A retrospective study comparing postoperative opioid prescribing practices in an academic medical centre.

Background: In the midst of the North American opioid crisis, identifying and intervening on drivers of high-risk opioid prescriptions is an important step towards reducing iatrogenic harm. Objectives: We aimed to identify factors associated with variations in high-risk opioid discharge prescriptions, following select surgical procedures, to guide future quality improvement initiatives. Methods: This retrospective cohort study analyzed 1322 patients who underwent select open pelvic and open abdominal surgeries between January 1 and December 31, 2017, in a tertiary health care centre in Montreal. Results: Patients who underwent open abdominal surgeries were prescribed significantly higher daily doses of morphine milligram equivalents (MME) (45 mg; interquartile range, 30-60), than patients who underwent either a caesarean delivery (20 mg, 20-20) or a hysterectomy (30 mg, 22-30). After adjustment for multiple potential confounders, abdominal surgery was associated with 4 times the odds of receiving more than 50 MME at hospital discharge compared with pelvic surgeries (odds ratio, 3.96; 95% confidence interval, 1.31-11.97). The availability of postoperative preprinted order sets with fixed high doses of opioids was also highly associated with the outcome. Conclusion: In our institution, some surgeries were more likely to receive high-risk opioid prescriptions at discharge. Efforts to optimize safer prescribing practices should address the creation and/or updating of preprinted order sets to reflect current best practice guidelines. This initiative could be overseen by hospital pharmacy and therapeutics committees.

Are Recommended Doses of Acetaminophen Effective for Children Aged 2 to 3 Years? A Pharmacokinetic Modeling Answer.

OBJECTIVES: Acetaminophen (APAP) elixir is a widely used pediatric antipyretic medication. It has been shown that up to 30% of febrile children presenting to a large urban pediatric emergency department received inadequate APAP dosages at home with errors primarily due to age-based dosing. Parental education material in the form of weight-based dosing guides has been proposed; however, validation of current recommended APAP dosages using pharmacokinetic models is needed. This study used a mathematical model of APAP absorption to predict plasma concentrations and to compare them with the range required to reach and achieve antipyresis (10-20 µg/mL). METHODS: A common APAP preparation (Children's Tylenol Elixir) was tested (children aged 2-3 years, 10.9-15.9 kg). The manufacturer's suggested dose of 160 mg was compared with the standard 10 to 15 mg/kg dose range. RESULTS: The model predicts a peak plasma concentration between 6.38 and 8.55 µg/mL for 10 mg/kg dose and 9.57 and 12.8 µg/mL for 15 mg/kg dose. The manufacturer's suggested dose of 160 mg was tested across the limits of the weight range (10.9-15.9 kg). A peak plasma concentration between 9.36 and 12.6 µg/mL was found for the lower weight limit (10.9 kg child) and 6.42 to 8.61 µg/mL for the upper weight limit (15.9 kg child). CONCLUSIONS: With the use of this model, the 10 mg/kg dose does not reach the plasma concentration value for antipyresis (10-20 µg/mL), whereas 15 mg/kg is adequate only if assuming a greater absorption constant. The 160 mg dose is effective only for children weighing 10.9 kg. Individual differences in drug bioavailability, volume of distribution, and absorption/elimination constants undoubtedly exist, and future studies directly measuring plasma APAP concentration and pharmacokinetics are needed. However, these results indicate that dosages for APAP in children should be weight based and manufacturers should review their dosing recommendations.

Clinical Pharmacy Services in Canadian Emergency Departments: A 2022 National Survey.

