A Systematic Review of Antimicrobial Stewardship Interventions to Improve Management of Bacteriuria in Hospitalized Adults.

OBJECTIVE: To determine whether implementation of antimicrobial stewardship (AMS) interventions improve management of bacteriuria in hospitalized adults. DATA SOURCES: EMBASE, MEDLINE, CINAHL, and Clinical Trials Registries via Cochrane CENTRAL were searched from inception through May 2021. Reference lists of included studies were searched, and Scopus was used to retrieve articles that cited included references. STUDY SELECTION AND DATA EXTRACTION: Randomized and nonrandomized trials, controlled before-after studies, interrupted time-series studies, and repeated measures studies evaluating AMS interventions for hospitalized adult inpatients with bacteriuria were included. Risk of bias was assessed independently by 3 team members and compared. Results were summarized descriptively. DATA SYNTHESIS: The search yielded 5509 articles, of which 13 met inclusion criteria. Most common interventions included education (N = 8) and audit and feedback (N = 5) alone or in combination with other interventions. Where assessed, resource and antimicrobial use primarily decreased and appropriateness of antimicrobial use improved; however, impact on guideline adherence was variable. All studies were rated as having unclear or serious risk of bias. This review summarizes and assesses the quality of evidence for AMS interventions to improve the management of bacteriuria. Results provide guidance to both AMS teams and researchers aiming to develop and/or evaluate AMS interventions for management of bacteriuria. CONCLUSIONS: This review demonstrated benefit of AMS interventions on management of bacteriuria. However, most studies had some risk of bias, and an overall effect across studies is unclear due to heterogeneity in outcome measures.

Community pharmacists' perspectives on assessing kidney function and medication dosing for patients with advanced chronic kidney disease: A qualitative study using the theoretical domains framework.

Background: The kidneys are responsible for the elimination of many drugs. Chronic kidney disease (CKD) is common, and medications may require adjustment to avoid adverse outcomes. Despite the availability of kidney drug dosing resources, people with CKD are at risk of inappropriate drug prescribing. Community pharmacists are in the ideal position to mitigate harm from inappropriate prescribing in this population. Methods: In this qualitative study, community pharmacists were interviewed on their perspective on kidney function assessment and dose adjustment in people with advanced CKD (estimated glomerular filtration rate <30 mL/min/1.73 m2). The theoretical domains framework for targeting behavioural change was used to inform the interview guide and analysis. Purposeful sampling was employed until data saturation. Semistructured virtual interviews were audio-recorded, transcribed verbatim and uploaded into NVIVO 12 Pro to facilitate thematic analysis. Deductive and inductive iterative coding approaches were employed to determine categories and themes. Results: Twelve pharmacists were interviewed, with a mean age of 42 years and 16 years of experience. Four themes comprising 10 categories were identified to influence kidney function assessment and dosing, including resources (information access, technology, references), environment (pharmacy infrastructure, practice setting), reflection (triggers, experience and training, collaboration) and leadership and governance (pharmacist role, advocacy). Feedback on an optimal CKD tool was collected, and enabling themes (categories) for implementation included knowledge and skills (education, training) and reflection (role, support, integration). Conclusions: Findings will inform the interventions needed to improve implementation of kidney assessment and dosing of high-risk medications in people with kidney impairment into community pharmacy practice. Can Pharm J (Ott) 2023;156:xx-xx.

A qualitative study evaluating barriers and enablers to improving antimicrobial use for the management of bacteriuria in hospitalized adults.

Objective: The objective of this study was to explore barriers and enablers to improving the management of bacteriuria in hospitalized adults. Design: Qualitative study. Setting: Nova Scotia, Canada. Participants: Nurses, physicians, and pharmacists involved in the assessment, diagnosis, and treatment of bacteriuria in hospitalized patients. Methods: Focus groups (FGs) were completed between May and July 2019. FG discussions were facilitated using an interview guide that consisted of open-ended questions coded to the theoretical domains framework (TDF) v2. Discussions were transcribed verbatim then independently coded to the TDFv2 by two members of the research team and compared. Thematic analysis was used to identify themes. Results: Thirty-three healthcare providers from five hospitals participated (15 pharmacists, 11 nurses, and 7 physicians). The use of antibiotics for the treatment of asymptomatic bacteriuria (ASB) was the main issue identified. Subthemes that related to management of ASB included: "diagnostic uncertainty," difficulty "ignoring positive urine cultures," "organizational challenges," and "how people learn." Barriers and/or enablers to improving the management of bacteriuria were mapped to 12 theoretical domains within these subthemes. Barriers and enablers identified by participants that were most extensively discussed related to the domains of environmental context and resources, belief about capabilities, social/professional role and identity, and social influences. Conclusions: Healthcare providers highlighted barriers and recognized enablers that may improve delivery of care to patients with bacteriuria. A wide range of barriers at the individual and organization level to address diagnostic challenges and improve workload should be considered to improve management of bacteriuria.

Opioid and Sedative Coprescription: Prescribing Patterns after an ICU Admission.

Background: Opioid misuse constitutes a health care crisis in Canada, and coprescription of opioids with sedatives has been associated with adverse events. Opioids and sedatives are frequently administered in the intensive care unit (ICU). The rate of continuation of opioid-sedative combinations after an ICU admission at the study institution was unknown. Objectives: To determine the rates of opioid and sedative coprescriptions following an ICU admission and to identify factors associated with continuation of hospital-initiated opioid-sedative coprescriptions at ICU transfer and hospital discharge. Methods: This retrospective chart review involved patients admitted to ICUs at a tertiary care centre between April 1, 2018, and March 31, 2019. Baseline characteristics were obtained from a clinical database and medication information from medication reconciliation forms. An opioid coprescription was defined as prescription of an opioid in combination with a sedative (benzodiazepine, z-drug, gabapentinoid, tricyclic antidepressant, or antipsychotic), and hospital-initiated coprescriptions encompassed various predefined scenarios of therapy started or modified before ICU transfer. Factors associated with hospital-initiated opioid coprescription were analyzed by multivariable logistic regression. Results: A total of 735 patients met the inclusion criteria. At ICU transfer, 23.0% (169/735) of the patients had an opioid coprescription, and 87.0% (147/169) of these coprescriptions were hospital-initiated. At hospital discharge, 8.6% (44/514) of the patients had an opioid coprescription, and 56.8% (25/44) of these coprescriptions were hospital-initiated. Male sex, home opioid coprescription, surgical patient, prolonged hospital stay, and in-hospital death were significantly associated with hospital-initiated opioid coprescription at the time of ICU transfer. Home opioid coprescription was significantly associated with opioid coprescription at the time of hospital discharge. Conclusions: Hospital-initiated opioid coprescriptions accounted for the majority of opioid coprescriptions at ICU transfer and hospital discharge. Pharmacists should assess all opioid coprescriptions to determine whether discontinuation and/or dose reduction is appropriate.

