Therapeutic alternatives and strategies for drug conservation in the intensive care unit during times of drug shortage: a report of the Ontario COVID-19 ICU Drug Task Force.

During the coronavirus disease (COVID-19) global pandemic, urgent strategies to alleviate shortages are required. Evaluation of the feasibility, practicality, and value of drug conservation strategies and therapeutic alternatives requires a collaborative approach at the provincial level. The Ontario COVID-19 ICU Drug Task Force was directed to create recommendations suggesting drug conservation strategies and therapeutic alternatives for essential drugs at risk of shortage in the intensive care unit during the COVID-19 pandemic. Recommendations were rapidly developed using a modified Delphi method and evaluated on their ease of implementation, feasibility, and supportive evidence. This article describes the recommendations for drug conservation strategies and therapeutic alternatives for drugs at risk of shortage that are commonly used in the care of critically ill patients. Recommendations are identified as preferred and secondary ones that might be less desirable. Although the impetus for generating this document was the COVID-19 pandemic, recommendations should also be applicable for mitigating drug shortages outside of a pandemic. Proposed provincial strategies for drug conservation and therapeutic alternatives may not all be appropriate for every institution. Local implementation will require consultation from end-users and hospital administrators. Competing equipment shortages and available resources should be considered when evaluating the appropriateness of each strategy.

RéSUMé: Pendant la pandémie mondiale du coronavirus (COVID-19), des stratégies urgentes pour réduire les pénuries sont nécessaires. L'évaluation de la faisabilité, de l'aspect pratique et du mérite des stratégies de préservation des médicaments et des alternatives thérapeutiques nécessite une approche collaborative au niveau provincial. Le Groupe de travail ontarien sur les médicaments à l'USI pendant la COVID-19 a reçu comme mandat d'élaborer des recommandations proposant des stratégies de préservation des médicaments et des alternatives thérapeutiques pour les médicaments essentiels utilisés dans les unités de soins intensifs courant un risque de pénurie pendant la pandémie de COVID-19. Des recommandations ont été rapidement élaborées en utilisant une méthode Delphi modifiée, puis évaluées selon leur facilité de mise en œuvre, leur faisabilité et les données probantes les préconisant. Cet article décrit les recommandations quant aux stratégies de préservation des médicaments et aux alternatives thérapeutiques aux médicaments possiblement à risque de pénurie fréquemment utilisés pour les soins des patients en état critique. Les recommandations sont identifiées comme 'à privilégier' ou 'secondaires' si moins souhaitables. Bien que la pandémie de la COVID-19 ait été l'impulsion incitant la création de ce document, ces recommandations devraient également être applicables pour réduire les pénuries de médicaments en contexte normal. Les stratégies provinciales proposées pour la préservation des médicaments et les alternatives thérapeutiques pourraient ne pas être adaptées pour toutes les institutions. La mise en œuvre locale nécessitera la consultation des utilisateurs et des administrateurs hospitaliers. Il faudrait tenir compte des pénuries de matériel concurrentes et des ressources disponibles lors de l'évaluation de la faisabilité de chaque stratégie.

Medication reconciliation during internal hospital transfer and impact of computerized prescriber order entry.

BACKGROUND: Internal hospital transfer is a vulnerable time during which patients are at high risk of medication discrepancies that can result in clinically significant harm, medication errors, and adverse drug events. OBJECTIVE: To identify, characterize, and assess the clinical impact of unintentional medication discrepancies during internal hospital transfer and to investigate the influence of computerized prescriber order entry (CPOE) on medication discrepancies. METHODS: All patients transferred between 10 inpatient units at 2 tertiary care hospitals were prospectively assessed to identify discrepancies. Interfaces included transfers between (1) units that both used paper-based medication ordering systems; (2) units that both used CPOE-based systems; and (3) units that used both paper-based and CPOE-based systems (hybrid transfer). The primary endpoint was the number of patients with at least 1 unintentional medication discrepancy during internal hospital transfer. Discrepancies were identified through assessment and comparison of a best possible medication transfer list with the actual transfer orders. A multidisciplinary team of clinicians assessed the potential clinical impact and severity of unintentional discrepancies. RESULTS: Overall, 190 patients were screened and 129 patients were included. Eighty patients (62.0%) had at least 1 unintentional medication discrepancy at the time of transfer, and the most common discrepancy was medication omission (55.6%). Factors that independently increased the risk of a patient experiencing at least 1 unintentional discrepancy included lack of best possible medication history, increasing number of home medications, and increasing number of transfer medications. Forty-seven patients (36.4%) had at least 1 unintentional discrepancy with the potential to cause discomfort and/or clinical deterioration. The risk of discrepancies was present regardless of the medication-ordering system (paper, CPOE, or hybrid). CONCLUSIONS: Clinically significant medication discrepancies occur commonly during internal hospital transfer. A structured, collaborative, and clearly defined medication reconciliation process is needed to prevent internal transfer discrepancies and patient harm.