Background: Support for the role of an emergency department (ED) clinical pharmacy team is evidence-based and recognized in numerous professional guidelines, yet previous literature suggests a low prevalence of ED clinical pharmacy services in Canadian hospitals. Objectives: To update (from a survey conducted in 2013) the description and quantification of clinical pharmacy services in Canadian EDs. Methods: All Canadian hospitals with an ED and at least 50 acute care beds were contacted to identify the presence of dedicated ED pharmacy services (defined as at least 0.5 full-time equivalent [FTE] position). Three separate electronic surveys were distributed by email to ED pharmacy team members (if available), pharmacy managers (at hospitals without an ED pharmacy team), and ED managers (all hospitals). The surveys were completed between November 2021 and January 2022. Results: Of the 254 hospitals identified, 117 (46%) had at least 0.5 FTE clinical pharmacy services in the ED (based on initial telephone screening). Of the 51 (44%) of 115 ED pharmacy team survey responses included in the analysis, 94% (48/51) had pharmacists and 55% (28/51) had pharmacy technicians. The majority of pharmacy managers and ED managers identified the need for ED pharmacy services where such services did not exist. Inadequate funding, competing priorities, and lack of training remain the most commonly reported barriers to providing this service. Personal safety concerns were reported by 20% (10/51) of respondents. Conclusions: Although the establishment of clinical pharmacy services in Canadian EDs has grown over the past 8 years, lack of funding and ED-specific training continue to limit this evidence-supported role in Canadian hospitals.

Contexte: La pratique de pharmacie clinique au service des urgences (SU) est fondée sur les données probantes et reconnue dans de nombreuses lignes directrices professionnelles. Cependant, des données portent à croire à une faible prévalence de ces services dans les SU des hôpitaux canadiens. Objectif: Mettre à jour la description et la quantification des services de pharmacie clinique dans les SU canadiens (à partir d'une enquête menée en 2013). Méthodes: Tous les hôpitaux canadiens dotés d'un SU et d'au moins 50 lits de soins de courte durée ont été contactés pour recenser la présence de services de pharmacie dédiés au SU (définis comme au moins 0,5 poste équivalent temps complet [ETC]). Trois sondages électroniques différents ont été distribués par courriel aux membres de l'équipe de la pharmacie du SU (le cas échéant), aux gestionnaires de pharmacie (dans les hôpitaux sans équipe de pharmacie au SU) et aux gestionnaires du SU (tous les hôpitaux). Les enquêtes ont été réalisées entre novembre 2021 et janvier 2022. Résultats: Sur les 254 hôpitaux recensés, 117 (46 %) disposaient d'au moins 0,5 ETC de services de pharmacie clinique au SU (d'après la sélection téléphonique initiale). Des 51 (44 %) sur 115 équipes de pharmacie du SU qui ont été inclus dans l'analyse, 94 % (48/51) avaient des pharmaciens et 55 % (28/51) avaient également du personnel technique en pharmacie. La majorité des directeurs de pharmacie et des directeurs des SU ont identifié le besoin de services de pharmacie au SU là où de tels services n'existent pas. Un financement inadéquat, des priorités concurrentes et le manque de formation demeurent les obstacles les plus souvent signalés à la prestation de ce service. Des problèmes de sécurité personnelle ont été mentionnés par 20 % (10/51) des répondants. Conclusion: Bien que l'établissement de services de pharmacie clinique dans les SU canadiens ait augmenté au cours des 8 dernières années, le manque de financement et de formation spécifique en pharmacie de médecine d'urgence continue de limiter ce rôle fondé sur des données probantes dans les hôpitaux canadiens.

Impact of Postgraduate Second-Year Pharmacy Training (PGY2) on Clinical, Financial, and Educational Outcomes: A Scoping Review.

OBJECTIVE: A scoping review was conducted to screen the published literature on the clinical, financial, and educational effect of postgraduate second year (PGY2) pharmacy residency training. FINDINGS: A search strategy was conducted in MEDLINE, EMBASE, CINAHL, Cochrane Central and Web of Science without study design, language, or time restrictions (inception to March 2022). Articles were reported using the PRISMA reporting items list. Studies were included if a measurable clinical outcome, a cost-avoidance calculation and/or involvement in teaching or research activities was reported. Studies were excluded if there was no mention of a PGY2 training. Of the 2534 articles that were screened, 21 articles met our inclusion criteria. Seven studies reported clinical outcomes, five reported cost avoidance, six reported educational outcomes and three studies reported both clinical and cost-avoidance outcomes. Four of the studies evaluating clinical outcomes took place in a psychiatric clinic setting. Better disease control was reported in four articles. Two studies evaluated readmission and emergency department visits at 30 days but only one showed significant reduction. The estimated cost avoidance reported ranged from $22,380 to $5,387,679 and two studies reported the services billed by the resident. In two studies, PGY2 pharmacists were more likely to be involved in teaching activities and were more likely to participate in research activities. CONCLUSION: Even though few studies evaluated the benefits of PGY2 pharmacy trainings, they showed to improve patient care, enhance involvement in teaching activities, and decrease financial burden for health-care systems. More studies should be done to reinforce the merits of such training.

