independent third party.
Description: The objective of this project is to quantify and characterize
medication-related QREs that were anonymously reported to a
third-party national error-reporting database by pharmacies in a
Canadian province over 7 years.
Action: A retrospective analysis was conducted on medication-related
QREs from pharmacies occurring between October 1, 2010 and June
30, 2017. Descriptive analysis was performed on all medication-related
QREs with respect to type of incident, discoverer, medication system
stages, medications, and outcome.
Evaluation: A total of 131, 031 QREs were anonymously reported by
301 pharmacies in Nova Scotia to a third-party national medication safety
organization. 74.87% (98, 097) was medication-related QREs. Overall,
82.05% (80, 488) of reported medication-related QREs did not reach
the patient (i.e. near misses) and only 0.95% (928) resulted in harm. Reports of incorrect dose/frequency (25.58%; 25, 089), incorrect quantity
(20.00%; 19, 619), and incorrect drug (14.22%; 13, 951) were most
common. Pharmacists discovered the majority of medication-related
QREs (75.17%; 73, 739). Order entry was the most frequently reported
medication system stage for error occurrence, followed by prescription
preparation/dispensing, and prescribing. The most reported medications
were levothyroxine sodium, amoxicillin, and rosuvastatin. Medications
with the highest proportion of QREs with harm were methadone,
risperidone, and warfarin.
Implications: Pharmacists play a significant role in patient safety
and preventing medication incidents. The most frequently reported
medications were among the top dispensed medications in Canada, but
we also identified new high-alert medications. Our findings suggested
the need for medication system stage-specific and medication-focused
interventions to mitigate harm and improve patient safety.
62
CJHP – Vol. 71, No. 1 – January–February 2018
Analysis of Smart Pump Continuous Quality
Improvement Data across Multiple Organizations
Al-Sukhni M
Baxter Corporation Canada, Mississauga, ON
Background: Smart pump technology can generate Continuous Quality
Improvement (CQI) data to provide objective information on IV
infusion practices and identify potential safety gaps. However, this
valuable data is not frequently shared between organizations.
Objectives: The project’s aim was to identify opportunities for increased
infusion safety by analyzing smart pump data across organizations
nationally.
Methods: A pooled, observational analysis was conducted by pooling
smart pump CQI data from five organizations across Canada in
November 2016. Data from 7430 pumps was weighted according to the
number of pumps per organization and analyzed, by evaluating average
drug library compliance, frequency of alerts due to soft or hard limit
events and the top 5 drugs with soft and hard limit events. Soft limit alert
events consist of overriding the exceeded soft limit or modification of the
dose to within soft limits. Hard limit alert events occurred when the set
hard limit was exceeded.
Results: An average drug library compliance of 97 percent was found
across organizations. No significant variance across patient care areas was
noted. Soft limit exceeded alert ranged from 3.6 percent to 11.2 percent
of all infusion starts. Hard limit attempted ranged from 1.2 percent to
6.5 percent of all infusion starts. The top five drugs with soft limit events
resulting in an override were propofol, hydromorphone, heparin,
vancomycin and norepinephrine. The top five drugs with soft limit events
resulting in a modification of the dose were morphine, propofol,
ondansetron, vancomycin and heparin. The top five drugs with hard
limit attempted events were heparin, IV fluids, vancomycin, piperacillin/
tazobactam and amiodarone.
Conclusions: Using smart pump data from multiple organizations
nationally provides the opportunity to improve drug safety by focusing
on common results, and providing benchmarking information. Changes
in drug libraries can also be made to reduce alert fatigue and increase
infusion safety.
Comparison of Weight-Based versus Fixed-Dose
Norepinephrine Dosing in Patients with Septic Shock
Azami A, Yrigoyen-DaCruz L, Duronio A
Windsor Regional Hospital, Windsor, ON
Background: Norepinephrine is the first line vasopressor recommended
by the 2016 Surviving Sepsis guidelines. There is limited data with respect
to superiority of commonly used dosing strategies (fixed versus weight
based).
Objective: The primary objective was to compare the two dosing
strategies in maintaining target mean arterial pressure (MAP) of 65 mm
Hg at six hours after initiation of norepinephrine. The secondary
objectives were to assess the need for add-on vasopressors, need for
hydrocortisone, ICU length of stay, mortality, and treatment side effects.
Method: This was a retrospective, pre-post intervention cohort study.
On March 1st 2016, the smart pump programming at this institution
changed from fixed-dose (mcg/min) to weight-based (mcg/kg/min).
All patients who received norepinephrine six months before and after
implementation of this change were screened. Patients who were started
JCPH – Vol. 71, no 1 – janvier–février 2018
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
on norepinephrine and met the 2016 Surviving Sepsis Campaign
definition of severe sepsis were included. The primary outcome was
analyzed using logistic regression analysis and secondary using descriptive
statistics.
Results: Overall 110 patients were included: 54 in the weight-based arm
and 56 in the fixed-dose arm. All the baseline characteristics were similar
between the two groups. There was a greater proportion of patients at
MAP of 65 mm Hg or greater at six hours in the weight-based arm
compared to the fixed-dose arm (94.4% vs. 75.0%). This corresponded
to an odds ratio of 3.5 (95 confidence interval 1.01 to 12.13). There was
no statistically significant difference comparing weight-based to fixeddose regimens in: mortality (50% vs. 55%; P=0.71), need for additional
vasopressors (28% vs. 45%; P=0.18), need for hydrocortisone (15% vs.
20%; P=0.67), and days spent in ICU (9 days vs. 10 days; P=0.26).
Conclusion: Weight-based dosing of norepinephrine is more likely to
maintain a MAP of 65 mm Hg or greater at six hours compared to a
fixed-dose strategy.
Varying Ammonia Levels with Two Formulations
of Sodium Phenylbutyrate
Villanueva J, Lee J
London Health Sciences Centre, London, ON
Background: Ornithine transcarbamylase (OTC) deficiency is a urea
cycle disorder treated with ammonia scavenging drugs to prevent
hyperammonemic morbidity and mortality. Sodium phenylbutyrate
(NaPB) is commercially available as Pheburane® and Buphenyl®. This
is the first case describing significant variation in ammonia levels
with two formulations of NaPB. Pheburane® coated granules can be
compounded into a 200mg/mL suspension, while Buphenyl® powder
is compounded into a 50 mg/mL suspension.
Case Description: A 3-day-old male was diagnosed with OTC deficiency
after ammonia >400 µmol/L was detected (reference range <50 µmol/L).
After the initial hyperammonemic crisis was treated, the patient was
started on maintenance Pheburane®, which was compounded into a
suspension. The patient’s ammonia remained consistently >100 µmol/L
while on Pheburane®. Pheburane® was switched to Buphenyl® after
ammonia peaked at 180 µmol/L 2 weeks into therapy. The following
day, the patient’s ammonia drastically declined and remained within
normal range for the remainder of therapy.
Assessment of Causality: Although a daily dose of 2.4 g NaPB was used
with both products, the Pheburane® suspension had a larger volume
and was compounded by crushing the coated granules. After reaching
peak ammonia levels of 180 µmol/L on Pheburane®, the patient was
switched to Buphenyl®. Upon the next blood draw fifteen hours later,
his ammonia level dropped to 39 µmol/L.
Literature Review: A bioequivalence study of subjects aged 19-50
demonstrated that Pheburane® coated granules displayed bioequivalence
to Buphenyl®. Moreover, a follow-up study found a reduction in
vomiting and hyperammonemic crises when patients switched nitrogenscavenging treatment to Pheburane®. Despite this promising evidence,
no studies have been published on Pheburane® in neonates.
Importance to Practitioners: Failure to treat neonatal OTC deficiency
can lead to coma and death. Clinicians should consider the use of
Buphenyl® over Pheburane® when treating neonates and infants.
CJHP – Vol. 71, No. 1 – January–February 2018
Stability of 8.4% Injectable Sodium Bicarbonate
When Stored at Room Temperature
Lam V2, Perks W1, Caku A1, Walker SE1,2
1
Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON
2
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
Background: Shortage of sodium bicarbonate injection required the
evaluation of alternatives.
Objective: To evaluate the stability of 8.4% injectable sodium bicarbonate
solution in glass vials, compounded in-house and stored at room
temperature unprotected from ambient room fluorescent light for 91 days.
Methods: On days 0,2,5,7,9,12,14,16,21,23,28,42,56,70 and 91, a
50mL volume (52.8g) of sodium bicarbonate solution was withdrawn
from each glass vial and titrated against 2M HCl to determine buffer
capacity. Sodium bicarbonate samples were also delivered to the biochemistry lab for determination of initial pH, sodium, and bicarbonate levels.
Results: Evaluation of titrations of 2M HCL against 50mL volumes
of bicarbonate indicated the method was reproducible. Within day
reproducibility for buffer capacity as determined by the standard
deviation of regression averaged 0.11% for pH 5. Similarly, between days
variability for sodium and bicarbonate analysis averaged 1.24% and
1.87%, respectively. The initial pH, before any 2M HCl was added,
indicates that solutions stored at room temperature increase in pH by
less than 0.05 pH units over the 91 day study period. Analysis of sodium
and bicarbonate concentrations indicates less than a 3% change occurred
during the study period and that it would take more than 91 days before
a 10% change was observed, with 95% confidence. Similarly, analysis of
buffer capacity, based on the volume of 2M HCl to achieve a pH of 5,
indicates that it would take more than 10,238 days before a 10% change
was observed and with 95% confidence this would not occur sooner than
1873 days.
Discussion: We observed that sodium bicarbonate solution, compounded
in-house, is stable for at least 91 days, with 95% confidence, when stored
at room temperature. A beyond-use date of 91 days should be used only
after due consideration of institutional capability, applicable standards,
sterility verification and completion of required quality tests.
Stability of Ropivacaine 2.7 mg/mL, Morphine
0.091 mg/mL and Ketorolac 0.27 mg/mL
in Polyvinyl Chloride Bags at 4°C
Sudbury B, Facca N, Smith N
Department of Pharmacy, London Health Sciences Centre, London, ON
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
Background: The National Association of Pharmacy Regulatory
Authorities (NAPRA) Model Standards for Pharmacy Compounding of
Non-Hazardous Sterile Preparations indicates that stability data from
peer reviewed literature or appropriate experimental studies are required,
to assign a beyond use date (BUD) to a given compound.
Objective(s): To determine the stability of ropivacaine 2.7 mg/mL,
morphine 0.091 mg/mL and ketorolac 0.27 mg/mL in sodium chloride
0.9% stored in polyvinyl chloride (PVC) plastic bags packaged in an
Ultra-Violet Light Inhibiting (UVLI) bag at 4°C over 9 days.
Methods: An arthroplasty infiltration solution was prepared and stored
in the dark at 4°C. From day 0 to 9, samples were taken and frozen
at -85°C, until analysed by purity-indicating gas chromatography mass
spectrometry (GC/MS). In each GC/MS run, chromatographic peaks
were generated for the drug and its internal standard. Drug/internal
standard peak area ratios were calculated for each analytical run. Peak
JCPH – Vol. 71, no 1 – janvier–février 2018
63
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
area ratios from quintuplicate test day samples were then calculated as a
percentage of the corresponding peak area ratios of quintuplicate day zero
samples analysed in the same GC/MS batch. 95% confidence limits
were calculated from these data. Daily physical inspections and pH
measurements were also performed.
Results: The 95% confidence limits for each measured drug remained
above 90% for the entire study indicating acceptable stability throughout.
The arthroplasty infiltration solution remained clear and colourless and
the pH remained essentially constant at a mean of 6.3 with a standard
deviation of 0.11. The mass spectra of the day 9 drug peaks were identical
to the corresponding mass spectra of the drug day 0 peaks, demonstrating
drug purity to the end of the study.
Conclusion(s): The ropivacaine, morphine and ketorolac arthroplasty
mixture in saline prepared in PVC bags stored in the dark at 4°C is stable
for at least 9 days.
Étude descriptive de la contamination urinaire
de travailleurs exposés au cyclophosphamide,
à l’ifosfamide, au méthotrexate et au fluorouracile
Chauchat L1, Therrien R2, Dufour A3, Gagné S4, Caron N4, Bussières JF1,5
Unité de recherche en pratique pharmaceutique, Département de
pharmacie, Centre Hospitalier Universitaire Sainte-Justine, Montréal, QC
2
Département de pharmacie, CISSS de Laval, Laval, QC
3
Département de pharmacie, CISSS de la Montérégie-Centre, Greenfield
Park, QC
4
Centre de toxicologie du Québec, Institut national de santé publique du
Québec, Québec, QC
5
Faculté de pharmacie, Université de Montréal, Montréal, QC
Contexte : Certains professionnels de la santé sont exposés aux médicaments dangereux et une absorption systémique de ces médicaments est
possible.
Objectif : Déterminer la faisabilité d’un programme de surveillance
biologique par détection de médicaments dangereux.
Méthodologie : Étude descriptive observationnelle. Cohorte d’infirmiers,
pharmaciens et assistants-technique manipulant des médicaments dangereux au sein de deux centres d’oncologie adultes (A (750 lits) et B (700
lits)). Ont été mesurés : cyclophosphamide (limite de détection:
0,009ng/mL), ifosfamide (0,0097ng/mL), méthotrexate (0,075ng/mL)
et FBAL, métabolite urinaire du fluorouracile (0,120ng/mL) par
UPLC/MS-MS. Chaque participant volontaire a fourni un échantillon
d’urine en fin de journée et complété un journal.
Résultats : Ont été recrutés 56 participants ayant au moins une activité
liée à la manipulation de médicaments dangereux ciblés soit 27/28 (A)
et 24/28 (B). En centre A, l’utilisation des gants était conforme pour
77/89(86,5%) des activités réalisées par 13 infirmiers. Deux infirmiers
(2/13) portaient une blouse et aucun (0/13) le masque pendant
l’administration. Tout le personnel de la pharmacie (15/15) portait les
protections recommandées pour l’ensemble des activités (34/34). En
centre B, l’utilisation des gants était conforme pour 49/68(72%) des
activités réalisées par 10 infirmiers. Neuf infirmiers (9/10) portaient une
blouse et quatre (4/10) portaient un masque pendant l’administration.
Les assistants techniques portaient l’équipement recommandé pour la
préparation et manipulation des médicaments dangereux en salle blanche
(3/3). Seulement deux pharmaciens (2/8) et deux assistants techniques
(2/9) portaient l’ensemble de l’équipement recommandé pendant leurs
activités. Aucun échantillon (0/56) ne comportait de trace détectable des
quatre médicaments dangereux.
1
64
CJHP – Vol. 71, No. 1 – January–February 2018
Conclusion : Il est faisable de mettre en place un programme de
surveillance biologique en établissement de santé. Un tel programme doit
comprendre un profil des mesures de protection appliquées par travailleur
exposé. Cette étude confirme l’absence de traces de quatre médicaments
dangereux dans l’urine de 56 travailleurs en oncologie adulte.
Stability of 10, 40 and 200 mcg/mL Hydromorphone
Solutions Stored in Syringes at Room Temperature
(23°C)
Hook R1, Riss V1, Scharrer E1, Neault A1, Law S2, Walker SE2,3
Departments of Pharmacy, Hospital for Sick Children, Toronto, ON
2
Sunnybrook Health Sciences Centre, Toronto, ON
3
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
Background: Inpatient hospital pharmacies must compound intravenous
products and assign an appropriate beyond-use-date (BUD) as per
NAPRA standards, because products are not commercially available.
Having opioid infusions available as ready-to-administer (RTA) products
on nursing units is important for safe and timely administration of pain
control. Paediatric patients require lower concentrations of opioid
continuous infusions than adults and previous publications have demonstrated the stability of hydromorphone, but not at lower concentrations
and not in syringes.
Objective: We sought to evaluate the chemical stability of lower concentrations of hydromorphone, prepared in syringes
Methods: On study day 0, 50mL solutions of 0.2mg/mL and 10mg/mL
concentrations of hydromorphone were prepared in BD syringes. 3 units
of each container and concentration were stored at room temperature.
Concentration analysis was completed on study days 0,1,3,7,14,24,
38,51,78 and 90. Hydromorphone concentrations were determined by
a validated stability-indicating liquid chromatographic method with UV
detection. Chemical stability was based on the intersection of the lower
limit of the 95% confidence interval of the observed degradation rate
and the time to achieve 90% of the initial concentration.
Results: The analytical method separated degradation products from
hydromorphone such that the concentration was measured specifically,
accurately (deviations from known averaged 2.1%) and reproducibly
(replicate error was less than 0.6%(CV(%)). During the study period all
solutions retained more than 98% of the initial concentration. Analysis
of variance revealed significant differences in percent remaining due to
concentration (p<0.001), but not study day (p=0.339). The study was
capable of detecting a 0.81% difference in concentration due to study
day or concentration. The calculated beyond-use-date exceeded the
90-day study period for all concentrations.
Conclusions: We conclude that 10, 40 and 200mcg/mL solutions of
hydromorphone diluted in saline and stored in BD polypropylene
syringes are physically and chemically stable for at least 90 days at room
temperature (23°C)
1
Atrial Fibrillation Patient Knowledge Gaps:
A Systematic Review
Salmasi S, Loewen P
Faculty of Pharmaceutical Sciences, University of British Columbia,
Vancouver, BC
Background: Atrial fibrillation (AF) patients frequently do not adhere to
their medication. Poor patient understanding of their disease has been
associated with poor adherence. Identifying patients’ knowledge gaps is
the first step towards improving patient education strategies, adherence
JCPH – Vol. 71, no 1 – janvier–février 2018
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
and health outcomes. To date, there are no systematic reviews of AF
patient knowledge gaps.
Objective: To characterize the published literature about AF patients’
knowledge of their condition and medications, and to identify knowledge
gaps.
Methods: Systematic review following PRISMA guidelines. We
systematically searched PubMed, Embase, CINAHL and PSYCHINFO
for quantitative and qualitative studies that measured people’s knowledge
about AF, stroke, rate/rhythm control and stroke prevention medications
using “AF patient knowledge” and closely-related terms. Qualitative data
was summarized narratively. We grouped quantitative data from related
questions into “knowledge categories”, calculating the median and IQR
of the % correct responses for each category. A category with median
≤50% was classified as a “knowledge gap”. Quality was assessed using
standard design-specific quality of reporting appraisal instruments.
Results: We included 19 studies involving 4,582 participants, with 89%
being of high quality. Less than half of the studied patients were aware
that AF can be asymptomatic, can recur, or predispose to heart failure and
stroke. Other knowledge gaps included: AF causes, symptoms, the rationale
for oral anti-thrombotic (OAT) therapy, and OAT- related dietary
restrictions. AF patients’ knowledge of stroke signs/symptoms, and
rate/rhythm medications could not be assessed due to paucity of data.