Contexte: L'abus d'opioïdes est une crise sanitaire au Canada, et les opioïdes coprescrits avec des sédatifs ont été associés à des événements indésirables. Les opioïdes et les sédatifs sont fréquemment utilisés en unité de soins intensifs (USI). Sur le lieu de l'étude, on ne connaissait pas le taux de maintien de l'utilisation de la combinaison opioïdes-sédatifs après une admission en USI. Objectifs: Déterminer les taux de coprescription d'opioïdes et de sédatifs suite à une admission en USI et identifier les facteurs associés au maintien de l'utilisation des coprescriptions d'opioïdes et de sédatifs amorcées par l'hôpital au moment du transfert hors de l'USI et du congé hospitalier. Méthodes: Cet examen rétrospectif des dossiers portait sur des patients admis en USI d'un centre de soins tertiaires entre le 1er avril 2018 et le 31 mars 2019. Les caractéristiques de base ont été obtenues à partir d'une base de données clinique et des informations sur les médicaments à partir des formulaires de bilan comparatif des médicaments. Une coprescription d'opioïdes a été définie comme « La prescription d'un opioïde associée à un sédatif (benzodiazépine, médicament z, gabapentinoïde, antidépresseur tricyclique ou antipsychotique) ¼. Les « coprescriptions amorcées par l'hôpital ¼ correspondaient à des coprescriptions initiées ou modifiées avant le transfert hors de l'USI, selon des scénarios préalablement définis. Les facteurs associés à la coprescription d'opioïdes amorcée par l'hôpital ont été analysés par régression logistique multivariée. Résultats: Au total, 735 patients répondaient aux critères d'inclusion. Lors du transfert hors de l'USI, des opioïdes étaient coprescrits à 23,0 % (169/735) d'entre eux; de ces coprescriptions, 87,0 % (147/169) étaient amorcées par l'hôpital. Au moment du congé hospitalier, des opioïdes étaient coprescrits à 8,6 % (44/514) d'entre eux; de ces coprescriptions, 56,8 % (25/44) étaient amorcées par l'hôpital. Le sexe masculin, la coprescription d'opioïdes à domicile, l'admission en chirurgie, le séjour prolongé à l'hôpital et le décès à l'hôpital étaient fortement associés à la coprescription d'opioïdes amorcée par l'hôpital au moment du transfert hors de l'USI. La coprescription d'opioïdes à domicile était fortement associée à la coprescription d'opioïdes au moment du congé de l'hôpital. Conclusions: Les coprescriptions d'opioïdes amorcées par l'hôpital représentaient la majorité des coprescriptions au moment du transfert hors de l'USI et au moment du congé de l'hôpital. Les pharmaciens doivent évaluer toutes les coprescriptions d'opioïdes pour déterminer si l'arrêt et/ou la réduction de la dose est appropriée.

Environmental scan of current strategies to decrease sedative-hypnotic drug use and promote sleep in hospital patients.

BACKGROUND: Sedative-hypnotic drugs are often initiated in hospital to manage insomnia and anxiety. Guidelines discourage their use, particularly in older adults, due to risks of falls, fractures, and delirium. AIM: To identify publicly available resources to decrease the use of sedative-hypnotic drugs and promote sleep in hospital. METHOD: An advanced Google search with 6 search strategies was conducted. Key websites were also identified and searched. Hospital- or community-based resources using non-pharmacologic measures to reduce sedative-hypnotic drug use and/or to promote sleep were included if they were publicly available in English within the past 5 years. Full text screening and data extraction was performed independently by 2 reviewers; a third reviewer resolved disagreements by consensus. RESULTS: A total of 79 resources met inclusion criteria, with 65 (82.3%) providing education and 31 (39.2%) describing sleep hygiene strategies. Other resources included deprescribing (17, 21.5%), relaxation training (13, 16.5%), cognitive behavioural therapy for insomnia (9, 11.4%), and policies (7, 8.9%). The resources primarily targeted patients (59, 74.7%) followed by healthcare providers (9, 11.4%). There were 9 resources (11.4%) that applied to both community and hospital settings, and another 2 (2.5%) designed specifically for hospital. CONCLUSION: Many resources were available to patients and healthcare providers to reduce inappropriate or ineffective use of sedative-hypnotic drugs and promote better sleep. Specific resources for the hospital setting were infrequent and recommended that clinicians stop hospital-initiated sedatives when patients are discharged. Identified resources can be adapted by healthcare organizations to develop sedative-hypnotic prescribing programs and policies.

Antimicrobial use among paediatric inpatients at hospital sites within the Canadian Nosocomial Infection Surveillance Program, 2017/2018.

BACKGROUND: Antimicrobial resistance threatens the ability to successfully prevent and treat infections. While hospital benchmarks regarding antimicrobial use (AMU) have been well documented among adult populations, there is less information from among paediatric inpatients. This study presents benchmark rates of antimicrobial use (AMU) for paediatric inpatients in nine Canadian acute-care hospitals. METHODS: Acute-care hospitals participating in the Canadian Nosocomial Infection Surveillance Program submitted annual AMU data from paediatric inpatients from 2017 and 2018. All systemic antimicrobials were included. Data were available for neonatal intensive care units (NICUs), pediatric ICUs (PICUs), and non-ICU wards. Data were analyzed using days of therapy (DOT) per 1000 patient days (DOT/1000pd). RESULTS: Nine hospitals provided paediatric AMU data. Data from seven NICU and PICU wards were included. Overall AMU was 481 (95% CI 409-554) DOT/1000pd. There was high variability in AMU between hospitals. AMU was higher on PICU wards (784 DOT/1000pd) than on non-ICU (494 DOT/1000pd) or NICU wards (333 DOT/1000pd). On non-ICU wards, the antimicrobials with the highest use were cefazolin (66 DOT/1000pd), ceftriaxone (59 DOT/1000pd) and piperacillin-tazobactam (48 DOT/1000pd). On PICU wards, the antimicrobials with the highest use were ceftriaxone (115 DOT/1000pd), piperacillin-tazobactam (115 DOT/1000pd), and cefazolin (111 DOT/1000pd). On NICU wards, the antimicrobials with the highest use were ampicillin (102 DOT/1000pd), gentamicin/tobramycin (78 DOT/1000pd), and cefotaxime (38 DOT/1000pd). CONCLUSIONS: This study represents the largest collection of antimicrobial use data among hospitalized paediatric inpatients in Canada to date. In 2017/2018, overall AMU was 481 DOT/1000pd. National surveillance of AMU among paediatric inpatients is necessary for establishing benchmarks and informing antimicrobial stewardship efforts.

Nocturnal Hypoglycemia Associated with Bedtime Administration of Premixed Insulin Preparations in Hospitalized Patients.

