Evaluation of the quality of 'do not use' medication abbreviation audits: a key enabler to successful implementation of audit and feedback.

Background Hospital pharmacy audit and feedback of 'do not use' medication abbreviations improves patient safety. For audit and feedback systems to be effective, the data captured must be of high quality such that end-users trust the information to guide practice change. The quality of data captured during monthly standardized pharmacy 'do not use' abbreviation audits is currently unknown. Objective We aimed to assess pharmacy 'do not use' abbreviation audit data quality. Method Primary audit data quality was assessed by examining a random sample of handwritten medication prescriptions for the presence and type of 'do not use' abbreviations. This data was compared with the pharmacy monthly audit data to determine data capture agreement and consistency over time. Results There were 1132 prescriptions from July, October, and December 2019 included. Data capture agreement between the pharmacy audit and the secondary assessment using Cohen's Kappa ranged from 0.53 to 0.63. The primary audit under-reported 'do not use' abbreviation rates, however this did not vary over time (χ2 = 1.215, p = 0.545). Conclusion Pharmacy staff audits under-reported 'do not use' abbreviation rates, however this was consistent over time. The quality of pharmacy audits should be assessed and disseminated to end-users prior to implementing feedback.

Barriers to and Enablers of Implementation of High-Value Interventions by Renal Pharmacists: A Qualitative Study Informed by the Theoretical Domains Framework.

BACKGROUND: Previous studies have shown that patients with chronic kidney disease who are followed by a renal clinical pharmacist have improved clinical outcomes. In 2016, a consensus list of quality indicator drug therapy problems (QI-DTPs) was developed by renal clinical pharmacists to help prioritize which renal patients should receive interventions. Before QI-DTP interventions can be implemented in clinical practice, barriers to and enablers of their use need to be identified, to allow development of strategies to overcome the barriers and apply the enablers. OBJECTIVE: To identify modifiable barriers to and enablers of implementation of renal QI-DTP interventions by renal clinical pharmacists. METHODS: In this exploratory qualitative descriptive study, one-on-one, semistructured, audio-recorded telephone interviews were conducted with renal clinical pharmacists to identify the barriers to and enablers of implementation of renal QI-DTP interventions. The interviews consisted of questions developed according to the Theoretical Domains Framework. RESULTS: Interviews were conducted with 13 renal pharmacists from across Canada. The main barriers to implementation of renal QI-DTP interventions that participants identified were knowledge gaps, prioritization, and nephrologist acceptance. The main enablers identified were training, colleague support, and better patient care. CONCLUSION: Three barriers to and three enablers of implementation of renal QI-DTP interventions were identified. These barriers and enablers can be used to help with pharmacist education and to optimize the care that pharmacists provide to renal patients.

CONTEXTE: Des études précédentes démontrent une amélioration des résultats cliniques de patients souffrant d'une maladie rénale chronique, qui sont suivis par un pharmacien clinicien en néphrologie. En 2016, des pharmaciens cliniciens en néphrologie ont mis au point une liste consensuelle des indicateurs de qualité des problèmes de pharmacothérapie (QI-DTP) pour les aider à prioriser les patients souffrant d'une insuffisance rénale, qui doivent subir une intervention. Avant de mettre en place ces QI-DTP en pratique clinique, on doit déterminer les éléments qui entravent et facilitent leur utilisation pour pouvoir élaborer des stratégies visant à surmonter les obstacles et à appliquer les éléments facilitateurs. OBJECTIF: Déterminer les éléments modifiables qui entravent et facilitent la mise en place des QI-DTP par les pharmaciens cliniciens en néphrologie lors d'interventions rénales. MÉTHODES: Dans cette étude exploratoire, descriptive et qualitative, des entretiens téléphoniques individuels, semi-structurés et enregistrés ont été menés auprès de pharmaciens cliniciens en néphrologie pour déterminer les éléments qui entravent et facilitent la mise en place de QI-DTP lors d'interventions rénales. Les entretiens consistaient en des questions préparées selon le Theoretical Domains Framework. RÉSULTATS: Les entretiens ont été menés auprès de 13 pharmaciens en néphrologie de partout au Canada. Les principaux éléments entravant la mise en place de QI-DTP lors d'interventions rénales déterminées par les participants étaient: le manque de connaissances, la priorisation et l'acception des néphrologues. Les principaux éléments facilitant la tâche étaient: la formation, le soutien des collègues et de meilleurs soins offerts aux patients. CONCLUSION: Trois éléments entravant et trois éléments facilitant la mise en place de QI-DTP lors d'interventions rénales ont été déterminés. Ils peuvent être utilisés pour contribuer à la formation du pharmacien et pour optimiser les soins offerts aux patients qui souffrent d'insuffisance rénale.

Contribution of Pharmacy Practice Residents to Resolution of Drug Therapy Problems for Patients: RES-DTP Study.

