A Systematic Review of Randomized Controlled Trials Comparing Hypertonic Sodium Solutions and Mannitol for Traumatic Brain Injury: Implications for Emergency Department Management.

OBJECTIVE: To comparatively evaluate hypertonic sodium (HTS) and mannitol in patients following acute traumatic brain injury (TBI) on the outcomes of all-cause mortality, neurological disability, intracranial pressure (ICP) change from baseline, ICP treatment failure, and serious adverse events. DATA SOURCES: PubMed, EMBASE, CENTRAL, Cochrane Database of Systematic Reviews, ClinicalTrials.gov, and WHO ICTRP (World Health Organization International Clinical Trials Registry Platform) were searched (inception to November 2015) using hypertonic saline solutions, sodium chloride, mannitol, osmotic diuretic, traumatic brain injury, brain injuries, and head injury. Searches were limited to humans. Clinical practice guidelines and bibliographies were reviewed. STUDY SELECTION AND DATA EXTRACTION: Prospective, randomized trials comparing HTS and mannitol in adults (≥16 years) with severe TBI (Glasgow Coma Scale score ≤8) and elevated ICP were included. ICP elevation, ICP reduction, and treatment failure were defined using study definitions. DATA SYNTHESIS: Of 326 articles screened, 7 trials enrolling a total of 191 patients met inclusion criteria. Studies were underpowered to detect a significant difference in mortality or neurological outcomes. Due to significant heterogeneity and differences in reporting ICP change from baseline, this outcome was not meta-analyzed. No difference between HTS and mannitol was observed for mean ICP reduction; however, risk of ICP treatment failure favored HTS (risk ratio [RR] = 0.39; 95% CI = 0.18-0.81). Serious adverse events were not reported. CONCLUSIONS: Based on limited data, clinically important differences in mortality, neurological outcomes, and ICP reduction were not observed between HTS or mannitol in the management of severe TBI. HTS appears to lead to fewer ICP treatment failures.

Development of clinical pharmacy key performance indicators for hospital pharmacists using a modified Delphi approach.

BACKGROUND: Key performance indicators (KPIs) are quantifiable measures of quality. There are no published, systematically derived clinical pharmacy KPIs (cpKPIs). OBJECTIVE: A group of hospital pharmacists aimed to develop national cpKPIs to advance clinical pharmacy practice and improve patient care. METHODS: A cpKPI working group established a cpKPI definition, 8 evidence-derived cpKPI critical activity areas, 26 candidate cpKPIs, and 11 cpKPI ideal attributes in addition to 1 overall consensus criterion. Twenty-six clinical pharmacists and hospital pharmacy leaders participated in an internet-based 3-round modified Delphi survey. Panelists rated 26 candidate cpKPIs using 11 cpKPI ideal attributes and 1 overall consensus criterion on a 9-point Likert scale. A meeting was facilitated between rounds 2 and 3 to debate the merits and wording of candidate cpKPIs. Consensus was reached if 75% or more of panelists assigned a score of 7 to 9 on the consensus criterion during the third Delphi round. RESULTS: All panelists completed the 3 Delphi rounds, and 25/26 (96%) attended the meeting. Eight candidate cpKPIs met the consensus definition: (1) performing admission medication reconciliation (including best-possible medication history), (2) participating in interprofessional patient care rounds, (3) completing pharmaceutical care plans, (4) resolving drug therapy problems, (5) providing in-person disease and medication education to patients, (6) providing discharge patient medication education, (7) performing discharge medication reconciliation, and (8) providing bundled, proactive direct patient care activities. CONCLUSIONS: A Delphi panel of hospital pharmacists was successful in determining 8 consensus cpKPIs. Measurement and assessment of these cpKPIs will serve to advance clinical pharmacy practice and improve patient care.

Evaluation of the quality of 'do not use' medication abbreviation audits: a key enabler to successful implementation of audit and feedback.