BACKGROUND: Patients with diabetes mellitus for whom premixed insulin preparations (PMIPs) are ordered in the hospital setting may be at risk of hypoglycemia if the PMIP is incorrectly administered at bedtime (instead of suppertime). OBJECTIVES: The primary objective was to determine, retrospectively, the incidence of bedtime administration of PMIPs at a tertiary teaching hospital. The secondary objective was to investigate whether bedtime administration of PMIPs led to an increase in nocturnal hypoglycemia. METHODS: Inpatient PMIP orders for the period April 1, 2013, to March 31, 2017, were extracted from the pharmacy information system of the Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia. Two hundred randomly selected inpatient admissions were audited, and instances of PMIP administration after 2000 (8 pm) were recorded. Data from an additional random sample of inpatient admissions, from January 1, 2016, to December 31, 2017, were reviewed to determine whether bedtime administration of PMIPs was associated with increased incidence of nocturnal hypoglycemia, relative to suppertime administration. RESULTS: In the randomly selected sample of 200 inpatient admissions, a PMIP was administered at bedtime at least once during 47 admissions (24%). In the additional sample of 123 inpatient admissions during which a PMIP had been administered, the mean nocturnal hypoglycemia rate was 4.15% for suppertime administration and 14.85% for bedtime administration (p = 0.13). CONCLUSIONS: For a substantial proportion of patients, PMIPs were inappropriately ordered and administered at bedtime in this hospital setting and may have been associated with nocturnal hypoglycemic events. Recommendations to reduce this practice include ongoing education and a review of preprinted order sets.

CONTEXTE: Les patients atteints de diabète sucré pour lesquels des préparations d'insuline prémélangées (PIPM) sont commandées en milieu hospitalier peuvent présenter un risque d'hypoglycémie si elles sont administrées à tort au coucher (au lieu de l'heure du souper). OBJECTIFS: L'objectif principal visait à déterminer, rétrospectivement, l'incidence de l'administration des PIPM au coucher dans un hôpital d'enseignement tertiaire. L'objectif secondaire visait quant à lui à déterminer si l'administration au coucher entraînait (ou non) une augmentation de l'hypoglycémie nocturne. MÉTHODES: Les données relatives aux commandes de PIPM pour les patients hospitalisés pendant la période du 1er avril 2013 au 31 mars 2017 ont été extraites du système d'information pharmaceutique du QEII Health Sciences Centre à Halifax (N.-É.). Deux cents admissions de patients hospitalisés sélectionnées au hasard ont été vérifiées et les cas d'administration des PIPM après 2000 (20 h) ont été enregistrés. Les données d'un échantillon aléatoire supplémentaire d'admissions de patients hospitalisés du 1er janvier 2016 au 31 décembre 2017 ont été examinées afin de déterminer si l'administration au coucher des PIPM était associée à une plus grande incidence d'hypoglycémie nocturne, par rapport à l'administration au souper. RÉSULTATS: Dans l'échantillon sélectionné au hasard de 200 admissions de patients hospitalisés, une PIPM a été administrée au coucher au moins une fois au cours de 47 admissions (24 %). Dans l'échantillon supplémentaire de 123 admissions de patients hospitalisés au cours desquelles une PIPM avait été administrée, le taux moyen d'hypoglycémie nocturne était de 4,15 % pour l'administration au souper et se montait à 14,85 % pour l'administration au coucher (p = 0,13). CONCLUSIONS: Pour une proportion considérable de patients, la PIPM a été prescrite de manière inappropriée et administrée au coucher dans ce milieu hospitalier et peut avoir été associée à des événements hypoglycémiques nocturnes. Les recommandations visant à réduire cette pratique comprennent une formation continue et un examen des ensembles de commandes préimprimés.

Interventions to reduce benzodiazepine and sedative-hypnotic drug use in acute care hospitals: A scoping review.

BACKGROUND: Benzodiazepines and sedative-hypnotic drugs (BZD/SHD) are commonly utilized in the acute care setting for insomnia and anxiety and are associated with cognitive impairment, falls, and fractures. Interventions to reduce use of BZD/SHD in hospitals are not well characterized. OBJECTIVE: The objective was to conduct a scoping review to identify and characterize interventions to reduce the use of BZD/SHD by adults in the acute care setting. METHODS: English language studies and abstracts that described an intervention to reduce BZD/SHD in adult hospital patients were included. Six databases (PubMed, EMBASE, CINAHL, PsycINFO, Scopus, and Web of Science) were searched up to July 2018 and updated to February 3, 2021. The grey literature (Opengrey, Grey Matters, Google Advanced) was searched up to July 2018. Titles and abstracts were screened and full-text articles were reviewed and charted by three independent reviewers. Stakeholders were consulted to inform the scoping review and collect perspectives on the findings. RESULTS: There were 13,046 records identified and 43 studies included. The most common study designs were uncontrolled before and after (23/43, 53.5%) and randomized controlled trials (7/43, 16.3%). The majority of studies tested a single intervention (32/43, 74.4%) such as education, deprescribing, relaxation training and sleep protocols. Patients were frequently the target of relaxation training and behavior change interventions; while sleep protocols, multifaceted interventions, education and deprescribing were usually directed at healthcare providers, either alone or in combination with patients. Most studies reported positive results in decreasing BZD/SHD use (27/43, 62.8%). CONCLUSIONS: The scoping review found a variety of interventions to decrease the utilization of BZD/SHD in hospitals. Multifaceted interventions aimed at patients and healthcare providers that include a combination of education, sleep protocols, and deprescribing may support reductions in BZD/SHD use. Stakeholders also recommended policy and system changes such as computer alerts due to feasibility and workload.

Trends in Canadian prescription drug purchasing: 2001-2020.

BACKGROUND: In 2019, more than $34.5 billion was spent on prescription drugs in Canada. However, little is known about the distribution of this spending across medications and settings (outpatient and inpatient) over time. The objective of this paper is to describe the largest expenditures by medication class over time in inpatient and outpatient settings. This information can help to guide policies to control prescription medication expenditures. METHODS: IQVIA's Canadian Drugstore and Hospital Purchases Audit data from January 1, 2001, to December 31, 2020, were used. In this dataset, purchasing was stratified by outpatient drugstore and inpatient hospital. Spending trajectories in both settings were compared to total expenditure over time. Total expenditure of the 25 medications with the largest expenditure were compared over time, stratified by setting. Nominal costs were used for all analysis. RESULTS: In 2001, spending in the outpatient and inpatient settings was greatest on atorvastatin ($467.0 million) and erythropoietin alpha ($91.2 million), respectively. In 2020, spending was greatest on infliximab at $1.2 billion (outpatient) and pembrolizumab at $361.6 million (inpatient). Annual outpatient spending, although increasing, has been growing at a slower rate (5.3%) than inpatient spending (7.0%). In both settings, spending for the top 25 medications has become increasingly concentrated on biologic agents, with a reduction in the diversity of therapeutic classes of agents over time. DISCUSSION: Identification of the concentration on spending on biologic agents is a key step in managing costs of prescription medications in Canada. Given the increases in spending on biologic agents over the last 20 years, current cost-control mechanisms may be insufficient. Future research efforts should focus on examining the effectiveness of current cost-control mechanisms and identifying new approaches to cost control for biologic agents.

Evaluating clinical pharmacy services on a surgical patient-care area: a nurses' satisfaction survey.

