INvestigation of the impact of a Pharmacist in a Hospital At Home Care Team (IN PHACT).

Background: In November 2020, Island Health, with the support of the British Columbia Ministry of Health, introduced the Hospital at Home (HaH) care model at Victoria General Hospital in Victoria, British Columbia. Given the acuity of the patients anticipated to receive care through this model, questions arose regarding how the delivery of clinical pharmacy services on which inpatients rely on could be included. With limited supporting evidence for the inclusion of a clinical pharmacist, Island Health launched the HaH program with 2 clinical pharmacists who provide services 7 days a week during daytime hours. The aim of this study is to assess the impact of the HaH pharmacist on patient care, from the perspective of the pharmacists serving in this role, patients, caregivers and program stakeholders. Methods: This prospective, observational mixed-methods study was conducted from December 2021 to March 2022. Data collection involved the HaH pharmacist documenting daily clinical activities and resolving drug therapy problems, patients and caregivers completing a 4-question postdischarge phone survey and program stakeholders completing a 9-question online survey and an optional 7-question interview. Results and Interpretation: It was found that one of the most significant roles the pharmacist plays is in identifying indications for medication therapy and making recommendations to initiate therapy where there is an absence. There was high congruence between patient, caregiver and stakeholder perceptions that the HaH pharmacist positively affects patient care within the Island Health model. Conclusion: This study provides support for the integration of a dedicated clinical pharmacist in the HaH care model.

Evaluation of compliance with the 2017 Canadian Paediatric Society Position Statement for the management of newborns at risk for early-onset sepsis: A retrospective cohort study.

INTRODUCTION: Due to the nonspecific clinical presentation, clinicians often empirically treat newborns at risk of early-onset sepsis (EOS). Recently, the Canadian Paediatric Society (CPS) published updated recommendations that promote a more judicious approach to EOS management. OBJECTIVE: To examine the compliance with the CPS statement at a tertiary perinatal site and characterize the types of deviations. METHODS: A retrospective chart review was conducted for all term and late pre-term newborns at risk for sepsis, between January 1 and June 30, 2018. The prevalence of newborns with EOS risk factors was measured during the first month. Management strategies for eligible newborns during the 6-month period were compared to the CPS recommendations to establish the rate of noncompliance. The type of noncompliance, readmission rate, and rate of culture-positive EOS were examined. RESULTS: In the first month, 29% (66 of 228) of newborns had EOS risk factors. Among the 100 newborns born in the 6-month period for whom the CPS recommendations apply, 47 (47%) received noncompliant management. Of those, 51% (N=24) had inappropriately initiated investigations, 17% (N=8) had inappropriate antibiotics, and 32% (N=15) had both. The rate of readmission for a septic workup was 1.6% (N= 2). None had culture-positive sepsis while admitted. CONCLUSION: A large proportion of term and late preterm newborns (29%) had EOS risk factors, but none had culture-confirmed EOS. The rate of noncompliance with the CPS recommendations was high (47%), mainly due to overzealous management. Future initiatives should aim at increasing compliance, particularly in newborns at lower EOS risk.

Pharmacists' Perceptions of the Influence of Interactions with the Pharmaceutical Industry on Clinical Decision-Making.

BACKGROUND: There is a paucity of literature examining the perceptions of Canadian pharmacists toward drug promotion by the pharmaceutical industry and pharmacist-industry interactions. OBJECTIVES: To determine whether hospital pharmacists perceive their interactions with the pharmaceutical industry as influencing their clinical decision-making or that of their colleagues and whether hospital pharmacists perceive that interactions with the pharmaceutical industry create a conflict of interest. METHODS: A cross-sectional survey of the complete sample of hospital pharmacists practising in 3 large health authorities in a single Canadian province was conducted from February to April 2010. RESULTS: A total of 224 responses were received from the approximately 480 pharmacists in the target health authorities (response rate approximately 47%). Fifty-eight percent of respondents (127/218) did not believe that information received at industry-sponsored events influenced their clinical decision-making. Most (142/163 [87%]) disagreed that small gifts influenced their clinical decision-making, whereas responses were divided for large gifts. Respondents were also divided on the issue of whether their interactions created conflicts of interest, with most of those who had received gifts agreeing that large gifts would create a conflict of interest (134/163 [82%]) whereas small gifts would not (100/163 [61%]). There were positive correlations between respondents' beliefs about their own susceptibility to influence from sponsored events or receipt of small or large gifts and the susceptibility of others, but 22% of respondents (28/127) expressed a different perception about sponsored events, all believing themselves to be less influenced than their colleagues. Only 6% (4/64) of those who received large gifts and 4% (5/142) of those who received small gifts and felt they were not influenced by these gifts reported that it was likely others would be influenced by the receipt of such gifts. CONCLUSIONS: Most hospital pharmacists who responded to this survey had attended industry-sponsored events, and the majority felt that it did not influence their clinical decision-making, despite recognition that the information received is unbalanced. Respondents were divided on the notion of whether these interactions led to conflicts of interest. Respondents generally felt that large and small gifts had different effects on influence and conflict of interest.