Pharmacy Practice in Quebec Emergency Departments: A Survey Study.

Background: According to a Canadian survey conducted in 2013, 37 of the 67 Quebec emergency departments (EDs) in hospitals with more than 50 beds reported having a pharmacist within the department. However, based on the 17 responses to the survey, it was not possible to determine patient care services offered by Quebec ED pharmacists, because the data were aggregated across all Canadian respondents. A provincial survey was undertaken to further define ED pharmacy practice within Quebec. Objectives: To measure pharmacist involvement in EDs in the province of Quebec and to describe patient care services and interventions offered by these pharmacists. Methods: A 47-question survey was sent to 33 directors of pharmacy departments, representing 90 hospitals and institutes with EDs in the province of Quebec. The directors of pharmacy were asked to forward the survey to an ED pharmacist for completion or to partially answer the survey themselves if their facilities had no pharmacists practising in the ED. The survey evaluated the presence of pharmacists in the ED, their training, the interventions they performed, and their involvement within the department. The presence and role of ED pharmacy technical staff were also evaluated. Results: Of the 43 completed surveys received, 30 reported at least 1 pharmacist providing patient care within the facility's ED. The most common tasks performed by ED pharmacists were, in decreasing order of frequency, answering questions from the multidisciplinary team, adjusting medications according to patients' allergies or their renal or hepatic function, managing drug interactions, and clarifying prescriptions. Pharmacists also reported teaching pharmacy students and residents and supporting the team in the resuscitation area. Conclusions: The majority of respondents reported having at least 1 pharmacist in the ED. Compared with previous Canadian results, this survey had more respondents from Quebec with better representation of ED pharmacy practice in the province. Patient care services provided by pharmacists were variable, possibly because of a lack of standardized practice guidelines.

Contexte: Selon une enquête canadienne menée en 2013, 37 des 67 services des urgences dans des hôpitaux québécois de plus de 50 lits ont déclaré avoir un pharmacien au sein de leur service. Cependant, à partir des 17 réponses de cette enquête, il n'a pas été possible de déterminer les services de soins aux patients offerts par les pharmaciens des services des urgences du Québec, car les données étaient agrégées pour tous les répondants canadiens. Une enquête provinciale a été menée pour mieux définir la pratique de la pharmacie au sein des services des urgences au Québec. Objectifs: Mesurer l'implication des pharmaciens dans les services des urgences du Québec et décrire les services de soins aux patients et les interventions offerts par ces pharmaciens. Méthodes: Un sondage comportant 47 questions a été envoyé à 33 chefs de départements de pharmacie, représentant 90 hôpitaux et instituts ayant un service des urgences au Québec. Les chefs de départements de pharmacie ont été invités à transmettre le sondage à un pharmacien du service des urgences pour qu'il y réponde; ou, si leur établissement ne comptait aucun pharmacien exerçant en service des urgences, à y répondre partiellement eux-mêmes. L'enquête a permis d'évaluer la présence des pharmaciens dans les services des urgences, leur formation, leurs interventions et leur implication au sein du département. La présence et le rôle du personnel technique en pharmacie des urgences ont également été évalués. Résultats: Sur les 43 questionnaires remplis reçus, 30 indiquaient avoir au moins un pharmacien prodiguant des soins aux patients dans le service des urgences de l'établissement. Les tâches les plus courantes consistaient, par ordre décroissant de fréquence, à répondre aux questions de l'équipe multidisciplinaire, à adapter les médicaments selon les allergies des patients ou leur fonction rénale ou hépatique, à gérer les interactions médicamenteuses et à clarifier les ordonnances. Les pharmaciens ont également déclaré former les étudiants et les résidents en pharmacie et soutenir l'équipe dans la salle de réanimation. Conclusions: La majorité des répondants ont déclaré avoir au moins un pharmacien au service des urgences. Par rapport aux résultats canadiens antérieurs, cette enquête comptait plus de répondants du Québec et indiquait une meilleure représentation de la pratique de la pharmacie au service des urgences dans la province. Les services de soins aux patients fournis par les pharmaciens étaient variables, peut-être en raison d'un manque de directives de pratique normalisées.

