Perceptions of pharmacy technician students of the CARD (Comfort Ask Relax Distract) e-module introduced as part of vaccine injection training.

Introduction: The scope of practice for pharmacy technicians is expanding to include vaccine administration in some provinces. Vaccine training courses and programs currently do not include education about mitigating immunization stress-related responses (ISRR) and improving the vaccination experience. We obtained feedback from pharmacy technician students about a new e-module that addresses this identified knowledge gap, whereby learners are educated about CARD (Comfort Ask Relax Distract), a vaccine delivery framework that reduces ISRR and improves the vaccination experience. Methods: Mixed-methods design including second-year pharmacy technician students who elected to take an accredited vaccine injection training program. Students were given access to the CARD e-module after completing mandatory vaccine education components. Eight students answered a quantitative survey and 4 (50%) additionally participated in a focus group. Qualitative data were analyzed deductively using the Consolidated Framework for Implementation Research (CFIR). Results: The study was conducted between April 28 and June 12, 2022. Students reported positive attitudes about the CARD e-module across quantitative and qualitative measures. Qualitative feedback spanned 4 CFIR constructs: intervention characteristics, outer setting, inner setting and individual characteristics. Students reported the e-module was well designed and that the content was relevant. They believed CARD facilitated provision of vaccinations using a person-centred approach that promotes vaccination. They felt that CARD could potentially add time to the vaccination appointment and that it would need to be acceptable to pharmacy leaders because of implications for training and vaccination delivery. They suggested that CARD education should be mandatory. CARD improved their confidence in delivering vaccinations, and they planned to integrate CARD into their practice. Conclusion: The CARD e-module was well received by pharmacy technician students when coupled with usual vaccine injection training.

Experiences of community pharmacists administering COVID-19 vaccinations: A qualitative study.

Background: Throughout the COVID-19 pandemic, community pharmacists have played an important role in the provision of patient care, including the delivery of COVID-19 vaccines. The additional workload and related demands arising from these extended services might affect worklife burnout. This qualitative study explored the experiences of Canadian community pharmacists in providing COVID-19 vaccines during the COVID-19 pandemic. Methods: Eighteen community pharmacists across 10 provinces were asked about vaccination processes and perceptions about their role in separate, virtual semistructured interviews. Interviews were transcribed verbatim and analyzed using a deductive approach using the Areas of Worklife Burnout framework, with pharmacists' self-reported descriptions of their activities summarized using the Association of Faculties of Pharmacy of Canada's (AFPC) professional competencies framework. Results: Participants identified aspects of their role that were rewarding and challenging. Some challenges included lack of control, increased workload, inadequate communication, unfair treatment and conflicting values. They described being able to meet challenges and demonstrating resiliency via adaptability, developing communities and valuing their contribution to ending the COVID-19 pandemic. Self-identified AFPC competencies contributing to their ability to manage their worklife included care-provider, professional, leader-manager, collaborator and scholar. Conclusion: Pharmacists accepted their additional responsibility of managing COVID-19 vaccines during the COVID-19 pandemic. However, they expressed some challenges with this role. To ensure sustainability of these services, prioritizing adequate resources, work processes and efficient communication with all relevant stakeholder groups, including public health, government and corporate leaders, is recommended for the future. Can Pharm J (Ott) 2023;156(Suppl):xx-xx.

Performance of Busulfan Dosing Guidelines for Pediatric Hematopoietic Stem Cell Transplant Conditioning.