OBJECTIVES: To determine nurses' perceptions and expectations of clinical pharmacists prior to, and 9 months after, clinical pharmacy services were introduced on two general and gastrointestinal surgery hospital wards in Canada. METHODS: A survey tool was developed based on previous research, validated to ensure reliability and accuracy, and administered to approximately 70 nurses on the surgery wards. KEY FINDINGS: Response rates for the pre and post surveys were 75% and 67% respectively. Nurses indicated that the quality of pharmacy service improved significantly from pre to post survey (85% versus 95%; P < 0.0001). There was a statistically significant increase in positive responses to seven out of eight statements such as accessibility of pharmacists, timely responses to drug-related questions, and timely delivery of unit doses and intravenous admixtures. Almost all statements about nursing staff expectations showed increases in agreement. At least 85% of nurses indicated their expectations had been met or exceeded for all but one clinical pharmacy service. A higher proportion of nurses in the post survey felt that clinical pharmacists positively impact on their roles and responsibilities as a nurse. Comments from nurses indicated enthusiastic support for clinical pharmacy services. CONCLUSIONS: A survey tool to assess the quality of pharmacy services in the hospital setting has been developed, validated, and distributed. A high level of nurses' satisfaction with the provision of new clinical pharmacy services on general surgery/gastrointestinal surgery wards was demonstrated. Nursing staff were more aware of the responsibilities of clinical pharmacists and how the clinical pharmacist role could assist them in their own nursing practice. The survey may be useful for other wards and other institutions to measure satisfaction with pharmacy services.

Pharmacist Intervention to Improve Medication Adherence in Patients with Acute Coronary Syndrome: The PRIMA-ACS Study.

BACKGROUND: Despite ample evidence of benefit, adherence to secondary prevention medication therapy after acute coronary syndrome (ACS) is often suboptimal. Hospital pharmacists are uniquely positioned to improve adherence by providing medication education at discharge. OBJECTIVE: To determine whether a standardized counselling intervention at hospital discharge significantly improved patients' adherence to cardiovascular medications following ACS. METHODS: This single-centre, prospective, nonrandomized comparative study enrolled patients with a primary diagnosis of ACS (January 2014 to July 2015). Patients who received standardized discharge counselling from a clinical pharmacist were compared with patients who did not receive counselling. At 30 days and 1 year after discharge, follow-up patient surveys were conducted and community pharmacy refill data were obtained. Adherence was assessed using pharmacy refill data and patient self-reporting for 5 targeted medications: acetylsalicylic acid, P2Y purinoceptor 12 (P2Y12) inhibitors, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, ß-blockers, and statins. Thirty-day and 1-year medication utilization, cardiovascular readmission rates, and all-cause mortality were also assessed. RESULTS: Of the 259 patients enrolled, 88 (34.0%) received discharge counselling. Medication data were obtained for 253 patients (97.7%) at 30 days and 242 patients (93.4%) at 1 year. At 1 year after discharge, there were no statistically significant differences between patients who did and did not receive counselling in terms of rates of nonadherence (11.9% versus 18.4%, p = 0.19), cardiovascular readmission (17.6% versus 22.3%, p = 0.42), and all-cause mortality (3.4% versus 4.2%, p > 0.99). Overall medication nonadherence was 2.8% (7/253) at 30 days and 16.1% (39/242) at 1 year. CONCLUSIONS: Discharge medication counselling provided by hospital pharmacists after ACS was not associated with significantly better medication adherence at 1 year. Higher-quality evidence is needed to determine the most effective and practical interventions to ensure that patients adhere to their medication regimens and achieve positive outcomes after ACS.

CONTEXTE: Malgré l'abondance de preuves démontrant ses avantages, l'adhésion à la pharmacothérapie de prévention secondaire après les syndromes coronariens aigus (SCA) est souvent « sous-optimale ¼. Les pharmaciens d'hôpitaux occupent une place unique pour améliorer l'adhésion en expliquant au patient l'usage des médicaments au moment du congé hospitalier. OBJECTIF: Déterminer si une consultation standardisée au moment du congé hospitalier améliore significativement ou non l'adhésion à la pharmacothérapie cardiovasculaire après les SCA. MÉTHODES: Des patients ayant reçu un diagnostic primaire de SCA (de janvier 2014 à juillet 2015) ont été inscrits pour participer à cette étude comparative unicentrique prospective et non randomisée. Ceux ayant bénéficié d'une consultation standardisée par un pharmacien clinicien au moment du congé ont été comparés aux patients qui n'en n'avaient pas reçu. Trente jours et un an après le congé, des enquêtes de suivi du patient ont été menées et les données de renouvellement d'ordonnance des pharmacies communautaires ont été recueillies. L'adhésion a été évaluée à l'aide des données de renouvellement d'ordonnance et celles rapportées par le patient pour cinq médicaments ciblés : l'acide acétylsalicylique, les inhibiteurs P2Y purinoceptor 12 (P2Y12), les inhibiteurs de l'enzyme de conversion de l'angiotensine ou les antagonistes des récepteurs de l'angiotensine II, les antagonistes ß et les statines. L'utilisation des médicaments à 30 jours et à un an, le taux de réadmission en raison d'un trouble cardiovasculaire et le taux de mortalité toutes causes confondues ont également fait l'objet d'une évaluation. RÉSULTATS: Sur les 259 patients inscrits, 88 (34 %) ont bénéficié d'une consultation au moment du congé. Des données concernant la médication de 253 patients ont été obtenues (97,7 %) à 30 jours et pour 242 patients (93,4 %) à un an. Un an après le congé, aucune différence statistique significative n'a été observée entre les patients ayant reçu ou non une consultation concernant la non-adhésion (11,9 % contre 18,4 %, p = 0,19), la réadmission en raison d'un trouble cardiovasculaire (17,6 % contre 22,3 %, p = 0,42), et le taux de mortalité toutes causes confondues (3,4 % contre 4,2 %, p > 0,99). La non-adhésion aux médicaments de manière générale se montait à 2,8 % (7/253) à 30 jours et à 16,1 % (39/242) à un an. CONCLUSIONS: La consultation concernant la médication donnée par les pharmaciens d'hôpitaux au moment du congé après les SCA n'était pas associée à un meilleur suivi de la médication un an plus tard. Des données probantes de meilleure qualité sont nécessaires pour déterminer les interventions les plus efficaces et pratiques pour que les patients adhèrent à leur régime médicamenteux et qu'ils obtiennent des résultats positifs après les SCA.

Point Prevalence Survey of Benzodiazepine and Sedative-Hypnotic Drug Use in Hospitalized Adult Patients.

