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Background: The Opioid Stewardship Program (OSP) was created to promote safe and rational prescribing of opioids, where the risks associated with providing opioids for patients must be balanced against the risk of patients experiencing uncontrolled pain. The pharmacist-led OSP was established at 2 Fraser Health Authority (FHA) sites, British Columbia, to provide clinical services through patient referrals and screening. The rate of acceptance of OSP pharmacists’ recommendations has been high, but there was a need to assess clinicians’ perceptions of the program. Objectives: To assess the perceptions of health care professionals at FHA hospitals offering the OSP regarding various aspects of the program and to identify areas of the program that could be modified to further optimize service delivery. Methods: A prospective cross-sectional survey was distributed to about 250 targeted health care professionals, who answered questions regarding their perceptions of the OSP. Data were analyzed using simple descriptive statistics. Results: A total of 71 respondents initiated the survey, of whom 59 were included in the final analyses. Most participants indicated that the OSP pharmacists’ suggestions were valuable for optimizing pain management (52/57, 91%) and preventing adverse events (49/56, 88%). Most participants were satisfied with the quality of communication (51/56, 91%), timeliness to consults (51/52, 98%), and recommendations provided (52/55, 95%). Increasing knowledge transfer, improving communication about intentions for patient follow-up, and expanding services at current sites and to other sites were recommended to improve the OSP. Conclusions: Clinicians responding to the survey reported a high level of satisfaction with and positive views of the pharmacist-led OSP. Providing more education and clarifying intentions for patient follow-up are modifications that could be made to improve the program. RÉSUMÉ Contexte : L’Opioid Stewardship Program (OSP) [programme de gestion des opioïdes] a été mis sur pied pour encourager la prescription sûre et rationnelle d’opioïdes qui permet de peser les risques associés à leur délivrance contre les risques que le patient ressente une douleur incontrôlée. L’OSP, dirigé par les pharmaciens, a été mis en place sur 2 sites de la Fraser Health Authority (FHA) (Colombie-Britannique) afin de fournir des services cliniques par l’entremise de l’aiguillage et du dépistage des patients. Le taux d’acceptation des recommandations des pharmaciens de l’OSP était élevé, mais il était nécessaire d’évaluer la perception des cliniciens à l’égard du programme. Objectifs : Évaluer les perceptions des professionnels de la santé dans les hôpitaux de la FHA offrant l’OSP à l’égard de divers aspects du programme et cerner ceux qui pourraient être modifiés pour optimiser la prestation de services. Méthodes : Une enquête prospective transversale a été distribuée à environ 250 professionnels de la santé ciblés, qui ont répondu à des questions portant sur leur perception de l’OSP. Les données ont été analysées à l’aide de statistiques descriptives simples. Résultats : Au total, les réponses de 71 répondants ont fait l’objet d’analyses. La plupart des participants ont indiqué que les suggestions des pharmaciens de l’OSP étaient utiles pour optimiser la gestion de la douleur (52/57, 91 %) et prévenir les événements indésirables (49/56, 88 %). La plupart des participants étaient satisfaits de la qualité de la communication (51/56, 91 %), de la rapidité des consultations (51/52, 98 %) et des recommandations fournies (52/55, 95 %). Les recommandations suivantes ont été formulées pour améliorer l’OSP : amélioration du transfert des connaissances; amélioration de la communication sur les intentions de suivi des patients; et élargissement des services sur les sites actuels et à d’autres sites. Conclusions : Les cliniciens qui ont répondu au sondage ont fait état d’un niveau élevé de satisfaction et d’opinions positives à l’égard de l’OSP dirigé par les pharmaciens. Une formation accrue et la clarification des intentions quant au suivi des patients sont des modifications qui pourraient être apportées en vue d’améliorer le programme.

The Physician Fee Schedule was updated in 2021 by the Centers for Medicare and Medicaid Services. A case study on Tetralogy of Fallot, the most common cyanotic congenital heart defect, is presented with guidance in billing the office visit to reflect the current guidelines.

Background: Drug–drug interactions are preventable medication errors that can lead to serious negative outcomes for patients. Community pharmacists are uniquely positioned with their medication knowledge and role in prescription clinical assessment. However, workplace pressures and limitations related to computer systems can lead to drug–drug interactions being missed. There is a lack of information as to how community pharmacists assess drug interactions. Methods: A qualitative study using key informant interviews of community pharmacists was conducted. Pharmacists were questioned on their perceptions and views of drug interactions. Results: Eight community pharmacists participated. Four main themes were identified from the interviews: 1) pharmacist process of identifying drug interactions, 2) tools that help pharmacists assess and respond to drug interactions, 3) challenges in identifying and responding to clinically important drug interactions and 4) measures to avoid missing interactions. Discussion: Community pharmacists experience challenges around their lack of access to patient information, which limits their ability to properly assess drug–drug interactions. In addition, increasing workload pressures have affected their ability to ensure their patients receive optimal pharmaceutical care. There is also a disconnect between the community pharmacy computer systems’ alerts and their clinical relevancy to their specific patients. The overall burdens can lead to professional abstinence in the assessment of drug–drug interactions. Conclusion: Community pharmacists are in an ideal position to prevent patients from experiencing drug–drug interactions. However, to further enable them to fulfill this role, increased access to patients’ health records, decreased workload and better customization of computer alerts need to occur.