BACKGROUND: Canadian pharmacy practice residency programs promote development of key competencies for direct patient care resulting in resolution of drug therapy problems (DTPs), which is 1 of 8 national clinical pharmacy key performance indicators. There are no Canadian data on the contribution of residents to resolution of DTPs, including DTPs for priority diseases covered in disease-state education modules (PD-DTPs) or quality indicator DTPs (QI-DPTs), as assessed through application of evidence-based interventions proven to reduce morbidity, mortality, or health resource utilization. OBJECTIVE: To describe the contribution of pharmacy practice residents to direct patient care using 3 process-of-care measures: resident-resolved DTPs, PD-DTPs, and QI-DTPs. METHODS: This prospective, observational single-group study was conducted across 5 rotation sites within the authors' health authority from September 2, 2013, to June 13, 2014. The primary outcome was number of DTPs resolved. The secondary outcomes were number of PD-DTPs resolved; number of QI-DTPs resolved; numbers of DTPs, PD-DTPs, and QI-DTPs resolved over time; and residents' satisfaction with electronic tracking of resolved DTPs (in terms of training, usability, efficiency, and time requirements). RESULTS: Four residents completed a total of twenty-one 4-week rotations and resolved a total of 1201 DTPs. Of these, 620 (52%) were PD-DTPs and 479 (40%) were QI-DTPs. Overall, the number of interventions increased for rotations 1-3, decreased for rotations 4 and 5, and increased again for rotation 6. The median score for all questions in all domains of the satisfaction survey was 4 out of 5 ("agree"). CONCLUSIONS: Pharmacy practice residents were resolving DTPs, PD-DTPs, and QI-DTPs for patients and were contributing significantly to direct patient care. On the basis of literature evidence, the number and type of interventions observed in this study would be expected to improve clinical and health economic outcomes for patients.

CONTEXTE: Les programmes de résidence canadiens en pratique pharmaceutique encouragent le développement de compétences clés relatives aux soins directs offerts aux patients. Ces compétences entraîneront la résolution des problèmes de pharmacothérapie (DTP), l'un des huit indicateurs clés nationaux de rendement relatifs à la pharmacie clinique. Il n'existe pas de données canadiennes portant sur la contribution des résidents à la résolution des problèmes de pharmacothérapie, notamment ceux relatifs aux maladies prioritaires (PD-DTP) couverts dans les modules d'éducation sur les problèmes de santé, ou les indicateurs de qualité des DTP (QI-DPT), évalués au moyen d'interventions fondées sur des données scientifiques dont il a été prouvé qu'elles réduisaient la morbidité, la mortalité ou l'utilisation des ressources sanitaires. Dans une étude, les intervenants avaient des opinions divergentes concernant la contribution des résidents à la résolution des DTP, des PD-DTP et des QI-DTP. OBJECTIF: Décrire la contribution des résidents dans le cadre de la pratique pharmaceutique des soins directs offerts aux patients à l'aide de trois mesures spécifiques du processus des soins : DTP, PD-DTP et QI-DTP résolus par les résidents. MÉTHODES: Cette étude prospective par observation portant sur un seul groupe a été menée dans cinq sites de rotation compris dans la sphère d'autorité sanitaire des auteurs, du 2 septembre 2013 au 13 juin 2014. Le résultat principal était le nombre de DTP résolus. Les résultats secondaires étaient les suivants : nombre de PD-DTP résolus; nombre de QI-DTP résolus; nombre de DTP, de PD-DTP et de QI-DTP résolus avec le temps; et la satisfaction des résidents à l'égard du suivi électronique de leurs DTP résolus (en termes de formation, de facilité d'utilisation, d'efficacité et d'exigences en matière de temps). RÉSULTATS: Quatre résidents ont effectué un total de 21 rotations de quatre semaines et ont résolu 1201 DTP. De ceux-ci, 620 (52 %) étaient des PD-DTP et 479 (40 %), des QI-DTP. Les interventions générales ont augmenté de la 1re à la 3e rotation; elles ont diminué à la 4e et à la 5e rotation; elles ont à nouveau augmenté à la 6e rotation. Le score moyen de toutes les questions posées dans l'enquête de satisfaction, tous domaines confondus, était de 4 sur 5 (ou « d'accord ¼). CONCLUSIONS: Les résidents en pratique pharmaceutique résolvaient les DTP, les PD-DTP et les QI-DTP des patients et contribuaient de manière significative aux soins directs aux patients. Sur base de la documentation, on pourrait s'attendre à ce que le nombre et le type d'interventions observées dans cette étude améliorent les résultats cliniques et sanitaires des patients.

Development of intervention-related quality indicators for renal clinical pharmacists using a modified Delphi approach.