BACKGROUND: Benzodiazepines and sedative-hypnotic drugs (BZD/SHDs), such as zopiclone and the antidepressant trazodone, pose risks such as falls, fractures, and confusion, especially for older adults. Use of these drugs in the acute care setting is poorly understood. OBJECTIVES: To determine the point prevalence and characteristics of use of BZD/SHDs in hospitals in Nova Scotia, Canada. METHODS: A point prevalence survey was conducted for adults admitted to all hospitals with at least 30 acute care beds between May and August 2016. Drugs administered intravenously, patients in long-term care, and patients receiving mental health services, addiction treatment, or critical care were excluded. The proportion of included patients who had received a BZD/SHD within the 24 h before the start of the survey was determined. A descriptive statistical analysis was performed. RESULTS: Overall BZD/SHD prevalence was 34.6% (487/1409) across the 16 eligible hospitals. The average age was 70.3 years, and 150 (30.8%) of the patients were 80 years or older. Among the 585 prescriptions for these patients, commonly used drugs were zopiclone (32.0%), lorazepam (21.9%), and trazodone (21.9%). The most common indications for use were bedtime/daytime sedation (60.0%) and anxiety (12.5%). More than half of the prescriptions (55.7%) had been initiated at home, 37.6% were started in hospital, and the place of initiation was unknown for 6.7%. Benzodiazepines were prescribed more frequently to patients under 65 years than those 80 years or older (41.3% versus 22.2%, p < 0.001) whereas trazodone was more frequently prescribed to the older of these 2 age groups (52.7% versus 14.3%, p < 0.001). CONCLUSIONS: BZD/SHDs were frequently used by hospitalized adult patients in Nova Scotia. Trazodone appears to have been substituted for benzodiazepines in the oldest age group. Pharmacists should direct their efforts toward preventing inappropriate initiation of BZD/SHDs in hospital, particularly for elderly patients.

CONTEXTE: Les benzodiazépines et les médicaments sédatifs-hypnotiques (BZD/MSH), comme la zopiclone et l'antidépresseur trazodone, comportent des risques de chute, de fracture et de confusion, particulièrement chez les personnes âgées. Il existe une mauvaise compréhension de l'utilisation de ces médicaments dans un contexte de soins intensifs. OBJECTIFS: Déterminer la prévalence ponctuelle et les caractéristiques de l'utilisation des BZD/MSH dans des hôpitaux en Nouvelle-Écosse, au Canada. MÉTHODES: Une enquête sur la prévalence ponctuelle a été menée entre mai et août 2016 auprès d'adultes admis dans les hôpitaux comptant au moins 30 lits en soins intensifs. Les patients recevant ces médicaments par voie intraveineuse, ceux en établissement de soins de longue durée, ceux recevant des services en santé mentale ou un traitement pour la toxicomanie ou encore ceux des soins intensifs ont été exclus de l'enquête. La détermination de la proportion des patients inclus dans l'étude portait sur ceux qui avaient reçu des BZD/MSH au cours des 24 h précédant le début de l'enquête, et elle a été suivie d'une analyse statistique descriptive. RÉSULTATS: e manière générale, l'usage des BZD/MSH s'élevait à 34,6 % (487/1409) dans les 16 hôpitaux participants. L'âge moyen des patients était de 70,3 ans et 150 (30,8 %) étaient âgés d'au moins 80 ans. Parmi les 585 prescriptions pour ces patients, les médicaments communément utilisés étaient la zopiclone (32,0 %), le lorazepam (21,9 %) et le trazodone (21,9 %). Les indications d'utilisation les plus répandues concernaient la sédation au coucher et en cours de journée (60 %) et l'anxiété (12,5 %). Plus de la moitié des prescriptions (55,7 %) ont commencé à domicile, 37,6 % ont commencé à l'hôpital, et le lieu du début de la prise de ces médicaments était inconnu dans 6,7 % des cas. La prescription des benzodiazépines s'adressait plus souvent aux patients de moins de 65 ans qu'à ceux d'au moins 80 ans (41,3 % par rapport à 22,2 %, p < 0,001), tandis que la prescription de trazodone s'adressait plus souvent aux personnes de la tranche d'âge plus avancée (52,7 % par rapport à 14,3 %, p < 0,001). CONCLUSIONS: Les BZD/MSH étaient fréquemment utilisés par les patients adultes hospitalisés en Nouvelle-Écosse. La trazodone semble avoir remplacé les benzodiazépines dans le groupe plus âgé. Les pharmaciens devraient orienter leurs efforts sur la prévention de la prise inappropriée des BZD/MSH en hôpital, particulièrement par les patients plus âgés.

Pharmacist-led intervention to improve medication use in older inpatients using the Drug Burden Index: a study protocol for a before/after intervention with a retrospective control group and multiple case analysis.

INTRODUCTION: Polypharmacy and potentially inappropriate medication use is common in older adults and is associated with adverse outcomes such as falls and hospitalisations. METHODS AND ANALYSIS: This study is a pharmacist-led medication optimisation initiative using an electronic tool (the Drug Burden Index (DBI) Calculator) in four hospital sites in the Canadian province of Nova Scotia. The study aims to enrol 160 participants between the preintervention and intervention groups. The Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT 2013 checklist) was used to develop the protocol for this prospective interventional implementation study. A preintervention retrospective control cohort and a multiple case study analysis will also be used to assess the effect of intervention implementation. Statistical analysis will involve change in DBI scores and assessment of clinical outcomes, such as rehospitalisation and mortality using appropriate statistical tests including t-test, χ2, analysis of variance and unadjusted and adjusted regression methods. ETHICS AND DISSEMINATION: Ethics approval has been granted by the Nova Scotia Health Authority Research Ethics Board. The findings of this study will be published in peer-reviewed journals and presented at local, national and international conferences. TRIAL REGISTRATION NUMBER: NCT03698487.

Antimicrobial use among adult inpatients at hospital sites within the Canadian Nosocomial Infection Surveillance Program: 2009 to 2016.

BACKGROUND: Antimicrobial resistance is a growing threat to the world's ability to prevent and treat infections. Links between quantitative antibiotic use and the emergence of bacterial resistance are well documented. This study presents benchmark antimicrobial use (AMU) rates for inpatient adult populations in acute-care hospitals across Canada. METHODS: In this retrospective surveillance study, acute-care adult hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP) submitted annual AMU data on all systemic antimicrobials from 2009 to 2016. Information specific to intensive care units (ICUs) and non-ICU wards were available for 2014-2016. Data were analyzed using defined daily doses (DDD) per 1000 patient days (DDD/1000pd). RESULTS: Between 2009 and 2016, 16-18 CNISP adult hospitals participated each year and provided their AMU data (22 hospitals participated in ≥1 year of surveillance; 11 in all years). From 2009 to 2016, there was a significant reduction in use (12%) (from 654 to 573 DDD/1000pd, p = 0.03). Fluoroquinolones accounted for the majority of this decrease (47% reduction in combined oral and intravenous use, from 129 to 68 DDD/1000pd, p < 0.002). The top five antimicrobials used in 2016 were cefazolin (78 DDD/1000pd), piperacillin-tazobactam (53 DDD/1000pd), ceftriaxone (49 DDD/1000pd), vancomycin (combined oral and intravenous use was 44 DDD/1000pd; 7% of vancomycin use was oral), and ciprofloxacin (combined oral and intravenous use: 42 DDD/1000pd). Among the top 10 antimicrobials used in 2016, ciprofloxacin and metronidazole use decreased significantly between 2009 and 2016 by 46% (p = 0.002) and 26% (p = 0.002) respectively. Ceftriaxone (85% increase, p = 0.0008) and oral amoxicillin-clavulanate (140% increase, p < 0.0001) use increased significantly but contributed only a small component (8.6 and 5.0%, respectively) of overall use. CONCLUSIONS: This study represents the largest collection of dispensed antimicrobial use data among inpatients in Canada to date. Between 2009 and 2016, there was a significant 12% decrease in AMU, driven primarily by a 47% decrease in fluoroquinolone use. Modest absolute increases in parenteral ceftriaxone and oral amoxicillin-clavulanate use were noted but contributed a small amount of total AMU. Ongoing national surveillance is crucial for establishing benchmarks and antimicrobial stewardship guidelines.