Medication reconciliation at hospital discharge: evaluating discrepancies.

BACKGROUND: Hospital discharge is an interface of care when patients are at a high risk of medication discrepancies as they transition from hospital to home. These discrepancies are important, as they may contribute to drug-related problems, medication errors, and adverse drug events. OBJECTIVE: To identify, characterize, and assess the clinical impact of unintentional medication discrepancies at hospital discharge. METHODS: All consecutive general internal medicine patients admitted for at least 72 hours to a tertiary care teaching hospital were prospectively assessed. Patients were excluded if they were discharged with verbal prescriptions; died during hospitalization; or transferred from or to a nursing home, another institution, or another unit within the same hospital. The primary endpoint was to determine the number of patients with at least one unintended medication discrepancy on hospital discharge. Medication discrepancies were assessed through comparison of a best possible medication discharge list with the actual discharge prescriptions. Secondary objectives were to characterize and assess the potential clinical impact of the unintentional discrepancies. RESULTS: From March 14, 2006, to June 2, 2006, 430 patients were screened for eligibility; 150 patients were included in the study. Overall, 106 (70.7%) patients had at least one actual or potential unintentional discrepancy. Sixty-two patients (41.3%) had at least one actual unintentional medication discrepancy at hospital discharge and 83 patients (55.3%) had at least one potential unintentional discrepancy. The most common unintentional discrepancies were an incomplete prescription requiring clarification, which could result in a patient delay in obtaining medications (49.5%), and the omission of medications (22.9%). Of the 105 unintentional discrepancies, 31(29.5%) had the potential to cause possible or probable patient discomfort and/or clinical deterioration. CONCLUSIONS: Medication discrepancies occur commonly on hospital discharge. Understanding the type and frequency of discrepancies can help clinicians better understand ways to prevent them. Structured medication reconciliation may help to prevent discharge medication discrepancies.

Pharmacist medication assessments in a surgical preadmission clinic.

BACKGROUND: In the hospital setting, postoperative admission is a key vulnerable moment when patients are at increased risk of medication discrepancies. This study measures the reduction of medication discrepancies associated with a combined intervention of structured pharmacist medication history interviews with assessments in a surgical preadmission clinic and a postoperative medication order form. METHODS: In the Surgical Pharmacist in Preadmission Clinic Evaluation (SPPACE) study, patients who had a preadmission clinic appointment before undergoing surgical procedures were eligible for inclusion. Patients were excluded if they were scheduled for discharge the same day as their surgery. Eligible patients were randomly assigned to the intervention arm (structured pharmacist medication history interview with assessment and generation of a postoperative medication order form) or to the standard care arm (nurse-conducted medication histories and surgeon-generated medication orders). The primary end point was the number of patients with at least 1 postoperative medication discrepancy related to home medications. RESULTS: Between April 19, 2005, and June 3, 2005, a total of 464 patients were enrolled in the study, of which 227 and 237 patients were randomized to the intervention and standard care arms, respectively. In the intervention arm, 41 (20.3%) of 202 patients had at least 1 postoperative medication discrepancy related to home medications, compared with 86 (40.2%) of 214 patients in the standard care arm (P<.001). In the intervention arm, 26 (12.9%) of 202 patients had at least 1 postoperative medication discrepancy with the potential to cause possible or probable harm, compared with 64 (29.9%) of 214 patients in the standard care arm (P<.001). These were mostly omissions of reordering home medications. CONCLUSION: A combined intervention of pharmacist medication assessments and a postoperative medication order form can reduce postoperative medication discrepancies related to home medications.

Do Combined Pharmacist and Prescriber Efforts on Medication Reconciliation Reduce Postdischarge Patient Emergency Department Visits and Hospital Readmissions?

BACKGROUND: Although medication reconciliation (Med Rec) has demonstrated a reduction in potential adverse drug events, its effect on hospital readmissions remains inconclusive. OBJECTIVE: To evaluate the impact of an interprofessional Med Rec bundle from admission to discharge on patient emergency department visits and hospital readmissions (hospital visits). METHODS: The design was a retrospective, cohort study. Patients discharged from general internal medicine over a 57-month interval were identified through administrative databases. Patients who received an enhanced, Gold level, Med Rec bundle (including both admission Med Rec and interprofessional pharmacist-prescriber collaboration on discharge Med Rec) were assigned to the intervention group. Patients who received partial Med Rec services, Silver and Bronze level, comprised the control group. The primary outcome was hospital visits within 30 days of discharge. RESULTS: Over a 57-month period, 9931 unique patient visits (n = 8678 patients) met the study criteria. The main analysis did not detect a difference in 30-day hospital visits between the intervention (Gold level bundle) and control (21.25% vs 19.26%; adjusted odds ratio, 1.06; 95% confidence interval [CI], 0.95-1.19). Propensity score adjustment also did not detect an effect (16.7% vs18.9%; relative risk of readmission, 0.88; 95% CI, 0.59-1.32). CONCLUSION: A long-term, observational evaluation of interprofessional Med Rec did not detect a difference in 30- day postdischarge patient hospital visits between patients who received enhanced versus partial Med Rec patient care bundles. In future prospective studies, researchers could focus on evaluating high-risk populations and specific elements of Med Rec services on avoidable, medication-related hospital admissions and postdischarge adverse drug events.

