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Background: The emergency department (ED) is a complex environment presenting unique challenges for high-risk populations such as critically ill patients who often require the use of high-risk medications1. One study suggests that clinical pharmacists (CPs) may improve the fulfillment of safety goals for the ED patient as per the Joint International Commission2. Some published reports have asserted that ED-based CPs would have the potential to increase patient safety3. In our hospital, the number of CPs covering the ED increased from 2 to 9 starting from November 2019. Methods: This is a retrospective audit covering the period from January 1st 2019 till October 25th 2020 at Hamad General Hospital (HGH) in Doha, Qatar, to determine the impact of increasing the number of CPs covering the ED on the number of identified, solved, and documented drug related problems (DRPs) on the electronic medical records of ED patients. The interventions retrieved from pharmacy reports were analyzed and evaluated in terms of numbers by classification and percentages by the investigators. Results: A total number of 8,946 interventions covering 6,284 patients were carried out in 2020 compared with 1,515 interventions covering 1,001 patients in 2019 (Figure 1) which represents a 6-fold increment by increasing the CPs from 2 to 9. Even the detection of adverse drug reactions increased by 1.5 times with only 38 documented in 2019 compared to 64 in 2020. Classifications and quantities of interventions were also analyzed in detail (Table 1). Conclusion: This audit demonstrates that pharmaceutical intervention can positively contribute to the identification and resolution of DRPs. The benefit of CP involvement in patient care was observed based on the number of interventions that occurred. Studies are needed to assess the impact of those interventions on patients’ outcomes and cost effectiveness.

Background: Throughout COVID-19, complex therapeutics and medication protocols left clinicians overwhelmed by contradicting information leading to drug-related problems (DRPs) potentially leading to ineffective pharmacotherapy and drug-related morbidity and mortality1,2. DRPs queries are time consuming, utilize numerous resources, and require skills and experience to provide accurate answers3. Quick answers are paramount in the Emergency Department (ED) especially during a pandemic period. Clinical pharmacists (CP) can identify and resolve DRPs but are only available in the ED during daytime hours. We set up an out-of-office CP service for ED DRPs. This study aimed to assess the capacity of the service to capture 100% of calls received and to measure the time taken to resolve DRP queries compared to the international standard3. Methods: A dedicated ED CP on-call phone line and rota until 10 pm daily was arranged by the Hamad General Hospital Pharmacy (Doha, Qatar). Data was documented in a logbook and within the Electronic Medical Records (EMR) and analysed using predefined parameters. Results: Between March-September 2020, 133 DRPs calls were received and resolved by a CP. 38% were related to drug interaction/safety (often about medications used in COVID-19 treatment protocols), adverse drug reactions, dose-adjustments, drug allergies and drug in pregnancy. 30% were about medication administration, such as infusion rates, titration, and intravenous compatibility. Those questions were mostly from nurses (Figure 1). Appropriate dose selection and appropriate indication represented 21% and 11% respectively (Figure 2). Caller's acceptance rate to responses provided by CP was 100%. Responses were documented in the patients’ EMR. The call-history-log showed an average duration of 4.66 minutes per call which is below the average standard of 15-30 minutes3. Conclusion: The availability of clinical pharmacists to provide quick, acceptable, responses to DRPs queries is crucial given the complexity and diversity of ED patients. During COVID-19, an on-call clinical pharmacy service has proven its capability to resolve DRPs and support the clinical decision-making process in a relatively short time.

Background Hydroxychloroquine (HC) ± azithromycin (AZ) is widely used for Covid-19. The Qatar Prospective RCT of Expediting Coronavirus Tapering (Q-PROTECT) aimed to assess virologic cure rates of HC±AZ in cases of low-acuity Covid-19. Methods Q-PROTECT employed a prospective, placebo-controlled design with blinded randomization to three parallel arms: placebo, oral HC (600 mg daily for one week), or oral HC plus oral AZ (500 mg day one, 250 mg daily on days two through five). At enrollment, non-hospitalized participants had mild or no symptoms and were within a day of Covid-19 positivity by polymerase chain reaction (PCR). After six days, intent-to-treat (ITT) analysis of the primary endpoint of virologic cure was assessed using binomial exact 95% confidence intervals (CIs) and χ2 testing. (ClinicalTrials.gov NCT04349592, trial status closed to new participants.) Findings The study enrolled 456 participants (152 in each of three groups: HC+AZ, HC, placebo) between 13 April and 1 August 2020. HC+AZ, HC, and placebo groups had 6 (3·9%), 7 (4·6%), and 9 (5·9%) participants go off study medications before completing the medication course (p = 0·716). Day six PCR results were available for all 152 HC+AZ participants, 149/152 (98·0%) HC participants, and 147/152 (96·7%) placebo participants. Day six ITT analysis found no difference (p = 0·821) in groups’ proportions achieving virologic cure: HC+AZ 16/152 (10·5%), HC 19/149 (12·8%), placebo 18/147 (12·2%). Day 14 assessment also showed no association (p = 0·072) between study group and viral cure: HC+AZ 30/149 (20·1%,), HC 42/146 (28·8%), placebo 45/143 (31·5%). There were no serious adverse events. Interpretation HC±AZ does not facilitate virologic cure in patients with mild or asymptomatic Covid-19. Funding The study was supported by internal institutional funds of the Hamad Medical Corporation (government health service of the State of Qatar).