Conclusions: Majority of patients lack knowledge of AF causes,
symptoms, risk of stroke, the rationale for anti-thrombotic therapy and
drug and food interactions. Our results highlight the need for more
widespread and better-quality patient education strategies.
A Feasibility Study: Implementing a Medication
Adherence Contract in Kidney Transplant Recipients
Followed by an Outpatient Transplant Clinic
Desai A1, Burger C1, Wallace C1, Treleaven D2, Shipley A1
1
Pharmacy Department, St. Joseph’s Healthcare Hamilton, Hamilton, ON
2
Division of Nephrology, Department of Medicine, St. Joseph’s Healthcare
Hamilton, ON
Background: Medication adherence contracts have been more effective
in improving adherence compared to providing educational pamphlets,
pillboxes and medication refill reminders alone.
Objectives: Primary objective was to determine patient enrollment.
Secondary objectives investigated patient retention, time required for
encounters, interventions by pharmacists, patient satisfaction, health
care professional acceptability and perception of patient adherence to
immunosuppressants.
Methods: Kidney transplant recipients transplanted within 0-6 months,
followed by the Outpatient Transplant Clinic, with access to a telephone
that could be communicated to in English were approached for consent.
The Contract was administered in clinic or Inpatient Transplant unit using
semi-structured discussions and reviewed in 3 to 9 weeks with patients
via phone.
Results: Seventeen of 47 eligible patients (36%) were enrolled over 3.3
weeks in the clinic (n=11) and on the inpatient unit (n=6). Patient
enrollment was 52% (17 of 33 patients) considering only 33 of 47 eligible
patients were approached. Barriers to enrollment were back to back clinic
appointments, lack of designated clinic space and prioritizing non-research
related responsibilities during the last 1-2 weeks of data collection. Median
time for administration and review of the Contract was 21 and 12 minutes
respectively. Interventions provided include discussion of adherence tools
(n=13); education on immunosuppressants (n=6), consequences of nonadherence (n=5) and anti-infective medications (n=4) as well as medication
CJHP – Vol. 71, No. 1 – January–February 2018
regimen simplification (n=5). Most patients found their encounters with
pharmacists valuable (n=6) or extremely valuable (n=6). More than half
of health care professionals were very likely to identify and refer patients
that may benefit from a Medication Adherence Contract (n=8).
Conclusion: Medication Adherence Contracts are feasible in practice
provided there is dedicated space and time for encounters. Majority of patients and professionals were satisfied with and accepting of the Contract
respectively. This study provides recommendations for those considering
adopting such contracts in practice.
An Emerging Challenge: Pharmacists’ Ability
to Counsel a Growing Immigrant Population
Jalal A
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
Background: Counselling provided by pharmacists is a critical
component for the safe and effective use of medications, which is
particularly important given the serious consequences of errors. In the case
of new international migrants, however, cultural barriers might be limiting
pharmacists’ ability to counsel effectively.
Objectives: The study aimed to identify: cultural factors noted in the
literature to influence interactions between pharmacists and immigrants
during counselling sessions; and potential solutions to cultural barriers in
pharmacy counselling.
Methods: A scoping review was conducted, which consists of the following 5 stages: (1) identifying the research questions, (2) identifying the
relevant studies, (3) identifying criteria for study selection, (4) charting
the data, and (5) collating the results. The quality of selected studies was
also assessed.
Results: Only 7 studies were found, but revealed 4 important factors:
preconceived beliefs about drugs and healthcare, language barriers, use of
informal interpreters, and nonverbal communication. Several solutions
for reducing medication errors and increasing patient safety were also
identified. One solution is to work towards achieving a certain level of
understanding about ethnic minority patients. This involves increasing
cultural sensitivity among pharmacists and learning about immigrant
patients’ culture and illness perception.
Conclusion: The literature is sparse, but confirms that assessment and
redress of cultural disparities is important to improve medication use and
the quality of encounters with patients of all cultural backgrounds.
Toxicology Education Needs of Emergency
Department Pharmacists
Dewaal C, Mink M
Alberta Health Services, Calgary, AB
Background: Emergency department (ED) pharmacists are routinely
consulted on the care of poisoned patients. Toxicology training varies by
country and the learning needs of pharmacists have not been explored.
Objective: To survey and compare subjective toxicology knowledge and
learning needs of ED pharmacists in Canada and the United States (US).
Methods: Pharmacists were surveyed via online emergency medicine
speciality networks hosted by the Canadian Society of Hospital Pharmacy
and American College of Clinical Pharmacy. Pharmacists rated their
knowledge and interest for future learning regarding 29 toxicology topics
using a 5-point Likert scale. Preferred learning formats were also surveyed.
Paired T-tests were conducted to assess knowledge and interest differences
between US and Canadian pharmacists.
JCPH – Vol. 71, no 1 – janvier–février 2018
65
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
Results: Two-hundred ED pharmacists (response rate 16%) responded
to the survey. Pharmacists rated their knowledge highest on analgesics and
communicating with poison centres. Chloroquine, metals and bioterrorism were rated as the least knowledgeable subjects. Pharmacists identified
drugs of abuse, blood gas and ECG interpretation as the most desired
topics for future learning. Respondents were least interested in learning
to communicate with poison centres, and about chloroquine and
theophylline poisonings. Webinars and podcasts were the preferred
learning formats for pharmacists. Online discussion forums, YouTube
videos and toxicology rotations were the least popular. US pharmacists
consistently rated their knowledge higher than Canadian pharmacists
(Mean Difference in Likert Scores 0.58, 95% CI: 0.48-0.69). No
significant difference was noted in interest levels between the two groups.
Conclusions: Future education for ED pharmacists should focus on
diagnostic assessment of the poisoned patient and drugs of abuse. Delivery
should be in webinar format. Toxicology residencies and fellowships are
available in the US and may reflect differences in knowledge assessment
scores.
Implementation of an Overnight Pharmacist Model
Charron M1, Chen E1, Bombassaro AM1,2, Harris V1,2, Newman J1
1
London Health Sciences Centre, London, ON
2
Western University, London, ON
Background: The Pharmacy Department at a tertiary care academic
centre initiated overnight pharmacist services in 2014 in response to
computerized physician order entry.
Description: One of the hospital sites developed an overnight model in
which 2 pharmacists rotate every 2 weeks through weeknight shifts (2230
to 0630 hours) and weekday clinical services to a surgical unit. The
pharmacists cross cover each other for vacations. Comprehensive overnight
services include order verification, therapeutic interventions and drug
information. Daytime pharmacists are scheduled to cover weekend
overnight services.
Action: After surveying 24 hour operations at select Ontario hospitals a
site-specific model was created through a consensus process. The goal was
to create a role that optimized professional satisfaction, recruitment and
retention. This was accomplished by ensuring opportunities similar to
those of daytime pharmacists with respect to direct patient care, education,
teaching and research with comparable scheduling percentages for
distribution and clinical time. Two pharmacists were recruited and
intensively trained over 3 months.
Evaluation: During a weeknight shift the pharmacist on average verifies
500 medication orders for 650 patients, of which 25 are new admissions,
thus alleviating the morning workload and alerting daytime pharmacists
to patients needing prioritized pharmaceutical care. The pharmacists are
clinically integrated into a surgical service, which previously had high
pharmacist turnover, with excellent feedback regarding the consistent
quality of service. Weekly discussions take place with the clinical practice
leader regarding patient cases and role feedback. Job satisfaction and
retention have been positive with approximate 3 year tenure for the current
team. A third pharmacist has been successfully recruited into the role.
Implications: This successful service model, as evidenced from operational
and clinical perspectives, can be used as a template for other hospitals
seeking to implement or modify an overnight pharmacist role, particularly
if retention has been challenging.
66
CJHP – Vol. 71, No. 1 – January–February 2018
A Literature-Based Algorithm for the Assessment,
Management and Monitoring of Drug-Induced
QTc Prolongation in the Psychiatric Population
Zolezzi M1, Cheung L2
1
College of Pharmacy, Qatar University, Doha, Qatar
2
Grey Nuns Hospital, Edmonton, AB
Background: Certain psychotropics and a number of other medications
used to treat medical conditions in psychiatric patients can increase the risk
of prolonging the corrected QT (QTc) interval on the electrocardiogram
which poses patients at risk of life-threatening ventricular arrhythmias
such as Torsades de Pointes. Pharmacists are often consulted about
medications which are known to prolong the QTc interval. Although this
information is often accessible, advising how to identify, assess, manage
and refer psychiatric patients at risk for drug-induced QTc prolongation
is more challenging.
Objectives: The objective of this project was first to review the literature
which describe guidelines and recommendations for the assessment and
management of drug-induced QTc prolongation, and then to design an
algorithm to be used by pharmacists working closely with mental health
professionals or who provide care to psychiatric patients.
Methods: A review of the literature was undertaken. Predefined keywords
were used to perform the database search in MEDLINE, EMBASE, and
International Pharmaceutical Abstracts to identify reviews, reports and
guidelines on the assessment, prevention or monitoring of drug-induced
QTc prolongation emphasizing on psychotropic medications and
management in the psychiatric population.
Results: A total of 560 relevant citations were retrieved from the electronic
database search, of which a total of 22 relevant articles were selected. Of
these, only 8 articles provided recommendations for the assessment and
management of drug-induced QTc prolongation in psychiatric patients.
Although the remainder 14 articles did not discuss strategies specifically
for the psychiatric population, they were still reviewed and some relevant
recommendations adapted in the development of the algorithm and
related guide.
Conclusion: The literature-based algorithm developed provides a stepped
based approach for the assessment, management and monitoring of
drug-induced QTc prolongation in the psychiatric population. After this
developmental phase, feedback on the algorithm and related guide by
pharmacists will be undertaken.
Provincial Smart Pump Program Improves
Patient Safety
Bunker J1, Herod C1, Lyons B2, Sellinger D1
Regina Qu’Appelle Health Region, Regina, SK
2
Prairie North Health Region, North Battleford, SK
Background: The use of Dose Error Reduction Software to inform pump
programmers of potential keystroke, entry errors or potentially harmful
doses reduces patient harm. The creation of a single province-wide drug
library ensures the same level of safety across the province and facilitates
patient movement between sites.
Description: A multi-disciplinary team from all Regional Health Authorities and the Cancer Agency developed the drug library and implemented
SMART pumps throughout the entire province. A provincial program
team was created to: maintain and update the drug library, maintain
provincial parenteral monographs, and report on regional and provincial
use of smart pumps.
1
JCPH – Vol. 71, no 1 – janvier–février 2018
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
Action: Once the smart pump was implemented in all health regions, the
Provincial Smart Pump Program was established to maintain, update and
report on the use of smart pumps. A monthly drug library update cycle
was established during the first year. Updates from the Program are
delivered to regional servers where local staff update their smart pumps
with the newest drug library.
Evaluation: Six percent of 2,351,379 program attempts created an alert;
2% of programs were edited based on the alert resulting in 46,213
program changes. Each program change may have avoided harm if infused
as originally programmed. The 10 Medication lines were responsible
for 34,699 alerts in 315,158 program attempts. Of these, 11,296 alerts
resulted in a programming change.
Implications: Province-wide standardization of the drug library, medication preparation and parenteral monographs facilitates the safe transfer of
patient throughout the continuum of care across the province without
wastefully re-preparing infusions for local protocols. Work standards
ensure regions continue to utilize the most current drug library. The Smart
Pump Program evaluates the drug library and alerts, with feedback from
users, for appropriateness. Reporting can highlight regional practice
variation for investigation. Dose limit notifications reduce potential patient
harm from infusions.
A Multi-Incident Analysis on Medication Incidents
Associated with Patient Harm
Boucher A1,2, Dhanjal S1,3, Ho C1,2,3
1
Institute for Safe Medication Practices Canada, Toronto, ON
2
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
3
School of Pharmacy, University of Waterloo, Waterloo, ON
Background: Medication incidents associated with patient harm can
either result in sub-optimal disease management or expose patients to
unnecessary life-threatening situations, calling for attention to such
incidents and the need to adopt strategies to improve overall patient and
medication safety.
Description: The objective of this multi-incident analysis was to gain a
deeper understanding of the possible contributing factors to incidents
associated with patient harm, and to develop potential recommendations
to prevent error recurrences.
Action: A total of 971 medication incidents associated with patient harm
were extracted from a national incident reporting database from 2009 to
2017, with the subsequent performance of a qualitative and thematic
analysis on 909 incidents that met the inclusion criteria.
Evaluation: Three main themes were identified from the multi-incident
analysis, which included (1) high-risk processes in pharmacy practice, (2)
communication gaps, and (3) preventable adverse drug reactions.
Subthemes were further developed for each theme, which included
(1) methadone maintenance therapy, (2) multi-medication compliance
aids, and (3) compounding; (1) patient-provider engagement and
(2) interprofessional collaboration; and lastly, (1) drug-drug interactions
and (2) documented drug allergies.
Implications: Independent double checks can be considered as a
gate-keeping strategy for high-risk processes that are involved in the
medication-use system. Clear communication within the circle of care is
crucial for safe and effective patient-centered care. Technology can serve
as clinical decision support for healthcare practitioners in mitigating
preventable adverse drug reactions. It is hoped that findings from this
analysis and potential solutions presented can aid with the adoption of
error reduction strategies and safe medication practices. Sharing lessons
learned from medication incidents will contribute to overall patient and
medication safety.
CJHP – Vol. 71, No. 1 – January–February 2018
Insourcing High-Risk Sterile Compounded
Injectables: Development of In-House Capacity
to Produce High-Quality Injectables during the
Sodium Bicarbonate Shortage
Perks W, Caku A, Lye M, DeFigueiredo S, Wun B, Walker SE
Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON
University of Toronto, Toronto, ON
Background: High-risk sterile compounding appears to have decreased
considerably in recent years given perceived risk and regulatory/media
attention. When commercial supplies are lacking and where alternatives
are inadequate, Pharmacies need to weigh patient risk from lack of access
against their ability to prepare a high quality compounded sterile product
(CSP).
Description: Formulation of a CSP - Sodium Bicarbonate 8.4% Injection
(SBI) was undertaken during disruption of commercial supply and used
to develop the infrastructure to extend this capability to other future CSPs.
Action: Specifications utilizing USP were developed for our SBI
formulation. Multiple test iterations were prepared until the desired
elements were attained. A “Quality by Design” (QBD) approach was
utilized in the formulation process which attempts to mitigate against
foreseeable risk elements during production. Validation and testing of the
finished product for endotoxin level and sterility were completed through
an outside laboratory and in-house quality testing for particulates, pH,
sodium and bicarbonate concentrations were completed for each batch.
Evaluation: Development of the SBI and the QBD approach required
approximately 0.25 FTE each of Pharmacist and Pharmacy Technician
time. Time to implementation of a patient-ready CSP was approximately
3 months from inception. Batch production quantity models for best
economic return were developed based on expected monthly use and
batch costs. The final SBI prepared lots met all USP specifications for
Sodium/Bicarbonate content, pH, endotoxin levels and sterility.
Implications: By following a QBD approach, Pharmacies can prepare
a high-quality injectable from raw non-sterile starting ingredients.
Appropriate final product quality testing should be undertaken. Up-front
investments and effort are required in order to safely develop the required
resources for safe compounding, but enhances patient access to necessary
products in the event of commercial supply disruption or inadequate
therapeutic alternatives.
Coordinating a Response to a Critical Drug
Shortage: Experience with Sodium Bicarbonate
Mysak T, Slobodan J, Simpson T, Horon K, Lazarenko G
Pharmacy Services, Alberta Health Services, AB
Background: In June 2017, a critical shortage of intravenous sodium
bicarbonate occurred across Canada. Our health authority needed to act
rapidly to ensure availability of a drug used in critically ill patients.
Description: Sodium bicarbonate as an intravenous solution is provided
by a single supplier with important therapeutic value in critically ill
patients. When production issues, compounded by a voluntary recall,
rapidly depleted the stock on hand and hampered any ability to procure
more, our heath authority faced a situation of having less than one week’s
stock on hand. At the time, usage patterns were approximately 2000 vials
per week. No commercially produced or compounded product was
available and Health Canada would not rapidly commit to allowing
importation of foreign supply.
JCPH – Vol. 71, no 1 – janvier–février 2018
67
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
Action: Our senior pharmacy leadership team ran a virtual Emergency
Operations Centre (EOC) to coordinate efforts across our sites and report
up to senior organizational leadership. EOC members met with clinical
stakeholders to determine restrictions on sodium bicarbonate use,
coordinated communication to all sites and impacted departments,
validated and tested a recipe for compounding, worked out a process for
sterile filtration of potentially contaminated product, and worked with
senior organizational leadership to prioritize the various strategies
developed to manage the crisis.
Evaluation: Weekly stock counts and utilization reporting at all sites
demonstrated that restricting product use resulted in an approximate 75%
reduction in overall consumption. This rate was maintained for the
duration of the shortage and may point to potential ongoing cost savings.
Follow-up with clinical stakeholders suggested minimal negative patient
impact from the restrictions.
Implications: By leveraging our central governance and coordination
efforts, our pharmacy team was able to overt a potentially critical situation.
Lessons learned for future shortages include exploration of our internal
compounding resources and ability to identify inappropriate use of drugs
in our health authority.
Development and Implementation of a Mobile
Antimicrobial Handbook App at a Tertiary Teaching
Hospital
Lo J1, Wan M1, Lepore J 2, Elligsen M1, Walker SAN1,3,4,5, Leis JA4,5,6
Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON
2
Digital and Visual Communications Department, Sunnybrook Health
Sciences Centre, Toronto, ON
3
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
4
Division of Infectious Diseases, Sunnybrook Health Sciences Centre,
Toronto, ON
5
Sunnybrook Health Sciences Centre Research Institute, Sunnybrook Health
Sciences Centre, Toronto, ON
6
Faculty of Medicine, University of Toronto, Toronto, ON
Background: Institutional antimicrobial guidelines were previously
available as printed and electronic format handbooks. With the ever
increasing use of technology to improve direct patient care, our hospital’s
Antimicrobial Stewardship Team (AST) recognized the need to optimize
the accessibility and usability of our current guidelines.
Description: In June 2015, our AST began developing an Antimicrobial
Handbook app for mobile devices and desktop computers. This electronic
tool includes treatment and prophylaxis guidelines, annual hospital
antibiograms, renal dosing guidelines, and safety guidelines for pregnancy
and breastfeeding.
Action: The mobile site was launched in November 2015, and promoted
to pharmacists and physicians at our institution and other practice sites.
The app content and format are continuously reviewed and updated based
on advances in clinical evidence and feedback from its users. Quantitative
user data is electronically provided monthly from Google Analytics
Solutions.