OBJECTIVE: To develop a list of renal Quality Indicator Drug therapy problems (QI-DTPs) that serve to advance renal pharmacy practice to improve patient care. METHODS: Eighteen (18) renal, clinical pharmacists participated in an internet-based three-round modified Delphi survey. Each of the three rounds took approximately 2 weeks to complete. Panellists rated 30-candidate renal QI-DTPs using seven selection criteria and one overall consensus criterion on a nine-point Likert scale. Consensus was reached if 75% or more of panellists assigned a score of 7-9 on the consensus criterion during the third Delphi round. KEY FINDINGS: All panellists completed three rounds of Delphi survey. Seventeen-candidate renal QI-DTPs met the consensus definition. CONCLUSIONS: A Delphi panel of renal clinical pharmacists successfully identified 17 consensus renal QI-DTPs. Assessment and implementation of these QI-DTPs will serve to advance renal pharmacy practice and improve patient care.

A theory-informed assessment of the barriers and facilitators to nurse-driven antimicrobial stewardship.

BACKGROUND: Nurses represent an underused workforce for performing antimicrobial stewardship (AMS) activities. Before engaging nurses in these activities, barriers and facilitators to the targeted behavior change should be identified using a validated model. METHODS: This was a prospective, qualitative, descriptive study to determine the barriers and facilitators to the promotion of intravenous (IV) to oral (PO) antimicrobials by nurses. Semi-structured 1-on-1 interviews of nurses were conducted from January-February 2017. Interviews were analyzed for themes within the domains of the theoretical domains framework (TDF) by directed-content analysis. RESULTS: Evaluation of the 14 TDF domains revealed 9 modifiable barriers to nurse promotion of IV to PO step-down, including insufficient knowledge, lack of prescriber cooperation, lack of self-confidence, and low priority activity. Nine facilitators that could enhance nurse promotion of step-down were identified, including capability to assess patients for step-down, ability to communicate assessment results to the team, and preexistence of a variety of resources available for nurse education and training. Nurses perceived that increased step-down rates would increase nursing efficiency. CONCLUSIONS: Nurses have the potential to improve AMS through promotion of IV to PO step-down of antimicrobials. Themes pertaining to barriers and facilitators of nurses' participation in IV to PO step-down of antimicrobials were identified.

Improving the Clinical Pharmacist Handover Process in the Intensive Care Unit with a Pharmacotherapy-Specific Tool: The I-HAPPY Study.

BACKGROUND: Pharmacists in the intensive care unit (ICU) provide pharmaceutical care to critically ill patients. Identification and resolution of drug therapy problems improves outcomes for these patients. To maintain continuity of care, pharmacotherapy plans should be transferred to a receiving pharmacist upon discharge of patients from the ICU. No previous studies have addressed the development or evaluation of a systematic, standardized clinical handover tool and process for pharmacists. OBJECTIVES: To assess pharmacists' satisfaction with and utilization of a pharmacotherapy-specific handover tool and process. METHODS: Plan-do-study-act methodology was employed to develop a clinical handover tool and process, which were implemented in a Canadian health authority. For evaluation of the tool and process, a multicentre, online survey questionnaire was distributed to 14 clinical pharmacists in the ICU and ward settings at 5 hospitals between February 15 and April 22, 2016. RESULTS: Thirteen of the pharmacists completed the survey. All 13 pharmacists (100%) were satisfied with usability; 12 (92%) were satisfied with training, organization, and accuracy of the process; and 11 (85%) were satisfied with completeness and efficiency. Most pharmacists conducted 1 or 2 handovers per week, with each having a duration of 3-5 min. Seven (54%) of the respondents reported that they communicated handovers mostly or exclusively by telephone, and 6 (46%) reported using mostly or exclusively face-to-face communication. However, 6 (46%) reported a preference for face-to-face communication, and 3 (23%) reported a preference for the telephone; the remaining 4 (31%) had no preference for mode of communication. CONCLUSIONS: Respondents were highly satisfied with the handover tool and process. ICU pharmacists appeared more satisfied with the training, organization, and completeness of handover, whereas ward pharmacists appeared more satisfied with the accuracy and efficiency of handover. Workload requirements were minimal, and face-to-face interaction, although slightly less well utilized than the telephone, was the preferred method of communication.

