Older Canadians' Perceptions of the Safety, Effectiveness and Accessibility of Cannabis for Medicinal Purposes: A Cross-Sectional Analysis.

BACKGROUND AND OBJECTIVE: Cannabis use is increasing among older adults, with use primarily for medicinal purposes. Much of the evidence on perceptions of cannabis is derived from younger populations and current users of cannabis. The purpose of this study was to describe community-dwelling older Canadians' perceptions of cannabis effectiveness, safety and accessibility for medicinal purposes and to identify factors influencing cannabis perceptions. METHODS: An online survey of older adults' perceptions, knowledge and experiences with cannabis was completed between February and September 2022. The survey was open to English-speaking and French-speaking Canadians aged 50 years and older regardless of their cannabis use history. RESULTS: A total of 1615 Canadians completed the survey. Respondents identified primarily as men (49.7%) or women (48.5%) of Caucasian decent. The majority of participants viewed cannabis as a reasonable alternative (65.8%) and an effective (70.5%) treatment modality for symptom management in older adults. Few respondents (16.4%) felt that older adults compared to younger adults were at a higher risk of side effects and 34.5% felt that cannabis is safe to use with most medicines. Cannabis perceptions were influenced by gender, cannabis use history (prior use vs current use) and reasons for cannabis use (recreational purposes vs medicinal purposes vs both purposes). CONCLUSIONS: Older Canadians have a positive view of the role of cannabis in symptom management. The perceptions of cannabis safety and effectiveness were influenced by gender, cannabis use history and reasons for cannabis use. Healthcare professionals should leverage these perceptions when discussing cannabis with their older patient populations.

Prevalence of Acetylsalicylic Acid Use for Primary Prevention of Cardiovascular Disease Amongst Older Adults From 2017-2021: a Retrospective Cross-Sectional Study.

Background: Three landmark trials on the use of acetylsalicylic acid (ASA) for primary prevention of cardiovascular disease (CVD) were published in 2018. Since then, major clinical practice guidelines have been updated with recommendations against the routine use of ASA for primary CVD prevention, particularly in older adults. However, little is known about the uptake of this evidence into real world practice. The purpose of this study was to assess the change in ASA usage for primary prevention of CVD in older adults between 2017 and 2021. Methods: A retrospective cross-sectional study of ASA use for primary prevention in ambulatory older adults without known CVD in an urban Canadian city was conducted. Results: Seven hundred and fifty-six participants were included. The mean age was 78.9 years (standard deviation 7.9) and 64.8% were female. One hundred and thirty (17.2%) participants used ASA for primary prevention, including 20.3% in 2017, 17.0% in 2018, 21.8% in 2019, 16.3% in 2020, and 11.0% in 2021 (p = .061). Female sex was associated with lower ASA use (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.29-0.68) and hypertension was associated with higher ASA use (OR 2.72, 95% CI 1.73-4.29). Conclusions: Use of ASA for primary CVD prevention in older Canadians decreased between 2017 and 2021, suggesting an uptake of clinical trial data and practice guideline recommendations. Focusing on deprescribing of ASA for primary CVD prevention continues to be warranted, given the risks associated with ASA in this population.

Appropriateness of proton pump inhibitor therapy in an ambulatory geriatrics clinic: A retrospective cross-sectional analysis.

Background: Proton pump inhibitors are considered potentially inappropriate medications in the geriatric population. The use of proton pump inhibitors by older adults has increased over the past several decades; however, existing literature suggests that only one-third of patients prescribed these medications have a valid indication for use. The aim of this study was to assess the appropriateness of proton pump inhibitor therapy in a population of ambulatory geriatric patients and to determine the impact of an interdisciplinary clinic on their use. Methods: This was a retrospective, cross-sectional study of patients referred to an ambulatory geriatrics clinic between October 2017 and March 2021. Participants were eligible for inclusion if they were taking a proton pump inhibitor at the time of clinic admission. Appropriateness of proton pump inhibitor therapy was assessed based on indication and dosing regimen. Results: In total, 280 participants were included. The mean age was 79.6 years (SD 7.7) and 60% were female. Overall, 94 of 280 (33.6%) participants had a documented valid indication for their proton pump inhibitor. The clinic team intervened to reduce the dose or discontinue 76 of 186 (40.8%) inappropriate proton pump inhibitors. Interpretation: Only one-third of proton pump inhibitors used by ambulatory geriatric patients have a documented appropriate indication for use. Given the medical complexity of this population and their vulnerability to adverse effects, the ambulatory geriatric population should be a priority target for proton pump inhibitor deprescribing initiatives.