Current fatality rate of suspected cyclopeptide mushroom poisoning in the United States.

OBJECTIVE: This study was designed to determine the fatality rate of suspected cyclopeptide-containing mushroom ingestions reported to the National Poison Data System (NPDS). BACKGROUND: Although silibinin reportedly improves survival in suspected cyclopeptide-containing mushroom ingestions, the greater than 20% untreated fatality rate that is often cited is based on decades-old data. An ongoing open-label silibinin trial will likely use historical cases as comparators. A recent single poison control center (PCC) study showed a fatality rate of 8.3%. This study was designed to validate those findings in the NPDS. METHODS: This study was an 11-year (1/1/2008-12/31/2018) retrospective review of suspected cyclopeptide-containing mushroom ingestions reported to NPDS. Inclusion and exclusion criteria were the same as the ongoing silibinin trial: Age >2-years-old; history of eating foraged mushrooms; gastrointestinal symptoms within 48 h of mushroom ingestion; and aminotransferases above the upper limit of normal within 48 h after ingestion. Each original participating PCC confirmed eligibility, diagnosis, treatment, and outcome on included cases. RESULTS: During the study period, 8,953 mushroom exposures were reported to NPDS, of which 296 met inclusion criteria. The PCC survey response rate was 60% (28/47 PCCs), and the individual case response rate was 59% (174/296). Twenty-six cases were subsequently excluded leaving 148 included cases. The overall mortality rate was 8.8% (13/148). Mortality in silibinin/silymarin-treated vs untreated cases was 9.5% (4/42), vs 8.5% (9/106), respectively. A mycologist identified mushrooms in 16.9% of cases (25/148), of which 80% (20/25) were cyclopeptide-containing. Among these confirmed cases, the mortality rate was 10% (1/10) in both silibinin/silymarin-treated and untreated cases. CONCLUSIONS: The contemporary mortality rate of patients with presumed cyclopeptide-mushroom poisoning is only 8.8%. This likely represents improved supportive care for patients with acute liver injury and should be considered the current standard for historical controls in the United States.

Benzodiazepine resistant alcohol withdrawal: What is the clinician's preferred definition?

OBJECTIVES: Although alcohol withdrawal is common, the recognition of benzodiazepine-resistant alcohol withdrawal is a relatively new concept. To provide a framework for both literature review and future research, we assessed clinicians' personal definition of resistant alcohol withdrawal. METHOD: We developed a cross-sectional web-based survey. Administrators from collaborating toxicology and emergency medicine associations deployed the survey directly to their respective memberships. Only physicians, pharmacists, and other clinicians routinely treating alcohol withdrawal were eligible to participate. Respondents selected their preferred definition among the three most common author sources - JB Hack, NJ Benedict, D Hughes - or provided their own. Additional criteria to define resistant alcohol withdrawal were explored. RESULTS: 384 individuals answered the survey. Respondents were mostly attending physicians (79%), in full-time practice (90%), in emergency medicine (70%), and from North America (90%). The majority (64%) described resistant alcohol withdrawal as a high benzodiazepine dosage. Seizures (26%) and persistent tachycardia (16%) were also main characteristics. The median dose to describe high benzodiazepine dose (n = 146) was 40 mg per hour of diazepam equivalents (IQR 20-50). Available definitions were ranked equally as the preferred one: Hack (27%); Benedict (28%); Hughes (28%). CONCLUSION: Our results did not identify one single preferred definition for resistant alcohol withdrawal even though a high total dose of benzodiazepine is a major component. Hourly requirements of 40 mg of diazepam equivalents or more emerged as a possible threshold. These findings serve as a base to explore consensus guidelines or future research.