CONTEXTE: Les pharmaciens exerçant dans les unités de soins intensifs (USI) prodiguent des soins pharmaceutiques aux patients gravement malades. Or, déceler et résoudre les problèmes pharmacothérapeutiques améliore les résultats cliniques pour ces patients. Afin de maintenir la continuité des soins, les plans pharmacothérapeutiques doivent être communiqués au moment du congé des patients de l'USI à un autre pharmacien qui prendra ensuite le relais. Aucune étude n'avait auparavant étudié la mise au point ou l'évaluation d'un outil et d'un processus normalisés de transfert des soins à être utilisés systématiquement par les pharmaciens. OBJECTIFS: Évaluer le taux de satisfaction des pharmaciens à l'égard d'un outil et d'un processus destinés au transfert des soins pharmacothérapeutiques et en analyser leur utilisation. MÉTHODES: La méthodologie planifier-exécuter-étudier-agir a été employée pour mettre au point un outil et un processus de transfert clinique introduits dans une régie de santé canadienne. Afin d'évaluer l'outil et le processus, un sondage en ligne a été présenté à 14 pharmaciens cliniciens travaillant soit dans les USI soit dans d'autres services intrahospitaliers de 5 hôpitaux, entre le 15 février et le 22 avril 2016. RÉSULTATS: Treize pharmaciens ont rempli le sondage. Les 13 (100 %) étaient satisfaits de la facilité d'emploi; 12 (92 %) étaient satisfaits de la formation, de l'organisation et de l'exactitude du processus; et 11 (85 %) étaient satisfaits du degré d'exhaustivité et de l'efficacité. La plupart des pharmaciens réalisaient 1 ou 2 transferts par semaine, chacun d'une durée de 3 à 5 minutes. Sept (54 %) répondants ont indiqué qu'ils communiquaient les transferts surtout ou seulement par téléphone et 6 (46 %) ont dit le faire surtout ou uniquement en personne. Or, 6 (46 %) ont indiqué une préférence pour la communication en personne et 3 (23 %) ont dit préférer la voie téléphonique. Les 4 (31 %) autres étaient indifférents au mode de communication utilisé. CONCLUSIONS: Les répondants étaient grandement satisfaits de l'outil et du processus de transfert. Les pharmaciens exerçant dans les USI semblaient plus satisfaits de la formation, de l'organisation et du degré d'exhaustivité du transfert alors que les pharmaciens travaillant dans d'autres services intra-hospitaliers semblaient plus satisfaits de l'exactitude et de l'efficacité du transfert. La charge de travail était minimalement accrue et la communication en personne, bien qu'utilisée moins fréquemment que celle par téléphone, était le mode préféré.

Positive and Negative Impacts of a Continuing Professional Development Intervention on Pharmacist Practice: A Balanced Measure Evaluation.

INTRODUCTION: Evaluations of behavior change interventions aimed at improving professional practice are increasingly focused on impacts at the practice and patient outcome levels. Many of these evaluations assume that if the intended changes occur, the result represents an improvement. However, given the systemic nature of clinical practice, a change in one area can produce changes in other areas as well, some of which may adversely affect the patient. Balancing measures are used to determine whether unintended consequences of an intervention have been introduced into other areas of the system. The aims of this study were to evaluate the impact of behavior change intervention-based continuing professional development (CPD) on pharmacist interventions (resolution of drug therapy problems-DTPs) and resolution of quality indicator DTPs and knowledge change for urinary tract infections (UTI) and pneumonia. As a balancing measure, we aimed to determine whether delivery of behavior change interventions targeting pneumonia and UTI practice results in a negative impact on other important pharmacist interventions, specifically the resolution of heart failure DTPs. METHODS: A quasiexperimental study was conducted at a Canadian health authority that evaluated the impacts of an 8-week multifaceted behavior change intervention delivered to 58 ward-based pharmacists. The primary outcome was change in proportion of UTI and pneumonia DTPs resolved from the 6-month preintervention to 6-month postintervention phase. Secondary outcomes were changes in proportion of UTI and pneumonia quality indicator DTPs resolved, knowledge quiz scores, and proportion of quality indicator DTPs resolved for heart failure as a balancing measure. RESULTS: A total of 58 pharmacists were targets of the intervention. The proportion of resolved UTI and pneumonia DTPs increased from 17.8 to 27.2% (relative risk increase 52.8%, 95% confidence interval [CI] 42.8-63.6%; P < 0.05). The proportion of resolved UTI and pneumonia quality indicator DTPs increased from 12.2% to 18.2% (relative risk increase 49.9%, 95% CI 34.5-67.0%; P < 0.05). Resolved heart failure DTPs decreased from 14.3 to 8.5% (RRR 40.4%, 95% CI 33.9-46.2%; P < 0.05). Thirty-six pharmacists completed the pre- and post-quiz. Scores increased from 11.3/20 ± 3.2/20 to 14.8/20 ± 2.9/20 (P < 0.05). DISCUSSION: CPD using a multifaceted behavior change intervention improved pharmacist behavior and knowledge for UTI and pneumonia. However, these improvements may be offset by reduced interventions for other disease states, such as heart failure. Strategies to mitigate the unintended effects on other professional behaviors should be implemented when delivering CPD focused on changing one aspect of professional behavior.

Roles of Infectious Diseases Consultant Pharmacists and Antimicrobial Stewardship Pharmacists: A Survey of Canadian Tertiary Care Academic Hospitals.

