Latest News

Latest News

Resource Spotlight: Venous Thromboembolism in Pregnancy 

January 26, 2023
 

Written by Duaa Osman

This article was written and researched by a CSHP student member for Interactions, our biweekly newsletter. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the student to select topics that are of interest and utility to both the student and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at practice@cshp.ca

Background

In Canada, venous thromboembolism (VTE) is the second most common cardiovascular disorder and is estimated to cause the healthcare system $600 million per year. Pregnancy is a well-established risk factor for VTE, with all stages of pregnancy resulting in increased risk, especially the post-partum period. When compared to non-pregnant women of similar age, pregnant women experience a 5 to 10-fold increase in risk of VTE during pregnancy and a 15 to 35-fold increase during the post-partum period. This “Resource Spotlight” contains links to associations and guidelines that help pharmacists learn more about VTE in the context of pregnancy, along with helpful resources to share with patients. To learn more about VTE in pregnancy, check out CSHP’s recent Clinical Pearls article on Venous Thromboembolism in Pregnancy. 

External Resources  

Unless otherwise noted, the Canadian Society of Hospital Pharmacists (CSHP) does not endorse or imply endorsement of the resources provided here. These resources are provided without warranty of any kind, either expressed or implied. It is the responsibility of the user of the resource to judge its suitability for his or her particular purpose within the context of his or her practice and the applicable legislative framework. In no event shall CSHP or any persons involved in providing the resource be liable for damages arising from its use. Resources are free unless otherwise indicated.  

Thrombosis Canada 

Thrombosis Canada is an organization aimed at improving the care of patients with thrombosis. They provide helpful resources such as point-of-care guides and educational resources for both patients and healthcare professionals. With respect to venous thromboembolism in the context of pregnancy, Thrombosis Canada offers clinical guides on the diagnosis, treatment, and prevention of DVT and PE in pregnant patients. To support patient education, they also offer Patient Information Sheets on a variety of topics relating to thrombosis such as drug and disease information sheets. Thrombosis Canada has also recently developed and launched a national survey aimed at patients currently on anticoagulant therapy with results expected to be released to their website by the end of January 2023.  

Canadian Venous Thromboembolism Research Network (CanVECTOR)

CanVECTOR is a pan-Canadian network of researchers, healthcare professionals, patient groups, and public/private partners with the overall goal of reducing incidence of VTE in Canada and improving the safety and quality of care of those impacted by VTE. One way the organization supports its mission is by providing funding for research pilot projects relating to VTE. Funding for these pilot projects is determined through an annual pilot trial competition. A list of the projects funded by CanVECTOR can be found here. With respect to VTE in the context of pregnancy and the post-partum period,  CanVECTOR also publishes Evidence Summary articles where they summarize key findings from studies to help healthcare providers make evidence-based decisions. Some notable examples of topics addressed in these articles include assessing the risk of recurrent VTE in women who experienced an unprovoked VTE, assessing the need for thromboprophylaxis during pregnancy, and the effects of hormone therapy on the risk of recurrent VTE

Canadian Patient Safety Institute

In Canada, VTE remains to be one of the leading causes of maternal mortality due to increased risk factors during pregnancy. In collaboration with the Canadian Institute for Health Information, the Canadian Patient Safety Institute released a Hospital Harm Improvement Resource detailing evidence-based recommendations hospitals can implement to reduce the incidence of hospital-acquired VTE in adult and obstetrical patients.  

Society of Obstetricians and Gynacologists 

The Society of Obstetricians and Gynaecologists of Canada published clinical practice guideline outlining their recommendations regarding the diagnosis, treatment and thromboprophylaxis of VTE in pregnancy and the post-partum period. The venous thromboembolism and antithrombotic therapy practice guideline summarizes available evidence and can act as a useful resource to healthcare providers. They also offer evidence-based patient-friendly resources about pregnancy and childbirth on their Pregnancy Info website.  