Background: Clinical decision support systems (CDSS) are used by pharmacists to assist in managing drug–drug interactions (DDIs). However, previous research suggests that such systems may perform suboptimally in providing clinically relevant information in practice. Objectives: The primary objective of this study was to develop a novel DDI management tool to reflect the clinical thought process that a pharmacist uses when assessing a DDI. The secondary objective was to investigate practitioners’ perceptions of this tool. Methods: This study was conducted in 3 phases: development of the DDI management tool, implementation of the tool in clinical practice, and collection of practitioners’ opinions of the tool through an online qualitative survey (although because of circumstances related to the COVID-19 pandemic, the study population for the survey phase included only pharmacy residents). A comprehensive literature search and analysis by an expert panel provided underlying context for the DDI management tool. The tool was validated through simulation against a known list of DDIs before implementation into practice by hospital pharmacists and pharmacy residents. Participating pharmacy residents were invited to provide feedback on the tool. Survey results were analyzed using descriptive statistics. Results: The novel tool that was developed in this study (called TLC-Act) consisted of components important to a pharmacist when assessing a DDI, including the duration of concomitant use of the interacting medications and patient-specific risk factors. Study participants implemented the tool in clinical practice for a total of 6 weeks. Of the 28 pharmacy residents surveyed, 15 (54%) submitted a response, of whom 11 (73%) found the TLC-Act tool to be slightly more useful for assessing a DDI than usual care with the CDSS alone. Conclusions: The TLC-Act tool maps out a pharmacist’s clinical thought process when assessing a DDI in practice. This novel tool may be more useful than a CDSS alone for managing DDIs, as it takes into account other important factors pertinent to the assessment of a DDI. RÉSUMÉ Contexte : Les systèmes d’aide à la décision clinique (SADC) sont utilisés par les pharmaciens pour les aider à gérer les interactions médicamenteuses (IM). Cependant, des recherches antérieures indiquent que ces systèmes peuvent fonctionner de manière sous-optimale pour fournir des informations cliniquement pertinentes dans la pratique. Objectifs : L’objectif principal de cette étude consistait à développer un nouvel outil de gestion des IM pour reproduire le processus de réflexion clinique adopté par un pharmacien quand il les évalue. L’objectif secondaire consistait, quant à lui, à enquêter sur les perceptions des praticiens à l’égard de cet outil. Méthodes : Cette étude a été menée en 3 phases : développement de l’outil de gestion des IM; sa mise en place dans la pratique clinique; et recueil des avis des praticiens sur celui-ci au moyen d’une enquête qualitative en ligne (bien qu’en raison des circonstances liées à la pandémie de COVID-19, la population étudiée pour la phase de l’enquête ne comprenne que des résidents en pharmacie). Une recherche documentaire et une analyse approfondies effectuées par un groupe d’experts ont fourni le contexte sous-jacent de l’outil de gestion des IM. L’outil a été validé par simulation par rapport à une liste connue d’IM avant sa mise en pratique par les pharmaciens hospitaliers et les résidents en pharmacie. Les résidents en pharmacie qui participaient à l’étude ont été invités à donner leur avis sur l’outil. Les résultats de l’enquête ont été analysés à l’aide de statistiques descriptives. Résultats : Le nouvel outil développé dans le cadre de cette étude (le « TLC-Act ») se composait d’éléments d’évaluation des IM importants pour un pharmacien, y compris la durée de l’utilisation concomitante des médicaments en interaction et les facteurs de risque propres au patient. Les participants à l’étude ont mis en œuvre l’outil dans la pratique clinique pendant un total de 6 semaines. Sur les 28 résidents en pharmacie interrogés, 15 (54 %) ont soumis une réponse, et 11 (73 %) d’entre eux ont trouvé que l’outil TLC-Act était légèrement plus utile pour évaluer les IM que le SADC seul utilisé habituellement. Conclusions : L’outil TLC-Act cherche à reproduire le processus de réflexion clinique d’un pharmacien lorsqu’il évalue les IM dans la pratique. Ce nouvel outil peut être plus utile qu’un SADC utilisé seul pour gérer les IM, car il prend en compte d’autres facteurs importants qui sont pertinents pour leur évaluation.

Background: Drug–drug interactions (DDIs) may cause adverse drug events, potentially leading to hospital admission. Clinical decision support systems (CDSSs) can improve decision-making by clinicians as well as drug safety. However, previous research has suggested that pharmacists are concerned about discrepancies between CDSSs and common clinical practice in terms of severity ratings and recommended actions for DDIs. Objectives: The primary objective was to characterize the level of agreement in terms of DDI severity ranking and actions recommended between the local CDSS and pharmacists. The secondary objectives were to determine the level of agreement among pharmacists concerning DDI severity, to determine the influence of the CDSS on clinicians’ decision-making, and to review the literature supporting the severity rankings of DDIs identified in the study institution’s database. Methods: This 2-part survey study involved pharmacists and pharmacy residents working at 1 of 4 health organizations within the Lower Mainland Pharmacy Services, British Columbia, who were invited to participate by email. Participants were first asked to rank the severity of 15 drug pairs (representing potential DDIs) on a 5-point Likert scale and to select an action to manage each interaction. Participants were then given the CDSS severity classification for the same 15 pairs and again asked to select an appropriate management action. Results: Of the estimated 500 eligible pharmacists, a total of 73 pharmacists participated, for a response rate of about 15%. For DDIs of moderate severity, most participants chose to monitor. For severe and contraindicated interactions, the severity ranking and action proposed by participants varied, despite the same severity classification by the CDSS. There was poor agreement among respondents about the severity of the various DDIs. Moreover, knowledge of the CDSS severity ranking did not seem to change the actions proposed by most respondents. Conclusion: This study identified a gap between the local CDSS and clinical practice. There were discrepancies in terms of severity rankings and actions proposed to manage DDIs, particularly for severe and contraindicated DDIs. The current CDSS did not appear to have a large impact on clinical decision-making, which suggests that it may not be functioning to its full potential. RÉSUMÉ Contexte : Les interactions médicamenteuses (IM) peuvent provoquer des réactions indésirables et entraîner potentiellement une admission à l’hôpital. Les systèmes d’aide à la décision clinique (SADC) peuvent améliorer le processus de prise de décision des cliniciens ainsi que la sécurité de l’usage des médicaments. Cependant, des recherches antérieures mentionnent que les divergences entre les SADC et la pratique clinique courante de l’évaluation de la gravité des IM ainsi que les mesures recommandées préoccupent les pharmaciens. Objectifs : L’objectif principal consistait à caractériser le degré de concordance entre les SADC locaux et les décisions des pharmaciens en termes d’évaluation du degré de gravité des IM ainsi que des mesures recommandées. Les objectifs secondaires visaient quant à eux à déterminer le degré de concordance entre l’évaluation du degré de gravité de l’IM par les pharmaciens, à définir l’influence des SADC sur le processus de prise de décision des cliniciens et à examiner la documentation appuyant les critères d’évaluation de la gravité d’une IM, déterminés dans la base de données de l’institution où s’est déroulée l’étude. Méthodes : Cette étude en deux volets, menée au moyen d’un sondage par courriel, impliquait les pharmaciens et les résidents en pharmacie travaillant dans l’un des quatre organismes de santé des Lower Mainland Pharmacy Services en Colombie-Britannique. On a tout d’abord demandé aux participants d’évaluer le degré de gravité de 15 paires de médicaments (représentant des IM potentielles) sur une échelle de Likert à 5 points et de choisir une mesure visant à gérer chaque interaction. Les participants ont ensuite reçu l’évaluation par les SADC de la gravité des mêmes 15 paires; on leur a ensuite demandé de choisir une mesure de gestion appropriée. Résultats : Sur une estimation de 500 pharmaciens admissibles, 73 ont participé à l’étude et le taux de réponse s’est établi à 15 %. Concernant les IM dont le degré de gravité est modéré, la plupart des participants ont choisi la surveillance. L’évaluation du degré de gravité et les mesures proposées par les participants variaient lorsqu’il s’agissait d’interactions contre-indiquées et graves, et cela malgré une évaluation identique du degré de gravité par les SADC. On a relevé une mauvaise concordance entre les répondants quant à la gravité des diverses IM. De plus, la prise de connaissance par les répondants de l’évaluation du degré de gravité faite par les SADC ne semblait pas modifier les mesures proposées par la plupart d’entre eux. Conclusion : Cette étude a mis en évidence un fossé entre les SADC locaux et la pratique clinique. On y a relevé des divergences entre l’évaluation du degré de gravité des IM et les mesures proposées pour les gérer, en particulier lorsque les IM sont graves et contre-indiquées. Le SADC utilisé couramment ne semble pas avoir d’impact important sur le processus de décision clinique, ce qui laisse supposer qu’il pourrait ne pas fonctionner au maximum de son potentiel.