BACKGROUND: Infectious diseases consultant (IDC) pharmacists work within an IDC service to care for inpatients with complex infections. With Accreditation Canada's new Required Organizational Practice promoting the establishment of antimicrobial stewardship (AMS) programs, AMS pharmacists are being employed in acute care hospitals. There is potential for overlap in responsibilities between IDC and AMS pharmacists, but there is no literature outlining the current duties for each group in Canada. OBJECTIVE: To describe the demographic characteristics and roles of IDC and AMS pharmacists in Canadian tertiary care academic hospitals. METHODS: A survey of IDC and AMS pharmacists at Canadian tertiary care academic hospitals was conducted between February and April 2015. The questionnaire included questions about the pharmacist's experience, education, and training; the institution where the pharmacist was practising; the IDC or AMS team characteristics; and the pharmacist's roles in clinical, educational, administrative, and research sectors. RESULTS: The survey response rate was 77% (68/88). The 68 respondents self-identified as IDC pharmacists (14 [21%]), AMS pharmacists (34 [50%]), or dual-role IDC and AMS pharmacists (20 [29%]). Compared with AMS pharmacists, IDC pharmacists reported more of the following unique clinical activities: directly communicating with patients, attending rounds, involving patients in decision-making, and providing patient education. The 3 groups of pharmacists described similar educational responsibilities. The AMS pharmacists performed more of the following administrative and research duties: development of antibiograms and preprinted orders, collection of antimicrobial metrics, and drug-use evaluations for antimicrobials. Dual-role IDC and AMS pharmacists were involved in fewer of the unique activities described by those who practised within a single subspecialty. CONCLUSIONS: Self-identified IDC and AMS pharmacists in Canadian tertiary care academic hospitals were performing many similar roles; however, distinct differences within the clinical, administrative, and research domains were identified among IDC pharmacists, AMS pharmacists, and those who identified as dual-role IDC and AMS pharmacists.

CONTEXTE: Les pharmaciens consultants en maladies infectieuses travaillent au sein d'un service de consultants en maladies infectieuses afin de prodiguer des soins aux patients hospitalisés atteints d'infections complexes. Or, en raison de la nouvelle Pratique organisationnelle requise d'Agrément Canada qui encourage la mise en œuvre de programmes de gérance des antimicrobiens, des pharmaciens sont affectés à cette fonction dans les hôpitaux de soins de courte durée. On distingue un possible chevauchement des responsabilités entre les pharmaciens consultants en maladies infectieuses et ceux chargés de la gérance des antimicrobiens, mais il n'y a aucun document qui définit les responsabilités actuelles pour chacun de ces groupes au Canada. OBJECTIF: Décrire les caractéristiques démographiques et les rôles des pharmaciens consultants en maladies infectieuses et de ceux chargés de la gérance des antimicrobiens dans les hôpitaux universitaires de soins tertiaires au Canada. MÉTHODES: Entre février et avril 2015, on a mené un sondage auprès des pharmaciens consultants en maladies infectieuses et de ceux chargés de la gérance des antimicrobiens travaillant dans les hôpitaux universitaires de soins tertiaires au Canada. Les questions portaient, entre autres, sur l'expérience du pharmacien, ses études et sa formation, l'établissement où il travaillait, les caractéristiques des équipes de consultants en maladies infectieuses et de gérance des antimicrobiens ainsi que sur ses rôles dans les secteurs cliniques et administratifs et dans les secteurs de la formation et de la recherche. RÉSULTATS: Le taux de réponse au sondage était de 77 % (68/88). Les 68 répondants s'identifiaient comme des pharmaciens consultants en maladies infectieuses (14 [21 %]), des pharmaciens chargés de la gérance des antimicrobiens (34 [50 %]) ou des pharmaciens occupant les deux rôles (20 [29 %]). Comparativement à leur collègues chargés de la gérance des antimicrobiens, les pharmaciens consultants en maladies infectieuses ont davantage indiqué accomplir les activités cliniques uniques suivantes : communiquer directement avec les patients, participer aux tournées médicales, amener les patients à participer aux prises de décisions et offrir des conseils aux patients. Les trois groupes de pharmaciens ont évoqué des responsabilités éducatives similaires. Les pharmaciens chargés de la gérance des antimicrobiens accomplissaient davantage les tâches administratives et de recherche suivantes : élaboration d'antibiogrammes et d'ordonnances préimprimées, cueillette de mesures sur les antimicrobiens et évaluation de l'utilisation des antimicrobiens. Les pharmaciens qui cumulaient les deux rôles participaient à un moins grand nombre des activités uniques décrites par ceux qui exerçaient une seule sous-spécialité. CONCLUSIONS: Les pharmaciens des hôpitaux universitaires de soins tertiaires au Canada qui s'identifiaient eux-mêmes comme des pharmaciens consultants en maladies infectieuses ou des pharmaciens chargés de la gérance des antimicrobiens exécutaient bon nombre de tâches similaires. Cependant, des différences marquées en ce qui touche aux domaines clinique et administratif et à celui de la recherche ont été repérées entre les pharmaciens consultants en maladies infectieuses, ceux chargés de la gérance des antimicrobiens et ceux occupant les deux rôles.

Development of clinical pharmacy key performance indicators for hospital pharmacists using a modified Delphi approach.