Achievement of a busulfan area-under-the-concentration versus time curve (AUC) of 900 to 1500 µM·min is associated with improved hematopoietic stem cell transplant (HSCT) outcomes. Multiple pediatric busulfan dosing guidelines aim to achieve this target. The authors' objective was to describe the AUCs achieved after simulated dosing using available pediatric i.v. busulfan dosing guidelines. The health records of children who received i.v. busulfan for HSCT conditioning at The Hospital for Sick Children were reviewed. Busulfan AUCs were calculated for each patient based on plasma busulfan concentrations using either a 1-compartment model or a validated limited-sampling strategy. Published pediatric busulfan dosing guidelines were identified. Initial busulfan doses were determined for all patients using each dosing guideline and total body weight (TBW). For overweight patients (TBW-to-ideal body weight [IBW] ≥ 1.25), initial busulfan doses were also determined using IBW and adjusted IBW (IBWadj). The resulting AUCs were simulated. The proportion of subjects (TBW/IBW < 1.25, TBW/IBW ≥ 1.25, and infants) with an AUC within target (900 to 1500 µM·min) after dosing simulation with each guideline was compared. One hundred eleven children (mean age, 6.2 years [SD, ±5.2]) who received i.v. busulfan were included. When dosing with each of the 12 i.v. busulfan dosing guidelines identified was simulated using TBW in 97 non-overweight patients, the proportion of patients with an AUC within the target range varied from 51% to 74% and from 45% to 64% in infants. Use of IBW or IBWadj to calculate initial busulfan doses in overweight children improved the performance of most guidelines. Current busulfan dosing guidelines vary in their ability to achieve AUCs within the target range. For children who are not overweight, we recommend 1 of 3 high-performing guidelines that allow individualization of the target busulfan AUC. Use of either IBW or IBWadj in overweight children improves the performance of most guidelines. Regardless of the guideline used, therapeutic drug monitoring is essential to verify achievement of the target AUC.

Implementation of a Meds to Beds Medication Use Program and Parent Experience at the Time of Transition From a Neonatal Intensive Care Unit to Home.

OBJECTIVE: This study aims to describe the overall experience of the neonatal intensive care unit (NICU) parent at time of transition home related to discharge medication use, following implementation of a Meds to Beds program. METHODS: A descriptive, qualitative study was used to explore parent experiences around medication use during transition home. Eleven parents whose infants required medications at the time of transition home from the NICU participated in a semi-structured telephone interview post-discharge. The data were coded and analyzed for themes. RESULTS: Major themes nested within the key stages of medication use in preparation for transition home from the NICU were identified: in-hospital preparation (practice early and often, Meds to Beds, and relationship with clinical pharmacist), transition home (schedule and routine, strategies for medication administration) and post-discharge (refills and long-term medication management). Strategies based on parent experiences to improve the process and ameliorate anxiety are presented. CONCLUSIONS: Parents expressed how effective the Meds to Beds program was on the transition home by increasing parental confidence and knowledge around medications and reducing stress around the acquisition of medications for home. They also reported comfort in having a relationship with the NICU clinical pharmacist, providing a tailored approach to coordinating care both in hospital and during the transition home. Regardless of implementation of a Meds to Beds program, great opportunities remain to refine the transition home. Implementing the suggested improvement strategies could provide significant positive effects with respect to patient care and parental stress during the transition home.

Pharmacists as vaccinators: An analysis of their experiences and perceptions of their new role.

OBJECTIVES: In 2012, Ontario pharmacists were granted immunization privileges to administer influenza vaccines to the public. This study explored the experiences and practices of pharmacist vaccinators and the impact of vaccination pain on their practice. METHODS: Semi-structured interviews were conducted with 12 pharmacists in the Greater Toronto Area. Transcribed interview data were coded and analyzed via thematic analysis. KEY FINDINGS: Data analysis revealed 4 main themes: 1) expanded scope of practice as an enhancement and challenge to relationships; 2) professional satisfaction and workload demands; 3) knowledge and attitudes regarding pain and fear; 4) practices regarding pain and fear management. Pharmacists reported satisfaction in their new role, despite the associated increased workload. Pharmacists felt that vaccination pain was not a key consideration when administering vaccines and that pain management was generally not necessary. Fear was identified as more important than pain and vaccinating children was challenging and time intensive. Pharmacists' main focus was on injection techniques in managing pain. CONCLUSION: These findings suggest that pharmacists are accepting of their role as vaccinators but more research is needed to examine impact on workload and pharmacist knowledge and perceptions of injection-related pain and fear.

Intraurethral Lidocaine for Urethral Catheterization in Children: A Randomized Controlled Trial.

