Expanding expedited partner therapy and HIV prophylaxis in the emergency department.

PURPOSE: Sexually transmitted infections (STIs) continue to have a disproportionate impact on individuals belonging to sexual, gender, and racial minorities. Across the nation, many emergency medicine pharmacists (EMPs) possess the skills and knowledge to expand the provision of expedited partner therapy (EPT) for STIs and provide HIV prophylaxis within existing practice frameworks. This report serves as a call to action for expanded provision of EPT and HIV prophylaxis by EMPs and highlights current barriers and solutions to increase pharmacist involvement in these practice areas. SUMMARY: Emergency medicine pharmacy practice continues to expand to allow for limited prescribing authority through collaborative practice agreements (CPAs). In recent years, CPA restrictions have been changed to facilitate treatment of more patients with less bureaucracy. This report addresses the unique challenges and opportunities for expanding EPT and HIV pre- and postexposure prophylaxis provision by pharmacists in emergency departments (EDs). Furthermore, current strategies and treatments for EPT, such as patient-delivered partner therapy and HIV prophylaxis, are discussed. Pharmacist involvement in STI treatment and HIV prevention is a key strategy to increase access to high-risk populations with high ED utilization and help close current gaps in care. CONCLUSION: Expanding EMP provision of EPT and HIV prophylaxis may be beneficial to reducing the incidence of STIs and HIV infection in the community. CPAs offer a feasible solution to increase pharmacist involvement in the provision of these treatments. Legislative efforts to expand pharmacist scope of practice can also contribute to increasing access to EPT and HIV prophylaxis. With these efforts, EMPs can play an essential role in the fight against STIs and HIV.

Ketamine Use in Adult and Pediatric Patients Receiving Extracorporeal Membrane Oxygenation (ECMO): A Systematic Review.

Background: Analgesia and sedation are often critical elements of therapy for patients undergoing extracorporeal membrane oxygenation (ECMO). Aside from potential drug-drug interactions, the PK changes associated with ECMO make appropriate analgosedative selection challenging. Ketamine is less lipophilic and has lower protein binding than alternative agents, and may be less impacted by the PK changes during ECMO. Objective: To systematically identify all instances of ketamine use during ECMO support in the literature to elucidate associated efficacy and safety outcomes and prevalence of use, as well as commonly used dosing strategies and pharmacokinetic data. Methods: Web of Science, Cochrane Library, Scopus, Ovid MEDLINE, PubMed, and OVID Embase were searched through 02/2023 using keywords ketamine and ECMO or extracorporal life support (ECLS). Case reports, case series, and studies were included that had (1) original data, (2) included patients that were on ECMO and continuous infusion ketamine, and (3) reported pertinent ketamine related clinical endpoints or prevalence of use. Results: Of the 307 articles screened, 25 were identified as relevant and 11 met our inclusion criteria. Heterogeneity of patient population, ketamine indication, reported outcomes, and reported safety endpoints were identified in the included articles. Commonly reported information includes indications, pharmacokinetics, dosing, adverse effects and use in pediatrics for ketamine, and suspected opioid sparing effect. Conclusion: Our review has found a lack of consistency in reporting and results in adult and pediatric patients. Increased consistency in reporting and larger studies are required to increase our knowledge of ketamine use in both the adult and pediatric patient population.

Implementation of Debriefing Services for Pharmacy Residents in a 24-Hour, In-House Clinical Pharmacy On-Call Program: A Pilot Study.