Barriers and enablers to deprescribing of older adults and their caregivers: a systematic review and meta-synthesis.

PURPOSE: The primary objective of this study was to identify the barriers and enablers to deprescribing from the viewpoint of community-dwelling older adults and their caregivers. METHODS: This meta-synthesis included a systematic review of the literature and an inductive thematic synthesis. Medline and EMBASE were searched for studies that qualitatively explored the perspectives of older adults or their caregivers on deprescribing. Studies had to use qualitative methodologies and include community-dwelling adults (or their caregivers) aged 60 years or older who were taking one or more chronic medications. The quality of studies was assessed using the CASP tool. RESULTS: Fourteen studies were included in the meta-synthesis. All studies included older adults, and 3 included caregivers or companions. Four barriers were identified: favorable perceptions of medications, fear of medication discontinuation, the complexity of the healthcare system and discouragement from healthcare professionals; and seven enablers were identified: medication safety concerns, patient autonomy and confidence, education, follow-up, deprescribing strategies, relationships with physicians, and patient-perceived benefits of deprescribing. CONCLUSION: Multiple barriers and enablers to deprescribing exist within the older adult population. Health system complexity and direct discouragement from healthcare providers were barriers uniquely identified in the older adult population. This population would benefit from interventions to increase their medication literacy, confidence, and autonomy in the deprescribing journey.

Retrospective Cross-sectional Analysis of Older Adults Living with Frailty and Anticoagulant Use for Atrial Fibrillation.

Background: Oral anticoagulation (OAC) is recommended for most individuals with atrial fibrillation (AF), including those who are frail. Based on previous literature, those who are frail may be less likely to be prescribed OAC, and up to one-third may receive an inappropriate dose if prescribed a direct oral anticoagulant (DOAC). The objectives of this study were to determine the proportion of frail ambulatory older adults with AF who are prescribed OAC, compare the rates of OAC use across the frailty spectrum, assess the appropriateness of DOAC dosing, and identify if frailty and geriatric syndromes impact OAC prescribing patterns. Methods: Retrospective cross-sectional review of individuals with AF referred to an ambulatory clinic for older adults living with frailty and/or geriatric syndromes. Rockwood clinical frailty score of ≥4 was used to define frailty and DOAC appropriateness was assessed based on the Canadian Cardiovascular Society AF guidelines. Results: Two hundred and ten participants were included. The mean age was 84 years, 49% were female and the median frailty score was 5. Of the 185 participants who were frail, 82% were prescribed an OAC (83% with frailty score of 4, 85% with a frailty score of 5, and 78% with a frailty score of 6). Of those prescribed a DOAC, 70% received a guideline-approved dose. Conclusions: Over 80% of ambulatory older adults with frailty and AF were prescribed an OAC. However, of those prescribed a DOAC, 30% received an unapproved dose, suggesting more emphasis should be placed on initial and ongoing dosage selection.

Use of Direct Oral Anticoagulants Versus Traditional Therapies for Acute Venous Thromboembolism After Direct Discharge From the Emergency Department or After Hospitalization: An Audit of 16 Canadian Hospitals.

PURPOSE: This study compares and describes the use of direct oral anticoagulants (DOACs) versus traditional therapies (parenteral anticoagulant with or without warfarin) for acute venous thromboembolism (VTE) between individuals discharged directly from the emergency department (ED) versus those hospitalized. This study also reports patterns based on discharge from an academic, community, or rural-based site. METHODS: This retrospective medical records study included patients discharged with acute VTE (2015-2016) from 16 institutions across 4 provinces. Patients with atypical clots, other indications for anticoagulants, or an anticipated lifespan <3 months or those who were pregnant or breastfeeding were excluded. FINDINGS: Overall, 590 individuals (30.0%) discharged from the ED and 809 (53.8%) discharged after hospitalization were studied. Hospitalized patients were significantly older, had more comorbidities (cancer, pulmonary disease, and heart failure), and were more likely to have pulmonary embolism than deep vein thrombosis. DOAC use was significantly higher in the ED cohort versus the hospitalized cohort (51.4% vs 44.3%; P < 0.004) and more common for those having lower risk of pulmonary embolisms (simplified Pulmonary Embolism Severity Index score of 0 compared with ≥1) in the ED (58.0% and 26.5%; P < 0.0001) and hospitalized cohorts (57.1% and 35.7%; P < 0.0001). Use of DOACs was lowest in academic settings (46.2%) and highest in rural sites (56.7%). Follow-up patterns were different, with specialists and VTE clinics being most common in academic sites and family physicians being most common in rural practices. IMPLICATIONS: DOACs were used in less than half of all patients, with more use in EDs and rural sites. Follow-up patterns (VTE clinic or specialist vs family physician) varied and likely contributed to therapy selection. Over time, use of DOACs is likely to increase, and patient factors (eg, those younger with fewer comorbidities) and health care contact (eg, place of discharge or availability of an ambulatory VTE clinic) will likely continue to influence practice patterns.