Health Care Providers' Perceptions of Antimicrobial Use and Stewardship at Acute Care Hospitals in Nova Scotia.

BACKGROUND: Antimicrobial use is the major factor in the development of antimicrobial resistance. Antimicrobial stewardship has been recommended as a strategy to improve antimicrobial use. OBJECTIVE: To learn about health care providers' perceptions of current antimicrobial use and stewardship, including barriers and facilitators to improving antimicrobial use at acute care hospitals in Nova Scotia. METHODS: This qualitative research study was conducted at acute care hospitals in Nova Scotia using focus groups and semistructured interviews. Health care providers (nurses, nurse practitioners, pharmacists, pharmacy students, and physicians) were invited to participate. Focus groups and interviews were conducted at each participant's place of employment. Interviews and focus groups were facilitated with an interview guide, audio-recorded, and transcribed verbatim. Transcripts were independently coded by 2 investigators and analyzed using thematic analysis. RESULTS: A total of 9 focus groups and 3 individual interviews were conducted between June and August 2017. Fifty-four health care professionals and trainees (24 pharmacists and pharmacy students, 14 physicians, and 16 nurses and nurse practitioners) from 5 hospitals participated. The following themes were identified: current practices, prescribing influences, access to information, collaboration and communication, resources, and antimicrobial stewardship. Within each theme, barriers and facilitators to improving antimicrobial use were identified as subthemes. CONCLUSION: Participants identified current barriers to appropriate use of antimicrobials and suggested facilitators that might improve the use of these drugs. The results of this study could be used by antimicrobial stewardship teams and decision-makers to improve antimicrobial use and stewardship initiatives throughout Nova Scotia, and may be applicable to hospitals outside the province.

CONTEXTE: L'utilisation des antimicrobiens est le principal facteur de développement de la résistance à cette classe de médicaments. La gestion des antimicrobiens a été recommandée comme stratégie visant à améliorer leur utilisation. OBJECTIF: Découvrir la perception des fournisseurs de soins de santé au sujet de l'utilisation et de la gestion actuelles des antimicrobiens, y compris les obstacles et les moyens destinés à favoriser l'amélioration de leur utilisation dans des hôpitaux de soins actifs en Nouvelle-Écosse. MÉTHODES: Cette recherche qualitative a été menée dans des hôpitaux de soins actifs en Nouvelle-Écosse à l'aide de groupes de discussion et d'entretiens semi-structurés. Les fournisseurs de soins de santé (infirmières, infirmières praticiennes, pharmaciens, étudiants en pharmacie et médecins) ont été invités à y participer. Les groupes de discussion et les entretiens ont été menés sur chaque lieu de travail des participants. Ils ont été facilités grâce à un guide d'entretien. Ils ont aussi été enregistrés (audio) et retranscrits textuellement. Les transcriptions ont été codées de façon indépendante par deux enquêteurs et étudiées à l'aide d'une analyse thématique. RÉSULTATS: Neuf groupes de discussion et trois entretiens individuels ont été menés entre juin et août 2017. Cinquante-quatre professionnels et stagiaires de la santé (24 pharmaciens et étudiants en pharmacie, 14 médecins, 16 infirmières et infirmières praticiennes) provenant de cinq hôpitaux y ont participé. Les thèmes suivants ont été soumis à la discussion : pratiques actuelles, influences en matière de prescription, accès aux informations, collaboration et communication, ressources et gestion des antimicrobiens. Chaque thème comportait deux sous-thèmes abordant les obstacles et les mesures favorisant l'amélioration de l'utilisation des antimicrobiens. CONCLUSION: Les participants ont relevé les obstacles actuels nuisant à une bonne utilisation des antimicrobiens et ont proposé des moyens pour améliorer l'utilisation de ces médicaments. Les résultats de cette étude pourraient être utilisés par les équipes de gestion des antimicrobiens ainsi que par les décideurs qui doivent favoriser l'amélioration de l'utilisation des antimicrobiens et les initiatives relatives à leur gestion partout en Nouvelle-Écosse. Ils sont aussi applicables aux hôpitaux extérieurs à la province.

Antimicrobial Use at Acute Care Hospitals in Nova Scotia: A Point Prevalence Survey.

BACKGROUND: Point prevalence surveys are used to monitor antimicrobial use and identify targets for improvement through antimicrobial stewardship activities. Few studies have evaluated antimicrobial use in Nova Scotia acute care institutions. OBJECTIVES: To determine the prevalence and characteristics of antimicrobial use in Nova Scotia hospitals. METHODS: A point prevalence survey was conducted between June and November 2015 for patients admitted to hospitals with at least 30 acute care beds. On each survey day, charts were reviewed to identify patients receiving antimicrobial agents on that day. Data were gathered on the type of antimicrobial agent prescribed, route of administration, intended duration of use, and indication. Adherence to regional and local treatment guidelines was assessed. Results were summarized descriptively. Findings were compared using the Fisher exact test or the Cochran-Armitage trend test. RESULTS: Twelve of the 13 eligible hospitals participated, and a total of 1499 patient charts were examined. The overall prevalence of antimicrobial use was 30.6% (458/1499). The prevalence of antimicrobial use differed significantly according to area of specialty, with the highest prevalence occurring in intensive care wards (47.2%, 50/106) and surgical wards (43.4%, 179/412), as compared with medical wards (27.9%, 192/687) and "other" specialty wards (11.1%, 32/289) (p < 0.001). Among the 520 indications for antimicrobial use, the most common was respiratory tract infection (81 or 15.6%). In total, 660 antimicrobial agents were prescribed to the 458 patients; a third of these patients (152 or 33.2%) received more than 1 antimicrobial agent. The class of antimicrobials most frequently prescribed was "other beta-lactam antimicrobials" (31.2%, 206/660). The majority of antimicrobials (62.0%, 409/660) were prescribed for administration via the parenteral route. Adherence to regional treatment guidelines was 29.9% (26 of 87 indications analyzed). Documentation of indication was lacking for 104 (20.0%) of the 520 indications, and documentation of the intended duration of antimicrobial use was lacking for 326 (62.7%) of the 520 indications. CONCLUSIONS: Antimicrobial agents were prescribed for about one-third of acute care patients in Nova Scotia. Specific targets for improvement in antimicrobial use include decreases in prescribing of broad-spectrum and parenteral antimicrobials, better adherence to guidelines, and improved documentation. In developing initiatives, antimicrobial stewardship programs in Nova Scotia should focus on identified targets for improvement.