Background Hospital pharmacy audit and feedback of 'do not use' medication abbreviations improves patient safety. For audit and feedback systems to be effective, the data captured must be of high quality such that end-users trust the information to guide practice change. The quality of data captured during monthly standardized pharmacy 'do not use' abbreviation audits is currently unknown. Objective We aimed to assess pharmacy 'do not use' abbreviation audit data quality. Method Primary audit data quality was assessed by examining a random sample of handwritten medication prescriptions for the presence and type of 'do not use' abbreviations. This data was compared with the pharmacy monthly audit data to determine data capture agreement and consistency over time. Results There were 1132 prescriptions from July, October, and December 2019 included. Data capture agreement between the pharmacy audit and the secondary assessment using Cohen's Kappa ranged from 0.53 to 0.63. The primary audit under-reported 'do not use' abbreviation rates, however this did not vary over time (χ2 = 1.215, p = 0.545). Conclusion Pharmacy staff audits under-reported 'do not use' abbreviation rates, however this was consistent over time. The quality of pharmacy audits should be assessed and disseminated to end-users prior to implementing feedback.

Prophylactic intravenous magnesium sulphate in addition to oral {beta}-blockade does not prevent atrial arrhythmias after coronary artery or valvular heart surgery: a randomized, controlled trial.

BACKGROUND: Atrial arrhythmias (AA) are an important cause of morbidity after cardiac surgery. Efforts at prevention of postoperative AA have been suboptimal. Perioperative beta-blocker administration is the standard of care at many centers. Although prophylactic administration of magnesium sulfate (MgSO(4)) has been recommended, review of all previously published trials of MgSO(4) reveals conflicting results. This study was designed to address methodological shortcomings from previous studies and is the largest randomized, placebo-controlled trial of intravenous (IV) MgSO(4) for the prevention of AA after coronary artery bypass grafting or cardiac valvular surgery. METHODS AND RESULTS: A total of 927 nonemergent cardiac surgery patients were stratified into 2 groups: isolated coronary artery bypass grafting (n=694), or valve surgery with or without coronary artery bypass grafting (n=233), and randomized to receive either 5g IV MgSO(4) or placebo on removal of the cross-clamp, followed by daily 4-hour infusions, from postoperative day 1 until postoperative day 4. All patients were treated according to an established oral beta-blocker protocol. Postoperative serum Mg levels were checked and standard of care was to administer IV MgSO(4) for low serum levels. The primary end point was AA lasting > or =30 minutes or requiring treatment for hemodynamic compromise. There were no differences in the incidence of AA between patients who received IV MgSO(4) or placebo (26.4% versus 24.3%, respectively). The results were similar when broken down according to stratified groups. CONCLUSIONS: In patients treated with a protocol for postoperative oral beta-blocker after nonemergent cardiac surgery, the addition of prophylactic IV MgSO(4) did not reduce the incidence of AA.

Identifying missed opportunities to curtail antimicrobial therapy for presumed ventilator-associated pneumonia using the clinical pulmonary infection score.

BACKGROUND: Early discontinuation of antimicrobial therapy for ventilator-associated pneumonia can reduce the emergence of antimicrobial resistance, the occurrence of adverse drug events, and the cost of therapy. Evidence suggests that discontinuation of therapy by day 3 may be appropriate for patients with a clinical pulmonary infection score of 6 or less at baseline and on day 3. OBJECTIVES: To determine the proportion of patients eligible for antimicrobial discontinuation on day 3 and day 7 of therapy and to determine the proportion of eligible patients for whom antimicrobials were discontinued within these timeframes. METHODS: A 6-month observational study was conducted from October 3, 2005, to March 31, 2006, in a 27-bed medical-surgical tertiary care intensive care unit. Clinical pharmacists attended daily rounds and prospectively identified patients for inclusion in the study. A study pharmacist retrospectively calculated clinical pulmonary infection scores. Other data were obtained from the quality-improvement database and patient health records for the intensive care unit. RESULTS: Ninety-two patients were treated for ventilator-associated pneumonia during the study period, of whom 49 were included in the analysis. At day 3, 17 (35%) of the 49 patients were eligible for early discontinuation of antimicrobial therapy, but therapy was discontinued for only 2 (12%) of these 17 patients. At day 7, 10 (32%) of 31 patients were eligible for antimicrobial discontinuation, but therapy was discontinued for only 1 (10%) of these 10 patients. CONCLUSIONS: A significant opportunity exists at the authors' institution to develop and implement an antimicrobial discontinuation policy that uses the clinical pulmonary infection score to guide antimicrobial use for patients with ventilator-associated pneumonia.