Evaluation: Between January 1, 2017 and June 30, 2017, there have been
over 10,000 page views of our app, by over 2,000 unique users. There has
been a 73% increase in usage, with an average of 1,720 visits per month
to the homepage in 2017, compared to 995 visits per month in 2016.
Similarly, the number of total users and new users has increased by 100%
and 84%, respectively. The majority of our users are located in the Greater
Toronto Area (75%), but our app also has frequent users from Hamilton,
1
68
CJHP – Vol. 71, No. 1 – January–February 2018
Ottawa, Montreal, and other Canadian cities. The most visited sections
are the treatment guidelines (37%), antimicrobials (27%), and renal
dosing guidelines (14%).
Implications: The Antimicrobial Handbook app is an extremely innovative
tool that has provided widespread access to clinically relevant information,
enabled efficient information updates, and allowed for timely, accurate
evaluation to assess the need for ongoing modifications. Evaluation of the
clinical impact of this app on antimicrobial prescribing practices is
planned.
Retrospective Multicentre Cohort Study Comparing
Safety and Efficacy Outcomes with Intermittent
Infusion versus Continuous Infusion Vancomycin
Ma N1,2, Walker SAN1,2,3,4,*, Elligsen M1, Palmay L1, Ho G5, Leis JA3,4,
Bansal V6, Powis J5
1
Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON
2
Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
3
Division of Infectious Diseases, Sunnybrook Health Sciences Centre,
Toronto, ON
4
Sunnybrook Health Sciences Centre Research Institute, Sunnybrook Health
Sciences Centre, Toronto, ON
5
Michael Garron Hospital, Toronto, ON
6
Holland Centre, Sunnybrook Health Sciences Centre, Toronto, ON
*Senior Author; sequence determines credit approach to authorship
Background: Patients with good renal function receiving intermittent
infusion vancomycin (IIV) may require total daily doses ≥4g to achieve
trough concentrations of 15-20mg/L, increasing the risk of vancomycin
associated nephrotoxicity (VAN). Continuous infusion vancomycin (CIV)
may enable attainment of concentrations between 15-20mg/L with a
lower daily vancomycin dose, potentially reducing the risk of VAN.
Objectives: The primary objective was to compare VAN risk (serum
creatinine (sCr) increase ≥50% from baseline) and renal damage (sCr
increase ≥100% from baseline) in patients receiving IIV versus CIV. The
secondary objective was to compare clinical cure between IIV and CIV in
patients who achieved vancomycin trough or steady state concentrations
of ≥15mg/L, respectively.
Methods: Retrospective chart reviews for eligible patients admitted to
Sunnybrook Health Sciences Centre or Holland Orthopaedic and
Arthritic Centre between January 1, 2010 and December 31, 2016 were
completed. Adult inpatients who received at least 48 hours vancomycin
for a documented gram positive infection and had at least one steady state
vancomycin concentration were eligible. Baseline patient characteristics,
safety and efficacy outcomes for the IIV and CIV cohorts were compared
using appropriate statistical tests (Fisher’s exact, Student’s t-test, or MannWhitney), with significance defined as P<0.05.
Results: Of 2134 patients identified, 1104 (52%) met inclusion criteria.
Chart review has been completed for 89 patients (113 courses of
vancomycin). Patients receiving courses of IIV were more likely to be at
risk of VAN (15/62 [24.2%] versus 4/51[7.8%]; P=0.02) and experience
renal damage (9/62 [14.5%] versus 1/51 [2.0%]; P=0.02). There was no
difference in clinical cure between IIV (19/27 [70.4%]) and CIV patients
(13/17 [76.5%]; P=0.74).
Conclusion: Patients in the IIV cohort were more likely to experience
increases in sCr resulting in VAN risk and renal damage. The results
indicate there is no difference in clinical cure between patients who
received IIV versus CIV.
JCPH – Vol. 71, no 1 – janvier–février 2018
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
Evaluation of Dosing Strategies with Meropenem
using Monte Carlo Simulations against Bacteria
with Raised MIC
Moscoso D1,2, Walker SAN1,2,3,4*
1
Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON
2
Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
3
Division of Infectious Diseases, Sunnybrook Health Sciences Centre,
Toronto, ON
4
Sunnybrook Health Sciences Centre Research Institute, Sunnybrook Health
Sciences Centre, Toronto, ON
*Senior Author; sequence determines credit approach to authorship
Background: The worldwide increased prevalence of gram negative
bacterial (GNB) resistance coupled with few therapeutically appropriate
available antibiotics (TAAAs) necessitates evaluation of dosing strategies
to optimize the use of TAAAs against more resistant pathogens. Burn
patients are a unique population, having altered pharmacokinetics for
many antibiotics and high risk of infection with resistant GNB, to add
increased complexity to their care.
Objective: The objective of this study was to identify optimal dosing of
meropenem in burn patients using pharmacokinetic and pharmacodynamic (PK-PD) targets for meropenem against bacteria with an elevated
minimum inhibitory concentration (MIC).
Methods: Weighted mean pharmacokinetic parameters for meropenem
in burn patients and healthy volunteers were determined from the
published literature. Monte Carlo simulations (MCS) with 1,000,000
iterations were completed to determine the probability of target attainment (PTA) for several intermittent infusion (IIV) and continuous
infusion (CIV) meropenem dosing regimens using weighted mean
pharmacokinetic parameters and MICs ranging from 0.5 to 32 mg/L for
burn patients and healthy subjects (HS). PK-PD targets evaluated were
% time above MIC (%T>MIC) of 30%, 50% and 80%.
Results: Compared to HS, burn patients had an increased meropenem
volume of distribution (V), and decreased elimination rate constant (k),
resulting in a calculated clearance (Cl) that was comparable to HS
(Cl=kV). PTA in burn patients was different than in HS with different
meropenem dosing regimens due to differences in V and k between these
patient populations. At higher MICs, CIV regimens had a better PTA
than IIV in HS and burn patients. Both meropenem CIV 1g IV q4h and
2g IV q8h provided optimal PTA with a high MIC of up to 8mg/L.
Conclusion: In burn patients with resistant GNB up to an MIC of
8mg/L, the optimal PTA is achieved with continuous infusion
meropenem of 1g IV q4h or 2g IV q8h.
provide specialized training but may not be ideal for practicing pharmacists. A national observership program was developed to meet the learning
needs of working pharmacists.
Description: The observership program was launched in 2017 by a
national network of HIV pharmacists. Program objectives were to improve
pharmacists’ confidence in HIV therapy management, to increase
awareness of different practice sites and subspecialties, and to promote
collaboration. All pharmacists wishing to gain clinical experience or
specialized knowledge through shadowing/teaching with another HIV
pharmacist were eligible to apply. Observerships of 1 to 5 days in duration
were offered.
Action: A working group developed terms of reference and application
criteria. Funding was secured for one year via an unrestricted industry
educational grant. Calls for applications were issued through the network,
with priority given to new practitioners or those from rural/ underserviced
areas.
Evaluation: To date, 4 observerships have been completed with all
participants completing surveys on their experience. On average, observers
had worked for 4 years, with less than 6 months of experience providing
HIV care in a hospital (50%) or clinic/community (50%) setting; 75%
were practicing in a small urban centre. Overall, pharmacists found
the observership to be extremely beneficial, and resulted in increased
confidence in therapeutic knowledge and ability to provide care and
enhanced professional networking with potential for future collaboration.
All preceptors felt the workload was reasonable and were willing to offer
future observerships.
Implications: A national clinical observership program has been successful
in providing learning and mentorship opportunities for HIV pharmacists.
Continued program funding is being pursued. This program may serve
as a model for implementation in other countries or in other therapeutic
areas.
An Innovative In-House Developed Access®
Database to Capture and Analyze Antimicrobial
Stewardship Interventions
Tseng A1,2, Yoong D3, Foisy MM4, Giguere P5, Robinson L6, Stuber M7,
on behalf of the Canadian HIV and Viral Hepatitis Pharmacists Network
(CHAP)
1
University Health Network, Toronto, ON
2
Leslie Dan Faculty of Pharmacy, Toronto, ON
3
St. Michael’s Hospital, Toronto, ON
4
Northern Alberta Program, Royal Alexandra Hospital, Edmonton, AB
5
The Ottawa Hospital, Ottawa, ON
6
Windsor Regional Hospital, Windsor, ON
7
Regina Qu’Appelle Health Region, Regina, SK
Background: Pharmacists play a significant role in optimizing care for
HIV patients, managing challenges of adherence, resistance, comorbidities,
polypharmacy and drug interactions. HIV residency programs or electives
Patel S, Patel M
Humber River Hospital, Toronto, ON
Background: Antimicrobial stewardship programs are responsible for
optimizing use of antimicrobials. Our program focuses on reviewing
antimicrobials on Day 3. Infectious disease physician and pharmacist are
responsible to review antimicrobials on clinical care areas. We utilize a
Meditech system, which provides antimicrobial utilization data; however,
it is currently not used to capture patient-specific antimicrobial stewardship interventions. It is imperative to capture these interventions and
analyze them to improve the program and patient outcomes.
Description: We developed an in-house database using Microsoft
Access® to capture antimicrobial stewardship interventions at the patientspecific level. The database captures information under 3-categories:
patient, visit, and intervention as shown below.
Action: For the image that goes with the “Action” section of this abstract,
please see Abstract Appendix, available at https://www.cjhp-online.ca/
index.php/cjhp/issue/view/125/showToc
Evaluation: We evaluated 6-months of data from September 2016 February 2017. We were able to categorized types of interventions by
frequency and identify which clinical care areas had the highest number
of interventions. We found that the majority of IV-to-PO conversions
were from piperacillin/tazobactam to amoxicillin-clavulanate. Meropenem
to ertapenem was the leading IV-to-IV conversion. It took about 3-3.5
CJHP – Vol. 71, No. 1 – January–February 2018
JCPH – Vol. 71, no 1 – janvier–février 2018
Development of an HIV National Clinical
Observership Program for Pharmacists
69
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
days to convert from either IV-to-PO or IV-to-IV. Piperacillin/tazobactam
was the leading antimicrobial for dose optimization. Finally, we were able
to demonstrate saving of $15,000 in direct antimicrobial costs during the
first 6-months.
Implications: The database allows us to capture and analyze stewardship
patient-specific interventions, which can be used to improve the program
and share results with stakeholders. We can also utilize the database to
calculate cost savings, acceptance rates, and benchmark physicians among
peers.
Performance of an Innovative Patient Decision Aid
for Atrial Fibrillation Stroke Prevention Therapy
Loewen P1, Bansback N1, Andrade J1,2, Bonet B4, Deyell M1,3, Hicklin J1,
Kapanena A1, Kwan L4, Lynd L1, McLean A1, McGillivray J2, Salmasi S1
1
The University of British Columbia, Vancouver, BC
2
Vancouver Coastal Health, Vancouver, BC
3
Providence Health Care, Vancouver, BC
4
Fraser Health, Vancouver, BC
Background: Choosing stroke prevention therapy in atrial fibrillation
(SPAF) is complicated because it requires patients to make trade-offs and
individual patient preferences are unpredictable. Misalignment between
prescribed therapy and patient preferences is associated with poor therapy
adherence and persistence and SPAF failure. To help address this misalignment, we have developed a unique online decision aid (DA), SPARC-DT,
which integrates patients’ stroke and bleeding risk, their values and
preferences for key therapy attributes, and best evidence to identify which
options are best matched with their preferences. Using SPARC-DT could
be a basis for shared decision-making (SDM).
Objective: To evaluate the performance of SPARC-DT in patients with
AF or at risk of AF.
Methods: Design: Prospective observational study. Participants were AF
patients or patients at risk of AF based on age>50 y/o recruited from AF
clinics and community centers. Consenting participants completed a
pre-DA questionnaire, the SPARC-DT decision aid, and a post-DA
questionnaire, either self-guided or by study personnel based on
participant preference. Study outcomes were pre- vs. post-SPARC-DT AF
knowledge assessment (AFKA), decisional conflict scale (DCS), System
Usability Scale (SUS), and qualitative user feedback.
Results: 38 patients (mean age 71) completed the study. Using SPARCDT improved AFKA scores (7.93 vs. 8.61/10; p=0.02), reduced overall
decisional conflict (DCS Δ -21/100; p<0.01), and improved all DCS
subscales (all p<0.05). Those “unsure” about their preferred therapy was
reduced by 50%. On the SUS and from qualitative feedback, most
participants found SPARC-DT easy to use and learn, expressed willingness
to use and confidence in using it, and found it to be well integrated.
Conclusion: SPARCT-DT performed well on all conventional measures
of decision aid performance, reducing decisional conflict, increasing
knowledge, and was deemed highly usable by participants. With
refinement, SPARC-DT could be a valuable facilitator of SDM.
70
CJHP – Vol. 71, No. 1 – January–February 2018
Novel Student-Preceptor Models in Pharmacy
Education: A Qualitative Analysis of the PharmD
Student Experience
McIntyre C1,2, Natsheh C1,2, Leblanc K1,2, Fernandes O1,2, Bjelajac-Mejia A2,
Raman-Wilms L2, Cameron K1,2
1
University Health Network, Toronto, ON
2
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
Background: Experiential rotation requirements in the Entry-to-Practice
PharmD program have increased. To accommodate significantly more
pharmacy learners on-site, institutions have explored novel studentpreceptor teaching models. These include peer-assisted-learning (PAL;
2 or more students of same educational level), near-peer-teaching (NPT;
1 or more junior students with 1 or more senior students), and copreceptorship (CoP; 2 or more preceptors).
Objective: To describe students’ experiences and perceptions of novel
teaching models and evaluate the effectiveness of these models on students’
learning using Kirkpatrick’s levels.
Methods: Pharmacy students from the class of 2015, 2016, and 2017
were invited to participate in semi-structure interviews. Interviews were
transcribed, coded, and analyzed for themes. Themes were mapped
according to the Kirkpatrick model for appraising educational training.
Results: Twenty semi-structured interviews were conducted with 10
pharmacy students from the class of 2017, and 5 each from the classes of
2016 and 2015. Forty-three experiences (19 CoP, 14 PAL, 10 NPT) were
described from 14 institutions. Many themes overlapped between the
three novel teaching models. In CoP, students described increased
preceptor availability and exposure to different patient care approaches.
Challenges arose when preceptors had different student expectations.
Students overwhelmingly endorsed a multi-learner environment. Both
PAL and NPT students felt well supported as collaboration with other
learners was readily fostered. Potential challenges in PAL and NPT
included student competitiveness and difficulties when personalities
conflicted. All three models allowed for the development of skills including
communication, collaboration, and teamwork. Because of their
experiences, students reported an improvement in their approach to
patient care. They also described a positive impact on their professional
practice and approaches to teaching as new preceptors.
Conclusion: Pharmacy students enjoyed their experiences in novel
student-preceptor models. These opportunities had a positive impact on
overall learning during the rotations and as new practitioners.
Evaluation of Physical Assessment Education for
Practicing Pharmacists: A Cross-Sectional Study
Barry A1,2, Egan G3, Turgeon R4, Leung M5
1
Faculty of Pharmaceutical Sciences, University of British Columbia,
Vancouver, BC
2
Chilliwack General Hospital, Lower Mainland Pharmacy Services,
Chilliwack, BC
3
Vancouver General Hospital, Lower Mainland Pharmacy Services,
Vancouver, BC
4
Faculty of Medicine & Dentistry (Division of Cardiology), University of
Alberta, Edmonton, AB
5
St. Paul’s Hospital, Lower Mainland Pharmacy Services, Vancouver, BC
Background: Pharmacists are now seeking to incorporate physical
assessment (PA) into their practice. This prompted the creation of a
30-hour PA course for practicing pharmacists developed by a Canadian
Society of Hospital Pharmacists branch.
JCPH – Vol. 71, no 1 – janvier–février 2018
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
Objectives: To evaluate pharmacists’ knowledge, skills, and confidence
with performing PA after completion of the course.
Methods: We invited all course participants via email to complete online
surveys immediately and 6 months after completion of the course.
Results: Of 218 pharmacists who completed the course, 102 (46.8%)
completed the immediate post-course survey. Two-thirds of respondents
did not use PA in their practice prior to the course. A lack of formal
training and comfort were the most frequently selected barriers to
performing PA prior to the course. All participants agreed the course
improved their knowledge of PA and 96% agreed it improved their skills.
Most respondents (90%) agreed the course improved their ability to care
for patients. After the course, 60% and 67%, respectively, agreed they felt
confident performing PA or intervening on a patient’s drug therapy based
on their PA findings. The most common suggestion for course improvement was more hands-on practice. Twenty-five of 158 eligible participants
(15.8%) completed the 6-month post-course survey, of which 79% had
performed PA in practice. Only 60% agreed they felt confident performing
PA, whereas 84% now agreed they would intervene on a patient’s drug
therapy based on their PA findings. The most frequently selected barrier
to performing PA was now lack of time. The primary limitation of this
study was potential responder bias.
Conclusions: The course improved pharmacists’ knowledge and skills
with performing PA. Six months after the course, most respondents used
PA in practice. While the proportion of participants that felt confident
performing PA had not increased, more were willing to use their PA
findings to change drug therapy.
International Normalized Ratio Point of Care
Testing in an Outpatient Anticoagulation Clinic
and the Impact on the Patient Experience:
A Quality Improvement Study
Chisholm K, Culley C, Spina S
Department of Pharmacy, Island Health, Victoria, BC
Faculty of Pharmaceutical Sciences, University of British Columbia,
Vancouver, BC
Background: Patients who are receiving warfarin therapy require ongoing
blood testing to monitor their international normalized ratio (INR). In
Canada, the standard for INR testing is by laboratory venipuncture. Pointof-care testing (POCT) is an alternative method, and previous studies
have shown that it may enhance patient convenience and comfort.
However, there is little information on the impact of INR POCT on the
patient experience in a pharmacist-led, outpatient anticoagulation clinic.
Objective: To evaluate how the implementation of an INR POCT device
for the initiation and stabilization of warfarin therapy in a pharmacist-led,
outpatient anticoagulation clinic impacts the patient experience compared
to laboratory testing.
Methods: We performed a prospective, before-and-after, quality improvement study of patients attending an outpatient anticoagulation clinic in
Victoria BC, Canada. Using an anonymous patient survey, we evaluated
outcomes measured before and after the implementation of an INR
POCT device. Outcomes included patient time spent and number of
visits to the hospital for anticoagulation-related care in one day, patient
satisfaction with their blood testing experience, cost to patient, missed
activities, and pain and discomfort. A one-month cost analysis was
completed to compare health care cost of INR POCT and laboratory
testing.
CJHP – Vol. 71, No. 1 – January–February 2018
Results: Fifty-eight patients completed the survey. Patients undergoing
POCT spent less time receiving anticoagulation-related care compared to
laboratory testing (59.7 min vs 144.5 min; p<0.05). Using a 10-point
scale to quantify satisfaction with their blood testing experience, patients
expressed higher satisfaction with POCT (9.6 vs. 7.8; p=0.001). There
were no differences in number of visits to the hospital, cost to patient,
missed activities, or patient pain and discomfort. Health care cost was
similar for both testing strategies when comparing one month of testing.