CONTEXTE: Les enquêtes de prévalence ponctuelle sont employées pour surveiller l'utilisation des antimicrobiens et cibler des points à améliorer grâce aux activités de gestion responsable des antimicrobiens. Peu d'études se sont penchées sur l'utilisation des antimicrobiens dans les établissements de soins de courte durée en Nouvelle-Écosse. OBJECTIFS: Déterminer quelle est la prévalence de l'utilisation des anti-microbiens dans les hôpitaux de la Nouvelle-Écosse et offrir un portrait de cette utilisation. MÉTHODES: Une enquête de prévalence ponctuelle a été menée entre juin et novembre 2015 pour les patients admis aux hôpitaux dotés d'au moins 30 lits de soins de courte durée. À chaque jour d'enquête, des dossiers médicaux ont été examinés afin de repérer les patients ayant reçu des agents antimicrobiens cette journée-là. On a recueilli des données sur le type d'agent antimicrobien prescrit, la voie d'administration, la durée attendue d'utilisation et l'indication. Le respect des lignes directrices thérapeutiques régionales et locales a aussi été évalué. Les résultats ont été résumés de façon descriptive. Les comparaisons ont été vérifiées à l'aide du test exact de Fisher ou du test de tendance de Cochran-Armitage. RÉSULTATS: Douze des 13 hôpitaux admissibles ont été inclus et un total de 1 499 dossiers médicaux de patients ont été examinés. Le taux de prévalence globale d'utilisation d'antimicrobiens était de 30,6 % (458/1499). La prévalence d'utilisation d'antimicrobiens variait significativement selon les unités de soins : en tête de liste, les unités de soins intensifs (47,2 %, 50/106) et les unités de chirurgie (43,4 %, 179/412) comparativement aux unités de médecine (27,9 %, 192/687) et aux « autres ¼ unités de soins (11,1 %, 32/289) (p < 0.001). Parmi les 520 indications pour l'utilisation des antimicrobiens, la plus fréquente était l'infection des voies respiratoires (81 ou 15,6 %). Au total, 660 agents antimicrobiens ont été prescrits aux 458 patients et le tiers de ces patients (152 ou 33,2 %) ont reçu plus d'un agent antimicrobien. La classe d'antimicrobien la plus souvent prescrite était les « autres bêtalactamines ¼ (31,2 %, 206/660). La voie parentérale était prescrite pour l'administration de la majorité des antimicrobiens (62,0%, 409/660). Le respect des lignes directrices régionales de traitement était de 29,9 % (26 des 87 indications analysées). Parmi les 520 indications, 104 (20,0 %) n'étaient pas mentionnées au dossier et 326 (62,7 %) étaient dépourvues de mention de la durée du traitement antimicrobien au dossier. CONCLUSIONS: Des agents antimicrobiens ont été prescrits à environ un tiers des patients recevant des soins de courte durée en Nouvelle-Écosse. L'amélioration de l'utilisation des antimicrobiens devrait cibler précisément les réductions de la prescription d'antibiotiques à large spectre et du recours à la voie parentérale, un plus grand respect des lignes directrices et une meilleure consignation. Les programmes de gestion responsable des antimicrobiens en Nouvelle-Écosse devraient être axés sur des objectifs d'amélioration définis afin de mettre au point des stratégies.

Chemotherapy Order Entry by a Clinical Support Pharmacy Technician in an Outpatient Medical Day Unit.

BACKGROUND: Pharmacy technicians are expanding their scope of practice, often in partnership with pharmacists. In oncology, such a shift in responsibilities may lead to workflow efficiencies, but may also cause concerns about patient risk and medication errors. OBJECTIVES: The primary objective was to compare the time spent on order entry and order-entry checking before and after training of a clinical support pharmacy technician (CSPT) to perform chemotherapy order entry. The secondary objectives were to document workflow interruptions and to assess medication errors. METHODS: This before-and-after observational study investigated chemotherapy order entry for ambulatory oncology patients. Order entry was performed by pharmacists before the process change (phase 1) and by 1 CSPT after the change (phase 2); order-entry checking was performed by a pharmacist during both phases. The tasks were timed by an independent observer using a personal digital assistant. A convenience sample of 125 orders was targeted for each phase. Data were exported to Microsoft Excel software, and timing differences for each task were tested with an unpaired t test. RESULTS: Totals of 143 and 128 individual orders were timed for order entry during phase 1 (pharmacist) and phase 2 (CSPT), respectively. The mean total time to perform order entry was greater during phase 1 (1:37 min versus 1:20 min; p = 0.044). Totals of 144 and 122 individual orders were timed for order-entry checking (by a pharmacist) in phases 1 and 2, respectively, and there was no difference in mean total time for order-entry checking (1:21 min versus 1:20 min; p = 0.69). There were 33 interruptions not related to order entry (totalling 39:38 min) during phase 1 and 25 interruptions (totalling 30:08 min) during phase 2. Three errors were observed during order entry in phase 1 and one error during order-entry checking in phase 2; the errors were rated as having no effect on patient care. CONCLUSIONS: Chemotherapy order entry by a trained CSPT appeared to be just as safe and efficient as order entry by a pharmacist. Changes in pharmacy technicians' scope of practice could increase the amount of time available for pharmacists to provide direct patient care in the oncology setting.

CONTEXTE: Les techniciens en pharmacie élargissent leur champ de pratique, souvent en partenariat avec les pharmaciens. En oncologie, un tel changement dans les responsabilités pourrait conduire à une optimisation de l'organisation du travail, mais il peut aussi soulever des inquiétudes au sujet des risques pour le patient et des erreurs de médicaments. OBJECTIFS: L'objectif principal était de comparer le temps passé à la saisie d'ordonnances et à la vérification de cette saisie avant et après avoir formé un technicien en pharmacie dédié au soutien clinique (TPDSC) à la saisie d'ordonnances de chimiothérapie. Les objectifs secondaires étaient de répertorier les interruptions de travail et d'évaluer les erreurs de médicaments. MÉTHODES: La présente étude observationnelle avant-après s'est intéressée à la saisie d'ordonnances de chimiothérapie pour les patients ambulatoires en oncologie. La saisie d'ordonnances était réalisée par des pharmaciens avant le changement de procédé (phase 1), puis, après le changement (phase 2), un TPDSC en avait la responsabilité. Un pharmacien vérifiait la saisie d'ordonnances au cours des deux phases. Les tâches étaient chronométrées par un observateur indépendant à l'aide d'un assistant numérique personnel. Un échantillon de commodité de 125 ordonnances était souhaité pour chaque phase. Les données ont été consignées dans un tableur Excel de Microsoft et les écarts de temps pour chaque tâche ont été évalués à l'aide d'un test t pour échantillons indépendants. RÉSULTATS: Au total, on a chronométré le temps de saisie pour 143 ordonnances à la phase 1 (pharmacien), puis de 128 ordonnances pour la phase 2 (TPDSC). Le temps total moyen nécessaire pour saisir une ordonnance était plus long au cours de la phase 1 (1 min 37 s contre 1 min 20 s; p = 0,044). Au total, on a chronométré la vérification (réalisée par un pharmacien) de saisie pour 144 ordonnances à la phase 1 et 122 ordonnances à la phase 2. Aucune différence notable n'a été relevée dans le temps total moyen de vérification (1 min 21 s contre 1 min 20 s; p = 0,69). On a dénombré 33 interruptions sans lien à la saisie d'ordonnances (totalisant 39 min 38 s) au cours de la phase 1 et 25 interruptions (totalisant 30 min et 8 s) durant la phase 2. Trois erreurs à la saisie d'ordonnances ont été observées pendant la phase 1 et une erreur à la vérification de la saisie d'ordonnances pendant la phase 2; ces erreurs ont été jugées sans effet sur les soins aux patients. CONCLUSIONS: La saisie d'ordonnances de chimiothérapie par un TPDSC formé semblait être tout aussi sûre et efficiente que si elle était réalisée par un pharmacien. Les changements apportés au champ de pratique des techniciens en pharmacie pourraient accroître le temps dont disposent les pharmaciens pour prodiguer des soins directs aux patients en oncologie.