Contribution of Pharmacy Practice Residents to Resolution of Drug Therapy Problems for Patients: RES-DTP Study.

BACKGROUND: Canadian pharmacy practice residency programs promote development of key competencies for direct patient care resulting in resolution of drug therapy problems (DTPs), which is 1 of 8 national clinical pharmacy key performance indicators. There are no Canadian data on the contribution of residents to resolution of DTPs, including DTPs for priority diseases covered in disease-state education modules (PD-DTPs) or quality indicator DTPs (QI-DPTs), as assessed through application of evidence-based interventions proven to reduce morbidity, mortality, or health resource utilization. OBJECTIVE: To describe the contribution of pharmacy practice residents to direct patient care using 3 process-of-care measures: resident-resolved DTPs, PD-DTPs, and QI-DTPs. METHODS: This prospective, observational single-group study was conducted across 5 rotation sites within the authors' health authority from September 2, 2013, to June 13, 2014. The primary outcome was number of DTPs resolved. The secondary outcomes were number of PD-DTPs resolved; number of QI-DTPs resolved; numbers of DTPs, PD-DTPs, and QI-DTPs resolved over time; and residents' satisfaction with electronic tracking of resolved DTPs (in terms of training, usability, efficiency, and time requirements). RESULTS: Four residents completed a total of twenty-one 4-week rotations and resolved a total of 1201 DTPs. Of these, 620 (52%) were PD-DTPs and 479 (40%) were QI-DTPs. Overall, the number of interventions increased for rotations 1-3, decreased for rotations 4 and 5, and increased again for rotation 6. The median score for all questions in all domains of the satisfaction survey was 4 out of 5 ("agree"). CONCLUSIONS: Pharmacy practice residents were resolving DTPs, PD-DTPs, and QI-DTPs for patients and were contributing significantly to direct patient care. On the basis of literature evidence, the number and type of interventions observed in this study would be expected to improve clinical and health economic outcomes for patients.

CONTEXTE: Les programmes de résidence canadiens en pratique pharmaceutique encouragent le développement de compétences clés relatives aux soins directs offerts aux patients. Ces compétences entraîneront la résolution des problèmes de pharmacothérapie (DTP), l'un des huit indicateurs clés nationaux de rendement relatifs à la pharmacie clinique. Il n'existe pas de données canadiennes portant sur la contribution des résidents à la résolution des problèmes de pharmacothérapie, notamment ceux relatifs aux maladies prioritaires (PD-DTP) couverts dans les modules d'éducation sur les problèmes de santé, ou les indicateurs de qualité des DTP (QI-DPT), évalués au moyen d'interventions fondées sur des données scientifiques dont il a été prouvé qu'elles réduisaient la morbidité, la mortalité ou l'utilisation des ressources sanitaires. Dans une étude, les intervenants avaient des opinions divergentes concernant la contribution des résidents à la résolution des DTP, des PD-DTP et des QI-DTP. OBJECTIF: Décrire la contribution des résidents dans le cadre de la pratique pharmaceutique des soins directs offerts aux patients à l'aide de trois mesures spécifiques du processus des soins : DTP, PD-DTP et QI-DTP résolus par les résidents. MÉTHODES: Cette étude prospective par observation portant sur un seul groupe a été menée dans cinq sites de rotation compris dans la sphère d'autorité sanitaire des auteurs, du 2 septembre 2013 au 13 juin 2014. Le résultat principal était le nombre de DTP résolus. Les résultats secondaires étaient les suivants : nombre de PD-DTP résolus; nombre de QI-DTP résolus; nombre de DTP, de PD-DTP et de QI-DTP résolus avec le temps; et la satisfaction des résidents à l'égard du suivi électronique de leurs DTP résolus (en termes de formation, de facilité d'utilisation, d'efficacité et d'exigences en matière de temps). RÉSULTATS: Quatre résidents ont effectué un total de 21 rotations de quatre semaines et ont résolu 1201 DTP. De ceux-ci, 620 (52 %) étaient des PD-DTP et 479 (40 %), des QI-DTP. Les interventions générales ont augmenté de la 1re à la 3e rotation; elles ont diminué à la 4e et à la 5e rotation; elles ont à nouveau augmenté à la 6e rotation. Le score moyen de toutes les questions posées dans l'enquête de satisfaction, tous domaines confondus, était de 4 sur 5 (ou « d'accord ¼). CONCLUSIONS: Les résidents en pratique pharmaceutique résolvaient les DTP, les PD-DTP et les QI-DTP des patients et contribuaient de manière significative aux soins directs aux patients. Sur base de la documentation, on pourrait s'attendre à ce que le nombre et le type d'interventions observées dans cette étude améliorent les résultats cliniques et sanitaires des patients.