Utilization of lipid emulsion therapy in fatal overdose cases: an observational study.

OBJECTIVE: Although anecdotal reports suggest that intravenous lipid emulsion (ILE) therapy is effective in a large variety of overdoses, the few controlled human trials published to date yielded disappointing results. Because of potential publication biases, there are few reports concerning the failure of ILE. The primary aim of this study was to identify fatal poisoning cases in the American Association of Poison Control Centers (AAPCC) National Poison Data System (NPDS) in which ILE was administered. METHODS: We obtained an approved release of data from NPDS for years 2010-2015 in which the words "lipid," "ILE," or "fat" appeared in the narrative. Duplicate cases were excluded as were cases in which ILE was not clearly given. Case data were extracted by one author using a predetermined tool, and the information was confirmed by a second author. The timing of ILE administration was characterized into one of four categories: cardiac arrest, first line, last resort, or part of multiple therapies given simultaneously. Response to ILE and adverse events was recorded. RESULTS: Of the 826 cases retrieved from NPDS, 459 met final inclusion criteria. Over 50% of included cases involved either a calcium channel blocker or a beta-adrenergic antagonist. Of note, less than 25% of cases involved a substance for which the Lipid Emulsion Working Group found evidence to support its use. Most often, ILE was given along with multiple therapies (277 cases) or as a last resort (137 cases). In 127 cases, ILE was given during cardiac arrest. ILE was used as first line therapy in 34 cases. Response rates were reported as follows: no response (45%), unknown response (38%), transient/minimal response (7%), ROSC (7%), and immediate worsening (3%). Possible adverse reactions included: ARDS in 39 patients, lipemia causing a delay in laboratory evaluation in three cases, lipemia causing failure of a CRRT filter in two cases, worsening or new onset seizure in two cases, asystole immediately after administration in two cases, and fat embolism in one case. CONCLUSION: Within the Association of Poison Control Centers (AAPCC) National Poison Data System (NPDS), hundreds of cases exist in which ILE therapy was given and death occurred. In many of these cases, ILE was given prior to cardiovascular collapse. Although there is some suggestion of transient improvement in a small subset of cases, adverse effects are also reported. When taken in totality, the number of published cases of failed lipid emulsion therapy outnumbers the published instances of ILE success. Given all the uncertainty generated by case reports, the evaluation of the role and efficacy of ILE therapy in non-local anesthetic poisoning needs robust controlled clinical trials.

Intraosseous administration of antidotes - a systematic review.

CONTEXT: Intraosseous (IO) access is an established route of administration in resuscitation situations. Patients with serious poisoning presenting to the emergency department may require urgent antidote therapy. However, intravenous (IV) access is not always readily available. OBJECTIVE: This study reviews the current evidence for IO administration of antidotes that could be used in poisoning. The primary outcome was mortality as a surrogate of efficacy. Secondary outcomes included hemodynamic variables, electrocardiographic variables, neurological status, pharmacokinetics outcomes, and adverse effects as defined by each article. METHODS: A medical librarian created a systematic search strategy for Medline, subsequently translated to Embase, BIOSIS, PubMed, Web of Science, Cochrane, Database of Abstracts of Reviews of Effects (DARE), and the CENTRAL clinical trial register, all of which we searched from inception to 30 June 2016. Interventions included IO administration of selected antidotes. Articles included volunteer studies, poisoning, or other resuscitation contexts such as cardiac arrest, burns, dehydration, seizure, hemorrhagic shock, or undifferentiated shock. We considered all human studies and animal experiments to the exception of in vitro studies. Two reviewers independently selected studies, and a third adjudicated in case of disagreement. Three reviewers extracted all relevant data. Three reviewers evaluated the risk of bias and quality of the articles using specific scales according to each type of study design. RESULTS: A total of 47 publications (46 articles and one abstract) met our inclusion criteria and described IO administration of 13 different antidotes. These included one case series and 21 case reports describing 26 patients, and 25 animal experiments. Of those, seven human case reports and four animal experiments specifically reported the use of antidotes in poisoning. Human case reports suggested favorable outcomes with IO use of atropine, diazepam, hydroxocobalamin, insulin, lipid emulsion, methylene blue, phentolamine, prothrombin complex concentrate, and sodium bicarbonate. Clinical outcomes varied according to the antidote used. The only reported adverse event was ventricular tachycardia following IO naloxone. Regarding the animal experiments, IO administration of lipid emulsion and of hydroxocobalamin showed improved survival in bupivacaine-poisoned rats and in cyanide-intoxicated swine, respectively. Animal data also suggested an equivalent bio-availability between IO and IV administration for atropine, calcium chloride, dextrose 50%, diazepam, methylene blue, pralidoxime, and sodium bicarbonate. Adverse effect reporting of fat emboli after IO administration of sodium bicarbonate, for example, was conflicting due to the significant heterogeneity in the timing of lung examination across studies. CONCLUSION: The evidence supporting the use of IO route for the administration of antidotes in a context of poisoning is scarce. The majority of the evidence consists of case reports and animal experiments. Common antidotes such as acetylcysteine, fomepizole, and digoxin-specific antibody fragments have not been studied or reported with the use of the IO route. Despite the low-quality evidence available, IO access is a potential option for antidotal treatments in toxicological resuscitation when IV access is unavailable.