Conclusions: Our findings support the continued use of INR POCT for
the initiation and stabilization of warfarin therapy in a pharmacist-led,
outpatient anticoagulation clinic.
Case Report: Fatal Arrhythmia in a Patient Receiving
an Aconite Herbal Product
Lee J, Bucci C
Sunnybrook Health Sciences Centre, Toronto, ON
Background: Aconite is commonly used in traditional Chinese medicine.
Aconite poisoning can lead to serious cardiac toxicity such as ventricular
arrhythmias.
Case Description: A 44 year old male was found unconscious for an
unknown duration. His rhythm showed ventricular tachycardia and
fibrillation, requiring defibrillation and an amiodarone infusion.
Arrhythmias subsided after 24 hours, however brain imaging was
consistent with brain death. The family noted that he had ingested a large
quantity of an herbal medication “Aconite”. The patient had previously
been boiling the medication prior to ingestion, but on the morning of
presentation, he consumed a large handful without boiling.
Assessment of Causality: Based on the Naranjo scale, there is a “probable”
chance of an adverse drug reaction (total score 6):
There are previous reports on this reaction (+1)
The event appeared after administration (+2)
There are no alternative causes that could have on their own caused the
reaction (+2)
The reaction was confirmed by objective evidence (+1)
Literature Review: Aconite poisoning has been well documented in the
Chinese literature. Patients may present with gastrointestinal (nausea and
vomiting), neurologic (paresthesias), and cardiac symptoms (arrhythmias).
Cardiac toxicity is thought to be related to the binding of fast voltage gated
sodium channels, resulting in persistent depolarization. Processing
(boiling) is recommended to hydrolyze the contents into less toxic
derivatives. Amiodarone and flecainide have been used with some success,
but no single agent have been shown to be of consistent benefit.
Importance to Practitioners: This case report is unique as it describes
a fatal arrhythmia after ingestion of an herbal medication. With the
increasing use of herbal products and the prevalence of Chinese
immigrants in Canada, pharmacists can play an important role in identifying and assessing their potential harmful effects.
JCPH – Vol. 71, no 1 – janvier–février 2018
71
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
A Survey of the Use of Cannabis in Children at a
Tertiary Teaching Hospital
Moreno M, Vaillancourt R, Pouliot A, Sell E, Hevenor B, Viracoumarane K
Children's Hospital of Eastern Ontario (CHEO), Ottawa, ON
Background: There has recently been an increase use of cannabis for
medical purposes in the pediatric population. However, limited data on
the efficacy and safety of cannabis in children has been published. A
comprehensive characterization of cannabis use in this population can
further contribute to a better understanding under which circumstances
cannabis is being used and the observed outcomes.
Objectives: To perform a retrospective drug use evaluation to describe all
inpatient and outpatient medical uses of cannabis in a tertiary teaching
hospital over the last 3 years.
Methods: A retrospective medical record review was completed of
inpatients and outpatients <18 years of age prescribed medical cannabis
between May 1st, 2014 and May 1st, 2017. Patients using cannabis
recreationally were excluded.
Results: There were a total of 300 unique patients identified and 37
children were included in this study. Of these, 30 patients were using
medical cannabis and most were using it for seizures (93%) where 82%
were described as having intractable/ refractory seizures. Among these,
78% reported a decrease in seizures and of those 76% had a transient effect
where a decrease was noted for 130.38 days (±99.14), but then seizures
increased once again. Additionally, a subgroup of 7 patients were selfmedicating with cannabis. They obtained cannabis without proper
authorization as a dried flower and were using it for chronic pain (71%)
and/or anxiety (71%).
Conclusions: Cannabis use is reported more often for childhood
refractory epilepsy compared to other chronic conditions. The use of
cannabis in children with medication-refractory epilepsy may be warranted
after trying first line anticonvulsant medications and after discussing
non-pharmacological options. Based on our data, decrease in seizures may
only be transient.
Current Identification and Management Practices
of Steroid-Induced Hyperglycemia in Brain and
Spinal Tumour Patients on a Neurosurgical Unit
Rankin S1, Gilmour J2, Halapy H1,2, Wong S2, Saccucci P2, Ng R2, Chan WWY2
University of Toronto, Toronto, ON
2
St. Michael’s Hospital, Toronto, ON
Background: Brain and spinal tumor (BST) patients often receive
dexamethasone to alleviate neurological symptoms. Steroid-induced
hyperglycemia (SIH) has been reported in 5-72% of Brain tumour
patients. Hyperglycemia has been associated with worsened clinical
outcomes, including shortened survival in brain tumour patients. We
hypothesize that a gap exists in identifying and managing SIH in BST
patients at our institution.
Objectives: We aim to describe the current identification and management
practices of SIH in BST patients at our institution.
Methods: A retrospective chart review of adult BST patients admitted to
the neurosurgical unit at a tertiary care hospital between January and
December 2016, and received dexamethasone as well as diabetic
medication(s), was performed. The primary endpoints included the
average proportion of blood glucose (BG) readings above 10 mmol/L per
admission and the percentage of patients with: 1) BG monitoring
for 48 hours after dexamethasone start; 2) incidences of hypoglycemia;
1
72
CJHP – Vol. 71, No. 1 – January–February 2018
3) a start on corrective insulin scale for initial glycemic control; 4) an
appropriate corrective insulin scale; 5) “STAT” dose of insulin; 6)
change(s) to diabetic medication(s) at discharge; and 7) endocrine or
medicine consult
Results: Thirty-six patients over 41 admissions were reviewed. The
primary endpoints were: 61.7% was the average proportion of BG
readings above 10mmol/L, 92.7% of patients had BG monitoring for 48
hours after dexamethasone start, 4 incidences of hypoglycemia, 56%
started on corrective insulin scale for initial glycemic control, 43.9%
received appropriate corrective insulin scale, 26.8% received “STAT” dose
insulin, 74% had change(s) to diabetic medication(s) at discharge, and
36.5 % had endocrine or medicine consult.
Conclusion: While screening for SIH seems reasonable, the management
of SIH at our institution appears to be sub-optimal and highly variable.
These results will enable us to design a quality improvement project that
optimizes SIH identification and management in BST patients.
Clonidine for Sedation in Critically Ill Adults:
A Retrospective Chart Review
Purivatra E1, Guenette M1, Coleman B3,4, Burry L1,2
1
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
2
Department of Pharmacy, Mount Sinai Hospital, Toronto, ON
3
Infectious Disease Research, Mount Sinai Hospital, Toronto, ON
4
Dalla Lana School of Public Health, University of Toronto, Toronto, ON
Background: The alpha2 agonist clonidine may be used as an adjunct for
Intensive Care Unit (ICU) sedation and analgesia to decrease traditional
sedative and opioid requirements. However, use has been associated with
hypotension and bradycardia.
Objectives: 1) To describe clonidine dosing regimens used for sedation
in a mixed medical surgical ICU, as well as adverse events associated with
use (i.e., hypotension, bradycardia, rebound withdrawal), and 2) to
determine if clonidine has sparing effects on traditional drugs used for
pain, sedation and agitation.
Methods: We conducted a retrospective chart review of all critically ill
adult patients admitted who had received at least one dose of clonidine
for sedation during a five-year study period. Patients were categorized for
the analysis into low dose (LD ≤ 0.4 mg/day) versus high dose (HD > 0.4
mg/day) based on the maximum total daily clonidine dose. Data was
analyzed using the Mann Whitney U test and Chi squared test for
continuous and binary variables, respectively. A p value < 0.05 was
considered statistically significant.
Results: Of the 166 patients that met inclusion criteria, seventy-eight
patients (47%) had clonidine titrated to HD. There were no statistically
significant differences in hypotension, bradycardia or withdrawal
symptoms between the LD and HD clonidine groups. There was a greater
reduction in mean daily opioid dose for HD clonidine versus LD (mean
-218.8 mcg vs. -42.5 mcg of fentanyl equivalents, p = 0.049). The decrease
in sedative usage post-clonidine initiation was not significant.
Antipsychotic doses increased for HD compared to LD (5.7 mg
olanzapine equivalents vs 0 mg, p = 0.04).
Conclusions: Clonidine doses titrated beyond 0.4 mg/day may decrease
patients’ opioid but not sedative requirements without causing statistically
significant adverse effects. Antipsychotic doses increased as clonidine was
titrated.
JCPH – Vol. 71, no 1 – janvier–février 2018
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
The Effect of Preoperative Cannabis Use on Opioid
Consumption Following Surgery: A Cohort Analysis
Jamal N1, Korman J1, Musing M1, Malavade A2, Coleman BL3,
Siddiqui N2, Friedman Z2
1
Department of Pharmacy, Sinai Health System, University of Toronto,
Toronto, ON
2
Department of Anesthesia and Pain Management, Sinai Health System,
University of Toronto, Toronto, ON
3
Infectious Diseases Epidemiology Research Unit, Sinai Health System,
University of Toronto, Toronto, ON
Background: Anecdotally, healthcare professionals on the Acute Pain
Service have observed that individuals consuming cannabis preoperatively
had higher opioid requirements in the postoperative period.
Objective: This study examined whether preoperative cannabis use
impacted opioid consumption in the first 24 postoperative hours, in
individuals undergoing abdominal surgery for inflammatory bowel disease
(IBD).
Methods: We conducted a chart review of patients who underwent
surgery for IBD at a tertiary, university affiliated hospital between January
2014 and December 2015. Patients were excluded if they used methadone
preoperatively, used synthetic forms of delta-9-tetrahydrocannabinol
preoperatively or received neuraxial analgesia. Demographic data, cannabis
use, as well as data on perioperative analgesia was collected. Linear
regression analysis was used to correct for potential confounding factors
in order to compare the opioid consumption in the first 24 hours
postoperatively between cannabis users (C) and non-users (NC).
Results: Of the 354 charts included, 42 (11.9%) were classified in the C
group and 312 (88.1%) in the NC group. The C group was significantly
(p<0.05) younger, with a higher percentage of males but did not differ
with respect to type of surgery, length of surgery, preoperative opioid use
or intraoperative opioid use compared with the NC group. Linear
regression analysis demonstrated an increase in postoperative opioid
consumption proportional to the amount of cannabis consumed
preoperatively. The cannabis group required an additional 1.13 mg
(95% CI: 1.02-1.25) morphine equivalent per gram of daily cannabis
used (p=0.015).
Conclusions: Our results demonstrated that cannabis use increased the
postoperative opioid consumption in patients undergoing IBD surgery.
This could influence postoperative pain management and increase the risk
of opioid side effects. Future prospective studies should expand beyond
the IBD population and look at the role of synthetic cannabinoids as
adjuncts for pain management.
Stability of Extemporaneously-Compounded
Temozolomide 10 mg/mL Suspension in Oral Mix
SF in Glass and Plastic Bottles and Plastic Syringes
Lingertat-Walsh KH1, Weilnau J3, Dupuis LL1,6, Ostrenga A4, Cober MP 3,5,
Law S2, Walker SE2,6
1
Departments of Pharmacy, Hospital for Sick Children, Toronto, ON
2
Sunnybrook Health Sciences Centre, Toronto ON
3
Akron Children’s Hospital, Akron, OH
4
University of Mississippi Medical Center, Jackson, MS
5
Northeast Ohio Medical University, College of Pharmacy, Rootstown, OH
6
Faculty of Pharmacy, University of Toronto, Toronto, ON
Background: Temozolomide oral suspension is not commercially
available. Colour changes and crystal formation have been observed with
previously published extemporaneous temozolomide suspension formulations.
CJHP – Vol. 71, No. 1 – January–February 2018
Objective: To evaluate the stability of 3 temozolomide 10mg/mL
suspensions prepared in Oral Mix SF stored in 3 types of containers
(amber glass, amber polyethylene terephthalate (PET) and polypropylene
oral syringes) at 4°C and 25°C.
Methods: Three separate batches of 3 different formulations in Oral Mix
SF with (i) povidone K-30; (ii) povidone K-30 and citric acid and (iii)
neither povidone K-30 nor citric acid were made and were stored in 3
container types (amber glass, amber PET and oral syringes). Half of the
aliquots in each container type was stored at 25°C, the other half at 4°C,
protected from light. On study days 0, 5, 8, 14, 21, 28, 35, 42, 56,
physical stability was assessed and the temozolomide concentration was
determined using a stability-indicating method for samples drawn from
each container type stored at each temperature. Chemical stability was
based on the intersection of the lower limit of the 95% confidence interval
(CI) of the observed degradation rate and the time to achieve 90% of the
initial concentration (T-90[95%]).
Results: The stability-indicating analytical method was accurate (deviation
<1.5%) and reproducible (CV%<1.5%). Samples stored at 25°C turned
from white to orange. Temozolomide concentrations in all refrigerated
samples in all container types remained above 90% of the initial concentration for 56-days, resulting in a T-90[95%] exceeding 56-days. Analysis
of variance demonstrated changes in concentration due to study day and
temperature (p<0.001) but not container (p=0.991) or formulation
(p=0.987).
Conclusions: Temozolomide 10mg/mL oral suspension in Oral Mix SF
with and without povidone K-30 or citric acid was chemically stable when
stored at 4°C and 25°C in in glass, PET, or oral syringes for 56 and
6-days, respectively.
Stability of 20, 40 and 50 mcg/mL Fentanyl
Solutions Stored in Syringes at Room Temperature
(23°C)
Riss V1, Hook R1, Low A1, Scharrer E1, Law S2, Walker SE2,3
Departments of Pharmacy, Hospital for Sick Children, Toronto, ON
2
Sunnybrook Health Sciences Centre, Toronto, ON
3
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
Background: Inpatient hospital pharmacies must compound intravenous
products and assign an appropriate beyond-use-date (BUD) as per
NAPRA standards, because products are not commercially available.
Furthermore, having medications in a Ready-To-Administer format on
nursing units is important for safe and timely administration. Paediatric
patients require lower concentrations of opioid continuous infusions than
adults and while previous publications have demonstrated the stability of
fentanyl, data for lower concentrations stored in syringes is not available.
Objective: We sought to evaluate the chemical stability fentanyl, prepared
in syringes.
Methods: On study day 0, 50mL solutions of 20mcg/mL, 40mcg/mL
and 50mcg/mL concentrations of fentanyl were prepared in BD syringes.
3 units of each container and concentration were stored at room
temperature. Concentration analysis was completed on study days
0,1,3,7,14,24,38,57,77 and 90. Fentanyl concentrations were determined
by a validated stability-indicating liquid chromatographic method with
UV detection. Chemical stability was based on the intersection of the
lower limit of the 95% confidence interval of the observed degradation
rate and the time to achieve 90% of the initial concentration.
1
JCPH – Vol. 71, no 1 – janvier–février 2018
73
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
Results: The analytical method separated degradation products from
fentanyl such that the concentration was measured specifically, accurately
(deviations from known averaged 2.5%) and reproducibly (replicate error
was less than 1.4%(CV(%)). During the study period all solutions retained
more than 96.7% of the initial concentration. Analysis of variance revealed
significant differences in percent remaining due to concentration
(p< 0.001), and study day (p< 0.001) although the study was capable
of detecting less than a 0.51% difference in percent remaining. The
calculated beyond-use-date was greater than 235days, exceeding the
90-day study period for all concentrations.
Conclusions: We conclude that 20 and 40mcg/mL solutions of fentanyl
diluted in saline and 50mcg/mL undiluted solutions of fentanyl, stored
in polypropylene BD syringes are physically and chemically stable for 90
days at room temperature (23°C).
Stability of Generic Formulations of Bortezomib
1.0 and 2.5 mg/mL in Vials and Syringes Stored
4°C and Room Temperature (23°C)
Law S1, Charbonneau LF1, Iazzetta J1, Perks W1, Walker SE1,2
1
Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON
2
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
Background: Generic versions of bortezomib raise questions about the
reliability of extending stability study data from brand to brand.
Objective: To evaluate the stability of Janssen, Teva, Actavis and
Dr.Reddy’s bortezomib formulations reconstituted to produce either 1.0
or 2.5mg/mL, during storage over at least 21-days at room temperature
(23°C), and under refrigeration (4°C) in plastic syringes and manufacturer
vials.
Methods: On study day 0, 2.5mg/mL and 1.0mg/mL concentrations of
the Janssen, Teva, Actavis and Dr.Reddy’s formulations were prepared.
Three units of each container were stored at 23°C and 3 at 4°C. Concentration and physical inspection were completed on at least 8-study
days over a 21-42 day study period. Bortezomib concentrations were
determined by a validated stability-indicating liquid chromatographic
method with UV detection. The end point of these studies is the time to
achieve 90% of the initial concentration (T-90). This was completed with
confidence determining the intersection of the lower limit of the 95%
confidence interval of the observed degradation rate and 90% of the initial
concentration (T-90[95%]).
Results: The analytical method separated degradation products from
bortezomib during all studies such that the concentration was measured
specifically, accurately (deviations less than 2.5%) and reproducibly
(replicate error averaged 2.5%). During all studies, all solutions retained
more than 94% of the initial concentration. The T-90[95%] exceeded the
study period for all formulations at all temperatures, concentrations and
container combinations. Analysis of variance failed to detect significant
differences between manufacturers (p=0.970).
Conclusions: We conclude that formulations of bortezomib currently
marketed in Canada by Janssen, Teva, Actavis or Dr.Reddy’s, reconstituted
with 1.4mL or 3.5mL of 0.9% sodium chloride to create solutions
containing 2.5mg/mL or 1.0mg/mL, respectively, are physically and
chemically stable for more than 21-days at 4°C or 23°C in both syringes
and the manufacturer's glass vial.
74
CJHP – Vol. 71, No. 1 – January–February 2018
Stability of 4 and 10 mcg/mL Remifentanil Solutions
Stored in Syringes at Room Temperature (23°C)
Hook R1, Riss V1, Scharrer E1, Law S2, Walker SE2,3
1
Departments of Pharmacy, Hospital for Sick Children, Toronto, ON
2
Sunnybrook Health Sciences Centre, Toronto, ON
3
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
Background: Inpatient hospital pharmacies must compound intravenous
products and assign an appropriate beyond-use-date (BUD) as per
NAPRA standards, because products are not commercially available.
Furthermore, having medications in a Ready-To-Administer format on
nursing units is important for safe and timely administration. Paediatric
patients require lower concentrations of opioid continuous infusions than
adults and while previous publications have demonstrated the stability
of remifentanil, data for lower concentrations stored in syringes is not
available.
Objective: We sought to evaluate the chemical stability remifentanil,
prepared in syringes.