Background: Despite the recent increase in opioid overdoses across Canada, few pharmacy-led initiatives have been implemented to address issues related to opioid prescribing in the hospital setting. Objectives: The primary objective of this study was to develop a clinical tool, intended for use by hospital pharmacists and informed by best practices from the literature, that would provide a structured approach to enhancing the safety of opioid prescribing. The secondary objective was to collect pharmacists’ opinions about the feasibility and utility of this tool. Methods: A comprehensive literature search and pharmacist focus group analysis provided content for development of a candidate clinical tool. This tool was then piloted by clinical pharmacists working on general medical and surgical units in a single hospital. Pharmacists participating in the pilot were invited to complete an online survey concerning their perceptions of the tool. Descriptive statistics were used to analyze the survey results. Results: The literature search and focus group analysis led to development of a candidate clinical tool that focused on Medication review, Optimization, Reassessment, and Education (MORE). It included key risk factors relating to opioid safety, along with suggested mitigating strategies. The MORE tool was piloted for 3 weeks by 14 clinical pharmacists, 9 of whom responded to the subsequent survey. Five respondents indicated that the clinical tool increased their ability to identify risk factors. Five respondents also noted an increase in their ability to identify possible interventions. Most respondents felt that the tool was useful and that it would be feasible to integrate it into their practice; however, they noted that a more streamlined version could improve ease of use. Conclusions: The MORE tool was well received by clinical pharmacists. Implementation of the tool into routine practice requires additional changes to improve ease of use. Suggestions for modifying and streamlining the tool will be incorporated into future versions. RESUME Contexte : Malgre l’augmentation recente des surdoses d’opioides au Canada, peu d’initiatives menees sous la houlette de pharmacies ont ete mises en place sur les enjeux potentiels lies a la prescription d’opiaces en milieu hospitalier. Objectifs : L’objectif principal de cette etude visait a elaborer un outil destine aux pharmaciens d’hopitaux, s’inspirant des meilleures pratiques rapportees dans la documentation, qui fournirait une approche structuree pour ameliorer la securite de la prescription d’opioides. L’objectif secondaire consistait a recueillir les opinions des pharmaciens sur la faisabilite et l’utilite d’un tel outil. Methode : Des recherches bibliographiques etendues ainsi qu’une analyse de groupes de discussion de pharmaciens ont fourni le contenu necessaire a l’elaboration d’un outil clinique experimental. Ensuite, cet outil a ete teste par des pharmaciens cliniciens travaillant dans des unites medicales generales et chirurgicales au sein d’un seul hopital. Les pharmaciens participant au projet pilote ont ete invites a repondre a une enquete en ligne sur leur perception de l’outil. Des statistiques descriptives ont permis d’analyser les resultats de l’enquete. Resultats : Les recherches bibliographiques et l’analyse des groupes de discussion ont debouche sur le developpement d’un outil clinique nomme MORE [pour Medication review, Optimization, Reassessment, and Education , ou Examen, optimisation, reevaluation et education aux medicaments]. Il comprenait des facteurs de risque lies a la securite des opioides ainsi que des suggestions de strategies d’attenuation. Quatorze pharmaciens cliniciens, dont neuf ont repondu a l’enquete qui a suivi, ont teste le MORE pendant trois semaines. Cinq repondants ont indique que l’outil clinique augmentait leur capacite a determiner les facteurs de risque. Cinq ont egalement note une meilleure capacite a determiner les interventions possibles. La plupart des repondants ont estime que l’outil etait utile et qu’il serait possible de l’integrer dans leur pratique; cependant, ils ont aussi note qu’une version simplifiee pourrait faciliter son utilisation. Conclusions : Les pharmaciens cliniciens ont bien accueilli l’outil MORE. Sa mise en oeuvre dans la pratique courante exige cependant des changements supplementaires pour faciliter son utilisation. Les versions a venir tiendront compte des propositions visant a le modifier et a le simplifier.