Health Care Professionals' Opinions and Expectations of Clinical Pharmacy Services on a Surgical Ward.

BACKGROUND: Pharmacists have made significant contributions to patient care and have been recognized as integral members of the interprofessional team. Health care professionals differ in their opinions and expectations of clinical pharmacy services. Very little has been published about health care professionals' perspectives on advanced clinical pharmacy roles, such as prescriptive authority or administration of vaccines. In 2013, clinical pharmacy services were introduced in a vascular and general surgery ward where a pharmacist had not previously been assigned. OBJECTIVES: To explore surgical nurses' and physicians' opinions and expectations of clinical pharmacy services and to determine how these views changed over time; to compare pharmacists' views of clinical pharmacy services with those of nurses and physicians; and to develop validated survey tools. METHODS: Three survey tools were created and validated, one for each profession. Surveys were distributed to nurses and physicians assigned to the general and vascular surgery ward before introduction of clinical pharmacy services and 8 months after implementation. Hospital pharmacists were invited to complete the survey at one time point. RESULTS: Differences existed in the opinions of nurses, physicians, and pharmacists about some traditional activities. Nurses and physicians indicated stronger agreement with pharmacists participating in medication reconciliation activities than did pharmacists (p < 0.001), whereas a greater proportion of pharmacists felt that they were the most appropriate health care professionals to provide medication discharge counselling, relative to nurses and physicians (p = 0.001). Respondents supported advanced roles for pharmacists, such as collaborative practice agreements, but there was less support for prescribing, physical assessments, and administration of vaccines. Nurses indicated the strongest agreement with pharmacist prescribing (82% versus 69% among pharmacists and 27% among physicians; p < 0.001). Nurses and physicians expressed strong endorsements of clinical pharmacy services in the surveys' comment sections. CONCLUSIONS: The introduction of clinical pharmacy services to a surgical health care team resulted in high levels of satisfaction among nurses and physicians who responded to this survey. Differences in perceptions of traditional clinical pharmacy service activities and advanced practice roles need to be studied in more depth to better understand the factors influencing health care professionals' views.

Les pharmaciens ont fait d'importantes contributions aux soins aux patients et ils ont d'ailleurs été reconnus comme membres à part entière de l'équipe interprofessionnelle. Les professionnels de la santé ont des opinions et des attentes variées en ce qui concerne les services de pharmacie clinique. Or, il n'y a que très peu de documents publiés à propos des points de vue soutenus par les professionnels de la santé sur les rôles en pharmacie clinique avancée, notamment le droit de prescrire et l'administration de vaccins. En 2013, des services de pharmacie clinique ont fait leur entrée dans une unité de chirurgie générale et vasculaire où aucun pharmacien n'avait été affecté auparavant.

Pharmacists' Perceptions of the Barriers and Facilitators to the Implementation of Clinical Pharmacy Key Performance Indicators.

BACKGROUND: In hospitals around the world, there has been no consensus regarding which clinical activities a pharmacist should focus on until recently. In 2011, a Canadian clinical pharmacy key performance indicator (cpKPI) collaborative was formed. The goal of the collaborative was to advance pharmacy practice in order to improve patient outcomes and enhance the quality of care provided to patients by hospital pharmacists. Following a literature review, which indicated that pharmacists can improve patient outcomes by carrying out specific activities, and an evidence-informed consensus process, a final set of eight cpKPIs were established. Canadian hospitals leading the cpKPI initiative are currently in the early stages of implementing these indicators. OBJECTIVE: To explore pharmacists' perceptions of the barriers and facilitators to the implementation of cpKPIs. METHODS: Clinical pharmacists employed by the Nova Scotia Health Authority were invited to participate in focus groups. Focus group discussions were audio-recorded and transcribed, and data was analyzed using thematic analysis. FINDINGS: Three focus groups, including 26 pharmacists, were conducted in February 2015. Three major themes were identified. Resisting the change was comprised of documentation challenges, increased workload, practice environment constraints, and competing priorities. Embracing cpKPIs was composed of seeing the benefit, demonstrating value, and existing supports. Navigating the unknown was made up of quality versus quantity battle, and insights into the future. CONCLUSIONS: Although pharmacists were challenged by documentation and other changes associated with the implementation of cpKPIs, they demonstrated significant support for cpKPIs and were able to see benefits of the implementation. Pharmacists came up with suggestions for overcoming resistance associated with the implementation of cpKPIs and provided insights into the future of pharmacy practice. The identification of barriers and facilitators to cpKPI implementation will be used to inform the implementation process on a local and national level.

Thiamine prescribing practices within university-affiliated hospitals: a multicenter retrospective review.

BACKGROUND: Patients with suspected thiamine deficiency should receive treatment with parenteral thiamine to achieve the high serum thiamine levels necessary to reverse the effects of deficiency and to circumvent problems with absorption common in the medically ill. OBJECTIVE: To quantify rates of parenteral administration of thiamine across university-affiliated hospitals and to identify factors associated with higher rates of parenteral prescribing. DESIGN: Multicenter, retrospective observational study of thiamine prescriptions. METHODS: Prescriptions for thiamine were captured from computerized pharmacy information systems across participating centers, providing information concerning dose, route, frequency, and duration of thiamine prescribed from January 2010 to December 2011. SETTING: Fourteen university-affiliated tertiary care hospitals geographically distributed across Canada, including 48,806 prescriptions for thiamine provided to 32,213 hospitalized patients. RESULTS: Parenteral thiamine accounted for a statistically significant majority of thiamine prescriptions (57.6%, P < 0.001); however, oral thiamine constituted a significant majority of the total doses prescribed (68.4%, z = 168.9; P < 0.001). Protocols prioritizing parenteral administration were associated with higher rates of parenteral prescribing (61.3% with protocol, 45.8% without protocol; P < 0.001). Patients admitted under psychiatry services were significantly more likely to be prescribed oral thiamine (P < 0.001). CONCLUSIONS: Although parenteral thiamine accounted for a statistically significant majority of prescriptions, oral thiamine was commonly prescribed within academic hospitals. Additional strategies are needed to promote parenteral thiamine prescribing to patients with suspected thiamine deficiency.