January 26, 2023
Resource spotlight: Venous Thromboembolism in Pregnancy

Latest News

Together 2023: Frequently Asked Questions

January 18, 2023
 
With no shortage of excellent programming, Together: Canada’s Largest Hospital Pharmacy Conference is sure to provide attendees with unmatched opportunities for education while connecting the hospital pharmacy community across Canada.
To help make everyone's experience as seamless as possible in this new hybrid format, CSHP has developed an FAQ to clarify any questions that you may have.
 
Q. How many CEUs can I earn in total? 
A. Together attendees can earn up to 22 CEUs (pending CCCEP accreditation).
Here is a breakdown of those credits:

Conference ticket
Pre-conference credits (separate paid registration)
Sponsored satellite symposia (individually accredited by the sponsor)
  • Additional credits may be available through separate registration for sponsored satellite symposia, depending on the sponsor completing the accreditation process independently. 
 
Q. Can I earn all 22 CEUs if I’m attending virtually?
A. Up to 15 CEUs are available to virtual attendees. Sessions like the hands-on Pre-Conference Sim Lab: An Introduction to Managing Common Overdoses - A Toxicology Sim Lab for Everyone and the Hospital Pharmacy in Canada Survey Workshop are only available for those attending in-person
 
 
Q. Which other conference items are unable to be broadcast virtually? 
A. The face-to-face Student and Resident Networking Event and hospitality suites are not available on the virtual portal. 
 
Q. How long will conference recordings remain available?
A. Most recordings will be available on demand for a full year! However, to receive your CEUs, you must complete the accredited sessions by March 26, 2023

Q. If I can’t attend a session, can I watch the recorded session and still get my CEUs?
A.  Yes. Regardless of if you're attending in person or virtually, you can watch missed recorded sessions via virtual portal access (accessible on Thursday, March 9). Be sure to watch these sessions by March 26, 2023 to obtain your CEUs!

Q. Is the conference accredited for both pharmacists and technicians?  
A.  Yes, the conference will be accredited for both!  
 
Q. How do I know which sessions are accredited?  
A.  The sessions that are accredited will be indicated on the conference website with the CCCEP accreditation logo  (which will be updated closer to the conference).
 
 
Have a question that hasn't been answered here? Reach out to events@cshp.ca.

  
Register
  

 
 
January 18, 2023
Together 2023: Frequently Asked Questions

Clinical Pearls: Venous Thromboembolism in Pregnancy 

January 16, 2023
By Duaa Osman

This article is part of a series appearing in Interactions, our biweekly newsletter, written and researched by CSHP's students. We've created this series as a valuable learning activity for pharmacy students undertaking rotations at CSHP. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the students to select hot topics that are of interest and utility to both the students and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at practice@cshp.ca.

Background

In Canada, venous thromboembolism (VTE) is the second most common cardiovascular disorder and is estimated to cause the healthcare system $600 million per year.1 Pregnancy is a well-established risk factor for VTE, with all stages of pregnancy resulting in increased risk, especially the post-partum period. When compared to non-pregnant women of similar age, pregnant women experience a 5 to 10-fold increase in risk of VTE during pregnancy and a 15 to 35-fold increase during the post-partum period.2

VTE is comprised of two main conditions, deep vein thrombosis (DVT) and pulmonary embolism (PE) – both of which are well established complications of pregnancy. Thrombosis typically occurs due to over-activation of hemostasis at the site of an injured or uninjured blood vessel. In general, factors that increase the risk of VTE are those that increase hypercoagulability, stasis of the blood, or vessel wall injury – also known as Virchow’s triad.3 Increases in clotting factors during pregnancy results in a hypercoagulable state. During the second and third trimesters, an increased resistance to activated protein C is observed, resulting in poor anticoagulant response. Stasis of the blood increases due to decreased venous capacitance and compression of the large veins caused by the enlargement of the uterus. Finally, an increase in vessel wall injury can occur due to labour and delivery, increasing the risk of VTE during the post-partum period.4 