Background Drug-induced liver injury (DILI) represents an increasing morbidity in the general population, but more so in the elderly cohort of patients. Despite this, the concept of its prevention through prospective analysis has largely remained unexamined. We evaluated the utility of recently validated adverse drug reactions (ADR) avoidability tool in a cohort of elderly patients with DILI. Methods We examined 38 DILI-drug pairs from n=38 patients in a prospective cohort of patients presenting with adverse drug reactions to a Weill Cornell-affiliated tertiary hospital between February 2019 and January 2020. DILI outcomes were adjudicated by the updated Roussel Uclaf Causality Assessment Method (RUCAM). Two clinical pharmacologists and two general physicians utilized the Liverpool adverse drug reactions avoidability tool (LAAT) and the modified Hallas tools to rate the preventability of DILI-drug pairs. Inter-rater, exact agreement proportions, as well as intraclass correlation coefficients were generated and expressed as ordinal outcomes. Results The cases examined for the determination of DILI avoidability had probability likelihood of “probable” or “highly probable” by the updated RUCAM scale. Examination of the 38 DILI-drug pairs (n= 38 patients) resulted in a total of 152 ordinal outcome decisions. We found about 32.3% (50/152) and 34.2% (52/152) of DILI-drug pairs were rated as “avoidable” (“probable” or “definite”) by the LAAT and the modified Hallas tools respectively. The overall median Krippendorf’s kappa with the LAAT was 0.61 (SE 0.12, CI 0.36, 0.85) and for modified Hallas tool was 0.53 (SE 0.18; CI 0.16, 0.89). The inter-rater correlation coefficient (ICC) for the LAAT and modified Hallas were 0.50 [0.32, 0.65] and 0.63 [0.48, 0.76] respectively. Exact pairwise agreement was present in 30/38 (IQR 29.5, 34.5), and 28/38 (IQR 27.5-35.5) of DILI-ADR pairs using the LAAT and modified Hallas tools respectively. Conclusion We found a significant proportion of drug-induced liver injury adjudicated by the updated RUCAM scale in elderly hospitalized cohort of patients were avoidable with significant implication for therapeutic commissioning as well as cost effectiveness interventions in this cohort of patients.

Plasmodium vivax is the most prevalent parasite worldwide, escalating by spread of drug resistance. Currently, in Qatar, chloroquine (CQ) plus primaquine are recommended for the treatment of P. vivax malaria. The present study examined the prevalence of mutations in dihydrofolate reductase (dhfr), dihydropteroate synthase (dhps) genes and CQ resistance transporter (crt-o) genes, associated with sulphadoxine-pyrimethamine (SP) and chloroquine resistance, among imported P. vivax cases in Qatar. Blood samples were collected from patients positive for P. vivax and seeking medical treatment at Hamad General Hospital, Doha, during 2013-2016. The Sanger sequencing method was performed to examine the single nucleotide polymorphisms in Pvdhfr, Pvdhps, and Pvcrt-o genes. Of 314 examined P. vivax isolates, 247 (78.7%), 294 (93.6%) and 261 (83.1%) were successfully amplified and sequenced for Pvdhfr, Pvdhps, and Pvcrt-o, respectively. Overall, 53.8% (N = 133) carried mutant alleles (58R/117N) in Pvdhfr, whereas 77.2% (N = 227) and 90% (N = 235) isolates possessed wild type allele in Pvdhps and Pvcrt-o genes, respectively. In addition, a total of eleven distinct haplotypes were detected in Pvdhfr/Pvdhps genes. Interestingly, K10 insertion in the Pvcrt-o gene was observed only in patients originating from the Indian subcontinent. The results suggested that CQ remains an acceptable treatment regimen but further clinical data are required to assess the effectiveness of CQ and SP in Qatar to support the current national treatment guidelines. In addition, limited distribution of genetic polymorphisms associated with CQ and SP resistance observed in imported P. vivax infections, necessitates regular monitoring of drug resistant P. vivax malaria in Qatar.