Development of intervention-related quality indicators for renal clinical pharmacists using a modified Delphi approach.

OBJECTIVE: To develop a list of renal Quality Indicator Drug therapy problems (QI-DTPs) that serve to advance renal pharmacy practice to improve patient care. METHODS: Eighteen (18) renal, clinical pharmacists participated in an internet-based three-round modified Delphi survey. Each of the three rounds took approximately 2 weeks to complete. Panellists rated 30-candidate renal QI-DTPs using seven selection criteria and one overall consensus criterion on a nine-point Likert scale. Consensus was reached if 75% or more of panellists assigned a score of 7-9 on the consensus criterion during the third Delphi round. KEY FINDINGS: All panellists completed three rounds of Delphi survey. Seventeen-candidate renal QI-DTPs met the consensus definition. CONCLUSIONS: A Delphi panel of renal clinical pharmacists successfully identified 17 consensus renal QI-DTPs. Assessment and implementation of these QI-DTPs will serve to advance renal pharmacy practice and improve patient care.

Corticosteroid treatment of severe community-acquired pneumonia.

OBJECTIVE: To assess the evidence for adjunctive corticosteroids for severe community-acquired pneumonia (CAP). DATA SOURCES: MEDLINE (1966-February 2007) and EMBASE (1980-February 2007) were searched to identify English- and French-language publications that evaluated the use of corticosteroids for CAP in adults. Major search terms included community-acquired pneumonia, intensive care unit, steroids, glucocorticoids, and adrenal cortex hormones. STUDY SELECTION AND DATA EXTRACTION: Clinical studies that evaluated the use of corticosteroids for CAP in adults were included. Clinical and surrogate markers of pneumonia were evaluated. DATA SYNTHESIS: Severe CAP is associated with an increase in pulmonary and circulatory cytokines such as interleukin-6 and tumor necrosis factor-alpha that may be associated with higher mortality. Corticosteroids suppress inflammatory reactions and prevent migration of inflammatory cells from the circulation to tissues by suppressing the synthesis of chemokines and cytokines. One observational comparative study and 2 randomized, controlled studies examined the effects of corticosteroid therapy at various doses on endpoints of pulmonary and systemic inflammation and clinical outcomes. One small observational pilot study revealed that methylprednisolone blunted some of the pulmonary and systemic markers of inflammation. One small, randomized, placebo-controlled study revealed that hydrocortisone had no significant effects on markers of pulmonary and systemic inflammation or clinical outcomes. Another small, randomized, placebo-controlled preliminary study with methodological limitations revealed improvements in oxygenation, organ dysfunction score, and markers of inflammation favoring hydrocortisone over placebo. CONCLUSIONS: Given the lack of proven benefit on clinically meaningful endpoints and adverse events, corticosteroids cannot be recommended for adjunctive treatment of severe CAP.