Methods: On study day 0, 5mL solutions of 4mcg/mL and 10mcg/mL
concentrations of remifentanil were prepared in 5mL BD syringes. 3 units
of each container and concentration were stored at room temperature.
Concentration analysis was completed on study days 0,1,3,7,14,24,
38,56,76 and 90. Remifentanil concentrations were determined by a
validated stability-indicating liquid chromatographic method with UV
detection. Chemical stability was based on the intersection of the lower
limit of the 95% confidence interval of the observed degradation rate and
the time to achieve 90% of the initial concentration (T-90).
Results: The analytical method separated degradation products from
remifentanil such that the concentration was measured specifically,
accurately (deviations from known averaged 2.65%) and reproducibly
(replicate error averaged 0.82%(CV(%)). During the study period all
solutions retained more than 96.96% of the initial concentration. Analysis
of variance revealed significant differences in percent remaining due to
study day (p= 0.002) but not concentration (p= 0.203). The study was
capable of detecting a difference of more than a 0.76%. The difference
due to concentration was less than 0.5%. The calculated T-90, with 95%
confidence, exceeded 156 days for both concentrations.
Conclusions: We conclude that 4 and 10mcg/mL solutions of remifentanil diluted in saline stored in polypropylene BD syringes are physically
and chemically stable for 90 days at room temperature (23°C).
Satisfaction des établissements de santé suite
à la mise en place d’une plateforme web de
surveillance environnementale
Chauchat L1, Bergeron M1, Tanguay C1, Bussières JF1,2
Unité de recherche en pratique pharmaceutique, Département de pharmacie,
Centre Hospitalier Universitaire Sainte-Justine, Montréal, QC
2
Faculté de pharmacie, Université de Montréal, Montréal, QC
Contexte : Une étude annuelle de surveillance environnementale de traces
de médicaments dangereux est menée au Canada depuis 2008 auprès des
établissements de santé participant. Jusqu’à maintenant, la communication
des rapports individualisés se faisaient par courriel.
Objectif : Évaluer la satisfaction des établissements de santé à la mise
en place d’une plate-forme web contenant le rapport surveillance
environnementale.
Méthodologie: Étude descriptive transversale. Une plate-forme web sur
un serveur Linux (PHP) a été développée avec une base de données
MySQL sur un domaine sécurisé par une connexion SSL (HTTPS). La
plate-forme inclut les données actuelles et historiques de tous les établisse1
JCPH – Vol. 71, no 1 – janvier–février 2018
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
ments et permet l’affichage et l’impression en temps réel des données d’un
établissement comparées aux données agrégées de tous les établissements.
La personne contact de chaque établissement a été invitée à répondre à
un questionnaire en ligne (14 questions) visant à évaluer leur satisfaction.
Résultats : La plate-forme a été lancée le 1er octobre 2017 auprès des 83
établissements ayant participé à l’étude 2017. Quarante-trois répondants
(taux de participation de 51,8%) ont complété le sondage. Quinze
répondants (35%) avaient plus de 15 civières en oncologie. Trente (70%)
ont participé à plus de deux études jusqu’à maintenant. Quarante-et-un
(95%) ont dit préféré avoir un accès en ligne en temps réel par rapport
aux rapports papier, 43 (100%) se sont dit satisfaits de la présentation
visuelle des données et 38 (88%) ont apprécié le format d’impression.
Douze (28%) ont rencontré des difficultés d’accès au départ compte
tenu de la nécessité de recopier un hyperlien et de blocages liés à certains
pare-feu. Ces problèmes ont été résolus.
Conclusion : Cette étude décrit le déploiement réussi d’une plateforme
web d’accès aux rapports de surveillance environnementale. Cet accès
facilité pourrait encourager le partage des données avec les équipes de
chaque établissement.
Medication Fluids in the Intensive Care Unit
Ignacy T1, Duffett M1,2, Carlin S1
Hamilton Health Sciences, Hamilton, ON
2
McMaster University, Hamilton, ON
Background: Fluid administration is essential to the care of critically ill
patients; however fluid overload is associated with increased morbidity
and mortality. Strategies to reduce fluid administration in this patient
population must consider the contribution of medications, but this has
not been well characterized.
Objectives: Our primary objective was to determine the contribution of
medications to overall fluid administered in the intensive care unit (ICU).
Secondary objectives include describing how fluid administration changes
over time, and whether medication fluid volume can be reduced.
Methods: This retrospective observational study included patients
admitted for >24h to either of two adult tertiary care ICUs between July
1 and October 31, 2016. We selected a random sample of 50 patients.
We collected baseline demographics, daily fluid intake categorized by fluid
type, and medication dose, concentration, and the associated fluid.
We identified the maximum concentrations of medications using
Micromedex, Pediatric Injectable Drugs and the Ottawa Manual.
Results: The median total volume of fluid administered is highest on day
1 at 3910 mL/day and decreases over time. Medications contribute 20%
of fluids administered in the ICU. Throughout patients’ stay in ICU,
medication fluids maintain a proportional contribution of 20%.
Antimicrobials are the largest contributor of medication fluid. Among
the top five antimicrobials used, medication fluid could be reduced by
up to 71%.
Conclusions: We identified opportunities to dramatically reduce the
fluid from medications. Future studies should identify which patient
populations would most benefit from limiting fluid volume. Any
interventions to reduce fluid intake should include assessing the feasibility
of further concentrating intravenous medications.
1
CJHP – Vol. 71, No. 1 – January–February 2018
Drug Use Evaluation of Oxycodone at a Canadian
Teaching Hospital
Wei H1, Too A1, Tanzini R2, Satchu S2, Dewhurst NF1,2
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
2
St. Michael’s Hospital, Toronto, ON
Background: Harms associated with prescription opioids are of increasing
public concern. Oxycodone lacks superiority compared to other opioids,
with an increased abuse potential. Since oxycodone’s removal from
the formulary at a Canadian hospital in 2012, its usage has not been
characterized. We hypothesized that oxycodone was over-utilized and that
opportunities exist for use optimization.
Objectives: This study was designed to characterize oxycodone use in
concordance with evidence-based assessment criteria.
Methods: A retrospective observational drug use evaluation (DUE) was
conducted for a four month period (April 1 to July 31, 2016) at a
Canadian, urban, university-affiliated, tertiary care centre. Inpatients who
received at least one dose of oxycodone immediate (IR) or controlled
released (CR) were included. The primary measure of the evidence-based
assessment criteria was the proportion of patients who received oxycodone
CR in hospital, and were also stabilized on a CR formulation prior to
admission. Patients were identified using the pharmacy computer system.
Patients’ electronic charts were reviewed using a standardized data
collection form. Descriptive statistical analyses were performed.
Results: A total of 147 patient encounters with 248 orders for oxycodone
were identified. Of oxycodone CR orders, 74/91 (81%) were deemed
appropriate as per the primary measure. Most oxycodone (IR and CR)
orders (52/248 [21%]) were initiated on the orthopedic ward. Four of the
five top oxycodone prescribers were acute pain service physicians. Patient
controlled analgesia (PCA) use was observed in 46% (67/147) of all
patient encounters. Of the patients prescribed oxycodone CR on
discharge, the majority (17/20 [85%]) were taking a CR formulation prior
to admission.
Conclusions: The majority of oxycodone utilized at our institution
was deemed appropriate according to the DUE assessment criteria.
Opportunities to further optimize its use may be explored through order
set modification or prescriber education.
1
Inpatient Insulin Stewardship Program: A Baseline
Needs Assessment
Halapy H1,2, Bruno B3, Chen L1, Lubchansky S3, Yu C1,3
1
Diabetes and Endocrinology Centre, St. Michael's Hospital, Toronto, ON
2
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
3
Department of Medicine, University of Toronto, Toronto, ON
Background: Inpatient insulin use often occurs in a non-standardized
way, including use of sliding scales without basal-bolus treatment as
recommended by Diabetes Canada Clinical Practice Guidelines. These
practices lead to poor glycemic control, which is associated with increased
infection and prolonged hospitalization. A previous study at our
institution indicated that 35% of inpatients have hyperglycemia, suggesting a need for improvement.
Objective: With the overall goal of improving inpatient diabetes management, a baseline hospital-wide needs assessment regarding diabetes
management was conducted in order to identify key barriers regarding
inpatient diabetes management to inform the development of an insulin
stewardship program, with the use of tailored interventions.
JCPH – Vol. 71, no 1 – janvier–février 2018
75
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
Methods: Surveys (online, hard-copy) and focus groups were conducted
with medical trainees (residents, students), nurse practitioners, medical
and surgical nurses, and clinical pharmacists. Surveys were analyzed using
descriptive statistics. Focus group recordings were transcribed and analyzed
thematically.
Results: Surveys (n=84) and focus groups (n=8) revealed provider-,
patient- and systems-related barriers to inpatient diabetes management.
Provider-related barriers included: 1) inconsistent insulin start education;
2) peri-operative insulin use; 3) hypoglycemia avoidance/ management;
4) converting between insulin regimens; 5) correctional insulin use; 6)
blood glucose monitoring education; and 7) when to consult the
endocrine service for diabetes management. Patient-related barriers
included appropriate use of home insulin in the inpatient setting.
System-related barriers included: 1) lack of knowledge and awareness of
standardized insulin order sets; 2) lack of resources available to support
diabetes management; and 3) lack of decision support for appropriate
insulin ordering.
Conclusion: Based on survey and focus group data, an insulin stewardship
program will be developed to target the above barriers. Interventions
include revised insulin order sets coupled with decision support; development of cheat sheets, standardized care protocols and manuals; revision
of professional roles (e.g. pharmacisits), and insulin ordering/ inpatient
diabetes management education.
Long-Term Beta-Blockers after Myocardial Infarction
in the Contemporary Era: A Systematic Review
Hong J1, Barry A1,2
1
Faculty of Pharmaceutical Sciences, University of British Columbia,
Vancouver, BC
2
Chilliwack General Hospital, Lower Mainland Pharmacy Services,
Chilliwack, BC
Background: Beta-blockers are currently recommended as standard of
care for patients who experience a myocardial infarction (MI) primarily
based on evidence from the pre-reperfusion era. The effect of longterm beta-blocker therapy in patients post-MI without left ventricular
dysfunction in the modern era is unknown.
Objective: To review the evidence for long-term (≥1 year) beta-blockers
as secondary cardiovascular preventive therapy on all-cause mortality and
major adverse cardiovascular events (MACE), specifically cardiovascular
mortality, nonfatal MI, and nonfatal stroke.
Methods: A systematic search of EMBASE, MEDLINE, and CENTRAL
(to September 2017) for randomized controlled trials or propensitymatched cohort studies published within the last 10 years that compared
beta-blockers to no beta-blockers on discharge in patients post-MI without
heart failure or reduced left ventricular ejection fraction (<30%) was
performed. Both authors independently completed the literature search,
data extraction, and study analysis.
Results: Eight cohort studies were included. Median study population
was 1838 and duration of beta-blocker use ranged from 1-5 years.
Definition of left ventricular dysfunction and reperfusion strategies varied
among studies. Two smaller studies showed a significant reduction in
all-cause mortality, whereas no difference was observed in 5 studies. One
study showed significantly reduced cardiovascular mortality at 1 year, but
no difference at 5 years, and no difference in all-cause mortality at 1 and
5 years. None of the 4 studies that reported MACE showed a significant
reduction with beta-blocker therapy. These data are limited by inherent
limitations of observational studies.
76
CJHP – Vol. 71, No. 1 – January–February 2018
Conclusions: Though heterogeneous, the majority of contemporary
studies identified did not demonstrate a reduction in death or MACE
with chronic beta-blocker therapy in patients post-MI without left
ventricular dysfunction. In the absence of an appropriately designed
randomized controlled trial, these data impart uncertainty regarding the
current standard of practice. Consequently, beta-blocker therapy should
be reassessed on a case-by-case basis in patients post-MI.
Clinical Guide for Pharmacists to Evaluate Risks and
Manage QTc Prolongation Drug-Drug Interactions
He T1,2, Ho C1,2,3
Institute for Safe Medication Practices Canada, Toronto, ON
2
School of Pharmacy, University of Waterloo, Waterloo, ON
3
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
Background: There is an increasing number of medications with potential
QTc prolongation risks and the subsequent degeneration into torsades de
pointes (TdP), a devastatingly fatal ventricular tachyarrhythmia.
Description: Our primary objectives were to identify recommendations
posed by clinicians in evaluating QTc prolongation risks and to create
a clinical algorithm or thought process aimed to help pharmacists in
assessing and managing these drug-drug interactions.
Action: We focused on three commonly prescribed medications that were
known to be associated with QTc prolongation risks (citalopram,
domperidone, and ciprofloxacin). We conducted an environmental scan
of recommendations made by national regulatory bodies and clinical
guidelines; and performed a systematic review of primary literature
between 2006 and 2016, with a primary focus on randomized controlled
trials, systematic reviews, and meta-analyses.
Evaluation: We reviewed 7 articles. The primary literature, current
recommendations from national regulatory authorities, and clinical
guidelines consensually state that the evaluation of QTc prolongation risks
requires a risk-benefit analysis of the drug combination. This analysis
should be based on the severity of the drug-drug interactions, the patient’s
modifiable risk factors, and the mechanism in which the drug interaction
results. In cases where the necessary doses may exceed the maximum
dosing recommendations, pharmacists should ensure that baseline and
steady-state 12-lead electrocardiograms are performed. Patients should be
made aware of the signs and symptoms of abnormal arrhythmias and
precipitating factors that may result in TdP. We developed a clinical
algorithm to guide pharmacists in assessing and managing drug-drug
interactions that involve potential QTc prolongation risks associated with
these 3 medications.
Implications: Until further large-scale risk assessment tests and scoring
can be performed, our clinical algorithm derived from a comprehensive
environmental scan and literature review suggests that pharmacists should
utilize their medication therapy expertise and effectively communicate
potential risks of QTc prolongation to patients.
1
JCPH – Vol. 71, no 1 – janvier–février 2018
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
Trickle-Down Antimicrobial Stewardship: Reduction
in Long-Term Care Resistance Rates Following
Implementation of a Prospective Audit and Feedback
Intervention in the Adjacent Acute Care Hospital
Peragine C1,2, Serbanescu C2, Leis JA3,4,5,6,7, Walker SAN1,2,3,4*
1
Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON
2
Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
3
Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON
4
Sunnybrook Health Sciences Centre Research Institute, Sunnybrook Health
Sciences Centre, Toronto, ON
5
Faculty of Medicine, University of Toronto, Toronto, ON
6
Division of Infectious Diseases, Department of Medicine, Toronto, ON
7
Department of Infection Prevention and Control, Toronto, ON
*Senior Author; first-last-author-emphasis approach to authorship
Background: The Sunnybrook Health Sciences Center Bayview Campus
is a shared site, home to a 627-bed acute care hospital and a 475-bed
long-term-care (LTC) facility. A multidisciplinary antimicrobial stewardship (AMS) intervention was implemented in the acute care facility in
October 2009. No specific intervention was initiated in LTC.
Objective: This study explores the impact of the acute care intervention
on the burden of resistance in the adjoining LTC facility in the 7 years
following the acute care program implementation.
Methods: Patient level data for clinical isolates of aerobic gram negative
bacteria, Staphylococcus aureus, and Enterococcus spp. were obtained over a
14 year time period. Changes in the trend (Δ slope) and level of
resistance between the pre-intervention (October 2002 – September 2009)
and post-intervention (October 2009 – September 2016) periods were
assessed using interrupted time-series analyses with segmented regression.
The primary outcome was the number of bacterial isolates exhibiting
resistance to at least one therapeutically active antibiotic per month
standardized to 10,000 patient days (PD) for all species collectively and
all gram-negative species (GNs).
Results: A statistically significant reduction in resistance rate trend was
found for all species collectively (Δ slope = -0.97 resistant isolates/10,000
PD/month, p=0.001) and all GNs (Δ slope = -0.82 resistant isolates/
10,000 PD/month, p=0.001). A significant reduction in the level of
resistance was found for all bacteria beginning at post-intervention month
18 (-3.24 resistant isolates, p=0.023) and at post-intervention month
30 for all GNs (-2.83 resistant isolates, p=0.046).
Conclusion: Time series modelling revealed that implementation of the
acute care AMS program was associated with significant improvements
in the adjoining LTC facility’s antibiotic resistance rates, suggesting a
trickle-down effect.
Enhancing Mental Health Services through
Hospital Outpatient Pharmacy and Assertive
Community Treatment Team Collaboration
Davie S, Stutchbury R, Wist A
Bluewater Health, Sarnia, ON
Background: The local Assertive Community Treatment (ACT) team is
a multidisciplinary team working with chronic mental health patients in
the community supported by the hospital. Outpatient community
hospital pharmacy is ideal to resolve potential gaps in pharmaceutical care
and further enhance services over traditional community pharmacy.
Description: Outpatient hospital pharmacy is able to provide individualized solutions for ACT team and their patients that will lead to outcomes
that reduce workload, reduce amount of medication on site, improve
storage conditions, increase clinical nursing time, implement educational
CJHP – Vol. 71, No. 1 – January–February 2018
initiatives and provide further support for both mental health inpatients
and outpatients.
Action: The hospital outpatient pharmacy devised a business case to
transition the medication distribution system for the local ACT team from
a retail pharmacy outside the community in order to enhance workflow,
increase medication monitoring, provide better transitional care and
increase flexibility. The projected revenue enabled pharmacy to provide a
full-time clinical pharmacist and pharmacy technician. Working closely
with the ACT team, pharmacy was able to identify offsite ACT office
clinical needs to ensure all necessary services, such as medication disposal,
were improved to meet internal hospital standards.
Evaluation: Implementation increased nursing clinical availability and
alleviated many technical aspects from their role. Pharmacy’s involvement
has been expanded to incorporate all facets of medication management
to increase safety measures and reduce areas of risk, such as implementing
improved storage and distribution solutions. Full-time access to a small
clinical pharmacy team with the capacity for on call support has increased
staff rapport and communication, reduced drug wastage, errors and
improved transition of care in and out of hospital.
Implications: Outpatient pharmacy in a hospital setting is ideal to service
hospital outpatient programs by providing the flexibility, availability,
quality and understanding that a community pharmacy may not always
be able to lend focus to.
Vancomycin Every 4 hours in Paediatric Patients:
A Case Series
Gelinas T1, Wong ETM1, Harris VC1,2
1
London Health Sciences Centre, London, ON
2
Schulich School of Medicine & Dentistry, Western University, London, ON
Background: Vancomycin target concentrations of 10-20 mg/L can be
difficult to attain in paediatric patients due to their developmental
pharmacokinetics. The usual starting dose for vancomycin is 15 mg/kg
IV every 6 hours in infants and children. In some cases, pharmacists have
used every 4 hour dosing in an attempt to reach therapeutic vancomycin
concentrations.