CONTEXTE: Il n'existe que très peu de documentation qui porte sur la perception des pharmaciens canadiens envers la promotion des médicaments par l'industrie pharmaceutique et leurs relations avec cette industrie. OBJECTIFS: Déterminer si les pharmaciens d'hôpitaux croient que leurs relations avec l'industrie pharmaceutique les influencent ou influencent leurs collègues dans leur prise de décision clinique et s'ils croient que les relations avec l'industrie pharmaceutique sont source de conflits d'intérêts. MÉTHODES: Une enquête transversale auprès de l'ensemble des pharmaciens d'hôpitaux exerçant au sein de trois grandes régies de la santé dans une seule province canadienne a été réalisée entre février et avril 2010. RÉSULTATS: En tout, on a obtenu 224 réponses des quelque 480 pharmaciens des régies de la santé visées (taux de réponse approximatif de 47 %). Cinquante-huit pour cent des répondants (127/218) ont affirmé ne pas croire que des informations obtenues au cours d'activités organisées par l'industrie aient une influence sur leur prise de décision clinique. La plupart (142/163 [87 %]) ne croyaient pas que des cadeaux modestes puissent influencer leur prise de décision clinique, alors que les réponses étaient partagées pour ce qui est des cadeaux importants. Les répondants étaient aussi partagés sur la question à savoir si leurs relations étaient source de conflits d'intérêts. La majorité de ceux ayant reçu des cadeaux affirmaient que recevoir des cadeaux importants pourrait créer des conflits d'intérêts (134/163 [82 %]), mais que ça ne serait pas le cas avec des cadeaux modestes (100/163 [61 %]). On a remarqué des corrélations positives entre les croyances des répondants à propos de la possibilité qu'ils puissent eux-mêmes être influencés par les activités commanditées ou par des cadeaux importants ou modestes et la vulnérabilité des autres à être influencés dans une même situation. Mais 22 % d'entre eux (28/127) ont indiqué avoir une perception différente en ce qui a trait aux activités organisées par l'industrie : ils croyaient tous être moins influencés que leurs collègues. Parmi les personnes qui ont répondu qu'elles ne croyaient pas avoir été influencées par des cadeaux perçus, seulement 6 % (4/64) de celles ayant reçu des cadeaux importants et 4 % (5/142) de celles ayant reçu des cadeaux modestes ont affirmé que les autres seraient probablement influencées par de tels cadeaux. CONCLUSIONS: La plupart des pharmaciens ayant répondu à cette enquête ont participé à des activités organisées par l'industrie. La majorité d'entre eux ne croyaient pas que cela ait eu une influence sur leur prise de décision clinique, et ce, bien qu'ils aient reconnu que les informations reçues n'étaient pas impartiales. Les répondants étaient partagés sur la question à savoir si ces relations étaient ou non source de conflits d'intérêts. En général, ils croyaient que l'importance du cadeau influençait différemment les gens et qu'elle influait sur l'existence ou non d'un conflit d'intérêts.

Nicotine replacement therapy in the intensive care unit: a systematic review.

OBJECTIVE: The objective of this review was to systematically review and evaluate available literature describing the effect of nicotine replacement therapy (NRT) on mortality and other outcomes in nicotine-dependent critically ill patients admitted to the intensive care unit (ICU). DATA SOURCES: A systematic search of the following databases was performed: MEDLINE (1948-August 2011), EMBASE (1980-August 2011), Cochrane Database of Systematic Reviews, International Pharmaceutical Abstracts (1970-August 2011), Google, and Google Scholar. STUDY SELECTION: Studies that reported outcomes associated with any form of NRT in any intensive care setting were included. Studies were included regardless of design or number of participants reported. Studies published in languages other than English were excluded. DATA EXTRACTION: Data from each study were extracted using a standardized data extraction tool. Information included the study design, number of patients, classification of ICU, baseline characteristics, outcomes assessed, and overall results. DATA SYNTHESIS: Our search identified 8 studies, of which 7 met the inclusion criteria. These 7 studies were qualitatively reviewed and critically appraised for methodological quality, robustness of results, and internal and external validity. The results of similar studies and populations were compared in order to draw conclusions pertaining to specific intensive care settings. CONCLUSIONS: We conclude that NRT should not be routinely prescribed to patients admitted to intensive care settings. With only equivocal evidence of efficacy and signals suggesting increased toxicity, we believe that its use should be limited to selected patients where the potential benefit clearly outweighs the risk. There is a need for adequately powered randomized controlled trials to confirm the benefits and risks of NRT in the ICU overall but also in its unique subpopulations.