Massive acetaminophen overdose: effect of hemodialysis on acetaminophen and acetylcysteine kinetics.

CONTEXT: Early onset acidosis from mitochondrial toxicity can be observed in massive acetaminophen poisoning prior to the development of hepatotoxicity. In this context, the efficacy of acetylcysteine to reverse mitochondrial toxicity remains unclear and hemodialysis may offer prompt correction of acidosis. Unfortunately, toxicokinetics of acetaminophen and acetylcysteine during extracorporeal treatments hemodialysis have seldom been described. CASE DETAILS: An 18-year-old woman presented to the emergency department 60 minutes after ingestion of 100 g of acetaminophen, and unknown amounts of ibuprofen and ethanol. Initial assessment revealed an agitated patient. Her mental status worsened and she required intubation for airway protection. Investigations showed metabolic acidosis with lactate peaking at 8.6 mmol/L. Liver and coagulation profiles remained normal. Acetaminophen concentration peaked at 981 µg/ml (6496 µmol/L). Pending hemodialysis, the patient received 100 g of activated charcoal and an acetylcysteine infusion at 150 mg/kg over 1 hour, followed by 12.5 mg/kg/h for 4 hours. During hemodialysis, the infusion was maintained at 12.5 mg/kg/h to compensate for expected removal before it was decreased to 6.25 mg/kg for 20 hours after hemodialysis. The patient rapidly improved during hemodialysis and was discharged 48 hours post-admission. TOXICOKINETICS: The acetaminophen elimination half-life was 5.2 hours prior to hemodialysis, 1.9-hours during hemodialysis and 3.6 hours post hemodialysis. The acetaminophen and acetylcysteine clearances by A-V gradient during hemodialysis were 160.4 ml/min and 190.3 ml/min, respectively. Hemodialysis removed a total of 20.6 g of acetaminophen and 17.9 g of acetylcysteine. CONCLUSION: This study confirms the high dialyzability of both acetaminophen and acetylcysteine. Hemodialysis appears to be a beneficial therapeutic option in cases of massive acetaminophen ingestion with coma and lactic acidosis. Additionally, these results suggest that the infusion rate of acetylcysteine must be more than double during hemodialysis to compensate for its ongoing removal and provide similar plasma concentrations to the usual acetylcysteine regimen.

Clinical Pharmacy Services in Canadian Emergency Departments: A National Survey.

