The Canadian journal of hospital pharmacy最新文献

Background: The preparation of injectable chemotherapy drugs is a critical process, given their toxicity and the large number of stakeholders involved. As such, systematic and proactive risk assessment is required.

Objective: To analyze the risks associated with the cytotoxic drug preparation process using the failure mode, effects, and criticality analysis (FMECA) method within a centralized cytotoxic drug preparation unit (CCDPU).

Methods: An analytical study was conducted in a CCDPU over a 6-month period. The risk analysis was performed using the FMECA method. An action plan was developed to address critical scenarios. A second FMECA cycle was conducted to evaluate the effectiveness of the implemented actions.

Results: A total of 189 failure modes were identified, of which 2% were deemed unacceptable and 30% were tolerable when controlled. An action plan was developed based on training, double visual inspection, and the implementation of analytical control. During the follow-up FMECA, a reduction of 23% in the overall criticality index was observed, with a significant improvement in criticality levels. Of the 60 actions, 73% were completed, and an updated action plan was proposed.

Conclusion: These results demonstrate the CCDPU team's genuine commitment to risk management and the usefulness of the FMECA method in a continuous improvement approach to the cytotoxic preparation circuit.

Background: Since November 2022, conversational tools powered by generative artificial intelligence (GAI) have become integrated into academic and professional practice within the health care field.

Objectives: To identify and quantify the prevalence of recommendations to authors regarding the use of GAI as issued by pharmaceutical journals, their publishers, and certain associations of peer-reviewed medical journals.

Methods: A cross-sectional descriptive study was conducted to evaluate the recommendations regarding GAI use issued by 3 medical journal associations (the International Committee of Medical Journal Editors, the Committee on Publication Ethics, and the World Association of Medical Editors), 8 journal publishers (Springer, Taylor & Francis, Elsevier, Wiley, Sage, Oxford Academic, BMJ, and Springer Nature), and 22 pharmaceutical journals. The presence or absence of specific recommendations was coded.

Results: The analysis led to synthesis of 16 recommendations concerning use of GAI in scientific publishing, which were classified into 3 categories: reporting and transparency, authorship and accountability, and restrictions on use. The recommendations most often emphasized disclosure of GAI use in manuscripts and the prohibition of GAI as an author. Overall, 14 of the 22 pharmaceutical journals included one or more of the 16 recommendations. Among these 14 journals, the average proportion of included recommendations was 39% (standard deviation [SD] 12%). When recommendations suggested by publishers and journal associations were included in the analysis, as applicable, this proportion increased to 51% (SD 28%).

Conclusions: Recommendations provided to authors about the use of GAI were highly variable. As such, this study highlights a lack of consensus on the integration of GAI within pharmaceutical journals, with many current guidelines being insufficient or outdated. The development of standardized and up-to-date guidelines is crucial to preserving the integrity of scientific publishing.

Background: In 2011, the Clinical and Laboratory Standards Institute revised its minimum inhibitory concentration (MIC) breakpoints for systemic cefazolin therapy to address rising antibiotic resistance. The revision was based on pharmacokinetic-pharmacodynamic analysis with limited real-world data. Institutional review led to anticipation of a shift in classification for a substantial proportion of isolates from "susceptible" to "intermediate sensitivity". This change would result in increased use of broad-spectrum antibiotics in situations where cefazolin therapy would previously have been suitable.

Objective: To compare the risk of treatment failure, as defined by mortality, intensive care admission, relapse bacteremia, and/or antimicrobial escalation, in hospitalized adult patients with community-acquired monomicrobial Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis bacteremia using MIC of ≤ 4 μg/mL versus 8 μg/mL for definitive cefazolin therapy.

Methods: This single-centre, retrospective chart review involved patients admitted to North York General Hospital, Toronto, Ontario, between January 1, 2015, and December 31, 2022. Multivariable logistic regression was used to model and compare treatment failure for MIC ≤ 4 μg/mL and MIC of 8 μg/mL.

Results: Of the 280 cultures eligible for analysis, 11 had MIC of 8 μg/mL, and the remaining 269 had MIC ≤ 4 μg/mL. For both groups, the treatment failure rate was 18.2%. With adjustment for confounding factors, there was a nonsignificant increase in the risk of treatment failure in patients with MIC of 8 μg/mL (odds ratio 1.29, 95% confidence interval 0.24-4.96, p = 0.74).

Conclusions: Consistent with the existing literature, this study showed a trend toward increased risk of treatment failure with higher MIC. Future research should validate clinical outcomes with contemporary MIC breakpoints and investigate MIC susceptibility in gram-negative bacteremia from urinary sources.

Background: Pharmacists in emergency departments (EDs) have been shown to enhance patient care, yet their integration into ED teams remains inconsistent.

Objectives: To determine whether involvement of an ED pharmacist influences patient flow in the ED (determined by length of the ED stay and return to the ED) and to describe the patient population seen by ED pharmacists.

Methods: This retrospective cohort study included adults who visited EDs from April 1 to November 30, 2023, at 11 hospitals in Alberta but were not admitted to hospital. Patients seen by pharmacists were identified using the pharmacy's workload tracking system. Primary end points were ED length of stay (LOS) and a composite of return ED visit and death within 7 and 30 days.