Jurisdictional Guidance on DOAC Use-Will It Affect Practice? A Comparison of European, American, and Canadian Product Monographs.

Objective: To identify clinically relevant areas of concordance and discordance between product monographs for 4 direct oral anticoagulants (DOACs) approved by regulatory authorities in Europe, the United States, and Canada. Data Sources: For each DOAC (apixaban, dabigatran, edoxaban, rivaroxaban), manufacturer product monographs were retrieved from the European Medicines Database, US Food and Drug Administration, and Health Canada Drug Product Database. Data Extraction: Monographs for each DOAC were independently reviewed by 2 investigators to identify areas of concordance and discordance. Discordance existed if it was deemed that a potentially clinically relevant difference existed. A heat map summarizing the data was created to identify areas of complete concordance, partial concordance (concordance between 2 of 3 monographs), and complete discordance. Data Synthesis: The areas of concordance were indications for use, use in extremes of weight, and switching to/from the DOAC. Areas of discordance included the following: differing recommendations for use/dosing with renal dysfunction; contraindication or use with caution with drug interactions, pregnancy, and hepatic/renal dysfunction; and timing of DOAC with spinal/epidural anesthesia after a procedure or traumatic puncture. Relevance to Patient Care and Clinical Practice: Concordance was most evident for uncomplicated patients with atrial fibrillation or venous thromboembolism, whereas discordance emerged for those having characteristics/factors wherein clinicians may seek clarification within product monographs (eg, impaired renal/hepatic function, drug interactions). As such, clinicians must be familiar with product information within their country of practice. Conclusion: Variability between jurisdictions was evident, and variability of DOAC use is likely to increase with expanding worldwide uptake.

Measuring Competency of Pharmacy Residents: A Survey of Residency Programs' Methods for Assessment and Evaluation.

BACKGROUND: The Canadian Pharmacy Residency Board (CPRB) specifies the competencies that pharmacy residents must attain and the need for assessment and evaluation. Methods of assessment and evaluation are left to the discretion of individual programs. There is a scarcity of published literature compiling and comparing the strategies used by Canadian residency programs. OBJECTIVES: To determine curricular components used for assessment and evaluation; to describe the tools used by programs; to characterize the scheduling, frequency, and repetition of curricular components; and to determine the individuals or groups involved. METHODS: Coordinators of hospital pharmacy residency programs with CPRB accreditation or accreditation pending were surveyed to collect information about the assessment and evaluation of select CPRB standards. RESULTS: From the 37 eligible residency programs, 20 unique responses (54%) were received. All respondents were general practice programs (100%) in predominantly multicentre organizations (70%). Programs were similar in terms of assessment components used, with all respondents citing care plan review, direct observation of patient care, journal clubs, creation of project timelines, and ethics submission. The predominant evaluation components were within-department presentations (100%), written manuscripts (95%), drug information rotations (85%), and longitudinal evaluations (75%). Standardized forms (70%-100%) defined by Bloom's taxonomy (65%) and the CPRB "levels and ranges" document (60%) were the principle means used. Assessments for patient care and for provision of education were generally carried out immediately (80% and 95%, respectively), whereas project management skills were assessed predominantly at final evaluation (75%). Self-assessment and assessment by pharmacy team members occurred for every competency, whereas patients (0%-10%) and allied health professionals (5%) were less frequently involved. CONCLUSIONS: The assessment and evaluation strategies reported by programs were congruent. The results provide a summary of national practices and will allow existing and developing programs to examine their approach to assessment and evaluation for alignment with national standards.