Background: Pharmacists often overlook drug interaction alerts because of limitations in clinical decision support (CDS) software systems intended to detect evidence-based, clinically significant drug-drug inter-actions (DDIs). Alert fatigue, which occurs when pharmacists become desensitized to an overload of DDIs, may also contribute. Objectives: To gain a better understanding of how pharmacists assess common DDIs and the extent to which computerized drug alerts affect their decision-making, as background for initiatives to overcome alert fatigue and improve detection of DDIs. Methods: This qualitative study used focus group methodology. A structured focus group was planned at each of 3 large tertiary hospitals. Pharmacists were invited to participate if their jobs included patient care and/or dispensary responsibilities. The focus group discussions were audio-recorded and subsequently transcribed, analyzed, and coded into themes using NVivo software. Four main categories of themes were identified: perceived challenges, pharmacists’ assessment of DDIs, barriers to responding to alerts, and proposed solutions. Results: The participants (n = 24) described a large discrepancy among CDS software systems in terms of the severity of specific DDIs, which made it difficult to view these systems as reliable sources. The participants agreed that alert fatigue is present and contributes to DDIs being overlooked. However, lack of patient information to make an initial assessment, as well as the constant need for multitasking, prevents pharmacists from focusing on the evaluation of DDIs. Conclusions: Although alert fatigue was reported to be a common factor responsible for pharmacists missing DDIs, other barriers also exist. Participants suggested ways to limit DDI alerts to those that are clinically relevant. Having a collaborative team of pharmacists periodically review the DDIs embedded in the CDS system, incorporating a colour-code system, and removing duplicate entries were discussed as ways to improve system efficiency. RESUME Contexte : Les pharmaciens ignorent souvent les alertes d’interactions medicamenteuses a cause des limites des logiciels d’aide a la decision clinique (ADC) concus pour detecter les interactions medicamenteuses (IM) factuelles et significatives d’un point de vue clinique. La fatigue liee aux alarmes (alert fatigue), qui survient lorsque les pharmaciens sont desensibilises a cause d’une surcharge d’IM, peut aussi contribuer a cette situation. Objectifs : Mieux comprendre comment les pharmaciens evaluent les IM courantes et dans quelle mesure les alertes medicamenteuses affectent leur prise de decision, dans le cadre de la mise en œuvre d’initiatives visant a surmonter la fatigue liee aux alarmes et a mieux detecter les IM. Methodes : La methodologie de cette etude qualitative se basait sur les groupes de discussion. Un groupe de discussion structure etait prevu dans chacun des trois grands hopitaux tertiaires. Les pharmaciens etaient invites a participer si leur travail comprenait des soins offerts aux patients ou des responsabilites dans la distribution de medicaments. Les discussions dans les groupes ont fait l’objet d’un enregistrement audio avant d’etre retranscrites, analysees et codees selon les themes a l’aide du logiciel NVivo. Quatre categories de themes principaux ont ete etablies : les defis percus, l’evaluation des IM par les pharmaciens, les obstacles a lever pour repondre aux alertes et les solutions proposees. Resultats : Les participants (n = 24) ont mentionne un ecart important dans les definitions de la gravite [severity] d’IM specifiques donnees par les logiciels d’ADC, de sorte qu’il etait difficile de se fier a ces systemes. Les participants ont indique que la fatigue liee aux alarmes existait bel et bien et qu’elle contribuait au manque de prise en compte des IM. Cependant, le manque d’information sur les patients pour faire l’evaluation initiale, ainsi que le besoin constant d’effectuer plusieurs tâches a la fois, empeche les pharmaciens de se concentrer sur l’evaluation des IM. Conclusions : Bien que la fatigue liee aux alarmes empeche frequemment les pharmaciens de remarquer les IM, il existe d’autres obstacles. Les participants ont propose de limiter les alertes d’IM a celles pertinentes d’un point de vue clinique. Les solutions examinees pour ameliorer l’efficacite du systeme ont porte sur la formation d’une equipe collaborative de pharmaciens qui examine periodiquement les IM integres dans le systeme ADC, l’incorporation d’un systeme de codes de couleur et l’elimination des entrees dupliquees.

The Doctor of Nursing Practice (DNP) faculty at the George Washington University (GW) decided to create a digital DNP Project Repository for our students in 2016 based on the American Association of Colleges of Nursing (AACN) 2015 recommendations to do so. We describe the two-year process during which the DNP faculty and the GW librarians at our Health Sciences Library collaborated to create the DNP project repository. This article contains important information that was learned about digital institutional repositories, the criteria used in deciding to make the GW library's Health Sciences Research Commons the home for the repository, along with questions and concerns that arose during the process. Our library internally collaborated to customize the digital collection to meet the needs of DNP students and their project teams. Development included creating the URL for the collection, customizing digital metadata fields, developing submission forms and guidelines, and adding embargo options for projects. A pilot collection of six DNP projects was completed in 2017; and in 2018, the first cohort of 34 students submitted their projects to our repository. Outcomes are reported of the repository launch, lessons learned, and repository submission experiences of two DNP students. We believe our journey may guide others.

Context Practice-based learning is a cornerstone of developing clinical and professional competence in health disciplines. Practice-based learning systems have many interacting components, but a key facet is the number of learners per preceptor. Different learner : preceptor ratios may have unique benefits and pose unique challenges for participants. This is the first comprehensive systematic review of the topic. Our research questions were: What are the benefits and challenges of each learner : preceptor ratio in practice-based learning from the perspectives of the learners, preceptors, patients and stakeholder organisations (i.e. the placing and health care delivery organisations)? Are any ratios superior to others with respect to these characteristics and perspectives? Methods Qualitative systematic review of published English-language literature since literature database inception, including multiple health disciplines. Results Seventy-three articles were included in this review. Eight learner : preceptor ratio arrangements were identified involving nursing, physiotherapy, occupational therapy, pharmacy, dietetics, speech and language therapy, and medicine. Each arrangement offers unique benefits and challenges from the perspectives of learners, preceptors, programmes and health care delivery organisations. Patient perspectives were absent. Despite important advantages of each ratio for learners, preceptors and organisations, some of which may be profession specific, the 2 : 1 and 2+ : 2+ learner : preceptor ratios appear to be most likely to successfully balance the needs of all stakeholders. Conclusions Regardless of the learner : preceptor ratio chosen for its expected benefits, our results illuminate challenges that can be anticipated and managed. Patient perspectives should be incorporated into future studies of learner : preceptor ratios.