BACKGROUND: Key performance indicators (KPIs) are quantifiable measures of quality. There are no published, systematically derived clinical pharmacy KPIs (cpKPIs). OBJECTIVE: A group of hospital pharmacists aimed to develop national cpKPIs to advance clinical pharmacy practice and improve patient care. METHODS: A cpKPI working group established a cpKPI definition, 8 evidence-derived cpKPI critical activity areas, 26 candidate cpKPIs, and 11 cpKPI ideal attributes in addition to 1 overall consensus criterion. Twenty-six clinical pharmacists and hospital pharmacy leaders participated in an internet-based 3-round modified Delphi survey. Panelists rated 26 candidate cpKPIs using 11 cpKPI ideal attributes and 1 overall consensus criterion on a 9-point Likert scale. A meeting was facilitated between rounds 2 and 3 to debate the merits and wording of candidate cpKPIs. Consensus was reached if 75% or more of panelists assigned a score of 7 to 9 on the consensus criterion during the third Delphi round. RESULTS: All panelists completed the 3 Delphi rounds, and 25/26 (96%) attended the meeting. Eight candidate cpKPIs met the consensus definition: (1) performing admission medication reconciliation (including best-possible medication history), (2) participating in interprofessional patient care rounds, (3) completing pharmaceutical care plans, (4) resolving drug therapy problems, (5) providing in-person disease and medication education to patients, (6) providing discharge patient medication education, (7) performing discharge medication reconciliation, and (8) providing bundled, proactive direct patient care activities. CONCLUSIONS: A Delphi panel of hospital pharmacists was successful in determining 8 consensus cpKPIs. Measurement and assessment of these cpKPIs will serve to advance clinical pharmacy practice and improve patient care.

Emergency department antimicrobial considerations in severe sepsis.

Severe sepsis and septic shock are common problems in the emergency department patient population and require expert clinical skill by members of the emergency department team to maximize optimal patient outcomes. Although various guidelines have been developed for the management of these patients, issues around antimicrobial-related considerations in critically ill patients require further evidence-based attention. In this review article, important factors related to patient illness, microorganism, timing of antimicrobial administration, and source control are discussed.

Incidence of and factors associated with manipulation of nimodipine dosage in patients with aneurysmal subarachnoid hemorrhage.

BACKGROUND: Aneurysmal subarachnoid hemorrhage is a significant cause of death and disability. Nimodipine 60 mg administered enterally every 4 h improves neurologic outcomes in these patients. However, hypotension is an adverse effect of nimodipine and is believed to prompt clinicians to prescribe an unproven, nonstandard nimodipine dosing regimen. OBJECTIVES: The primary objective was to determine the prescribing incidence of a nonstandard nimodipine dosing regimen (30 mg every 2 h) after initial prescription of the standard dose (60 mg every 4 h). The secondary objective was to determine factors associated with this dosage change. METHODS: This retrospective cohort study evaluated participants receiving nimodipine for aneurysmal subarachnoid hemorrhage at a tertiary care teaching hospital between October 2005 and December 2011. Univariate and multivariate regression analyses were performed to identify factors associated with dosage manipulation. RESULTS: A total of 166 eligible patients were identified. For all of these patients, nimodipine 60 mg every 4 h was prescribed initially. Subsequently, 81 (49%) of the patients were switched to nimodipine 30 mg every 2 h, whereas 85 (51%) continued on the original dosage (nimodipine 60 mg every 4 h) for the duration of their treatment. Multivariate analysis revealed that occurrence of vasospasm (odds ratio [OR] 5.30, 95% confidence interval [CI] 2.08-13.47; p < 0.001) and exposure to vasopressor therapy (OR 3.29, 95% CI 1.27-8.50; p = 0.014) were associated with increased odds of receiving the nonstandard nimodipine regimen. CONCLUSIONS: Half of patients for whom nimodipine was prescribed for aneurysmal subarachnoid hemorrhage were exposed to an unproven regimen. Vasospasm and exposure to vasopressor therapy were associated with higher odds of receiving the nonstandard regimen. Further research is needed to evaluate whether nimodipine 30 mg every 2 h is efficacious and safe for patients in this population.