CONTEXTE: Le Conseil canadien de résidence en pharmacie (CCRP) précise les compétences que les résidents en pharmacie doivent acquérir ainsi que le besoin d'observation et d'évaluation. Les méthodes d'observation et d'évaluation sont laissées à la discrétion de chacun des programmes. La littérature publiée qui compile et compare les stratégies utilisées par les programmes en résidence canadiens est rare. OBJECTIFS: Déterminer les composantes des programmes utilisés pour l'observation et l'évaluation des normes; décrire les outils utilisés par ces programmes; établir l'horaire, la fréquence et la répétition des éléments qui constituent ces programmes et déterminer les personnes ou les groupes concernés. MÉTHODES: Les coordinateurs des programmes de résidence en pharmacie hospitalière ayant un agrément ou dont l'agrément est en cours de procédure ont été interrogés afin qu'ils fournissent des informations concernant l'observation et l'évaluation des normes CCRP sélectionnées. RÉSULTATS: Des 37 programmes de résidence admissibles, 20 réponses individuelles (54 %) sont parvenues aux investigateurs. Tous les répondants représentaient des programmes de pratique générale (100 %) dans des organismes majoritairement multicentriques (70 %). Les programmes étaient similaires en termes de points à observer : tous les répondants citaient l'examen des plans de soins, l'observation directe des soins aux patients, les clubs de journaux, la création d'échéanciers pour la réalisation de projets et la proposition de documents sur l'éthique. Les critères d'évaluation prédominants consistaient en des présentations au sein du département (100 %), la rédaction de manuscrits (95 %), des rotations reliées au service d'information pharmacothérapeutique (85 %) et les évaluations longitudinales (75 %). Les formulaires standardisés (70 %­100 %) définis par la taxonomie de Bloom (65 %) et le document Levels and ranges (niveaux de performance des compétences) du CCRP (60 %) étaient les ressources de base utilisées. L'observation des soins aux patients et de la formation avait généralement lieu immédiatement (respectivement 80 % et 95 %,), tandis que les compétences en matière de gestion de projet étaient majoritairement évaluées en dernier (75 %). L'auto-observation et l'observation effectué par des membres de l'équipe de pharmacie portaient sur chaque compétence, tandis que les patients (0 % ­ 10 %) et les autres professionnels de la santé (5 %) participaient plus rarement à cette observation. CONCLUSIONS: Les stratégies d'observation et d'évaluation rapportées par les programmes concordaient. Les résultats fournissent un résumé des pratiques nationales et permettront aux responsables des programmes existants et en cours d'élaboration d'étudier l'approche de l'observation et de l'évaluation pour l'aligner sur les normes nationales.

Anticoagulant therapies for acute venous thromboembolism: a comparison between those discharged directly from the emergency department versus hospital in two Canadian cities.

OBJECTIVE: To compare the characteristics/management of acute venous thromboembolism (VTE) for patients either discharged directly from the emergency department (ED) or hospitalised throughout a year within two urban cities in Canada. DESIGN: Retrospective medical record review. SETTING: Hospitals in Edmonton, Alberta (n=4) and Regina, Saskatchewan (n=2) from April 2014 to March 2015. PARTICIPANTS: All patients discharged from the ED or hospital with acute deep vein thrombosis or pulmonary embolism (PE). Those having another indication for anticoagulant therapy, pregnant/breast feeding or anticipated lifespan <3 months were excluded. PRIMARY AND SECONDARY OUTCOMES: Primarily, to compare proportion of patients receiving traditional therapy (parenteral anticoagulant±warfarin) relative to a direct oral anticoagulant (DOAC) between the two cohorts. Secondarily, to assess differences with therapy selected based on clot burden and follow-up plans postdischarge. RESULTS: 387 (25.2%) and 665 (72.5%) patients from the ED and hospital cohorts, respectively, were included. Compared with the ED cohort, those hospitalised were older (57.3 and 64.5 years; p<0.0001), more likely to have PE (35.7% vs 83.8%) with a simplified Pulmonary Embolism Severity Index (sPESI) ≥1 (31.2% vs 65.2%), cancer (14.7% and 22.3%; p=0.003) and pulmonary disease (10.1% and 20.6%; p<0.0001). For the ED and hospital cohorts, similar proportions of patients were prescribed traditional therapies (72.6% and 71.1%) and a DOAC (25.8% and 27.4%, respectively). For the ED cohort, DOAC use was similar between those with a sPESI score of 0 and ≥1 (35.1% and 34.9%, p=0.98) whereas for those hospitalised lower risk patients were more likely to receive a DOAC (31.4% and 23.8%, p<0.055). Follow-up was most common with family physicians for those hospitalised (51.5%), while specialists/VTE clinic was most common for those directly discharged from the ED (50.6%). CONCLUSIONS: Traditional and DOAC therapies were proportionately similar between the ED and hospitalised cohorts, despite clear differences in patient populations and follow-up patterns in the community.