Background: In the past, impurities in vancomycin formulations were thought to contribute to nephrotoxicity. In contrast, when current, purer formulations are dosed at conventional trough levels (i.e., 5–15 mg/L), the incidence of nephrotoxicity is relatively low. Recent guidelines have recommended targeting higher vancomycin trough levels in treatment of complicated methicillin-resistant Staphylococcus aureus infections. Dosing based on these higher trough levels may be associated with nephrotoxicity, so the potential risk factors for vancomycin-associated nephrotoxicity require clearer definition. Objectives: To determine the occurrence of nephrotoxicity in patients receiving more than 7 days of vancomycin therapy with high trough levels (15–20 mg/L) and to identify and evaluate specific risk factors related to development of vancomycin-associated nephrotoxicity (i.e., serum creatinine ≥ 44.2 μmol/L or increase ≥ 50% [i.e., ≥ 26.2 μmol/L] from baseline on 2 consecutive days). Methods: Health care records were reviewed for patients seen at 2 major teaching hospitals between January 2008 and March 2011. Patients who had attained high trough levels of vancomycin were screened for eligibility. Patients with unstable renal function, those undergoing hemodialysis, and those for whom dosage and/or sampling times were unclear were excluded. Univariate and multivariate analyses were performed to identify risk factors associated with nephrotoxicity. Univariate variables with p < 0.1 were included in the logistic regression model. Results: Of the 176 patients with high trough levels included in the analysis, 24 (14%) experienced nephrotoxicity. In univariate analysis, admission to a general medicine unit (the setting of care for 16 [67%] of the 24 patients with nephrotoxicity) and extended duration of vancomycin treatment were identified as risk factors for nephrotoxicity (p < 0.1). Other risk factors included gastrointestinal comorbidity (p = 0.056), malignancy (p = 0.044), and febrile neutropenia (p = 0.032). Multivariate analysis identified treatment on general medicine units and treatment courses longer than 7 days as independent predictors of vancomycin-associated nephrotoxicity. Conclusion: Patients being treated on general medicine units and those receiving vancomycin for more than 7 days had an increased likelihood of experiencing nephrotoxicity. The increased risk for patients on general medicine units is likely multifactorial. The relationship between treatment duration and risk of nephrotoxicity appeared to be linear. When using extended-duration, high-trough vancomycin therapy, clinicians should be vigilant in monitoring for nephrotoxicity. RESUME Contexte : On croyait autrefois que les impuretes contenues dans les preparations de vancomycine pouvaient contribuer a causer une nephrotoxicite. D’un autre cote, lorsque les preparations actuelles plus pures sont dosees selon les concentrations minimales classiques (c.-a-d., 5–15 mg/L), les cas de nephrotoxicite sont relativement peu nombreux. Des lignes directrices recentes recommandaient de viser des concentrations minimales plus elevees de vancomycine pour traiter les infections compliquees a Staphylococcus aureus resistant a la methicilline. Comme ces concentrations minimales plus elevees peuvent etre associees a la nephrotoxicite, il est necessaire de mieux definir les facteurs de risque potentiels de nephrotoxicite associee a l’administration de vancomycine. Objectifs : Determiner le nombre de cas de nephrotoxicite chez les patients recevant un traitement de vancomycine de plus de sept jours avec des concentrations minimales elevees (15–20 mg/L), ainsi que cerner et evaluer les facteurs de risque precis associes a une nephrotoxicite causee par la vancomycine (c.-a-d., une creatinine serique de ≥ 44,2 μmol/L ou une augmentation de ≥ 50 % [c.-a-d., ≥ 26,2 μmol/L] par rapport aux valeurs de base pendant deux jours consecutifs). Methodes : Les dossiers medicaux des patients rencontres entre janvier 2008 et mars 2011 dans deux importants hopitaux universitaires ont ete examines. Les patients chez qui les concentrations minimales de vancomycine avaient atteint des valeurs elevees ont ete evalues afin de juger s’ils etaient admissibles. Les patients dont la fonction renale etait instable, ceux qui subissaient une hemodialyse et ceux pour qui la posologie ou le temps d’echantillonnage n’etaient pas clairs ont ete exclus. Des analyses univariee et multivariee ont ete effectuees pour cerner les facteurs de risque associes a une nephrotoxicite. Les variables univariees dont le p etait inferieur a 0,1 ont ete incorporees dans le modele de regression logistique. Resultats : Parmi les 176 patients avec des concentrations minimales elevees, 24 (14 %) ont souffert de nephrotoxicite. Lors de l’analyse univariee, l’hospitalisation dans un service de medecine generale (unite ou les soins etaient prodigues pour 16 [67 %] des 24 patients souffrant de nephrotoxicite) ainsi que la prolongation du traitement avec la vancomycine ont ete reconnues comme des facteurs de risque de nephrotoxicite (p < 0,1). La comorbidite gastro-intestinale (p = 0,056), le cancer (p = 0,044) et la neutropenie febrile (p = 0,032) representaient aussi des facteurs de risque. L’analyse multivariee a determine que le traitement dans un service de medecine generale et les traitements de plus de sept jours etaient des indicateurs independants de risque de nephrotoxicite associee a la prise de vancomycine. Conclusion : Les patients ayant ete traites dans un service de medecine generale et ceux ayant recu un traitement de vancomycine de plus de sept jours presentaient un plus grand risque de nephrotoxicite. Le risque accru pour les patients sejournant dans un service de medecine generale est probablement multifactoriel. Le lien entre la duree du traitement et le risque de nephrotoxicite semble lineaire. Lorsqu’ils font appel a un traitement de vancomycine a concentration minimale elevee, les cliniciens doivent proceder a un suivi attentif pour deceler tout signe de nephrotoxicite.