VTE can manifest during pregnancy as an isolated DVT in the lower extremities, or a portion of the embolus may travel from the lower extremity to the lungs resulting in a PE. Early detection and treatment of DVT and PE during pregnancy is crucial as PE represents the 7th leading cause of maternal mortality, accounting for 9% of maternal deaths.4

Diagnosing VTE in pregnancy

Distinguishing symptoms of DVT from symptoms of pregnancy can be difficult as there are many hemodynamic changes that occur during pregnancy. With respect to clinical presentation, pregnant women have a higher likelihood to experience left-sided DVT than non-pregnant women, with greater than 80% of DVT cases in pregnancy occurring in the left leg.2 DVT in pregnant women is also more likely to be isolated to the iliac and/or femoral veins than in non-pregnant patients.2 This is thought to be due to the right common iliac artery compressing the left common iliac vein as a result of the enlargement of the uterus.5 Signs and symptoms of DVT include erythema, leg swelling, and warmth of the lower extremity.2

The Society of Obstetricians and Gynaecologists of Canada (SOGC) recommends investigating suspected DVT using compression ultrasound of the proximal venous system from the iliac to the popliteal vein. Doppler studies should also be performed on the external iliac vein to ensure presence of blood flow. If the initial examination is negative, the test should be repeated within 7 days. If an isolated DVT is suspected to be in the iliac vein, an MRI can be considered following the initial examination.6 Suspected cases of PE can be investigated using D-dimer test combined with compression ultrasonography.6 Once an acute case of VTE is confirmed, anticoagulation therapy should be promptly initiated. The SOGC guidelines recommend that pregnant women should be hospitalized or closely monitored as outpatients for the first two weeks of VTE treatment following diagnosis.6

Therapeutic options: Anticoagulants 

The cornerstone of VTE therapy is anticoagulation therapy; however, during pregnancy certain safety considerations must be kept in mind to uphold maternal and fetal safety.  

Table 1: Anticoagualnt options available for the treatment of VTE 7,8

*Except in patients with a history of heparin-induced thrombocytopenia

In most cases, subcutaneous LMWH is the drug of choice for the treatment of DVT in pregnancy due to its safety and efficacy profile. UFH is preferred for patients with severe renal failure, or those at increased risk of bleeding or persistent hypotension resulting from PE.6

Warfarin is contraindicated during the first trimester of pregnancy since it can cause warfarin embryopathy resulting in stippled bones, midfacial and limb malformations. Warfarin use during pregnancy can also result in fetal hemorrhage or death. Therefore, the use of warfarin should only be considered in exceptional circumstances, for example, in women with mechanical heart valves.9

Anticoagulants should be administered for a minimum of 3 months when treating acute VTE. Following this initial treatment period, anticoagulant use can be decreased to intermediate or prophylactic use for the remainder of the pregnancy. Treatment can be discontinued at 6 weeks post-partum.6

Thromboprophylaxis in pregnancy  

The need for thromboprophylaxis in pregnancy should be assessed during pregnancy, the post-partum period, and at any transitions of care. Pharmacologic and non-pharmacologic options are available for thromboprophylaxis. Non-pharmacologic options include graduated compression stockings or use of intermittent pneumatic compression devices.  
 
Pharmacologic prophylaxis can be considered for pregnant women with a history of multiple VTEs or estrogen associated VTE. The preferred agent for pharmacologic prophylactic treatment is LMWH. In patients with severe renal insufficiency, UFH is preferred. It is recommended that prophylactic therapy be continued through the pregnancy. During the final weeks of pregnancy, prophylactic treatment should be reassessed to determine if any changes or discontinuation is needed.10 

Determining the optimal dosing for LMWH during pregnancy and the post-partum period remains to be a challenge due to existing knowledge gaps.5 A recent multicentre open-label, randomised controlled trial, the Highlow study, sought to determine optimal dosing of LMWH in pregnant and post-partum women with a history of VTE.11 The primary efficacy outcome of the study was incidence of confirmed VTE, and the primary safety outcome was assessing for risk of bleeding. The study randomised 1110 pregnant women to receive either a weight-adjusted intermediate dose of LMWH or a fixed low dose of LMWH. The study found that fixed low dose of LMWH is an appropriate thromboprophylaxis dosing strategy during pregnancy in patients with a history of VTE. With respect to the post-partum period, a post-hoc analysis of the study suggested that an intermediate dose of LMWH may be more effective than a low dosing strategy, however this needs to be confirmed through future studies.11