Objectives: To review cases of hospitalized paediatric patients who have
received vancomycin every 4 hours, in order to determine if this dosing
interval appears safe and effective.
Methods: For this quality assurance case series, patients who had received
vancomycin every 4 hours for ≥24 hours were identified from a report of
paediatric patients prescribed vancomycin from February 2014 until
October 2017. Vancomycin trough levels, drawn within 30 minutes of
the scheduled dose, were used as a surrogate marker for efficacy. Safety
parameters included serum creatinine and urea, which were assessed
at baseline and during vancomycin treatment. Descriptive statistics
were used.
Results: A total of 18 paediatric patients, aged 6 months to 8 years old
were included in the case series. All patients achieved therapeutic concentrations during their treatment. A total of 4 patients had supratherapeutic
trough concentrations. Observations indicate that serum creatinine and
urea trended upward as trough concentrations increased.
Conclusions: Our observations suggest that vancomycin dosing every
4 hours in the paediatric population correlates with a high frequency of
supratherapeutic trough concentrations, along with increased urea and
serum creatinine. Further investigation is required to identify which
patients are most likely to benefit from every 4 hour vancomycin dosing
and those more likely to experience supratherapeutic concentrations.
JCPH – Vol. 71, no 1 – janvier–février 2018
77
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
Comparison of Clinical Pharmacy Services
in General Medicine and Surgery Patients:
A Workload Measurement Study
Peragine C1,2, Walker SE1,2
Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON
2
Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
Background: Canadian data describing the clinical services provided by
hospital pharmacists (clinical pharmacy services, CPS) is lacking.
Moreover, no Canadian study has examined if CPS demand and provision
times differ for general medicine (GM) and surgery (GS) inpatients.
Objective: To describe the clinical services that hospital pharmacists
provide, determine the incidence and provision times for various CPS,
and identify differences in pharmacist workload as a function CPS and
patient partition (GM or GS).
Methods: A data collection form to capture patient characteristics and
CPS frequency and service times was developed. CPS activities included
best possible medication history (BPMH), medication reconciliation,
pharmacotherapy care plan, medication order review, insurance inquiries,
dose clarification, therapeutic drug monitoring, antibiotic follow-up,
thromboprophylaxis assessment, health care team discussions, inpatient
counselling, discharge preparation activities, and “other” clinical activities.
Ward pharmacists were asked to complete one documentation form for
each patient admitted to their care over a 1 month period. Differences in
patient characteristics, CPS frequency, CPS service times, total-timeper-patient, and daily-time-per-patient between GM and GS patients were
evaluated using chi-squared and Mann-Whitney tests.
Results: Workload data for 273 GM patients and 191 GS patients were
obtained. Inpatient counselling (8% vs. 3%, p<0.05) and discharge
preparation activities (19% vs. 9%, p<0.05) were reported more frequently
for GM patients, while pharmacotherapy care plan (64% vs. 77%,
p<0.05), medication order review (7% vs. 29%, p<0.05), “other” activities
(9% vs. 25%, p<0.05) were reported less frequently. Median service times
for BPMH (15m vs. 10m, p<0.001), pharmacotherapy care plan (15min
vs. 10min, p<0.001), and “other” activities (10min vs. 5min, p=0.019)
were higher for GM patients. No difference in total-time-per-patient was
detected. Daily-time-per-patient was higher for GS patients (6min
vs. 4min, p<0.001).
Conclusion: Significant differences in PCS frequency, PCS service times,
and daily-time-per-patient were found between GM and GS patients.
1
Validation of a Screening Tool to Assist in the Early
Identification of Bloodstream Infection in Older
Patients
Walker SAN1,2,3,4*, Peragine C1,2, Ma N1,2, Bannerman H1, Elligsen M1,
Palmay L1, Williams E5,6, Liu B6,7
1
Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON
2
Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
3
Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON
4
Sunnybrook Health Sciences Centre Research Institute, Sunnybrook Health
Sciences Centre, Toronto, ON
5
Division Long-Term Care, Sunnybrook Health Sciences Centre, Toronto, ON
6
Faculty of Medicine, University of Toronto, Toronto, ON
7
Division of Geriatric Medicine, Sunnybrook Health Sciences Centre, Toronto,
ON
*Senior Author; sequence determines credit approach to authorship
78
CJHP – Vol. 71, No. 1 – January–February 2018
Background: Delayed diagnosis of blood stream infection (BSI) occurs
in >20% of older patients. A validated BSI screening tool (ST) to identify
older patients with a high probability of BSI may improve early diagnosis
and management.
Objective: The objective was to validate a BSI-ST in older patients.
Methods: Inpatients ≥65 years old admitted between March 12, 2010December 2, 2013 were eligible. A retrospective chart review of a matched
cohort of older patients with and without documented BSI was
completed. Data analysis was done for two age cohorts (≥ 80 years old
and 65-79 years old) and for all patients ≥ 65 years old. Bacteremia
pre-test probability, sensitivity, specificity, accuracy, false positive and
negative rates of bacteremia, and positive and negative predictive value,
post-test probability, and likelihood ratios were determined.
Results: The BSI-ST was validated in 310 patients. Of 25942 patients
≥65 years old admitted during the study, 534 had BSI, corresponding to
a period prevalence (PP) of BSI in older patients of 2.1%. At the 2.1%
BSI PP, the negative predictive value is 100% with a 0.4% probability of
missing a BSI in an older patient.
Conclusion: The BSI-ST has excellent predictive capability for identifying
older patients in whom a blood culture should be obtained, with a positive
predictive value of 92% and false positive rate of only 10%. Although the
false negative rate was 20%, a negative test in a patient with a BSI would
occur in only 0.4% of patients at the institutional PP of BSI in older
patients. Therefore, the retrospective validation of the BSI screening tool
supports its implementation and pragmatic prospective evaluation.
For the table that goes with this abstract, please see Abstract Appendix,
available at https://www.cjhp-online.ca/index.php/cjhp/issue/view/125/
showToc
Patterns of Antimicrobial Use in an Outpatient
Hemodialysis Unit
Sivarajahkumar S1,2, So M1,2, Bell C1,3,4, Morris A1,3,4, Battistella M1,2
1
University Health Network, Toronto, ON
2
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
3
Sinai Health System, Toronto, ON
4
Faculty of Medicine, University of Toronto, Toronto, ON
Background: Hemodialysis (HD) patients are at high risk for infections,
including those caused by multi-drug resistant organisms (MDROs).
Since antimicrobial exposure is the main risk factor for the emergence of
MDROs, minimizing inappropriate antimicrobial use is imperative.
Objectives: To optimize antimicrobial use, it is first important to
understand patterns of antimicrobial prescribing in the HD setting. The
objectives of this study were to: (1) measure antimicrobial use, and (2)
describe antimicrobial prescribing patterns, among patients receiving
outpatient HD.
Methods: A retrospective observational cohort study was performed in
an outpatient HD unit at an academic centre from February 1 – April 30,
2017. Eligible patients included adults who were prescribed at least one
oral or intravenous (IV) antimicrobial by a hospital or community
prescriber. Data were retrieved from the HD unit infection control database and analyzed using descriptive statistics. The primary outcome was
total antimicrobial days of therapy (DOT) per 1000 patient-days.
Secondary outcomes were antimicrobial prescriptions characterized by
type of antimicrobial, purpose, indication, route, and prescriber type.
Results: A total of 53 patients were eligible for inclusion and 75 antimicrobial prescriptions were included for analysis. Antimicrobial use occurred
in 53 (16%) of 330 total outpatient HD patients. Over the 3-month study
JCPH – Vol. 71, no 1 – janvier–février 2018
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
period, antimicrobial use was 27.5 DOTs/1000 patient-days. The most
common indication for antimicrobial therapy was skin and soft tissue
infection, followed by bloodstream infection and respiratory tract
infection. Fluoroquinolones were the most frequently prescribed
antimicrobials, accounting for 23% of prescriptions, while the second
most prescribed were first-generation cephalosporins (21%).
Conclusion: Overall, this study indicates that antimicrobial use was
common, with 1 in 6 HD patients receiving antimicrobials during the
3-month study period. This may be the first study to describe prescribing
patterns for both oral and IV antimicrobials in an outpatient HD
population.
Impact of an Antimicrobial Stewardship
Bloodstream Infection Surveillance Program
in Hospitalized Patients
Dow G1, MacLaggan T1, Allard J2
The Moncton Hospital, Horizon Health Network, Moncton, NB
2
Universite de Moncton, Moncton, NB
Background: Bloodstream infections (BSI) in hospitalized patients
represent sentinel events characterized by increased mortality. These
infections represent an attractive stewardship opportunity because they
warrant rapid initiation of empiric antimicrobial therapy, deft transition
to directed (gram stain guided) and definitive (susceptibility guided)
therapy.
Objectives: To measure the impact of a bloodstream infection surveillance
program (BISP) on the adequacy and timing of antimicrobial therapy in
hospitalized patients and model factors impacting antimicrobial cost,
length of stay, and mortality in BSI patients.
Methods: A pre-post study design by retrospective chart review was carried
out 18 months before and 18 months after initiation of a hospital BISP.
The hospital ward and attending physician were notified of all positive
blood cultures pre-intervention. Post-intervention an infectious disease
pharmacist collaborating with an infectious disease consultant was notified
in addition to standard notifications. Pre- and post-groups were compared
using t-tests and Fisher exact tests. Antimicrobial costs and mortality were
analysed using log-linear and logistic models, respectively.
Results: BSI were identified in 226 patients pre-intervention and 195
patients post-intervention. The two cohorts were similar in baseline
characteristics and source of infection. E. coli, S. aureus, other enterobacteriaceae and beta-hemolytic streptococci were the most common
bloodstream isolates. The post-intervention cohort received directed
therapy 4.36 hours earlier (p=0.003), were more
1
Objectives: This study aims to characterize our health system’s CPE
bacteremia population and evaluate the antimicrobials used for treatment,
including the effect of monotherapy versus combination therapy on
mortality.
Methods: A dual-centre retrospective chart review was conducted of adult
CPE bacteremia patients admitted between January 1, 2010 and April
30, 2017. Baseline demographics included out-of-country hospitalization,
causative organism, and susceptibilities. Measured outcomes included
length of hospitalization, mortality within 30 days of index blood cultures,
and re-admission within 30 days of discharge. Prescribing pattern data
included antimicrobial agent, dosing regimen, and use of monotherapy
or combination therapy.
Results: Thirteen cases of CPE bacteremia were reviewed. They most
frequently occurred in patients with prior hospitalization outside of
Canada, particularly in the Indian subcontinent (9/13, 69%). Ninety-two
percent (12/13) of isolates produced New Delhi metallo-beta-lactamase.
All isolates were susceptible or intermediate to tigecycline. Tigecyline and
colistin were the most commonly prescribed antimicrobials, respectively
used in 62% (8/13) and 54% (7/13) of cases. Thirty-day mortality and
readmission rates were 54% (7/13) and 50% (3/6), respectively. Survivors
were 4 times more likely to have received combination therapy versus
monotherapy (Odds ratio: 4.0, 95% confidence interval: 0.36 – 41.11,
P = 0.26).
Conclusions: This study highlights the largest Canadian CPE bacteremia
cohort to date. Our results suggest that combination therapy is more
effective than monotherapy in improving survival outcomes. The inclusion
of tigecycline as part of empiric combination therapy should be considered
when CPE bacteremia is being considered or confirmed within our health
system.
Development and Implementation of a Provincial
Beta-Lactam Allergy Management Initiative
Pang S1, Haghshenas E1, Richardson D1, Baqi M2
1
William Osler Health System: Brampton Civic Hospital, Brampton, ON
2
William Osler Health System: Etobicoke General Hospital, Etobicoke, ON
Background: The increasing incidence of carbapenemase-producing
Enterobacteriaceae (CPE) bacteremia is a growing concern. With
mortality rates exceeding 50%, there remains no consensus surrounding
optimal antimicrobial treatment. There is little literature pertaining
to CPE in Canada. The majority of isolates submitted to our provincial
Public Health Laboratory are from our health system’s service area.
Landry D1, MacLaggan T2
Dr. Georges-L.-Dumont University Hospital Centre, Vitalité Health
Network, Moncton, NB
2
The Moncton Hospital, Horizon Health Network, Moncton, NB
Background: Beta-lactam allergies are often over diagnosed and over
reported. Up to 10% of the population will report a penicillin allergy;
however, as many as 95% of these patients are not truly allergic. Healthcare
providers are more likely to prescribe non beta-lactam alternatives to these
patients, which may be: less effective, more toxic, broader spectrum, more
expensive and more likely to lead to infection or colonization with resistant
organisms.
Description: The Provincial Anti-Infective Stewardship Committee
(ASC) includes members from the two regional health authorities. Among
its delegated tasks, the ASC develops educational resources and guidelines
to improve the appropriateness, safety and cost-effectiveness of antiinfective use.
Action: The ASC developed the “Management of Penicillin and BetaLactam Allergy” guideline along with an executive summary document
that condensed the main recommendations into a pocket sized booklet.
A month-long educational and communication initiative was executed
for their launch. The implementation initiative included announcement
memos, educational bulletins, e-learning and live educational sessions.
PRE/POST surveys were also sent to all health professionals of the target
audience within both regional health authorities to assess the impact of
the targeted educational program paired with the implementation of the
guideline.
CJHP – Vol. 71, No. 1 – January–February 2018
JCPH – Vol. 71, no 1 – janvier–février 2018
Epidemiology of Carbapenemase-Producing
Enterobacteriaceae Bacteremia and Evaluation of
Antimicrobial Prescribing Practices in a Community
Hospital Setting
1
79
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
Evaluation: Response rates for the PRE and POST surveys were low at
7.8% and 3.9% respectively. The table summarizes key results from the
surveys.
Implications: Results showed that there was a significant degree of interest
in the guidelines and a trend in improvement in antibiotic related
knowledge and feelings of preparedness; however, response rates were
poor and 54% felt their practice had not changed. Results highlight the
importance of active interventions to engage practice change in antimicrobial stewardship.
For the table that goes with this abstract, please see Abstract Appendix,
available at https://www.cjhp-online.ca/index.php/cjhp/issue/view/
125/showToc
Factors Affecting Time to Fill Antiplatelet Therapy
for Patients Discharged from Hospital
Mulrooney S1,2, Urquhart E2, Harris R2
School of Pharmacy, Dalhousie University, Halifax, NS
2
Horizon Health Network, Saint John, NB
Background: Delays in filling antiplatelet therapy following hospital
discharge have been identified in other parts of North America for patients
who have undergone percutaneous coronary intervention (PCI) to treat
acute coronary syndrome (ACS). These delays have been associated with
an increased risk of recurrent myocardial infarction and all-cause mortality.
It is unknown if delays exist for patients at the study site and what factors
may affect this.
Objectives: The purpose of this study was to determine if delays exist for
patients in the study area, and if so, the impact on hospital readmission
rates. The secondary objective was to assess the impact of medication
attitude, distance to home from site of discharge, site of discharge and
medication insurance status on the time to fill antiplatelet therapy.
Methods: Prospective, observational, single-centre pilot project;
conducted between January-April 2017. Patients 19 years of age and older,
admitted to undergo PCI to treat ACS and discharged on clopidogrel,
prasugrel or ticagrelor were eligible for enrolment during the index
hospitalization. At 7-10 days post-discharge, prescription filling data was
collected by telephone survey with participant and participant’s community pharmacy. The Merck Adherence Estimator was administered at this
time to gauge participant medication attitudes. Readmission to hospital
data was collected from the provincial Electronic Health Record (EHR)
30-45 days post-discharge.
Results: Nineteen participants (79.2%) reported filling a prescription for
their antiplatelet agent on the day of discharge. No statistically significant
delay was identified. Merck Adherence Estimator score (p=0.0463)
and distance to home from site of discharge (p=0.0062) were identified
as factors impacting time to fill.
Conclusions: Delays in filling antiplatelet therapy may not be an issue
for our patients. This should be confirmed with further investigation. The
Merck Adherence Estimator may be an appropriate tool to screen patients
who may be at risk of experiencing delays.
1
80
CJHP – Vol. 71, No. 1 – January–February 2018
Evaluation of the Impact of Pharmacist-Led
Penicillin Allergy Assessments on Antibiotic
Utilization in a Large Community Teaching Hospital
Saleh M1, Landry C1,2, Do K1, Khan I1, Chagnon N1,2, Chauret D1,2
1
Hôpital Montfort, Ottawa, ON
2
Institut de Savoir Montfort, Ottawa, ON
Background: Penicillins are the most common cause of allergic drug
reactions with a prevalence of up to 20% in hospitalized patients. To date,
there are limited Canadian publications describing pharmacist involvement in penicillin skin-testing. The purpose of this study is to evaluate
the impact of a pharmacist-led initiative in a community hospital on
de-labelling penicillin allergies and reducing the use of two broad spectrum
antibiotics, meropenem and vancomycin.
Objectives: To determine the proportion of patients in whom an antibiotic
change was made as a result of a penicillin allergy assessment and identify
barriers for not de-escalating therapy in patients deemed non penicillin
allergic. Potential drug cost savings were also examined for skin-tested
patients.
Methods: This is an observational cohort study conducted in a community teaching hospital between October 1st 2016 and May 31st 2017,
following the implementation of a policy allowing pharmacists to refer
patients to an inpatient allergist for skin testing.
Results: Pharmacists recommended a penicillin skin test (PST) for 15 of
32 identified patients (46.9%) with a penicillin allergy who were
prescribed meropenem or vancomycin. Nine of 15 eligible patients (60%)
underwent a PST, with five patients having their antimicrobial therapy
de-escalated to a beta-lactam antibiotic. Four patients had their therapy
modified based only on the pharmacist assessment. De-escalation of
therapy led to an average cost saving of was $137.89 for patients switched
to a beta-lactam after PST.
Conclusion: A minimal-cost, pharmacist-led initiative to reduce broadspectrum antibiotic use in penicillin allergic patients resulted in
antimicrobial de-escalation in nine patients, demonstrating another
opportunity for pharmacist involvement in antimicrobial stewardship.
Pharmacy Technician Continuing Education Program
at a Large Teaching Hospital
Natsheh C1,2, Cameron K1,2
1
University Health Network, Toronto, ON
2
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
Background: Provincial College of Pharmacists mandates that its
members maintain professional knowledge and skills appropriate for their
scope of practice. At a large, teaching hospital, pharmacists have multiple
opportunities to receive continuing education (CE) in an organized
process; however, technician CE was not yet established.
Description: To describe the design and delivery of a structured, CE
program for pharmacy technicians.