Background: This clinical pharmacy on-call program (CPOP) is a 24-hour, in-house service provided by pharmacy residents. During shifts, challenging situations may arise, which may correlate with depression, anxiety, and stress. Objective: This pilot study aims to describe the implementation of a debriefing program and characterize mental health patterns of residents in the CPOP. Methods: A structured debriefing process was developed to provide support to residents in the CPOP. Over a 1-year period, twelve outgoing pharmacy residents and ten incoming pharmacy residents completed a modified Depression Anxiety Stress Scale (mDASS-21) questionnaire and received a stress perception score (SPS) during debriefing. Data from first and final on-call shifts were compared via a paired Wilcoxon signed-rank test. Residents were referred to an Employee Assistance Program (EAP) based on mDASS-21 and SPS results. Scores from final on-call shifts were compared between residency classes via a Wilcoxon rank sum test. Results: Following successful implementation, 106 debriefing sessions were completed. Pharmacy residents responded to a median number of 38 events per shift. Significant reductions in anxiety and stress scores were observed from the first and final on-call shifts. Six residents were referred to EAP. A lower incidence of depression, anxiety, and stress was observed in pharmacy residents who received debriefing compared to previous residents. Conclusion: The debriefing program provided emotional support to pharmacy residents participating in the CPOP. Implementation of debriefing demonstrated a reduction of anxiety and stress from the beginning to the end of the academic year and in comparison to the previous year.

A pilot multi-centre prospective randomised controlled trial of RECELL for the treatment of venous leg ulcers.

Venous leg ulcers (VLUs) have a significant impact on approximately 3% of the adult population worldwide, with a mean NHS wound care cost of £7600 per VLU over 12 months. The standard care for VLUs is compression therapy, with a significant number of ulcers failing to heal with this treatment, especially with wound size being a risk factor for non-healing. This multicentre, prospective, randomised trial evaluated the safety and effectiveness of autologous skin cell suspension (ASCS) combined with compression therapy compared with standard compression alone (Control) for the treatment of VLUs. Incidence of complete wound closure at 14 weeks, donor site closure, pain, Health-Related Quality of Life (HRQoL), satisfaction, and safety were assessed in 52 patients. At Week 14, VLUs treated with ASCS + compression had a statistically greater decrease in ulcer area compared with the Control (8.94 cm2 versus 1.23 cm2 , P = .0143). This finding was largely driven by ulcers >10 to 80 cm2 in size, as these ulcers had a higher mean percentage of reepithelialization at 14 weeks (ASCS + compression: 69.97% and Control: 11.07%, P = .0480). Additionally, subjects treated with ASCS + compression experienced a decrease in pain and an increase in HRQoL compared with the Control. This study indicates that application of ASCS + compression accelerates healing in large venous ulcers.

Facilitating organizational mergers: amalgamation of community care access centres.

BACKGROUND: The development of 14 Local Health Integration Networks (LHINs) in Ontario necessitated the re-organization of Community Care Access Centres (CCACs). The achievement of LHIN objectives was contingent upon the organizations responsible for home and long-term care placement being aligned within the LHIN geographic boundaries. This re-alignment required 42 provincial organizations to re-structure, integrate and reduce to 14. ASSESSMENT OF PROBLEM: This project was focused on the amalgamation of two CCACs in the Waterloo Wellington LHIN. Both were distinctly different due to their organizational evolution, the composition of the region and leadership approach. The different organizational cultures, if not managed properly, could result in a derailing of several current projects that were underway and were also key to the overall health system transformation agenda. A literature search provided a plethora of critiques of organizational change approaches and practical suggestions. Of particular relevance was a report to the Royal Commission on Health Care in 2002 that authenticates the dismal success in health care to meet change objectives. The project included a joint planning day for the leadership teams of the two organizations followed by an Organizational Readiness Assessment conducted by the Canadian Council on Health Services Accreditation (CCHSA). RESULTS: Both activities brought the leadership and staff of Waterloo and Wellington together, started the integration process and solicited staff participation. A follow-up survey of the leadership teams revealed the effectiveness of the project in advancing integration between the two organizations and recognizing organizational cultural differences. The CCHSA Organizational Readiness Assessment process was viewed as an effective means for advancing the integration of the two organizations, particularly as it relates to allowing the staff groups to define for themselves the benefits of the merger. LESSONS AND MESSAGES: The lack of hard evidence on the benefits of a merger could have been problematic in terms of resistance to change if the CCHSA process had not been used. The readiness assessment report provided 49 recommendations that served as baseline information needed for the design of a change strategy that is anchored in knowledge of variation in organizational culture, practice, communications, client service and leadership style.