Chemical Stability of Plerixafor after Opening of Single-Use Vial.

BACKGROUND: The addition of the immunostimulant plerixafor to the current standard-of-care regimens of granulocyte colony-stimulating growth factor with or without chemotherapy has improved clinical results in terms of successful stem cell mobilization and the outcomes of stem cell transplant in various settings. With this medical innovation has come an added financial cost for institutions where stem cell transplants are routinely performed, and there may be a further financial burden when the contents of partial vials of the drug are wasted, given that plerixafor vials (Mozobil, Sanofi-Aventis Canada Inc) are currently deemed suitable only for single use. OBJECTIVE: To determine whether the portion of plerixafor remaining in an opened vial of the Mozobil product after administration of a single dose is chemically stable, by comparison with the original product. METHODS: Stability testing of partial drug contents of an opened vial, stored at room temperature or under refrigeration (4°C), was conducted using liquid chromatography-tandem mass spectrometry analysis. The mean concentration of plerixafor (µmol/L), standard deviation, coefficient of variation, and bias were determined on days 2, 3, 11, 17, 24, and 31. Method validation included determination of precision, sensitivity, recovery, dilution linearity, and carryover. RESULTS: Throughout the 4-week testing period, measured plerixafor concentration in aliquots stored at room temperature and under refrigeration, tested in series over time, appeared similar. The mean residual drug concentration after initial opening was slightly, but not significantly, higher for the sample designated for storage at room temperature than the one designated for refrigerated storage (40.4 versus 39.9 µmol/L; p = 0.37). CONCLUSIONS: Residual plerixafor after initial opening of a vial of the Mozobil product remained chemically stable for at least 2 weeks both at room temperature and under refrigeration. The results of this study provide in vitro evidence to support multiple uses, instead of single use, of vials of this drug in an aseptic, controlled environment.

CONTEXTE: L'ajout de l'immunostimulant plérixafor aux traitements reconnus comme la norme de soins actuelle quant au facteur de stimulation des colonies de granulocytes, accompagné ou non de chimiothérapie, a amélioré les résultats cliniques de mobilisation des cellules souches et les résultats de greffe de cellules souches dans différents contextes. Cela dit, avec cette innovation médicale vient un poids financier supplémentaire pour les établissements où l'on exécute couramment des greffes de cellules souches. En outre, comme les fioles de plérixafor (Mozobil, Sanofi-Aventis Canada Inc.) sont présentement jugées adéquates pour un usage unique seulement, l'excédent de médicament gaspillé peut représenter une dépense additionnelle. OBJECTIF: Déterminer si ce qui reste de Mozobil dans une fiole ouverte après l'administration d'une dose unique est chimiquement stable comparativement au produit de départ. MÉTHODES: Une étude de stabilité du contenu partiel d'une fiole de médicament ouverte, entreposé à température ambiante ou conservé au réfrigérateur (4°C), a été réalisée par chromatographie en phase liquide couplée à la spectrométrie de masse en tandem. La concentration moyenne de plérixafor (µmol/L), l'écart-type, le coefficient de variation et le biais ont été établis aux jours 2, 3, 11, 17, 24 et 31. La méthode de validation comprenait la détermination de : la précision, la sensibilité, la récupération, la limite de linéarité et la contamination inter-échantillons. Résultats :Tout au long des quatre semaines d'analyse, les concentrations mesurées des aliquotes de plérixafor, entreposées à température ambiante ou conservées au réfrigérateur et analysées en séries chronologiques, semblaient similaires. Les concentrations moyennes de médicament restant après l'ouverture initiale étaient légèrement plus élevées lorsqu'entreposées à température ambiante (40,4 µmol/L) que lorsque réfrigérées (39,9 µmol/L) (p = 0,37), mais pas de façon significative. CONCLUSIONS: Le plérixafor résiduel, après l'ouverture initiale des fioles de Mozobil, demeurait chimiquement stable pendant au moins deux semaines, qu'il soit entreposé à température ambiante ou conservé au réfrigérateur. Les résultats de la présente étude offrent des données in vitro qui soutiennent une utilisation multiple, plutôt qu'un usage unique, des fioles de ce médicament en milieu aseptique contrôlé.

Thorough planning and full participation by pharmacists is key to MOE/MAR success.

The successful implementation of the Medication Order Entry/Medication Administration Record project was dependent on the Pharmacy department working collaboratively with many other stakeholders in the organization. To do this, the Pharmacy department faced numerous technical, staffing, workflow and clinical practice challenges during the design and implementation of MOE/ MAR.