BACKGROUND: Providing clinical pharmacy services in emergency departments (EDs) is important because adverse drug events commonly occur before, during, and after ED encounters. Survey studies in the United States have indicated a relatively low presence of clinical pharmacy services in the ED setting, but a descriptive survey specific to Canada has not yet been performed. OBJECTIVES: To describe the current status of pharmacy services in Canadian EDs and potential barriers to implementing pharmacy services in this setting. METHODS: All Canadian hospitals with an ED and at least 50 acute care beds were contacted to identify the presence of dedicated ED pharmacy services (defined as at least 0.5 full-time equivalent [FTE] position). Three different electronic surveys were then distributed by e-mail to ED pharmacy team members (if available), pharmacy managers (at hospitals without an ED pharmacy team), and ED managers (all hospitals). The surveys were completed between July and September 2013. RESULTS: Of the 243 hospitals identified, 95 (39%) had at least 0.5 FTE clinical pharmacy services in the ED (based on initial telephone screening). Of the 60 ED pharmacy teams that responded to the survey, 56 had pharmacists (27 of which also had ED pharmacy technicians) and 4 had pharmacy technicians (without pharmacists). Forty-four (79%) of the 56 ED pharmacist services had been established within the preceding 10 years. Order clarification, troubleshooting, medication reconciliation, and assessment of renal dosing were the services most commonly provided. The large majority of pharmacy managers and ED managers identified the need for ED pharmacy services where such services do not yet exist. Inadequate funding, competing priorities, and lack of training were the most commonly reported barriers to providing this service. CONCLUSIONS: Although the establishment of ward-based pharmacy services in Canadian EDs has increased over the past 10 years, lack of funding and a lack of ED training for pharmacists were reported as significant barriers to the expansion of this role in most hospitals.

CONTEXTE: Offrir des services de pharmacie clinique dans les services des urgences est important, car des événements indésirables liés aux médicaments se produisent fréquemment avant, pendant et après y avoir séjourné. Des études par sondage réalisées aux États-Unis font état d'une présence relativement faible des services de pharmacie clinique dans les services des urgences. Malheureusement, aucune enquête descriptive n'a été menée au Canada à ce jour. OBJECTIFS: Dresser le portrait actuel des services de pharmacie au sein des services des urgences du Canada et présenter les obstacles potentiels à l'établissement de services de pharmacie dans ce milieu. MÉTHODES: On a communiqué avec l'ensemble des hôpitaux canadiens disposant d'un service des urgences et d'au moins 50 lits de soins de courte durée afin de savoir s'ils profitaient de services de pharmacie consacrés au service des urgences (soit au moins 0,5 d'un poste équivalent temps plein). Trois différents sondages électroniques ont ensuite été envoyés par courriel : un aux membres du personnel de pharmacie affectés aux services des urgences (le cas échéant); un aux gestionnaires de pharmacie (des hôpitaux sans équipe de pharmacie au service des urgences); et un aux gestionnaires des services des urgences (de tous les hôpitaux). Les sondages ont été remplis entre juillet et septembre 2013. RÉSULTATS: Des 243 hôpitaux recensés, 95 (39 %) avaient au moins 0,5 d'un poste équivalent temps plein pour la prestation de services de pharmacie clinique au service des urgences (résultat établi au moyen d'une présélection téléphonique). Parmi les 60 équipes de pharmacie affectées au service des urgences ayant répondu au sondage, 56 disposaient de pharmaciens (et parmi celles-ci, 27 comptaient aussi sur des techniciens en pharmacie) et 4 étaient composées exclusivement de techniciens en pharmacie. Quarante-quatre (79 %) des 56 équipes comprenant des pharmaciens avaient été mises en place au cours des dix dernières années. La clarification des ordonnances, le dépannage, l'établissement de bilans comparatifs des médicaments et l'évaluation de l'ajustement posologique chez les insuffisants rénaux représentaient les services les plus souvent offerts. La vaste majorité des gestionnaires de pharmacie et des gestionnaires des services des urgences ont souligné la nécessité d'avoir des services de pharmacie au service des urgences dans les établissements où il n'y en avait pas encore. Le manque de financement, le nombre foisonnant de priorités et l'insuffisance de formation représentaient les éléments faisant le plus souvent obstacle à l'instauration de ce service selon les répondants. CONCLUSIONS: Bien que la mise en place de services de pharmacie clinique consacrés aux services des urgences ait augmenté au Canada durant les dix dernières années, le manque de financement et l'insuffisance de formation des pharmaciens pour le travail au service des urgences ont été présentés comme étant d'importants obstacles à l'accroissement de ce rôle dans la plupart des hôpitaux.