Action: A pilot was initiated in 2012 based on the structure of an existing
pharmacist CE. It consisted of 30 minute, monthly presentations delivered
at each site by pharmacy students. In 2013, an anonymous, needs
assessment survey was sent for feedback. Comments were analyzed and
incorporated into developing the final program launched in 2013.
Evaluation: Data from January 2014 to June 2017 was collected from
2 main sources; needs assessment surveys in 2013 and 2015 (total 33
respondents) and written feedback collected after presentations. Results
showed that presentation topics were initially predominated by clinical
therapeutic foci. However, over time, there was increase in the numbers
of non-therapeutic topics reflecting real-time incorporation of technicians’
JCPH – Vol. 71, no 1 – janvier–février 2018
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
feedback. There was equal interest for therapeutic and non-therapeutic
topics. Pharmacy students comprised majority of presenters (90%),
pharmacists and technicians represented 5% each. Forty-one percent of
respondents expressed most interest in receiving education from peers
(other technicians). Ninety percent felt more knowledgeable about the
topic presented and 71% found the sessions were meeting their
educational needs. Some common challenges to attending CE was workload, presentation time of day, location, and lack of interest in the topic.
Implications: A pharmacy technician CE program has been a sustainable
initiative at our institution. A lead facilitator is necessary to coordinate the
schedule and recruit presenters. Future directions include standardization
of feedback survey to capture timely feedback, leverage digital media to
increase access and explore opportunities to enable more peer-technician
presenters.
5 Questions to Ask about Your Medications
Watt A 1, Sever L1, Hyland S1, Herold D2, Hughes L2, Murray M2, Cass M3
1
Institute for Safe Medication Practices Canada, Toronto, ON
2
Patients for Patient Safety Canada, Edmonton, AB
3
Canadian Patient Safety Institute, Edmonton, AB
Background: Patients are the constant in every transition of care and can
be at high risk of adverse drug events, particularly at discharge from
hospital to home. Knowing the right questions to ask can empower
patients to be an active partner in their health and can help to mitigate
risk of harm from medications.
Description: “5 Questions to Ask” is a national campaign to help patients
and hospital pharmacists engage in a conversation about medication safety.
Action: The intervention was to develop, test, evaluate and disseminate a
medication safety ‘checklist’ for use by patients and healthcare providers.
Through small tests of change the ‘checklist’ was re-designed to the
‘5 Questions’.
Evaluation: A national online survey of patients and healthcare providers
(n=291) revealed that 85% of patients would feel comfortable asking their
healthcare provider the ‘5 Questions’, 84% of healthcare providers would
be willing to answer their patient’s ‘5 Questions’ and 75% of patients
responded that the answers to these ‘5 Questions’ would be very useful to
help them understand their medications. A key performance measure was
the extent of collaboration and use of the ‘5 Questions’ among healthcare
organizations. More than 150 Canadian organizations, at local, provincial
and national levels have formally endorsed the ‘5 Questions’ and implemented programs to increase reach and dissemination. Collective evaluation results demonstrate a commitment to a shared aim of empowering
patients with questions to ask about their medications. There have been
over 30,000 downloads of the poster since launch. The YouTube video
has been viewed over 4000 times since its launch September 2016. Social
media measures are also being collected.
Implications: The ‘5 Questions’ with visible organization endorsements
and translation in over 22 languages has demonstrated a shared interest
in empowering patients. These questions may be a useful counselling
framework or teach-back tool to help hospital pharmacists communicate
more effectively with patients so they can better understand how to safely
use their medications before they leave the hospital.
CJHP – Vol. 71, No. 1 – January–February 2018
A Pharmacy-Led Interdisciplinary Teaching Model
in Specialized Pharmacotherapy: An HIV Pharmacy
Rotation for Medical Residents.
Naccarato M1,2, Yoong D1,2, Gough K2,3, Arbess G3,4
1
Department of Pharmacy, St. Michael’s Hospital, Toronto, ON
2
Division of Infectious Diseases, St. Michael’s Hospital, Toronto, ON
3
Faculty of Medicine, University of Toronto, Toronto, ON
4
Department of Family & Community Medicine, St. Michael’s Hospital,
Toronto, ON
Background: The medical training model has traditionally been
physician-to-physician, contrasting the current interdisciplinary healthcare practice environment. Pharmacists with specialized drug knowledge
are well-positioned to provide expert training in complex antiretroviral
therapy. We developed a collaborative teaching model, incorporating a
pharmacist-led rotation for medical residents to learn specialized HIV
pharmacotherapy.
Description: In 2010 a postgraduate residency program was inaugurated
in which family practice medical residents could receive focused training
in the delivery of HIV care. The provision of HIV care, however, is
multifaceted and drug treatment can be complex. Thus, in 2013, a
specialized HIV pharmacy rotation at our university-affiliated ambulatory
clinic was created and offered to these family practice residents as an
elective, with the primary goal to augment HIV drug knowledge and
better equip physicians to providing exemplary HIV care. The concept
was for the medical trainee to “become the pharmacist”, learning to
recognize and manage common drug-therapy issues in HIV-infected persons.
Action: A formalized curriculum was developed, including rotation goals
to foster key competencies in family medicine while addressing gaps in
pharmacology training and HIV care. The rotation could be tailored to
the resident but generally consists of a core set of one-on-one teaching,
case-based learning, and application of pharmacotherapeutics in a busy
specialized ambulatory HIV clinic.
Evaluation: A pre- and post-rotation survey was developed to assess
whether the pharmacy rotation improved the resident’s confidence in their
knowledge of HIV pharmacotherapy. This survey also gathered feedback
and recommendations to enhance future rotations. Thus far, 5 medical
residents have completed this residency with the elective pharmacy
rotation and have strongly endorsed the rotation as valuable to their future
practice.
Implications: This collaborative teaching model appears to be extremely
valuable to enhance patient care and should be considered in other highlyspecialized pharmacotherapeutic areas.
Influence of Manufacturer on Cefazolin Stability
Xu Y, Walker SE
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON
Background: Some Canadian institutions have interpreted NAPRA
and USP 797 guidance as requiring unique stability data for each manufacturer’s brand to determine the beyond-use-date for sterile products.
However, no studies have been done to validate the effect of manufacturer
variations on cefazolin stability.
Objective: To evaluate if variations in drug manufacturer contributes to
variations in cefazolin admixture stability.
Methods: We conducted a systematic review and meta-analysis of studies
assessing the stability of cefazolin sodium in sterile preparations. We
searched the PubMed, Scopus, and EMBASE for all studies (in English)
from January 1950 to October 2017 and extracted data pertaining to
JCPH – Vol. 71, no 1 – janvier–février 2018
81
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
the lab performing the study, study days, percent of drug remaining, drug
manufacturer, temperature of storage (refrigerated or room temperature),
container (polyvinylchloride minibags, glass, or polypropylene syringe),
diluent (dextrose 5%, normal saline or sterile water) and drug concentration. Eligibility criteria included: stability quantified using high pressure
liquid chromatography, absence of freezing and thawing, single drug
admixtures, and full text availability. We performed multiple linear
regression on the percent remaining reported in cefazolin stability studies.
Results: Our search revealed 3449 studies. Duplicates were removed, and
a total of 8 studies met our inclusion criteria resulting in 172 data points.
Six different manufacturers were recorded for cefazolin (Eli Lilly, Smith
Kline, Bristol-Myers, Apothecon, Novopharm, Apotex). Multiple linear
regression demonstrated that manufacturers, container, diluent and
concentration do not significantly impact cefazolin stability, while study
day, temperature and lab did significantly impact stability (Table).
Conclusions: Our evidence suggests that manufacturer differences do not
significantly contribute to variations in stability. Future research is needed
to investigate the role of other contributing factors identified.
For the table that goes with this abstract, please see Abstract Appendix,
available at https://www.cjhp-online.ca/index.php/cjhp/issue/view/125/
showToc
Opioid Selection in the Neonatal Intensive Care
Unit: Morphine versus Fentanyl: Impact on Total
Opioid Exposure and Time to Enteral Feeds
Brunton J1, Gerges S2, Dunn M2, Banihani R2, Choudhury J2
Sunnybrook Health Sciences Centre, Pharmacy Department, Toronto, ON
2
Sunnybrook Health Sciences Centre, Women and Babies Program, Toronto, ON
Background: Opioids are often used to treat neonatal pain. However,
there is limited information to guide initial opioid selection in the neonatal
intensive care unit (NICU).
Objective: The objective of this study is to determine if there is an
association between initial opioid selection and time to full enteral feeds
or total opioid exposure.
Methods: A retrospective chart review was conducted of neonates who
were admitted to a level 3 academic perinatal critical care unit and received
morphine or fentanyl continuous infusions between October 1, 2015 and
April 1, 2017. Primary outcomes were time to enteral feed volume of 120
mg/kg/day and total duration of opioid exposure. Secondary outcomes
included cumulative opioid dose. Cumulative doses were compared
between groups using a conversion factor of 1:60 to convert fentanyl to
morphine equivalents. Outcomes were compared between neonates who
received morphine and those that received fentanyl using appropriate
statistical tests (t-test, Wilcoxon-Mann-Whitney test or chi-square test).
Results: There were no significant differences in primary outcomes
between groups. The median time to enteral feed volume of
120 mL/kg/day was 13 days in the morphine group (n=19) and 15 days
in the fentanyl group (n=19). The median duration of opioid exposure
was 11 days in the morphine group and seven days in the fentanyl group.
Neonates in the fentanyl group received significantly more cumulative
opioid (median: 6015 mcg/kg morphine equivalents) compared to
neonates in the morphine group (median: 1646 mcg/kg) (p<0.0001).
Conclusions: Initial opioid selection was not associated with a difference
in primary outcomes of time to achieve feed volume of 120mL/kg/day
or duration of opioid exposure. Neonates in the fentanyl group received
significantly larger cumulative opioid doses compared to morphine. The
clinical significance of larger cumulative opioid doses is currently unclear.
Future neurobehavioural outcome studies will be performed in this patient
population.
1
82
CJHP – Vol. 71, No. 1 – January–February 2018
The Prevalence of Mortality due to Rebound
Toxicity after “Treat and Release” Practices In
Prehospital Opiate Overdose Care: A Systematic
Review
Greene JA1, 2, Deveau BJ1, Dol JS1, Butler M1
Dalhousie University, Halifax, NS
2
Emergency Health Services, Halifax, NS
Background: Traditionally, patients who have overdosed on opiated that
are managed by emergency medical services (EMS) are treated with
naloxone, provided ventilatory support and transported to hospital.
However, some EMS agencies have allowed paramedics to not transport
if patients have the capacity to refuse transport.
Objectives: The safety of this practice has not been examined by a
systematic review. Therefore, we aimed to determine the prevalence
of mortality and serious adverse events within 48 hours of EMS treat
and release due to suspected rebound opiate toxicity after naloxone
administration.
Methods: A systematic search was performed on May 11th 2017 in
PubMed, Cochrane Central, Embase and CIHAL using search strategies
developed with the aide of a health sciences librarian. No search limits
were applied. Included studies were hand searched. Two authors
conducted the screening, selection and data extraction process.
Discrepancies were resolved via discussion. A modified QUIPs tool
was used to evaluate risk of bias. Analysis for prevalence of outcomes
were preformed.
Results: 1401 records were screened after duplicate removal. Eighteen full
text studies were reviewed with 8 selected for inclusion. Included studies
had a low risk of bias. The prevalence of mortality within 48 hours was so
infrequent that it could not be quantitatively meta-analyzed. There were
4/4912 (0.00081%) total reported deaths of suspected rebound etiology
from included patients across all studies. Only one study reported on
adverse events of patients released on scene. This study found no incidence
of adverse events from their sample of 71 released patients.
Conclusion: The prevalence rate of mortality or serious adverse events
due to suspected rebound toxicity was very low. Therefore, we conclude
this practice may be considered as an alternative to traditional transport.
Additional prospective studies need to be performed to strengthen knowledge around adverse events.
1
A Pan-Canadian Study on the Compounded
Medicines Most in Need of Commercialized
Oral Pediatric Formulations
Autmizguine J1,2,3, Allakhverdi Z1,2, Gilpin G1, Tessier J-E1, Giroux D1,
Lebel D1,4, Litalien C1,2,3
1
The Rosalind & Morris Goodman Family Pediatric Formulations Centre of
the CHU Ste-Justine (The Goodman Centre), Montréal, QC
2
Department of Pediatrics, CHU Ste-Justine, University of Montreal,
Montréal, QC
3
Department of Pharmacology, University of Montreal, Montréal, QC
4
Department of Pharmacy, CHU Ste-Justine, Montréal, QC
Background: A large number of drugs administered to children have no
commercially available formulations. As a result, health care providers and
parents manipulate dosage forms designed for adults. Although
compounding is essential to increase access to medicines for children,
it can result in adverse events or therapeutic failure. There is an urgent
need to undertake a mapping of the needs for child-friendly medicines
in Canada.
JCPH – Vol. 71, no 1 – janvier–février 2018
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
Objectives: To determine: 1) the most frequently compounded medicines
in Canadian pediatric hospitals; 2) the challenges associated with drug
compounding; and 3) medicines most in need of commercialized oral
pediatric formulations.
Methods: Sixteen Canadian pediatric academic hospitals were contacted
to participate in a telephone survey including 12 open-, close-ended or
Likert-scale questions.
Results: Thirteen centers participated in the survey (81.3%). Fifty-three
drugs were identified as most in need of a commercialized oral pediatric
formulation. Of those, 12 were reported by ≥4 hospitals as a priority
(Table). The most frequently reported compounding challenges were: lack
of standardization, bad taste, lack of awareness of prescribers, stability of
the formulation, and availability of compounding pharmacies.
Conclusions: This study highlights which drugs are most in need for
pediatric oral formulations in Canada. For compounded medicines with
pediatric formulations available in other countries, we are currently
assessing their adequacy and partnering with pharmaceutical industry to
bring them to the Canadian market. As for those medicines without
pediatric formulations in Canada or abroad, we are looking for
pharmaceutical partners interested in developing such formulations.
Furthermore, harmonized regulations and data-sharing should be pursued
to facilitate access to child-friendly medicines for the largest number
of children across borders.
A Comparison of Intravenous Iron Dosing
Regimens for Anemia Management in Patients
Undergoing Hemodialysis
Di Vecchia S1, Cahill J2, Soong D1
1
Windsor Regional Hospital, Windsor, ON
2
Cornwall Community Hospital, Cornwall, ON
Background: Anemia is common in patients undergoing hemodialysis
and can result in decreased quality of life, cardiovascular events, and need
for blood transfusions. Guidelines recommend the use of intravenous (IV)
iron and erythropoietin stimulating agents (ESAs) for anemia
management. Optimization of doses used for IV iron and ESAs is warranted,
as both are associated with adverse reactions and significant costs.
Objective: The objective of this study was to compare the efficacy of a
lower once weekly dose (62.5mg) of IV sodium ferric gluconate versus
the standard dosing regimen (125mg of IV sodium ferric gluconate)
utilized at our institution.
Methods: A retrospective, observational, cohort study was conducted on
patients receiving hemodialysis. Primary outcome was hemoglobin level
(g/L) at 3 months. Secondary outcomes included mean weekly ESA use
(units), need for blood transfusions (%), and mean cumulative iron dose
(mg) over the 3-month intervention period.
Results: Of the 102 eligible patients, 52 patients received the once weekly
low-dose regimen and 50 patients received the once weekly standard-dose
regimen. Multiple linear regression analysis demonstrated that IV
iron-dosing regimen was not a significant predictor of hemoglobin level
at 3 months (p=0.859). Mean hemoglobin levels (g/L) in the once weekly
low-dose and once weekly standard-dose regimens were 112.58 ± 12.63
and 114.68 ± 10.32, respectively. Mean weekly ESA use (units) was
significantly higher in the once weekly low-dose regimen (12 686.81 ±
6774.07 vs. 7040 ± 7392.66; p<0.001). Number of patients requiring
transfusions did not differ significantly between the two dosing regimens
(11.32% vs. 20%; p=0.367).
CJHP – Vol. 71, No. 1 – January–February 2018
Conclusion: Neither of the two IV iron-dosing regimens was associated
with lower hemoglobin levels. Analysis suggests this may be due to the
higher ESA use in the once weekly low-dose regimen. Based on these
results, it may be more optimal to continue with the standard once weekly
dosing regimen.
User Satisfaction Regarding Standard Assessment
Tool for Field-Based Pharmacy Training
Halapy H1,4, Lee A1, Manson K3, Spizzirri D2, Tolmie A3
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
2
Ontario College of Pharmacists, Toronto, ON
3
School of Pharmacy, University of Waterloo, Waterloo, ON
4
Hospital Pharmacy Residency Forum of Ontario, Toronto, ON
Background: A province-wide standard competency-based assessment
tool with companion glossary was collaboratively developed and
implemented by schools of pharmacy, residency training sites and
provincial licensing body within the last year in order to improve
consistency of learner performance assessments.
Description: A user (preceptor/assessor, learner) satisfaction survey was
conducted post-implementation of the province-wide assessment tool in
order to assess user opinions regarding its usability and overall satisfaction.
Action: The survey questions were derived through a collaborative process
including review by assessment experts and typical assessment tool users.
After completion of each field-based final assessment utilizing the tool,
preceptors/assessors and learners (students/residents) were invited via email
to participate in the survey. A reminder email was sent at a scheduled
follow-up time to encourage survey completion.
Evaluation: Preliminary survey results (n=236) showed the following: the
layout of the tool was easy to follow (87% preceptors/assessors, 94%
learners), the tool’s accompanying glossary was seen as helpful (83%
preceptors/assessors, 59% learners), the tool accurately captures learner’s
performance (75% preceptors/assessors, 53% learners), the tool does not
have redundant areas of assessment (80% preceptors/assessors, 73%
learners), and the tool is not missing important content areas of assessment
(73% preceptors/assessors, 83% learners). Seventy-two percent of
preceptors/assessors were satisfied with the tool while 54% of learners were
satisfied with the tool. The majority of comments indicated the tool
was well designed, comprehensive and fair. A suggestion was to review
the length.
Implications: Users indicated that the province-wide assessment tool
is usable. The tool’s measurement domains were generally seen to be
appropriate. Preceptors were more satisfied overall with the tool versus
learners. Work continues to determine details around these results and to
further validate the province-wide assessment tool.
1
Pharmacy Student-Led Best Possible Medication
History Quality Audit
Smith A1, Jones B-J2, Goodine C2
1
College of Pharmacy, Dalhousie University, Halifax, NS
2
Horizon Health Network, Dr. Everett Chalmers Regional Hospital,
Fredericton, NB
Background: In May of 2016, our hospital implemented a change in
practice and reconciliation of the Best Possible Medication History
(BPMH) resulted in physician orders. The majority of BPMH are
collected and documented by a registered nurse (RN) in our hospital and
although the rate of BPMH documentation was good, reconciliation by
JCPH – Vol. 71, no 1 – janvier–février 2018
83
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
physicians was below target. There was a perception that the quality of
BPMH by an RN differed based on the unit where it was completed. A
BMH quality audit was undertaken to explore this perception.