Anticoagulant therapies for acute venous thromboembolism among a cohort of patients discharged from Canadian urban and rural hospitals.

OBJECTIVE: To determine anticoagulant therapy at hospital discharge for patients with acute venous thromboembolism (VTE) and secondarily, to describe factors affecting choice of therapy. DESIGN: A retrospective chart review. SETTING: Canadian hospitals in Edmonton, Alberta (n=4), Regina, Saskatchewan (n=2) and rural Alberta (n=3) from April 2014 to March 2015. PARTICIPANTS: All patients discharged with an acute VTE were screened. Those with atypical clots, another indication for anticoagulation, pregnancy/breast feeding or lifespan <3 months were excluded. PRIMARY AND SECONDARY OUTCOMES: Primarily, we identified the proportion of patients discharged from hospital with acute VTE that were prescribed either traditional therapy (parenteral anticoagulant±warfarin) or a direct oral anticoagulant (DOAC). Secondarily, management based on setting, therapy choice based on deep vein thrombosis (DVT) versus pulmonary embolism (PE), clot burden and renal function was compared. DOAC dosing was assessed (when prescribed), length of hospital stay based on therapy was compared and planned follow-up in the community was described. RESULTS: Among the 695 patients included, most were discharged following a diagnosis of PE (82.9%) on traditional therapy (parenteral anticoagulant±warfarin) (70.2%) with follow-up by either a family doctor (51.5%) or specialist/clinic (46.9%) postdischarge. Regional variation was most evident between urban and rural sites. Of those prescribed a DOAC (28.3%), the majority were dosed appropriately (85.8%). DOAC use did not differ between those with DVT and PE, was proportionately higher for less severe clots and declined with worsening renal function. Patients prescribed DOACs versus traditional therapy had a shorter length of stay (4 vs 7 days, respectively). CONCLUSIONS: Uptake of DOAC therapy for acute VTE was modest and may have been influenced by the timing of the audit in relation to the approval of these agents for this indication. Future audits should occur to assess temporal changes and ongoing appropriateness of care delivery.

Management of acute venous thromboembolism among a cohort of patients discharged directly from the emergency department.

OBJECTIVE: To report the proportion of patients discharged directly from the emergency department (ED) on traditional therapy (parenteral anticoagulant±warfarin) or a direct oral anticoagulant (DOAC) for the management of acute venous thromboembolism (VTE). DESIGN: Retrospective medical record review across four EDs in Edmonton, Alberta, two in Regina, Saskatchewan and three in rural Alberta. SETTING: EDs from April 2014 through March 2015. PARTICIPANTS: Discharged directly from the ED with acute VTE. Patients were excluded if they had another indication for anticoagulants, were pregnant/breastfeeding or anticipated lifespan <3 months. PRIMARY AND SECONDARY OUTCOME MEASURES: Primarily, the proportion of patients discharged directly from the ED that were prescribed traditional therapy or a DOAC, with comparisons between Edmonton, Regina and rural Alberta. Secondarily, therapy selection was compared based on deep vein thrombosis (DVT) versus pulmonary embolism (PE) and clot burden. Dosing of DOACs was assessed (when applicable) and follow-up in the community was compared. RESULTS: After screening 1723 patients, 417 (24.2%) were included with DVT and PE occurring in 65.5% and 34.5%, respectively. More patients with PE were discharged from EDs in Edmonton (43%) than Regina (7%). Overall, the majority of patients were discharged on traditional therapy (70.7%), with 27.8% receiving a DOAC. Uptake of DOAC use was highest in rural Alberta (53.3%) compared with Edmonton (29.6%) and Regina (12.1%). DOACs were more commonly prescribed for PE (34.0%) than DVT (24.5%) (p=0.04), proximal versus distal DVT (28.4% and 17.3%; p<0.001), and when prescribed were appropriately dosed in 79.3%. Follow-up most commonly occurred via a VTE clinic in Edmonton or family physician in Regina and rural Alberta. CONCLUSIONS: Regional variation in discharging patients directly from the ED with PE is evident. While traditional therapy is most common, uptake of DOACs was modest given the timing of indication approval.