Positive and Negative Impacts of a Continuing Professional Development Intervention on Pharmacist Practice: A Balanced Measure Evaluation.

INTRODUCTION: Evaluations of behavior change interventions aimed at improving professional practice are increasingly focused on impacts at the practice and patient outcome levels. Many of these evaluations assume that if the intended changes occur, the result represents an improvement. However, given the systemic nature of clinical practice, a change in one area can produce changes in other areas as well, some of which may adversely affect the patient. Balancing measures are used to determine whether unintended consequences of an intervention have been introduced into other areas of the system. The aims of this study were to evaluate the impact of behavior change intervention-based continuing professional development (CPD) on pharmacist interventions (resolution of drug therapy problems-DTPs) and resolution of quality indicator DTPs and knowledge change for urinary tract infections (UTI) and pneumonia. As a balancing measure, we aimed to determine whether delivery of behavior change interventions targeting pneumonia and UTI practice results in a negative impact on other important pharmacist interventions, specifically the resolution of heart failure DTPs. METHODS: A quasiexperimental study was conducted at a Canadian health authority that evaluated the impacts of an 8-week multifaceted behavior change intervention delivered to 58 ward-based pharmacists. The primary outcome was change in proportion of UTI and pneumonia DTPs resolved from the 6-month preintervention to 6-month postintervention phase. Secondary outcomes were changes in proportion of UTI and pneumonia quality indicator DTPs resolved, knowledge quiz scores, and proportion of quality indicator DTPs resolved for heart failure as a balancing measure. RESULTS: A total of 58 pharmacists were targets of the intervention. The proportion of resolved UTI and pneumonia DTPs increased from 17.8 to 27.2% (relative risk increase 52.8%, 95% confidence interval [CI] 42.8-63.6%; P < 0.05). The proportion of resolved UTI and pneumonia quality indicator DTPs increased from 12.2% to 18.2% (relative risk increase 49.9%, 95% CI 34.5-67.0%; P < 0.05). Resolved heart failure DTPs decreased from 14.3 to 8.5% (RRR 40.4%, 95% CI 33.9-46.2%; P < 0.05). Thirty-six pharmacists completed the pre- and post-quiz. Scores increased from 11.3/20 ± 3.2/20 to 14.8/20 ± 2.9/20 (P < 0.05). DISCUSSION: CPD using a multifaceted behavior change intervention improved pharmacist behavior and knowledge for UTI and pneumonia. However, these improvements may be offset by reduced interventions for other disease states, such as heart failure. Strategies to mitigate the unintended effects on other professional behaviors should be implemented when delivering CPD focused on changing one aspect of professional behavior.

Etomidate for rapid sequence intubation in the emergency department: is adrenal suppression a concern?

Etomidate has become one of the most commonly used induction agents in the United States during emergency department (ED) endotracheal intubation. While etomidate may be popular, concerns have been raised about possible adrenal suppression and subsequent adverse effects. In this paper we critically evaluate the recent literature and perspectives regarding the effect of etomidate on the adrenocortical system.

Selecting antibacterials for outpatient parenteral antimicrobial therapy : pharmacokinetic-pharmacodynamic considerations.