OBJECTIVES: To determine whether lidocaine is superior to nonanesthetic lubricant (NAL) for relieving pain in children undergoing urethral catheterization (UC). METHODS: Children 0 to 24 months requiring UC were randomized to NAL or topical and intraurethral 2% lidocaine gel. Primary outcome was facial grimacing in the pre to during drug administration and catheterization phases. Secondary outcome was caregiver satisfaction by using a Visual Analog Scale. RESULTS: There were 133 participants (n = 68 lidocaine, n = 65 NAL). There were no significant differences in mean (SD) scores during UC between lidocaine and NAL (86.4% [121.5%] vs 85.2% [126.6%]), respectively (Δ [confidence interval (CI)] = -1.2 [-21.0 to 49.0], P = .4). There was a significantly greater difference in mean (SD) scores during instillation of lidocaine versus NAL (61.8% [105.6%] vs 3.2% [84.9%]), respectively (Δ [CI] -58.6 [-95.0 to -32.0], P < .001). There were no significant differences in mean (SD) parental satisfaction scores between lidocaine and NAL (4.8 [3.2] vs 5.9 [2.9]), respectively (CI-0.1 to 2.2; P = .06). In the subgroup analysis, age, gender, and positive urine culture did not significantly influence between-group differences in facial grimacing. CONCLUSIONS: Compared with NAL, topical and intraurethral lidocaine is not associated with significant pain reduction during UC, but significantly greater pain during instillation. Therefore, clinicians may consider using noninvasive pain-reducing strategies for young children who require UC.

Addressing parental concerns about pain during childhood vaccination: is there enough time to include pain management in the ambulatory setting?

OBJECTIVE: Pain from vaccine injections remains undertreated, despite the availability of numerous pain-relieving strategies. Healthcare providers report lack of time within current office workflows as a major barrier to routine pain management. The objective was to document the total time involved in outpatient vaccine appointments to test the hypothesis that offering pain-relieving strategies can be practically implemented when considering the element of time to vaccine injection. PATIENTS AND METHODS: Prospective naturalistic study in 8 urban outpatient primary care clinics (4 pediatric and 4 family practice) in Toronto. For 48 to 59 consecutive childhood vaccination appointments at each site, child waiting time from clinic arrival until first vaccine injection was tracked. RESULTS: Altogether, 405 vaccine appointments were included. The median age of the child undergoing vaccination was 12 months. The mean (SD) time from clinic arrival until first vaccine injection was 41.6 minutes (20.9), with a range of 7 to 132 minutes. Linear regression identified a significant (P<0.05) difference according to clinic [ranging from 19.4 min (6.5) to 57.5 min (20.2)] and number of family members in the appointment [ranging from 40.6 min (21.0) for an appointment in the index child only to 50 min (14.3) for an appointment in the index child and 2 other family members]. CONCLUSIONS: Contrary to healthcare provider perceptions, the timing of outpatient childhood vaccine appointments allows for the inclusion of pain management interventions. Efforts should now focus on educating healthcare providers and parents about the value of pain management and how to implement evidence-based strategies.

Evaluation of the reliability, validity and practicality of 3 measures of acute pain in infants undergoing immunization injections.

There is a need to identify a primary measure of infant pain that can be used to assess pain in infants undergoing vaccine injections in order to facilitate vaccine outcomes research. The aim of the present study was to determine the reliability, validity and practicality of 3 measures of acute pain in infants; the Modified Behavioural Pain Scale (MBPS), Neonatal Infant Pain Scale (NIPS), and Face Legs Activity Cry Consolability Scale (FLACC). Five raters rated pain from videotapes in 120 infants aged 2-6 months undergoing vaccine injections that participated in a randomized controlled trial designed to compare pain responses between two vaccines, DPTaP-Hib vaccine and PCV vaccine. Inter-rater reliability coefficients for baseline and vaccine injections were all greater than 0.85. Cronbach's alpha ranged from 0.83 to 0.94. Construct validity was demonstrated for all measures by vaccine injection scores that were higher (p<0.001) than baseline scores and by PCV scores that were higher than DPTaP-Hib scores. Concurrent validity was demonstrated by bi-variate correlation coefficients that ranged from 0.84 to 0.92. Intra-rater reliability coefficients for scores obtained after a single viewing (simulating real time assessment) versus multiple viewings were ≥ 0.96. All measures demonstrated a significant difference in pain scores between the more painful (PCV) and less painful (DPTaP-Hib) vaccine for scores obtained after a single viewing. The majority of raters (4 out of 5) preferred the MBPS. Together, these results provide preliminary support for the MBPS as the primary outcome of pain during vaccine injections in infants.