Baseline Competency Assessment of Pharmacists Prescribing and Managing Vancomycin Therapy in the Regina Qu'Appelle Health Region.

BACKGROUND: Pharmacists in the Regina Qu'Appelle Health Region (RQHR), Saskatchewan, independently dose, monitor, and adjust vancomycin therapy. No framework exists for ongoing competency assessment of pharmacists. OBJECTIVES: The primary objective was to determine pharmacists' overall level of competency for all components of the vancomycin prescribing procedure. The secondary objectives were to determine competency for individual prescribing phases, to stratify overall competency in relation to pharmacist and patient factors, and to identify the 3 most frequent errors. METHODS: A retrospective chart audit was performed of patients who received a prescription for vancomycin between November 1, 2015, and January 31, 2016. Patients were included if they received pharmacist-prescribed vancomycin as an inpatient or outpatient of an RQHR facility. Patients under the care of a pediatrician, those receiving vancomycin for surgical prophylaxis or via any route other than the IV route, and those whose vancomycin was prescribed by a current pharmacy resident were excluded. A rubric was created that assigned a numeric value for the appropriate completion of various procedure criteria. RESULTS: A total of 326 patients received vancomycin during the study period, of whom 200 met the inclusion criteria, representing 511 discrete episodes of prescribing by 42 pharmacists. The median overall competency rate, for all phases of prescribing, was 100% (interquartile range [IQR] 90.1%-100%). The median competency rates for the empiric therapy and monitoring phases were 94.4% (IQR 88.9%-100%) and 100% (IQR 87.5%-100%), respectively. No statistically significant differences were found in relation to pharmacists' experience or postbaccalaureate education, patients' level of acuity, or timing of prescribing. The competency score was significantly higher among pharmacists prescribing for patients with normal renal function than among those prescribing for patients with reduced renal function (p = 0.008). The 3 most common errors were failure to document risk factors for nephrotoxicity, failure to document requirement to obtain future trough levels, and failure to document that samples for trough levels had been drawn correctly. CONCLUSIONS: During the study period, pharmacists at RQHR showed competency in all phases of vancomycin prescribing using the approved procedure. Documentation of clinical plans and assessments was identified as an area for improvement.

CONTEXTE: Des pharmaciens de la régie régionale de la santé de Regina Qu'Appelle (RRSRQ) en Saskatchewan s'occupent euxmêmes de doser la vancomycine ainsi que d'en surveiller et d'en ajuster la posologie. Or, à ce jour, aucun cadre n'entoure l'évaluation continue de la compétence de ces pharmaciens. OBJECTIFS: L'objectif principal était de déterminer le niveau global de compétence des pharmaciens pour tous les éléments de la marche à suivre pour prescrire la vancomycine. Les objectifs secondaires consistaient à déterminer le niveau de compétence pour chaque étape de la prescription, à stratifier le niveau global de compétence en fonction de facteurs se rapportant au pharmacien et au patient et à identifier les trois erreurs les plus courantes. MÉTHODES: On a réalisé une vérification rétrospective des dossiers médicaux de patients qui se sont fait prescrire la vancomycine entre le 1er novembre 2015 et le 31 janvier 2016. Les patients admis à l'étude devaient avoir reçu la vancomycine sur la prescription d'un pharmacien alors qu'ils étaient hospitalisés ou en consultation externe dans un établissement de la RRSRQ. Les patients soignés par un pédiatre, ceux ayant reçu un traitement prophylactique de vancomycine pour une intervention chirurgicale, ceux ayant reçu le médicament autrement que par voie intraveineuse et ceux dont la vancomycine a été prescrite par un résident en pharmacie à l'époque ont été exclus. Une grille d'évaluation a été créée afin d'accorder une valeur numérique selon le degré de conformité de l'exécution aux différents critères de la marche à suivre. RÉSULTATS: Au total, 326 patients ont reçu la vancomycine pendant la période d'étude. Parmi eux, 200 répondaient aux critères d'inclusion, ce qui représentait 511 actes distincts de prescription réalisés par 42 pharmaciens. Le taux de compétence global médian pour toutes les phases de la prescription était de 100 % (écart interquartile [ÉIQ] de 90,1 % à 100 %). Les taux de compétence médians pour les phases de l'antibiothérapie empirique et du suivi étaient respectivement de 94,4 % (ÉIQ de 88,9 % à 100 %) et de 100 % (ÉIQ de 87,5 % à 100 %). Aucune différence statistiquement significative quant à la compétence n'a été relevée par rapport à l'expérience du pharmacien, aux études universitaires de cycles supérieurs, à la gravité de l'état du patient ou au moment de la réalisation de la prescription. Le score de compétence était significativement plus élevé chez les pharmaciens prescrivant à des patients dont la fonction rénale est normale que pour ceux prescrivant à des patients atteints d'insuffisance rénale (p = 0,008). Les trois erreurs les plus courantes étaient : négliger de consigner les facteurs de risque néphrotoxique, négliger de consigner que l'obtention de futures concentrations minimales était nécessaire et négliger de consigner que les échantillons pour les concentrations minimales avaient été prélevés correctement. CONCLUSIONS: Pendant la période d'étude, les pharmaciens travaillant à la RRSRQ ont fait preuve de compétence dans l'ensemble des phases de prescription de la vancomycine en utilisant la marche à suivre approuvée. On a noté qu'il fallait améliorer la consignation des plans cliniques et des évaluations.