CONTEXTE: L'hémorragie sous-arachnoïdienne anévrismale représente une cause importante de mortalité et d'invalidité. L'administration par voie entérale de 60 mg de nimodipine toutes les 4 heures permet d'améliorer l'issue neurologique chez ces patients. Malheureusement, l'hypotension est un effet secondaire de la nimodipine et l'on croit que l'apparition de cet effet incite des cliniciens à prescrire un schéma posologique de nimodipine non standard et empirique. OBJECTIFS: L'objectif principal visait à déterminer la fréquence de prescription d'un schéma posologique non standard de nimodipine (30 mg toutes les 2 heures) après une première prescription d'un schéma posologique standard (60 mg toutes les 4 heures). L'objectif second était de déterminer quels sont les facteurs associés à ce changement de schéma posologique. MÉTHODES: La présente étude de cohorte rétrospective observe les cas de participants qui ont reçu de la nimodipine, en raison d'une hémorragie sous-arachnoïdienne anévrismale, dans un hôpital universitaire de soins tertiaires entre octobre 2005 et décembre 2011. Des analyses de régression univariées et multivariées ont été menées afin d'identifier les facteurs motivant les changements au schéma posologique. RÉSULTATS: Au total, 166 patients admissibles ont été retenus. Tous ces patients se sont d'abord vu prescrire initialement 60 mg de nimodipine toutes les 4 heures. Par la suite, 81 d'entre eux (49 %) se sont vu prescrire 30 mg de nimodipine toutes les 2 heures, alors que 85 (51 %) continuaient de suivre le schéma posologique initial (60 mg toutes les 4 heures) pour la durée de leur traitement. Une analyse multivariée a révélé que les cas de vasospasmes (risque relatif approché [RRA] de 5,30, intervalle de confiance [IC] à 95% de 2,08­13,47; p < 0,001) et l'exposition à un traitement par vasopresseur (RRA de 3,29, IC à 95% de 1,27­8,50; p = 0.01) sont associés à une augmentation du risque pour le patient d'exposition au schéma posologique non standard. CONCLUSIONS: La moitié des patients qui se sont vu prescrire de la nimodipine en raison d'une hémorragie sous-arachnoïdienne anévrismale ont reçu un schéma posologique dont l'efficacité n'a pas été établie. La présence de vasospasme ainsi que l'administration d'un vasopresseur ont été liées à l'augmentation du risque pour le patient d'exposition au schéma posologique non standard. De plus amples recherches sont nécessaires pour évaluer l'efficacité et l'innocuité d'un schéma posologique de 30 mg de nimodipine toutes les 2 heures chez les patients de cette population. [Traduction par l'éditeur].

Corticosteroids in the treatment of severe community-acquired pneumonia.

Controversy surrounds the use of adjunctive corticosteroids in severe community acquired pneumonia (CAP) as current guidelines either do not address or discourage their use. Double-blind, placebo-controlled, randomized controlled trials examining systemic corticosteroids in the treatment of severe CAP were summarized and their impacts on patient-important outcomes assessed. Four trials describing systemic corticosteroid use in adults with severe CAP were identified. One trial had a significant mortality difference favoring corticosteroids. However, this may be the result of a CAP severity imbalance within the trial and the mortality benefit was not confirmed in a larger trial conducted in a similar critical care setting. Pneumonia severity, mortality assessment timing, comorbidities, corticosteroid and antibiotic choice and timing in the CAP disease course, and bias risks varied across the four trials. Because of the clinical heterogeneity of available studies and the unknowns pertaining to clinical efficacy and safety, we do not recommend the use of adjunctive corticosteroids in severe CAP.

Presence and accuracy of drug dosage recommendations for continuous renal replacement therapy in tertiary drug information references.

BACKGROUND: Clinicians commonly rely on tertiary drug information references to guide drug dosages for patients who are receiving continuous renal replacement therapy (CRRT). It is unknown whether the dosage recommendations in these frequently used references reflect the most current evidence. OBJECTIVE: To determine the presence and accuracy of drug dosage recommendations for patients undergoing CRRT in 4 drug information references. METHODS: Medications commonly prescribed during CRRT were identified from an institutional medication inventory database, and evidence-based dosage recommendations for this setting were developed from the primary and secondary literature. The American Hospital Formulary System-Drug Information (AHFS-DI), Micromedex 2.0 (specifically the DRUGDEX and Martindale databases), and the 5th edition of Drug Prescribing in Renal Failure (DPRF5) were assessed for the presence of drug dosage recommendations in the CRRT setting. The dosage recommendations in these tertiary references were compared with the recommendations derived from the primary and secondary literature to determine concordance. RESULTS: Evidence-based drug dosage recommendations were developed for 33 medications administered in patients undergoing CRRT. The AHFS-DI provided no dosage recommendations specific to CRRT, whereas the DPRF5 provided recommendations for 27 (82%) of the medications and the Micromedex 2.0 application for 20 (61%) (13 [39%] in the DRUGDEX database and 16 [48%] in the Martindale database, with 9 medications covered by both). The dosage recommendations were in concordance with evidence-based recommendations for 12 (92%) of the 13 medications in the DRUGDEX database, 26 (96%) of the 27 in the DPRF5, and all 16 (100%) of those in the Martindale database. CONCLUSIONS: One prominent tertiary drug information resource provided no drug dosage recommendations for patients undergoing CRRT. However, 2 of the databases in an Internet-based medical information application and the latest edition of a renal specialty drug information resource provided recommendations for a majority of the medications investigated. Most dosage recommendations were similar to those derived from the primary and secondary literature. The most recent edition of the DPRF is the preferred source of information when prescribing dosage regimens for patients receiving CRRT.

Local cutaneous necrosis secondary to a prolonged peripheral infusion of methylene blue in vasodilatory shock.