To promote heightened vigilance concerning antibiotic agents in Canadian hospitals, Accreditation Canada has implemented antibiotic stewardship as a required organizational practice.1 Antibiotic stewardship is the process of ensuring that only necessary and appropriate antibiotic agents are used and that their use is appropriate for each individual patient. It involves optimizing all steps of antibiotic therapy, including appropriate selection, dosing, route, and duration. Through antibiotic stewardship strategies, a hospital can optimize the use of antibiotics, reduce the risk of opportunistic infections, stabilize or reduce antibiotic resistance, promote patient safety, and reduce health care costs.1,2 According to the American Society of HealthSystem Pharmacists, pharmacists have the ability, while providing care to individual patients, to effectively participate in antibiotic stewardship through their activities as members of health care teams and committees and by using their knowledge and abilities to focus on proper antibiotic utilization.3,4 The current study was conducted within the Providence Health Care health authority, which comprised 2 acute care hospitals and several residential facilities in the lower mainland of British Columbia. In this health authority, pharmacistinitiated antibiotic stewardship practices have been in place for many years, despite the absence of a formal antibiotic stewardship program. No pharmacists or physicians were specifically assigned responsibility for ensuring that antibiotic use was appropriate for admitted patients. However, pharmacists at Providence Health Care were involved on a day-to-day basis in pharmaceutical care related to all aspects of drug therapy for admitted patients, including antibiotic therapy. In the course of providing care, pharmacists frequently performed antibiotic stewardship activities, such as making recommendations to narrow the spectrum of activity of prescribed therapy, adjusting dosages, stepping down from parenteral to oral therapy, stopping unnecessary antibiotics, and switching to more appropriate antibiotics. The Antibiotic Subcommittee of the health authority’s Pharmacy and Therapeutics Committee had established restrictions, procedures, and recommendations regarding the use of antibiotic agents. The Pharmacy Department had an expectation that all pharmacists would perform activities appropriate for ensuring the optimal use of antibiotic agents. The purpose of this study was to quantify the antibiotic stewardship activities performed by pharmacists at Providence Health Care before implementation of a formal anti biotic stewardship program. A literature search identified no studies quantifying antibiotic stewardship activities performed by pharmacists in any Canadian hospital. The primary objective of the study was to quantify the various potential antibiotic stewardship activities related to target broad-spectrum antibiotics at St Paul’s Hospital and Mount Saint Joseph Hospital, the 2 acute care hospitals within Providence Health Care. The primary outcome was the proportion of patients included in the review who received the target antibiotics and experienced at least one antibiotic stewardship intervention by a pharmacist. The secondary objective was to determine the frequency of each type of antibiotic stewardship intervention.

Background: Recent guidelines recommend a vancomycin trough (predose) level between 15 and 20 mg/L in the treatment of invasive gram-positive infections, but most initial dosing nomograms are designed to achieve lower targets (5–15 mg/L). Clinicians need guidance about appropriate initial dosing to achieve the higher target. Objective: To develop and validate a high-target vancomycin dosing nomogram to achieve trough levels of 15–20 mg/L. Methods: A retrospective study was conducted at 2 teaching hospitals, St Paul’s Hospital and Vancouver General Hospital in Vancouver, British Columbia. Patients who were treated with vancomycin between January 2008 and June 2010 and who had achieved a trough level of 14.5–20.5 mg/L were identified. Demographic and clinical data were collected. Multiple linear regression was used to develop a vancomycin dosing nomogram for each hospital site. An integrated nomogram was constructed by merging the data from the 2 hospitals. A unique set of patients at each institution was used for validating their respective nomograms and a pooled group of patients for validating the integrated nomogram. Predictive success was evaluated, and a nomogram was deemed significantly different from another nomogram if p < 0.05 via “X 2 testing. Results: Data from 78 patients at one hospital and 91 patients at the other were used in developing the respective institutional nomograms. For each hospital’s data set, both age and initial serum creatinine were significantly associated with the predicted dosing interval ( p < 0.001). Validation in a total of 105 test patients showed that the integrated nomogram had a predictive success rate of 56%. Conclusions: A novel vancomycin dosing nomogram was developed and validated at 2 Canadian teaching hospitals. This integrated nomogram is a tool that clinicians can use in selecting appropriate initial vancomycin regimens on the basis of age and serum creatinine, to achieve high-target levels of 15–20 mg/L. The nomogram should not replace clinical judgment for patients with unstable and/or reduced renal function. RESUME Contexte : Des lignes directrices recentes recommandent des concentrations minimales (predose) entre 15 et 20 mg/L pour le traitement des infections envahissantes a bacteries Gram-positif, mais la plupart des nomogrammes pour la posologie initiale sont concus pour obtenir des concentrations cibles plus faibles (entre 5 et 15 mg/L). Les cliniciens ont besoin de conseils pour etablir la posologie initiale appropriee permettant d'atteindre des concentrations cibles plus elevees. Objectif : Developper et valider un nomogramme posologique ciblant des concentrations minimales elevees entre 15 et 20 mg/L. Methodes : Une etude retrospective a ete menee dans deux hopitaux universitaires de Vancouver (Colombie-Britannique), l’Hopital St. Paul et l’Hopital general de Vancouver. Les patients traites par la vancomycine entre janvier 2008 et juin 2010 chez qui on a obtenu des concentrations minimales se situant entre 14,5 et 20,5 mg/L ont ete recenses. Les donnees demographiques et cliniques ont ete collectees. Une analyse de regression lineaire multiple a servi a developper un nomogramme posologique pour la vancomycine a chaque hopital. Un nomogramme integre a ete construit en fusionnant les donnees des deux hopitaux. Une serie unique de patients a chaque hopital a servi a valider leur nomogramme respectif; un groupe combine de patients, le nomogramme integre. La reussite revisionnelle a ete evaluee et un nomogramme etait juge comme etant significativement different d’un autre si p < 0,05 d’apres le test du chi carre. Resultats : Les donnees de 78 patients dans l’un des hopitaux et de 91 patients dans l’autre ont ete utilisees pour developper leurs nomogrammes respectifs. Pour l’ensemble de donnees de chaque hopital, l’âge et la creatininemie etaient tous deux des variables predictives significatives de l’intervalle posologique ( p < 0,001). La validation chez un total de 105 patients experimentaux a montre que le nomogramme integre avait un taux de reussite previsionnel de 56 %. Conclusions : Un nomogramme posologique novateur pour la vancomycine a ete developpe et valide dans deux hopitaux universitaires canadiens. Ce nomogramme integre aidera les cliniciens a choisir les posologies initiales de vancomycine en tenant compte de l’âge et de la creatininemie, afin d’atteindre les concentrations cibles elevees de 15 a 20 mg/L. Le nomogramme ne doit pas remplacer le jugement du clinician chez les patients dont la fonction renale est instable ou reduite.