Development of Left Atrial Thrombus After Coadministration of Dabigatran Etexilate and Phenytoin.

Dabigatran etexilate is a substrate of the P-glycoprotein (adenosine triphosphate-binding cassette subfamily B member 1) transport system and is subject to interactions with medications that induce or inhibit this system. The clinical relevance of the interaction between dabigatran and phenytoin has not been well described. We report a case of left atrial thrombus in a patient receiving concomitant dabigatran etexilate and phenytoin, which is a P-glycoprotein inducer. This case illustrates the potential clinical significance of the interactions of medications that affect P-glycoprotein and dabigatran.

Development of a Documentation Rubric and Assessment of Pharmacists' Competency for Documentation in the Patient Health Record.

BACKGROUND: Documentation of information in the health record by pharmacists is vital to patient care. Failure to document, or failure to document appropriately, may have negative effects on patients. OBJECTIVES: The primary objective was to determine pharmacists' competency in 18 elements of chart note documentation at 2 tertiary care centres and 1 rehabilitation centre. The secondary objectives were to quantify the number of episodes of documentation by pharmacists, to characterize the clinical activities associated with this documentation, and to determine whether there were differences in level of competency according to years of hospital experience, additional clinical training, and note type. METHODS: This study used prospective audit methodology. Notes documented during a 6-week study period (February to April 2015) were assessed using a rubric specifically created to evaluate 18 of the essential elements of documentation, as defined by the Canadian Society of Hospital Pharmacists. Four of the elements of chart note documentation were assessed on a yes/no basis, and Bloom's taxonomy was used to define the level of competency for the other 14 elements. Values were assigned to each level and were then used to calculate mean scores. RESULTS: A total of 115 pharmacist notes, created by 29 of the 35 pharmacists included in the study, were assessed. The mean competency score per pharmacist was 2.2 (standard deviation [SD] 0.3; maximum score 3). Elements of documentation with the highest level of competency were diplomatic tone, conciseness, and clarity; elements with the lowest level of competency were medication list, note title, monitoring, and drug-related problem statements. The most frequent note types concerned drug-related problems (50 [43%]), pharmacokinetics (25 [22%]), and patient education (19 [17%]). Levels of competency were highest for notes related to patient education (mean 2.4, SD 0.2) and lowest for notes concerning drug-related problems (mean 2.1, SD 0.3) and notes providing clarification (mean 2.1, SD 0.3). The level of competency was not significantly affected by additional clinical training or years of hospital experience. CONCLUSIONS: Pharmacists in this study documented concisely, clearly, and in a diplomatic tone; however, there was room for improvement in the frequency and elements of chart note documentation in the patient health record.