Imported malaria has been a great challenge for public health in Qatar due to influx of large number of migrant workers. Antimalarial drug resistance has emerged as one of the greatest challenges facing malaria control today. Monitoring parasite haplotypes that predict susceptibility to major antimalarial can guide treatment policies. This study aimed to determine molecular drug resistance pattern in imported malaria cases in Qatar. Blood samples from the uncomplicated P. falciparum malaria patients were collected at Hamad General Hospital, HMC, Doha, Qatar. The samples were further confirmed by nested-polymerase chain reaction (PCR) for P. falciparum. Molecular markers of chloroquine (Pfcrt and Pfmdr1) were analyzed by using nested PCR- RFLP method to determine the key point mutations associated with chloroquine (CQ) drug resistance. A total 118 blood samples were positive for P. falciparum. Overall, by RFLP, 72% harboured wild type allele (N86) of Pfmdr1 gene. The prevalence of Pfcrt mutant (T76), WT (K76) and mixed alleles (K76T) was 63.6% (n = 75), 22.9% (n = 27) and 13.5% (n = 16), respectively. Mean parasitaemia level was higher among the wild type alleles of Pfcrt gene as compared to the mixed/mutant alleles whereas mixed alleles of Pfmdr1 gene having high parasitaemia. Molecular surveillance strategy based on imported malaria cases can be used to detect and track CQ drug-resistant malaria. The data presented here might be helpful for enrichment of molecular surveillance of antimalarial resistance and will be useful for developing and updating antimalarial guidance for non-immune imported cases in Qatar.

Background: As part of improving the service in ED, we conduct Pharmacist-led Pharmacy round (PLPR) led by Pharmacist to ensure best patient care is provided by pharmacist. Objective: No such experience was reported in the literature up to our knowledge so we decided to describe our experience, in the successful establishment of PLPR in ED and to identify whether implementing a pharmacy based round, provide better patients care in terms of finding more drug related problems and providing educations to all clinical pharmacists. Methods: The PLPR started daily at 11 am by brief meeting to discuss any pharmacy related issue then the PRPR team start rounding according to a planned schedule. The PLPR often involves ED pharmacists of different levels of experience the ED pharmacy specialist, clinical pharmacists who have reviewed the patient's case, pharmacy fellows and medical and pharmacy students. During the round, the pharmacist assigned for the area present each case using the Care Plan Form (CPF) to review the suggested recommendations or interventions, further recommendations to the clinical pharmacist may be given if necessary. The extra recommendations or discussion (ERD) conducted during the PLPR are documented and analyzed to evaluate the impact of the pharmacy based round. For each intervention, the following data were documented: date, time, medication, types of intervention. Results: A total of seventy five ERD were documented during this period. Interventions related to adding, initiating or selecting drug therapy were the most common performed 58 (77%), pharmacotherapy options were the second most common interventions done by the team 13 (17.3%), requesting laboratory tests to optimize pharmacotherapy management were made 7 (9%) followed by dosage adjustment 6 (8%). Conclusion: Implementation of PLPR is an initiative to improve pharmaceutical care in ED and training among Clinical pharmacist at point of care.

Background The presence of a clinical pharmacist in a hospital’s Emergency Department (ED) is important to decrease the potential for medication errors. To our knowledge, no previous studies have been conducted to evaluate the impact of implementing clinical pharmacy services in the ED in Qatar. Objective To characterize the contributions of clinical pharmacists in a short stay unit of ED in order to implement and scale-up the service to all ED areas in the future. Methods A retrospective study conducted for 7 months in the ED of Hamad General Hospital, Qatar. The intervention recommendations were made by clinical pharmacists to the physician in charge during medical rounds. Results A total of 824 documented pharmacist recommendations were analyzed. The interventions included the following: Providing information to the physician (24.4 %) and recommending medication discontinuation (22.0 %), dose adjustment (19.3 %), medication addition (16.0 %), changes in frequency of medications (7.6 %), medication resumption (5.7 %), and patient education (5.0 %). Conclusion Clinical pharmacists in the ED studied play an important role in patient care.