Description: Quality audits are not part of our regular pharmacy
operations therefore, a second-year pharmacy student intern was hired to
lead the BPMH audit under the supervision of a staff pharmacist.
Action: The pharmacy student completed site-specific BPMH training
and had their skills validated by a staff pharmacist. Convenience sampling
was used to identify eligible patients. The pharmacy student obtained
verbal consent to conduct a second BPMH and quality was determined
by comparing the two independent BPMH (nurse and pharmacy student)
to identify discrepancies. Discrepancies were reviewed, classified, and
reconciled by a staff pharmacist. Discrepancy rates were calculated based
on number of home medications and descriptive statistics were used to
report total discrepancies, and to compare results between units.
Evaluation: Twenty BPMH interviews were repeated for 2 clinical
programs; 10 from each program. Ninety–five discrepancies were
evaluated; 83 documented by nursing staff, and 12 by the pharmacy
student. Discrepancy rate for BPMH by an RN 38.8% in one program
and 38.7% in the other.
Implications: A pharmacy student successfully conducted a BPMH
quality audit. The audit demonstrated that there was an opportunity to
improve BPMH by RNs and that there was no difference in BPMH
quality between programs. Audit results will be shared within our facility
and used to inform our interventions.
A Work-Sampling Study of Clinical Pharmacists
Kertland H1,2, Dewhurst NF1,2, Tom E2, Halapy H1,2, Yee R1, Duan P1,
Tsoi V1, Babaei-Rad R1, Chant C1,2
1
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
2
St. Michael’s Hospital, Toronto, ON
Background: As part of a broader practice standardization project, an
education program was developed. A series of therapeutic topics with focus
on high risk medications were identified for practice standardization.
Anticoagulants are high risk medications that require pharmacists to have
minimal baseline knowledge of in order to identify and resolve related
drug therapy problems (DTPs).
Description: To ensure pharmacists possess the required knowledge and
skills, an anticoagulation education module was developed, implemented
and evaluated.
Action: The anticoagulation education module consisted of a voiced-over
slideshow presentation, which included supporting institutional policies
and procedures. The education module underwent review and feedback
from expert and typical pharmacist users prior to deployment. Assessment
of the pharmacist’s knowledge and skills consisted of a 20-question
multiple choice test that was administered both at baseline and after review
of the module. Point-biserial (p-bis) and p-values were used to ensure test
question validity and reliability. Pharmacists were required to score at least
80% on the post-module test. Program evaluation consisted of a
questionnaire asking about the pharmacist’s own confidence and that of
their colleagues to identify and resolve anticoagulation related DTPs, and
the perceived value of the program.
Evaluation: Fifty-one pharmacists completed the pre- and post-module
tests. Post-module completion, the average test score increased from 76%
to 90%. The majority of the pharmacists (49/51 [96%]) passed the test.
Responses from the post-module questionnaire indicated that pharmacists
were overall confident in their own and colleagues’ ability to identify and
resolve anticoagulation DTPs, and perceived the program as beneficial to
improve patient care and safety.
Implications: The results suggest that pharmacists benefitted from an
anticoagulation education program. Completion of the education module
and post-module test are now mandatory for all new staff. Based on the
program’s success, future modules on different therapeutic topics are in
development.
Wong D1, Feere A1, Dahri K1,2, Partovi N2, Yousefi V2
University of British Columbia, Vancouver, BC
2
Vancouver Coastal Health, Vancouver, BC
Background: As Canadian pharmacists have gradually expanded their
scope of practice, this has also increased the demand on pharmacists’ time.
There is a current lack of literature examining the tasks that clinical
pharmacists perform in Canada and how much time each task typically
consumes. It is unclear whether there are indirect patient care activities
that may be reassigned to support staff or regulated technicians in order
to allow more time for direct patient care activities.
Objective: To quantify the total amount of time that clinical pharmacists
spend on direct and indirect patient care activities and determine which
activities require the most time.
Methods: An observational work-sampling study was conducted at two
urban hospitals. Trained observers followed clinical pharmacists individually for 1.5-4 hours in a variety of different wards and recorded their
activities in 1-minute intervals and sorted each activity as a direct or
indirect patient care activity. Simple descriptive statistics were used to
analyze the time consumed by each activity.
Results: 2044 minutes of activity from 11 pharmacists were recorded.
82.8% of their time was spent on direct clinical activities, such as: 40.9%
assessment and evaluation (includes 9.9% and 17.0% on reviewing paper
charts and computer systems, respectively), 23.3% rounds, 9.5%
therapeutic interventions. Only 17.2% of their time was spent on indirect
clinical activities, such as: 4.6% walking, 2.7% looking for something.
Conclusions: Although it was an excellent finding that pharmacists spend
minimal time on indirect activities (17.2%), the majority of the time they
spent on direct clinical activities was assessment and evaluation – namely,
review of paper charts and computer systems. An electronic medical record
as well as technicians may be beneficial in organizing pertinent patient
data for quicker chart reviews and workups.
Goulois S1, Porteils C1, Thibault M1, Lebel D1, Bussières JF1,2
1
Département de pharmacie et Unité de recherche en pratique
pharmaceutique, CHU Sainte-Justine, Montréal, QC
2
Faculté de pharmacie, Université de Montréal, Montréal, QC
Contexte : L’oculométrie regroupe un ensemble de techniques permettant
d’enregistrer les mouvements oculaires.
Objectif : Évaluer la concordance des données recueillies par oculométrie
selon deux méthodes d’analyse de données.
Méthodologie : Étude descriptive. Une simulation de validation
pharmaceutique du dossier pharmacologique avec interactions en
personne et au téléphone (< 15 minutes, 12 ordonnances de médicaments)
a été menée auprès de 16 participants. Les données recueillies par
l’oculomètre (Redn, Sensomotoric Instruments, Teltow, Allemagne) ont
été couplées par le logiciel utilisé à une captation de l’écran de validation
vu par les participants et ces vidéos ont été analysées et recodées manuellement par deux assistantes de recherche afin d’identifier les champs d’intérêt
CJHP – Vol. 71, No. 1 – January–February 2018
JCPH – Vol. 71, no 1 – janvier–février 2018
1
84
Development and Evaluation of an Anticoagulation
Education Program for Pharmacists
Évaluation de l’oculométrie comme outil de rétroaction
en validation pharmaceutique : étude pilote
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
regardés par les participants. Nous avons évalué la concordance (Kappa)
de périodes de validation active de champs d’intérêt du dossier
pharmacologique entre les données issues de l’analyse de la captation vidéo
et les données brutes de l’oculomètre. Une valeur de p inférieure à
0,05 est considérée statistiquement significative.
Résultats : Seulement 13 des 16 captations vidéos ont permis de générer
des données exploitables pour un total de 903 paires de périodes de
validation active. La concordance est partielle entre la captation vidéo et
les données brutes de l’oculomètre soit, en ordre décroissant de champs
d’intérêt du dossier pharmacologique: posologie (0,633), équivalence
(0,499), date d’ordonnance (0,490), dose (0,469), dosage (0,171),
médecin prescripteur (0,079), trame (0,066).
Conclusion : Il existe une faible concordance entre les données issues de
l’analyse de la captation vidéo et les données brutes de l’oculomètre. Nous
pensons que l’oculométrie représente un outil potentiellement très utile
pour offrir une rétroaction en temps réel à un pharmacien ou un
assistant-technique en pharmacie lors de la validation des ordonnances.
Toutefois, il est nécessaire d’identifier une plate-forme logicielle mieux
adaptée aux besoins de recherche.
Qualitative Thematic Analysis of Interprofessional
Perspectives on Clinical Pharmacy Key Performance
Indicators
Fernandes O1,2, Raymond C3, Mourao D1, Meade A4, Toombs K5,
Slobodan J5, Hao B2, Sreeskantharajan S2, Poggemoeller K6, Attfield E7,
Gorman S8,6
1
University Health Network, Toronto, ON
2
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
3
Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, MB
4
Nova Scotia Health Authority, Halifax, NS
5
Alberta Health Services, Red Deer, AB
6
University of British Columbia, Vancouver, BC
7
Lower Mainland Pharmacy Services, Surrey, BC
8
Interior Health Authority, Kelowna, BC
Background: Eight national clinical pharmacy key performance indicators
(cpKPIs) were developed by hospital pharmacists to advance pharmacy
practice and improve the quality of patient care. Six of the eight cpKPIs
have been adopted by the CSHP Excellence program. Interprofessional
feedback is essential to optimize, refine and effectively communicate the
importance and meaning of the cpKPIs.
Description: To identify, on a national scale, qualitative themes related
to interprofessional perspectives on cpKPIs and specific areas for improved
cpKPI description.
Action: This was a prospective, multi-centre, multi-province, qualitative
descriptive study. Stakeholders were defined as a healthcare professional
or administrator who interacts with a hospital pharmacist regularly and/
or is involved in the measurement of quality/performance indicators.
Focus group and individual interviews were conducted to gather interprofessional stakeholder feedback about the cpKPIs with a semi-structured
interview guide. All discussions were audio-recorded and transcribed.
Two investigators conducted the qualitative thematic analysis using NVivo
software.
Evaluation: Thematic analysis using feedback provided by 92 participants
across 4 Canadian provinces revealed 8 major themes and 13 sub-themes
related to interprofessional perceptions of cpKPIs (See Table 1). Study
participants included a wide variety of stakeholders including physicians,
nurses, allied health professionals, hospital administrators, and nonhospital pharmacists.
CJHP – Vol. 71, No. 1 – January–February 2018
Implications: Thematic analysis of interprofessional cpKPI perspectives
revealed valuable opportunities to refine the cpKPIs with a focus on their
importance to support the need for pharmacists and their patient care
role. The analysis also identified specific description enhancements to
improve comprehension of the cpKPIs by an interprofessional audience.
These perspectives can serve to inform implementation of cpKPIs
nationally.
For the table that goes with this abstract, please see Abstract Appendix,
available at https://www.cjhp-online.ca/index.php/cjhp/issue/view/125/
showToc
Enabling Expanded Scope in Hospital Practice:
Implementation of a Pharmacist Modification
Orders Protocol
Carlin S, Wynne C, Tonkin M
Hamilton Health Sciences, Hamilton, ON
Background: The revised Pharmacy Act and Pharmacy Act Regulations
expanded pharmacists’ scope of practice in Ontario to include prescribing.
Pharmacists are not listed as prescribers in the Public Hospitals Act
Regulations which currently restricts pharmacists from exercising their
expanded scope in the hospital setting.
Description: A protocol was developed at our institution to provide a
mechanism for pharmacists to modify medication orders for inpatients.
Pharmacists use “pharmacist modification” heading to write an order in
the patient chart that the pharmacist is authorized to write, based on their
clinical judgment and scope of practice. Pharmacist modification orders
may include: change in dose, dosage form, directions for use, route of
administration, concentration, diluent or rate of administration through
a parenteral route, administration time or medication hold. Pharmacists
use “pharmacist suggests” heading to make a suggestion to the medical
team when the pharmacist is not authorized to independently write
an order.
Action: The Pharmacist Scope of Practice working group reviewed
practice at other hospitals within and outside of Ontario. Building on
current collaborations with physicians, pharmacists and nurses, the
working group ensured organization readiness for the protocol through
stakeholder discussions and meetings. Approval and endorsements were
obtained from appropriate pharmacy, interprofessional, and medical
advisory committees followed by education sessions for pharmacists and
clinical teams and subsequent implementation in July 2017.
Evaluation: A one-day audit of pharmacist orders was completed approximately one month after protocol implementation. Pharmacists wrote
188 orders: 47 modifications, 102 suggestions, 22 automatic substitutions
and 17 others. Interventions included: 32% initiations, 23% dose
adjustments, 16% medication management and 12% discontinuations.
Pharmacist feedback has been positive with respect to patient care and
workflow.
Implications: This protocol has enabled pharmacists to expand their scope
of practice in order to improve effectiveness, safety, efficiency and costeffectiveness of patient care.
Design, Implementation, and Evaluation of a
Clinical Pharmacy Key Performance Indicator
Tracker: DIE‐cpKPI Study
Slavik RS1,2, Scott, K2, Gorman SK1,2, Bruchet, N1,2, Dalen D1,2, Hutton L3,
Fernandes O3,4
1
Pharmacy Services, Interior Health, Kelowna, BC
JCPH – Vol. 71, no 1 – janvier–février 2018
85
PPC 2018 POSTER ABSTRACTS / RÉSUMÉS DES AFFICHES DE LA CPP 2018
2
Faculty of Pharmaceutical Sciences, University of British Columbia,
Vancouver, BC
3
Pharmacy Department, University Hospital Network, Toronto, ON
4
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
Background: High-quality evidence shows clinical pharmacists providing
Canadian consensus clinical pharmacy key performance indicator (cpKPI)
activities with their inter-professional team improve health and economic
outcomes. A cpKPI tracker is required to measure health service delivery,
advance pharmacy practice, and improve patient care.
Objective: To design, implement, and evaluate a theory-informed and
evidence-based professional behavior change intervention (BCI) used to
implement a cpKPI tracker.
Methods: Prospective, quasi-experimental, one group, PRE/POST study
at three hospitals from January 30th to June 30th, 2017. The primary
outcome was the mean difference in scores of a 45-item PRE and POST
BCI questionnaire scores. Secondary outcomes included the mean difference in PRE and POST BCI questionnaire scores across each of the 14
domains of the Theoretical Domains Framework (TDF), percentage of
clinical pharmacists “satisfied” with the BCI, and percentage of discharged
patients receiving cpKPI interventions during 2-month pilot period.
Results: Twenty four (80%) of representative pharmacists participated in
the study. The mean (95% confidence interval) difference in PRE and
POST BCI questionnaire scores was -0.75 (-0.65 to -0.84). Scores were
significantly reduced across all TDF domains except “intentions”. Overall,
71% of the participants were “satisfied” with the intervention provided.
Overall, 634 of 7264 (8.7%) of discharged patients received at least one
cpKPI intervention. Participation in interprofessional patient care rounds,
implementing a PC plan, resolving DTPs, and providing inpatient
education and counseling were provided most frequently. Admission
and discharge medication reconciliation and discharge education and
counselling were provided less frequently.
Conclusions: An evidence-based BCI was systematically designed,
efficiently implemented, and successfully evaluated. The BCI reduced
perceived barriers to cpKPI tracking, and pharmacists were satisfied with
the BCI used to implement the cpKPI tracker. Pilot data captured was
successfully retrieved and reported. Several hypotheses may explain
the frequency of cpKPI activities reported, which will guide additional
pre-implementation work.
From “Dot” to “Dot Com”: Navigating Pharmacist
Handoff in a Digital Era
Boucher A1,2, Ho C1,2, Hardy J3, Carlson R3, Eros R3
1
Institute for Safe Medication Practices Canada, Toronto, ON
2
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
3
College of Pharmacists of Manitoba, Winnipeg, MB
Background: Safety IQ is a standardized continuous quality improvement
(CQI) program in Manitoba designed to prevent medication incidents
from happening in pharmacies.
Description: The objective of this project was to explore the current
perceptions, benefits, barriers, and experience of CQI programs in
pharmacy professionals prior to the launch of the province-wide Safety
IQ initiative.
Action: We administered a 28-item online questionnaire over a two-week
period to all registered pharmacists and pharmacy technicians in
Manitoba. We conducted descriptive statistics and qualitative thematic
analysis, accordingly, on the responses collected.
Lui J, Patel M, Ahmed E, Fontana P, Bahadur D, Karas A, Wood C
Humber River Hospital, Toronto, ON
Background: Effective communication is an important aspect of
providing exceptional patient-centered care. During transition of care
points, a requirement for timely, accurate and important information to
the receiving provider is necessary. Referred to as a ‘handoff’, transfer
of care occurs when two or more health care professionals exchange
information pertinent to a patient’s care. The shift to computerized
provider order entry (CPOE) and a vision of “Lean, Green and Digital”
for our new hospital provided an opportunity to evaluate and standardize
our pharmacist handoff processes.
Description: Our previous pharmacist handoff processes involved various
methods, dependent on the pharmacist at the initial point of care. A
“sticker dot” on the original paper order was the most common (greater
than 50%) method of communication. The dot would be accompanied
with handwritten notes. The aim of our intervention was to provide
congruency between pharmacists at handoff; ensuring communication
was clear, concise, timely, and inclusive.
Action: A group of key stakeholders including the pharmacy managers,
director, pharmacists, drug utilization, and informatics pharmacists led
this project. A baseline documentation survey was sent to all pharmacists
to address the needs and concerns. Utilizing these results, we were able
to facilitate automated reports that were customizable; allowing for prioritization of handoff interventions. Extensive educational sessions were held
for pharmacists to ensure uptake of the new handoff tool.
Evaluation: The Plan-Do-Study-Act (PDSA) cycle was used to ensure the
tool was relevant and useful. Follow up educational sessions were required
for front line pharmacists to use the handoff tool appropriately and
effectively. Our pharmacists utilize the automated tool on a daily basis and
have implemented it into their daily workflow processes.
Implications: The success of standardizing the electronic handoff
processes has allowed for seamless transfer of care between pharmacists.
Future enhancements may focus on documentation standardization
for pharmacists.
CJHP – Vol. 71, No. 1 – January–February 2018
JCPH – Vol. 71, no 1 – janvier–février 2018
Assessing the Perception and Implementation
of Continuous Quality Improvement in Pharmacy
Professionals: A Pre-Safety IQ Initiative
86
Evaluation: We collected 125 responses, with 32% pharmacy managers,
56.80% staff pharmacists, and 11.20% pharmacy technicians. Pharmacy
professionals had a fairly positive perception of CQI program and its
associated benefits to patient care and safety. They viewed CQI program
as a platform for communication and shared leaning with the ultimate
goal of preventing medication incidents. There were concerns regarding
CQI program implementation, such as the potential requirement for
additional financial and human resources, as well as fear of reporting and
discussing incidents. Time was considered to be the greatest challenge in
CQI program implementation. Pharmacy professionals preferred a simple,
efficient CQI program, and perceived that support from management
would be required for its sustainability. They shared a wide range of
experiences with current CQI programs in their practice.
Implications: Implementation of CQI programs vary widely in Manitoba
and most seem to be generally informal and internally focused. Despite
concerns in increased resource requirements, pharmacy professionals
appeared to be open and supportive of a standardized CQI program. They
expect such a program will provide benefits including a more positive work
environment, increased public trust, and a reduction in medication errors.
This project provides support for the implementation of Safety IQ as a
standardized CQI program to improve patient and medication