Some infectious diseases require management with parenteral therapy, although the patient may not need hospitalisation. Consequently, the administration of intravenous antimicrobials in a home or infusion clinic setting has now become commonplace. Outpatient parenteral antimicrobial therapy (OPAT) is considered safe, therapeutically effective and economical. A broad range of infections can be successfully managed with OPAT, although this form of treatment is unnecessary when oral therapy can be used. Many antimicrobials can be employed for OPAT and the choice of agent(s) and regimen should be based upon sound clinical and microbiological evidence. Assessments of cost and convenience should be made subsequent to these primary treatment outcome determinants. When designing an OPAT treatment regimen, the pharmacokinetic and pharmacodynamic characteristics of the individual agents should also be considered. Pharmacokinetics (PK) is the study of the time course of absorption, distribution, metabolism and elimination of drugs (what the body does to the drug). Clinical pharmacokinetic monitoring has been used to overcome the pharmacokinetic variability of antimicrobials and enable individualised dosing regimens that attain desirable antimicrobial serum concentrations. Pharmacodynamics (PD) is the study of the relationship between the serum concentration of a drug and the clinical response observed in a patient (what the drug does to the body). By combining pharmacokinetic properties (peak [C(max)] or trough [C(min)] serum concentrations, half-life, area under the curve) and pharmacodynamic properties (susceptibility results, minimum inhibitory concentrations [MIC] or minimum bactericidal concentrations [MBC], bactericidal or bacteriostatic killing, post-antibiotic effects), unique PK/PD parameters or indices (t > MIC, C(max)/MIC, AUC(24)/MIC) can be defined. Depending on the killing characteristics of a given class of antimicrobials (concentration-dependent or time-dependent), specific PK/PD parameters may predict in vitro bacterial eradication rates and correlate with in vivo microbiologic and clinical cures. An understanding of these principles will enable the clinician to vary dosing schemes and design individualised dosing regimens to achieve optimal PK/PD parameters and potentially improve patient outcomes. This paper will review basic principles of useful PK/PD parameters for various classes of antimicrobials as they may relate to OPAT. In summary, OPAT has become an important treatment option for the management of infectious diseases in the community setting. To optimise treatment course outcomes, pharmacokinetic and pharmacodynamic properties of the individual agents should be carefully considered when designing OPAT treatment regimens.

Intravenous amiodarone for conversion of atrial fibrillation: misled by meta-analysis?

Therapeutic goals for atrial fibrillation (AF) include ventricular rate control, stroke prevention, conversion to normal sinus rhythm, and maintenance of normal sinus rhythm. The optimal strategy of rate versus rhythm control for acute management of patients with AF is a continuing debate. However, selected patients may require acute treatment with antiarrhythmic agents for conversion of symptomatic AF episodes to normal sinus rhythm. Recently published randomized controlled trials, qualitative systematic reviews, meta-analyses, and evidence-based international consensus guidelines have addressed the controversy regarding acute conversion of AF using antiarrhythmic therapy. Although meta-analyses often provide the highest level of evidence, the validity and application of their results are based on the quality of their methodology and accuracy of reporting. Authors of the most recent meta-analysis of amiodarone for conversion of AF state that the drug is effective and relatively rapid acting in converting AF to normal sinus rhythm in a wide range of patients, and they recommend it as a first-line drug. We feel that these conclusions are overstated and potentially misleading due to methodologic limitations of the analysis. The results of this meta-analysis and others concerning acute conversion of AF should be viewed as hypothesis generating and not the definitive answer to this question. Ultimately, well-designed, adequately powered, randomized placebo- or rate-controlled trials are needed in specific patient populations with AF to determine the absolute benefit of intravenous amiodarone for conversion of AF to normal sinus rhythm. Until more data are available, intravenous amiodarone cannot be promoted as a first-line agent for this purpose.

Intravenous amiodarone for acute pharmacological conversion of atrial fibrillation in the emergency department.

Atrial fibrillation (AF) is the most common arrhythmia seen in patients presenting to the emergency department (ED). Pharmacological conversion of atrial fibrillation to normal sinus rhythm (NSR) may be a feasible management strategy in selected patients. Recent guidelines have recommended intravenous amiodarone, a class III antiarrhythmic agent, for the conversion of AF to NSR. The purpose of this review is to examine the published evidence for the efficacy of IV amiodarone for the acute conversion of AF to NSR in the ED. Currently available data from 11 randomized, controlled trials and 3 meta analyses do not support the use of conventional doses of IV amiodarone for acute conversion in the ED. High dose IV or combined IV and oral administration may be effective as early as 8 hours in patients with recent-onset AF of <48 hour duration in patients without contraindications to these high dose regimens. There are no data to support the use of IV amiodarone for acute conversion in patients with an ejection fraction of <40% or clinical heart failure, so its use in these scenarios should be limited to symptomatic patients who are refractory to electrical conversion. More well-designed studies are required to determine the role of IV amiodarone for the acute conversion of AF in the ED.