Background: Vancomycin is commonly prescribed at the authors’ institution because of a high prevalence of invasive infections caused by methicillin-resistant Staphylococcus aureus (MRSA) in a generally younger population. The most commonly prescribed empiric dosing interval is every 12 h (q12h). However, observations have suggested that younger adult patients require more frequent dosing, such as every 8 h (q8h). Initial underdosing of vancomycin may increase the risk of antibiotic failure. Objective: To determine whether patients under 40 years of age are more likely than older patients to require q8h dosing of vancomycin and whether recommendations can be made to alter current prescribing practices. Methods: This retrospective unmatched case–control study involved patients who had received vancomycin for suspected or confirmed severe MRSA infections. The cases were patients who had been confirmed as requiring q8h dosing, and the controls were patients who had been confirmed as requiring q12h dosing (on the basis of target predose serum levels). The influence of age (the predictor variable) on outcome (the vancomycin regimen) was evaluated by logistic regression. Results: The odds ratio for patients under 40 years of age requiring q8h dosing was 3.1 (95% confidence interval 1.5–6.3) (p = 0.002). Sixty percent of patients under 40 ultimately required a q8h regimen to achieve target predose serum levels. Patients who required q8h dosing took longer to achieve their first therapeutic serum level than those with q12h dosing (median 6 versus 4 days; p Conclusions: In this patient population, age less than 40 years was a strong predictor for requiring more frequent dosing of vancomycin. The authors suggest that doses of 15 mg/kg IV q8h be used empirically for younger patients with severe infections and normal renal function. RESUME Contexte : La vancomycine est couramment prescrite a l’etablissement des auteurs a cause de la prevalence elevee d’infections envahissantes a Staphylococcus aureus resistant a la methicilline (SARM) dans une population de patients generalement plus jeunes. L’intervalle posologique empirique le plus souvent prescrit est de 12 heures (q12h). Cependant, des observations ont permis de constater que les plus jeunes adultes requierent des frequences d’administration plus rapprochees, comme toutes les huit heures (q8h). Un intervalle posologique initial insuffisamment rapproche pourrait donc accroitre le risque d’echec de l’antibiotherapie par la vancomycine. Objectif : Determiner si les patients de moins de 40 ans sont plus susceptibles que les patients plus âges d’avoir besoin d’une frequence d’administration de la vancomycine toutes les 8 heures et si on peut formuler des recommandations visant a modifier les habitudes de prescription actuelles. Methodes : Cette etude retrospective de cas-temoins non apparies est fondee sur des patients qui avaient recu de la vancomycine pour une infection a SARM confirmee ou soupconnee. Les cas consistaient en des patients pour lesquels on avait confirme le besoin d’une frequence d’administration q8h et les temoins etaient des patients pour lesquels on avait confirme le besoin d’une frequence d’administration q12h (d’apres les concentrations seriques residuelles cibles). L’influence de l’âge (la variable predictive) sur les resultats (le regime posologique de la vancomycine) a ete evaluee a l’aide d’une analyse de regression logistique. Resultats : Le risque relatif approche pour les patients de moins de 40 ans qui avaient besoin d’une frequence d’administration q8h etait de 3,1 (intervalle de confiance a 95 % : 1,5-6,3) (p = 0,002). Soixante pour cent de ces patients ont finalement necessite une frequence d’administration q8h afin d’atteindre les concentrations seriques residuelles souhaitees. Les patients qui avaient besoin d’une frequence d’administration q8h ont atteint moins rapidement leur premiere concentration serique therapeutique que ceux dont la frequence d’administration etait q12h (nombre median de 6 jours contre 4 jours, respectivement; p Conclusions : Un âge inferieur a 40 ans s’est revele etre un puissant facteur de prediction du besoin de recourir a une frequence d’administration de la vancomycine plus rapprochee dans cette population. Les auteurs suggerent l’utilisation empirique de doses de 15 mg/kg i.v. q8h chez les patients plus jeunes souffrant d’infections graves et dont la fonction renale est normale.