CONTEXTE: La consignation d'information par les pharmaciens dans les dossiers de santé est essentielle aux soins des patients. Négliger de consigner l'information ou le faire inadéquatement peut avoir des effets négatifs pour les patients. OBJECTIFS: L'objectif principal était de déterminer le niveau de compétence des pharmaciens en ce qui concerne 18 éléments de consignation aux dossiers médicaux de patients dans deux établissements de soins tertiaires et dans un établissement de réadaptation. Les objectifs secondaires étaient de quantifier le nombre de cas de consignation par les pharmaciens, d'offrir un portrait des activités cliniques associées à cette prise de notes et de déterminer s'il y avait des différences quant au niveau de compétence selon le nombre d'années d'expérience en hôpital, la formation clinique supplémentaire et le type de notes. MÉTHODES: La présente étude a employé l'audit prospectif comme méthodologie. Les notes consignées durant une période de 6 semaines (de février à avril 2015) ont été jugées à l'aide d'une grille conçue spécialement pour évaluer 18 des éléments essentiels de la prise de notes tels qu'ils sont définis par la Société canadienne des pharmaciens d'hôpitaux. Une évaluation dichotomique (soit oui soit non) a été utilisée pour quatre des éléments de la prise de notes et la taxonomie de Bloom a servi à définir le niveau de compétence pour les 14 autres éléments. Des valeurs ont été attribuées à chaque niveau et ont ensuite été utilisées pour calculer les scores moyens. RÉSULTATS: Au total, 115 notes rédigées par 29 des 35 pharmaciens visés par l'étude ont été analysées. Le score moyen de compétence par pharmacien était de 2,2 (écart-type de 0,3; score maximum de 3). Les éléments de la prise de notes présentant le niveau de compétence le plus élevé étaient : le ton diplomatique, la concision et la clarté. Les éléments affichant le plus bas niveau de compétence étaient : la liste des médicaments, le titre de la note, le suivi et l'énonciation des problèmes liés à la pharmacothérapie. Les types de notes les plus fréquents traitaient : de problèmes liés à la pharmacothérapie (50 [43 %]), de la pharmacocinétique (25 [22 %]) et des conseils aux patients (19 [17 %]). Les niveaux de compétence étaient plus élevés pour les notes à propos des conseils aux patients (moyenne de 2,4, écart-type de 0,2) et les niveaux étaient plus faibles pour les notes concernant les problèmes liés à la pharmacothérapie (moyenne de 2,1, écart-type de 0,3) et celles fournissant un éclaircissement (moyenne de 2,1, écart-type de 0.3). Le niveau de compétence n'était pas significativement influencé par une formation clinique supplémentaire ou les années d'expérience en hôpital. CONCLUSION: Les pharmaciens évalués dans la présente étude consignaient leurs notes de façon concise et claire sur un ton diplomatique. Par contre, il y avait lieu d'améliorer la fréquence et les éléments des notes consignées dans les dossiers médicaux des patients.

High-Dose, Extended-Interval Gentamicin and Tobramycin for Pediatric Inpatients: A Survey of Canadian Hospital Pharmacists.

BACKGROUND: The use of high-dose, extended-interval aminoglycosides, a common practice in adult populations, is less well established for pediatric patients. In younger populations, these drugs are often administered according to a multiple daily dosing method. OBJECTIVE: To characterize prescribing practices for aminoglycosides in pediatric inpatients across Canada, with a focus on high-dose, extended-interval regimens. METHODS: This study was based on an electronic survey of pharmacists representing Canadian health care delivery organizations that provided pediatric inpatient services, which was distributed in March 2015. Questions focused on demographic characteristics; indications for high-dose, extended-interval tobramycin or gentamicin; use of these regimens in patients with particular comorbidities; empiric dosing; monitoring parameters; and the extent of pharmacists' authority to independently prescribe doses and order monitoring parameters for aminoglycosides at their respective institutions. RESULTS: Forty-five (48%) of the 94 prospective participants responded to the survey. Of these 45 respondents, 35 (78%) indicated that their respective health regions used high-dose, extended-interval tobramycin or gentamicin in pediatric inpatients. The patient characteristics for use of such regimens were varied. The median reported doses were 10 mg/kg for pulmonary exacerbation in cystic fibrosis, 7 mg/kg for urinary tract infection, and 8 mg/kg for febrile neutropenia. Thirty-one (89%) of the 35 respondents using these regimens reported that they monitored serum levels, and 27 (77%) reported monitoring for nephrotoxicity. With regard to prescriptive authority, 7 (16%) of the 45 respondents indicated that pharmacists were authorized to independently adjust dosing at their institutions, and pharmacists at 14 (31%) of 45 sites were authorized to order monitoring parameters. CONCLUSIONS: High-dose, extended-interval aminoglycoside therapy was frequently used for pediatric patients across Canada, although the dosages and monitoring practices varied greatly. The information from this study can be used for cross-comparison of practice by other centres across Canada.

L'utilisation de doses élevées d'aminosides administrées à intervalle prolongé est une pratique répandue chez l'adulte, mais moins bien établie chez l'enfant. Dans les populations plus jeunes, ces médicaments sont souvent donnés selon une méthode d'administration multiquotidienne.