Presence and accuracy of drug dosage recommendations for continuous renal replacement therapy in tertiary drug information references.

BACKGROUND: Clinicians commonly rely on tertiary drug information references to guide drug dosages for patients who are receiving continuous renal replacement therapy (CRRT). It is unknown whether the dosage recommendations in these frequently used references reflect the most current evidence. OBJECTIVE: To determine the presence and accuracy of drug dosage recommendations for patients undergoing CRRT in 4 drug information references. METHODS: Medications commonly prescribed during CRRT were identified from an institutional medication inventory database, and evidence-based dosage recommendations for this setting were developed from the primary and secondary literature. The American Hospital Formulary System-Drug Information (AHFS-DI), Micromedex 2.0 (specifically the DRUGDEX and Martindale databases), and the 5th edition of Drug Prescribing in Renal Failure (DPRF5) were assessed for the presence of drug dosage recommendations in the CRRT setting. The dosage recommendations in these tertiary references were compared with the recommendations derived from the primary and secondary literature to determine concordance. RESULTS: Evidence-based drug dosage recommendations were developed for 33 medications administered in patients undergoing CRRT. The AHFS-DI provided no dosage recommendations specific to CRRT, whereas the DPRF5 provided recommendations for 27 (82%) of the medications and the Micromedex 2.0 application for 20 (61%) (13 [39%] in the DRUGDEX database and 16 [48%] in the Martindale database, with 9 medications covered by both). The dosage recommendations were in concordance with evidence-based recommendations for 12 (92%) of the 13 medications in the DRUGDEX database, 26 (96%) of the 27 in the DPRF5, and all 16 (100%) of those in the Martindale database. CONCLUSIONS: One prominent tertiary drug information resource provided no drug dosage recommendations for patients undergoing CRRT. However, 2 of the databases in an Internet-based medical information application and the latest edition of a renal specialty drug information resource provided recommendations for a majority of the medications investigated. Most dosage recommendations were similar to those derived from the primary and secondary literature. The most recent edition of the DPRF is the preferred source of information when prescribing dosage regimens for patients receiving CRRT.

Evaluation of the research grant program of the Foundation of the Canadian Society of Hospital Pharmacists, 1995-2008.

BACKGROUND: Pharmacist-led research has grown substantially over the past 10 to 15 years. The Research Grant Program of the Research and Education Foundation of the Canadian Society of Hospital Pharmacists (CSHP Foundation), initiated in 1992, is the only funding opportunity available specifically to members of the Society. OBJECTIVE: To evaluate the status of research projects funded by the Research Grant Program of the CSHP Foundation, to examine the outcomes of these projects, and to determine the opinions of grant recipients regarding this competition. METHODS: An e-mail survey was sent to each of the 34 hospital pharmacist researchers who received funding from the Research Grant Program of the CSHP Foundation during the period 1995 to 2008. Survey questions sought to evaluate scholarly outcomes (i.e., publications and presentations) from funded projects. The opinions of grant recipients about the value of the program were also solicited. RESULTS: One of the potential respondents had returned the grant money and was ineligible for the survey. Of the 33 potential respondents, 30 (91%) responded to the survey. Overall, 24 of the projects had been completed at the time of the survey, and 19 of these had been published, resulting in a total of 26 manuscripts. Abstracts had been presented for 21 of the projects. In total, 49 abstracts had been presented at national (22), international (13), provincial (7) and local (7) conferences. The median award was $5000 (interquartile range $5000 to $7500). Eleven of the projects had received additional funding, primarily from the recipient's hospital or health authority or from university sources. The survey respondents indicated that the grant from the CSHP Foundation had been critical to completion of their projects and had been of assistance in securing additional funding, when such funding was necessary. Respondents felt that dedicated research funding for hospital pharmacists in Canada should continue. CONCLUSIONS: The Research Grant Program of the CSHP Foundation has been important to hospital pharmacists, enabling a variety of research projects to be initiated and completed. The high rate of project completion and the large number of publications and presentations resulting from this work speak to both the quality of the work and the dedication of the research teams. The CSHP Foundation should continue to fund this competition and should explore a more robust model, with larger awards and more funded projects each year.