Background: Alcohol withdrawal protocols involving symptom-triggered administration of benzodiazepine have been established to reduce the duration of treatment and the cumulative benzodiazepine dose (relative to usual care). However, the effects of a protocol combining fixed-schedule and symptom-triggered benzodiazepine dosing are less clear. Objective: To assess the efficacy and safety of a combination fixedscheduled and symptom-triggered benzodiazepine dosing protocol for alcohol withdrawal, relative to usual care, for medical inpatients at a tertiary care hospital. Methods: A chart review of admissions to the internal medicine service for alcohol withdrawal was conducted to compare treatment outcomes before (October 2005 to April 2007) and after (October 2007 to April 2009) implementation of the combination protocol. The primary outcome was duration of benzodiazepine treatment for alcohol withdrawal. The secondary outcomes were cumulative benzodiazepine dose administered, safety implications, and use of adjunctive medications. Results: A total of 159 patients met the inclusion criteria. Assessable data were available for 71 charts from the pre-implementation period and 72 charts from the post-implementation period. The median duration of benzodiazepine treatment was 91 h before implementation and 57 h after implementation ( p < 0.001). Use of the protocol was also associated with a significant reduction in severe complications of alcohol withdrawal (50% versus 33%, p = 0.019), median cumulative benzodiazepine dose (in lorazepam equivalents) (20.0 mg versus 15.5 mg, p = 0.026), and use of adjunctive medications (65% versus 38%, p = 0.001). The incidence of serious adverse outcomes of treatment with benzodiazepines was not significantly different between the 2 groups. Conclusions: Implementation of an alcohol withdrawal protocol with a combination of fixed-schedule and symptom-triggered enzodiazepine dosing in a medical ward was associated with a shorter duration of benzodiazepine use and a lower incidence of severe complications of alcohol withdrawal. RESUME Contexte : Les protocoles de sevrage alcoolique impliquant l’administration de benzodiazepine adaptee a la symptomatologie ont ete mis en place pour reduire la duree du traitement et la dose cumulative de benzodiazepine (par comparaison aux soins habituels). Cependant, les effets d’un protocole combinant l’administration de benzodiazepines a horaire fixe et adaptee a la symptomatologie sont moins clairs. Objectif : Evaluer l’efficacite et l’innocuite d’un protocole de sevrage alcoolique combinant l’administration de benzodiazepines a horaire fixe et adaptee a la symptomatologie, par comparaison aux soins habituels, chez des patients hospitalises dans un service medical d’un hopital de soins tertiaires. Methodes: Une analyse des dossiers medicaux des patients hospitalises dans un service de medecine interne pour un sevrage alcoolique a ete effectuee afin de comparer les resultats du traitement avant (entre octobre 2005 et avril 2007) et apres (octobre 2007 a avril 2009) la mise en oeuvre du protocole mixte. Le principal parametre d’evaluation etait la duree du traitement par les benzodiazepines pour le sevrage alcoolique. Les parametres d’evaluation secondaires etaient la dose cumulative de benzodiazepines administree, les repercussions sur l’innocuite et le recours a des medicaments d’appoint. Resultats : Un total de 159 patients ont satisfait aux criteres d’inclusion. Des donnees evaluables etaient disponibles pour 71 dossiers medicaux dans la periode precedant la mise en oeuvre du protocole et pour 72 dossiers medicaux dans la periode suivant la mise en oeuvre du protocole. La duree mediane du traitement par les benzodiazepines pour chaque periode ci-dessus etait de 91 et 57 heures, respectivement ( p < 0.001). L’utilisation de ce protocole a egalement ete associee a une reduction significative des complications graves du sevrage alcoolique (50 % contre 33 %; p = 0,019), de la dose cumulative mediane de benzodiazepines (en equivalent-lorazepam) (20,0 mg contre 15,5 mg, p = 0,026) et du recours a un medicament d’appoint (65 % contre 38 %, p = 0,001). La frequence des consequences indesirables serieuses du traitement par les benzodiazepines n’etait pas significativement differente entre les deux groupes. Conclusions : La mise en oeuvre d’un protocole de sevrage alcoolique combinant l’administration de benzodiazepines a horaire fixe et adaptee a la symptomatologie dans un service medical a ete associee a un traitement par les benzodiazepines plus court et a une frequence moindre des complications serieuses du sevrage alcoolique.

In a recent study, 50% of the patients who were admitted to a hospital's general medicine ward had at least one error in medication orders at the time of admission related to inaccuracies in the medication history. The use of computerized prescription databases has been suggested as a way to improve medication reconciliation at the time of admission.To quantify and describe unintended discrepancies between a best possible medication history and medications ordered on admission to the general medicine ward in a hospital with routine access to a provincial outpatient prescription database (British Columbia's PharmaNet).This prospective study involved 20 patients who were regularly using at least 4 prescription medications before admission to hospital. The best possible medication history for each patient (based on a review of the medical chart and the PharmaNet record and an interview with the patient) was compared with the physician's admission orders to identify any discrepancies. The frequency and perceived severity of discrepancies, graded independently by 3 physicians, were compared with observations from a similar study conducted at a hospital where a prescription database was not available.The 20 patients were recruited between September 2005 and January 2006. For 8 patients (40%), information in the PharmaNet database was consistent with the prescription medication list obtained during the best possible medication history at the time of admission. For the other 12 patients, a total of 30 unintended discrepancies were identified, 13 (43%) of which were classified as having potential for moderate or severe harm. The proportion of patients with unintended discrepancies was similar to that for the comparison cohort (60% versus 54%). Although the percentage of discrepancies involving omissions was lower than in the comparison population (37% versus 46%), these results were offset by a higher proportion of commission discrepancies (27% versus 0%).Unintended discrepancies were frequent, despite use of the PharmaNet database at the time of admission. Inconsistencies between the PharmaNet record and patients' actual medication use, coupled with failure to verify PharmaNet data with patients, were likely contributing factors.

To determine the association between antibiotic exposure in the first year of life and the development of childhood asthma.Metaanalysis of observational studies retrieved through systematic search of all available electronic data sources. Studies included in the metaanalyses were those with populations exposed to one or more courses of antibiotics during the first year of life, and asthma diagnosis was defined as diagnosis by a physician between the age of 1 to 18 years.Retrospective and prospective studies published in the English-language literature from 1966 to present.Eight studies (four prospective and four retrospective) examined the association between exposure to at least one course of antibiotics and development of childhood asthma. The total number of subjects for the analysis comparing exposure to at least one antibiotic to no exposure in the first year of life was 12,082 children and 1,817 asthma cases. In the dose-response analysis, we included data from a total of 27,167 children and 3,392 asthma cases. The pooled odds ratio (OR) for the eight studies was 2.05 (95% confidence interval [CI], 1.41 to 2.99). The association was significantly stronger in the retrospective studies (OR, 2.82; 95% CI, 2.07 to 3.85) than the prospective studies (OR, 1.12; 95% CI, 0.88 to 1.42). Five of the eight studies examined whether the association was related to the number of courses of antibiotics taken in the first year of life. The overall OR for the dose-response analysis was 1.16 (95% CI, 1.05 to 1.28) for each additional course of antibiotics; however, this association was not significantly stronger in the retrospective studies (OR, 1.37; 95% CI, 1.18 to 1.60) relative to the prospective studies (OR, 1.07; 95% CI, 0.95 to 1.20).Exposure to at least one course of antibiotics in the first year of life appears to be a risk factor for the development of childhood asthma. Because of the limitations of the studies conducted to date, additional large-scale, prospective studies are needed to confirm this potential association.