Survey of Canadian Pharmacists' Responses to Warnings of Potential Interactions Between Ceftriaxone and Calcium in IV Solutions.

BACKGROUND: In 2007, because of a potential interaction between ceftriaxone and calcium-containing IV solutions, Roche Laboratories (manufacturer of Rocephin [ceftriaxone] in the United States) issued letters to health care professionals advising them of changes to the product monograph. Subsequently, warning letters were also issued by the US Food and Drug Administration (FDA) and Health Canada. The Health Canada recommendations and their implications for clinical practice generated debate in the Canadian hospital pharmacy community. OBJECTIVE: To evaluate the response to the warnings among hospital pharmacists and their respective institutions. METHODS: An anonymous, voluntary 10-question survey was distributed to members of the Pharmacy Specialty Networks of the Canadian Society of Hospital Pharmacists. Requests to participate were solicited via 2 e-mail messages. Responses were analyzed descriptively. RESULTS: A total of 152 pharmacists participated in the survey. Forty-three respondents (28.3%) reported being very concerned and 86 (56.6%) reported being somewhat concerned about the Health Canada Notice to Hospitals. About half (77/152 [50.7%]) of the respondents felt that the Health Canada notice did not need to be strictly heeded. Two-thirds (98/145 [67.6%]) reported that their institutions had addressed the risk of an interaction through a change in policy regarding the administration of ceftriaxone. Eighty-eight (61.5%) of 143 participants indicated that their institution's official position on the notice was that it represented a "relative contraindication" (i.e., the benefit may outweigh the risk). CONCLUSIONS: Warning letters issued by the manufacturer, the FDA, and Health Canada generated concern within the Canadian hospital pharmacy community. However, a large proportion of hospital pharmacy practitioners did not agree with strict adherence to the Health Canada notice.

Fluoroquinolones for the treatment of pulmonary tuberculosis.

Tuberculosis (TB) continues to be a significant problem globally. Treatment includes a multiple drug regimen with isoniazid, rifampicin (rifampin), pyrazinamide and ethambutol. Often, one of these medications needs to be replaced as a result of adverse events or because Mycobacterium tuberculosis develops resistance against one these first-line agents. Fluoroquinolones, particularly the newer ones, possess good in vitro (levofloxacin, gatifloxacin, moxifloxacin) and in vivo (gatifloxacin and moxifloxacin) bactericidal activity against M. tuberculosis, making them attractive agents for the treatment of pulmonary TB. All relevant clinical trials, cohort studies and case reports investigating the clinical efficacy and tolerability of fluoroquinolones when used for the treatment of pulmonary TB were evaluated for this review. Specifically, efficacy and safety in the following indications were investigated: (i) first-line treatment of drug-sensitive pulmonary TB; (ii) first-line treatment for multi-drug resistant (MDR) TB; and (iii) treatment of patients with drug intolerance. Twenty-seven articles met our inclusion criteria; nine articles presented data from randomised, controlled or cohort studies. Seven studies used fluoroquinolones as first-line agents in drug-sensitive TB (1469 patients), 15 studies used fluoroquinolones to treat MDR-TB (1025 patients) and six studies (951 patients) investigated the use of fluoroquinolones in patients intolerant to other TB medications. In patients with susceptible M. tuberculosis strains, substitution with a fluoroquinolone did not have an effect on cure or radiological improvement at 8 weeks or failure at 12 months. Substitution of older fluoroquinolones into a regimen, especially ciprofloxacin, resulted in a higher rate of relapse and a longer time to sputum-culture conversions. The use of fluoroquinolones in patients with MDR-TB is supported by some trials where others show a lack of improvement in efficacy of a regimen. Our review of the literature does not support the use of older fluoroquinolones, especially ciprofloxacin, as substitute agents for drug-sensitive or drug-resistant TB. However, newer fluoroquinolones, such as moxifloxacin, may be a reasonable alternative based on results from one large clinical trial. Fluoroquinolones have an important role as substitute agents for those who are intolerant of first-line TB agents.