A critical appraisal of the quality of critical care pharmacotherapy clinical practice guidelines and their strength of recommendations.

OBJECTIVE: Clinical practice guideline (CPG) quality assessment is important before applying their recommendations. Determining whether recommendation strength is consistent with supporting quality of evidence is also essential. We aimed to determine quality of critical care pharmacotherapy CPGs and to assess whether high quality evidence supports strong pharmacotherapy recommendations. METHODS: MEDLINE (1966-February 2008), EMBASE (1980-February 2008), National Guideline Clearinghouse (February 2008) and personal files were searched to identify CPGs. Four appraisers evaluated each guideline using the appraisal of guidelines, research and evaluation (AGREE) instrument. AGREE assesses 23 items in six domains that include scope/purpose, stakeholder involvement, rigor of development, clarity, applicability and editorial independence. Standardized domain scores (0-100%) were determined to decide whether to recommend a guideline for use. One appraiser extracted strong pharmacotherapy recommendations and supporting evidence quality. RESULTS: Twenty-four CPGs were included. Standardized domain scores were clarity [69% (95% confidence interval (CI) 62-76%)], scope/purpose [62% (95% CI 55-68%)], rigor of development [51% (95% CI 42-60%)], editorial independence [39% (95% CI 26-52%)], stakeholder involvement [32% (95% CI 26-37%)] and applicability [19% (95% CI 12-26%)]. The proportion of guidelines that could be strongly recommended, recommended with alterations and not recommended was 25, 37.5 and 37.5%, respectively. High quality evidence supported 36% of strong pharmacotherapy recommendations. CONCLUSION: Variation in AGREE domain scores explain why one-third of critical care pharmacotherapy CPGs cannot be recommended. Only one-third of strong pharmacotherapy recommendations were supported by high quality evidence. We recommend appraisal of guideline quality and the caliber of supporting evidence prior to applying recommendations.

Update on cardiopulmonary resuscitation and emergency cardiovascular care guidelines.

PURPOSE: The key changes included in the 2005 cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC) guidelines are reviewed. Advances since publication of the current guidelines are also discussed. SUMMARY: The 2005 CPR and ECC guidelines include several key changes from the previous version published in 2000. The new guidelines place an increased emphasis on chest compressions and recommend a compression:ventilation (C:V) ratio of 30:2. Current knowledge on defibrillation has also been incorporated by recommending that Emergency Medical Service (EMS) rescuers give two minutes of CPR before defibrillation when the response interval is greater than four to five minutes and EMS responders did not witness the arrest. Another major change is the recommendation for a single shock to be administered followed immediately by CPR with no check of the cardiac rhythm until two minutes of CPR has been performed postdefibrillation. The 2005 guidelines recommend that an automated external defibrillator should be implemented in public locations where there is a relatively high likelihood of witnessed cardiac arrest. In addition, the most recent guidelines highlight the shift from primary-rhythm-based therapies and resuscitation to a focus on neurologic outcomes. CONCLUSION: Several evidence-based changes were included in the 2005 CPR and ECC guidelines, including a C:V ratio of 30:2 and mitigation of hands-off time, early defibrillation, administration of a single shock versus a three-shock sequence, use of public-access defibrillators, and a shift from primary-rhythm-based therapies to a focus on neurologic outcomes.