OBJECTIVE: To report a case of methylene blue extravasation and subsequent tissue necrosis in a patient with refractory septic shock. CASE SUMMARY: A 47-year-old female presented with febrile neutropenia secondary to chemotherapy. The patient quickly decompensated to refractory septic shock in the critical care unit despite implementation of early goal-directed therapy as well as intravenous norepinephrine and vasopressin to stabilize her hemodynamic status. She received a 16-hour infusion of 1% methylene blue 0.25 mg•kg(-1)•h(-1), titrated up to 0.5 mg•kg(-1)•h(-1), via a peripheral intravenous catheter. Ten hours after the start of the methylene blue infusion, she experienced a local extravasation injury, which led to distal digital necrosis. While her hemodynamic status improved dramatically, allowing discharge from the intensive care unit and eventually to home, the extravasation site became necrotic and required debridement and skin graft. DISCUSSION: Methylene blue is a vasoactive chemical that has been shown to provide hemodynamic stability in the treatment of refractory septic shock. Methylene blue administration is not considered standard of practice in the treatment of refractory septic shock and many aspects of its dosing, route, duration, and adverse effects are poorly described. As such, there is little guidance for its administration. We postulate that, in our patient, in the presence of systemic vasopressin and norepinephrine, methylene blue caused extensive vasoconstriction at the site of extravasation, resulting in tissue ischemia and necrosis. Tissue necrosis secondary to peripheral intravenous extravasation has not been previously described and is not listed as an adverse outcome on the drug monograph. The Naranjo probability scale indicates that the tissue necrosis was probably caused by the methylene blue extravasation. CONCLUSIONS: To mitigate future risk to limb and skin, we recommend that methylene blue infusions be delivered via central venous catheter. Extra care should be given to patients with risk factors for extravasation, such as sedation, presence of systemic disease, proximal intravenous puncture sites, and improperly placed catheters.

A critical appraisal of the quality of critical care pharmacotherapy clinical practice guidelines and their strength of recommendations.

OBJECTIVE: Clinical practice guideline (CPG) quality assessment is important before applying their recommendations. Determining whether recommendation strength is consistent with supporting quality of evidence is also essential. We aimed to determine quality of critical care pharmacotherapy CPGs and to assess whether high quality evidence supports strong pharmacotherapy recommendations. METHODS: MEDLINE (1966-February 2008), EMBASE (1980-February 2008), National Guideline Clearinghouse (February 2008) and personal files were searched to identify CPGs. Four appraisers evaluated each guideline using the appraisal of guidelines, research and evaluation (AGREE) instrument. AGREE assesses 23 items in six domains that include scope/purpose, stakeholder involvement, rigor of development, clarity, applicability and editorial independence. Standardized domain scores (0-100%) were determined to decide whether to recommend a guideline for use. One appraiser extracted strong pharmacotherapy recommendations and supporting evidence quality. RESULTS: Twenty-four CPGs were included. Standardized domain scores were clarity [69% (95% confidence interval (CI) 62-76%)], scope/purpose [62% (95% CI 55-68%)], rigor of development [51% (95% CI 42-60%)], editorial independence [39% (95% CI 26-52%)], stakeholder involvement [32% (95% CI 26-37%)] and applicability [19% (95% CI 12-26%)]. The proportion of guidelines that could be strongly recommended, recommended with alterations and not recommended was 25, 37.5 and 37.5%, respectively. High quality evidence supported 36% of strong pharmacotherapy recommendations. CONCLUSION: Variation in AGREE domain scores explain why one-third of critical care pharmacotherapy CPGs cannot be recommended. Only one-third of strong pharmacotherapy recommendations were supported by high quality evidence. We recommend appraisal of guideline quality and the caliber of supporting evidence prior to applying recommendations.

Identifying missed opportunities to curtail antimicrobial therapy for presumed ventilator-associated pneumonia using the clinical pulmonary infection score.

BACKGROUND: Early discontinuation of antimicrobial therapy for ventilator-associated pneumonia can reduce the emergence of antimicrobial resistance, the occurrence of adverse drug events, and the cost of therapy. Evidence suggests that discontinuation of therapy by day 3 may be appropriate for patients with a clinical pulmonary infection score of 6 or less at baseline and on day 3. OBJECTIVES: To determine the proportion of patients eligible for antimicrobial discontinuation on day 3 and day 7 of therapy and to determine the proportion of eligible patients for whom antimicrobials were discontinued within these timeframes. METHODS: A 6-month observational study was conducted from October 3, 2005, to March 31, 2006, in a 27-bed medical-surgical tertiary care intensive care unit. Clinical pharmacists attended daily rounds and prospectively identified patients for inclusion in the study. A study pharmacist retrospectively calculated clinical pulmonary infection scores. Other data were obtained from the quality-improvement database and patient health records for the intensive care unit. RESULTS: Ninety-two patients were treated for ventilator-associated pneumonia during the study period, of whom 49 were included in the analysis. At day 3, 17 (35%) of the 49 patients were eligible for early discontinuation of antimicrobial therapy, but therapy was discontinued for only 2 (12%) of these 17 patients. At day 7, 10 (32%) of 31 patients were eligible for antimicrobial discontinuation, but therapy was discontinued for only 1 (10%) of these 10 patients. CONCLUSIONS: A significant opportunity exists at the authors' institution to develop and implement an antimicrobial discontinuation policy that uses the clinical pulmonary infection score to guide antimicrobial use for patients with ventilator-associated pneumonia.