Results: Of the 183 182 qualifying ED visits, pharmacists were involved in 7441. Patients in the group seen by a pharmacist were older, used more medications, and had more comorbidities. Relative to a matched cohort without pharmacist involvement, patients seen by pharmacists had longer median LOS in the ED (7.7 vs 6.7 hours, p < 0.001) and higher composite of return ED visit and death rates at 7 days (22.1% vs 9.2%, p < 0.001) and 30 days (30.0% vs 17.3%, p < 0.001).

Conclusions: Although previous literature has shown that pharmacists improve quality-of-care measures in the ED, the findings of the current study suggest that ED pharmacists' services could be optimized further by targeting activities that reduce LOS and return visits. The study emphasizes the need for high-quality research on ED pharmacist practice to optimize clinical pharmacy services in the ED.

Background: Pharmacy residents are at risk of burnout, which can affect their well-being and performance and reduce their sense of satisfaction. Support interventions, specifically peer support, mentorship, and connectedness, may help to alleviate stress and improve well-being.

Objectives: To describe the current opportunities for and perceptions of support available to Canadian year 1 (Y1) pharmacy residents and to identify their interest in and desire for additional support opportunities.

Methods: A cross-sectional national online survey of Canadian Y1 residents from the 2021/22, 2022/23, and 2023/24 residency years was conducted. A subset of survey respondents participated in an online focus group designed to further explore themes identified in the survey.

Results: A total of 109 residents participated in the survey, and 7 participated in the focus group. Participants reported that support was available to them in the forms of mentorship (n = 99, 90.8%), wellness or self-care opportunities (n = 45, 41.3%), and peer connection (n = 94, 86.2%). Mentorship and peer connection were highly valued, yet just over half of participants reported being satisfied with the level of mentorship and peer connection they experienced. Identified opportunities for improvement included formalizing mentorship programs, with clear roles, protected time, intentional matching, and paid training for mentors; enhancing access to health and wellness resources; and designating site-based support for residents.

Conclusions: Mentorship and peer connection were the most commonly provided and highly valued supports for the Canadian Y1 pharmacy residents who participated in this study. Opportunities exist to enhance all forms of support offered to Y1 pharmacy residents, which ultimately may help to reduce resident burnout and improve resident well-being.

Background: Pharmaceutical interventions (PIs) are essential for ensuring medication safety in high-risk settings like intensive care units (ICUs). Assessment of the potential relevance of PIs generally considers their clinical, economic, and organizational impacts.

Objective: To analyze PIs in an ICU and to evaluate the level of agreement on their impact across clinical, economic, and organizational dimensions.

Methods: A retrospective study was conducted in a 10-bed ICU. All documented PIs performed by clinical pharmacists for patients admitted to the ICU and meeting the inclusion criteria were included. The clinical, economic, and organizational (CLEO) tool was used to assess the impacts of each intervention. Agreement among 3 health care professionals regarding the impact of these interventions was evaluated using the Fleiss kappa (κ) statistic.

Results: A total of 178 PIs were documented, of which 145 (involving 158 patients) were included in the analysis, after exclusion of PIs with incomplete data. The mean age of the 158 patients was 48 (standard deviation 20) years, and 117 (74%) were male. According to the clinical pharmacist evaluator, clinical impact was rated as "major" for 30 (21%) of the 145 PIs. In addition, 62 (43%) of the PIs were considered to have a "favourable" organizational impact, and 46 (32%) had a positive economic impact (i.e., decreased cost). The Fleiss κ coefficient revealed a low level of agreement among health care professionals regarding their evaluation of PIs across all 3 dimensions.

Conclusions: In the ICU setting, PIs play a vital role in improving patient outcomes; however, standardization of evaluation methods is essential to ensure consistency, reduce subjectivity, and enhance the overall impact of such interventions.

Background: Unprovoked venous thromboembolism (VTE) has a high risk of recurrence, typically warranting indefinite anticoagulation. Direct-acting oral anticoagulants (DOACs) have several advantages over warfarin and are thus recommended preferentially for long-term use. Until January 2024 in Nova Scotia, DOAC use beyond 6 months was often cost-prohibitive due to limited provincial funding.

Objective: To evaluate the impact of drug coverage on duration of anticoagulation for unprovoked VTE in Nova Scotia.

Methods: A retrospective chart review was completed for patients with unprovoked VTE seen in the Halifax Thrombosis Clinic between 2018 and 2020. Patients were grouped by anticoagulant class, type of insurance (private, provincial, or neither), and anticoagulation continuation or noncontinuation beyond 6 months. The primary outcome was the difference in anticoagulation use at 6 months according to type of insurance based on χ² testing.

Results: The chart review identified 1016 patients seen during the study period, of whom 222 were included in the analysis. No significant difference in treatment duration was found among patients with private insurance, those covered under provincial pharmacare, and those with no insurance (mean duration 14.47, 12.39, and 13.89 months, respectively; p = 0.25). Scores for the Charlson comorbidity index and patient age did not significantly affect treatment duration. Patients with private insurance were more likely to receive a prescription for DOACs (p = 0.015 relative to provincial pharmacare, p < 0.001 relative to no insurance).

Conclusions: This study showed no statistically significant difference among types of insurance in terms of duration of anticoagulation after unprovoked VTE. However, patients with private insurance were more likely to use DOACs than warfarin. Since this study was completed, Nova Scotia Pharmacare now covers DOACs, but coverage remains limited in many other provinces. The results of this study may serve as evidence to lobby for extended DOAC funding in other provinces as a way to enhance care.