Pharmacist's role

 As part of a multidisciplinary team, pharmacists can play a vital role in the care of patients with VTE. Anticoagulation therapy requires frequent assessment and monitoring to ensure safety and efficacy. Several studies have found that effective patient education and regular long-term follow-up help improve medication adherence.12 In an assessment of the impacts of a pharmacist-led DOAC monitoring clinic, Haché et al. found an increase in patient adherence to guideline-directed care along with a decrease in observed adverse events. In this clinic, pharmacists were the first point of contact for patients during follow-up appointments where patients were assessed for adverse events and adherence. During these visits pharmacists were also able to make changes to medication regimens based on patient assessment, ensuring medication management was in accordance with guideline recommendations.12 In addition, a study by Ogilvie et al. assessing a pharmacist-lead prescribing model in an Australian emergency department found a significant improvement in accuracy and safety of the medications prescribed to patients for VTE.13   With respect to oral contraceptive medication use during the post-partum period, it is recommended that women at risk of VTE avoid combined oral contraceptives during the first 6 weeks of the post-partum period.7 This presents an opportunity for pharmacist intervention for patients at high risk of VTE. Pharmacists are well positioned to make tailored recommendations regarding oral contraceptives based on a patient’s risk of VTE. They can also play a significant role in patient education, effectively enhancing patient safety. 

 

References

  1. Canadian Venous Thromboembolism Clinical Trials and Outcomes Research Network. Venous thromboembolism. Accessed December 14, 2022. https://www.canvector.ca/venous-thromboembolism  
  2. Thrombosis Canada. Pregnancy: Diagnosis of DVT and PE. Updated September 14, 2021. Accessed December 14, 2022. https://thrombosiscanada.ca/clinicalguides/?search=pregnancy#  
  3. Nicholson M, Chan N, Bhagirath V, Ginsberg J. Prevention of Venous Thromboembolism in 2020 and Beyond. J Clin Med. 2020;9(8):2467. Published 2020 Aug 1. doi:10.3390/jcm9082467 
  4. Malhotra A, Weinberger SE. Deep vein thrombosis in pregnancy: Epidemiology, pathogenesis, and diagnosis. In: Post T, ed. UpToDate. UpToDate; 2022. Accessed December 9, 2022. www.uptodate.com  
  5. Devis P, Knuttinen MG. Deep venous thrombosis in pregnancy: incidence, pathogenesis and endovascular management. Cardiovasc Diagn Ther. 2017;7(Suppl 3):S309-S319. doi:10.21037/cdt.2017.10.08 
  6. Chan WS, Rey E, Kent NE, et al. Venous thromboembolism and antithrombotic therapy in pregnancy. J Obstet Gynaecol Can. 2014;36(6):527-553. doi:10.1016/s1701-2163(15)30569-7 
  7. Kosar L, LeBras M. Peri-Pregnancy: Drug treatment considerations for women. May 2022. Available from www.rxfiles.ca 
  8. Thrombosis Canada. Pregnancy: Venous thromboembolism treatment. Updated 2, 2022. Accessed December 14, 2022. https://thrombosiscanada.ca/clinicalguides/?search=pregnancy#  
  9. Malhotra A, Weinberger SE. Deep vein thrombosis and pulmonay embolism in pregnancy: treatment. In: Post T, ed. UpToDate. UpToDate; 2022. Accessed December 9, 2022. www.uptodate.com  
  10. Malhotra A, Weinberger SE. Deep vein thrombosis and pulmonay embolism in pregnancy: Prevention. In: Post T, ed. UpToDate. UpToDate; 2022. Accessed December 9, 2022. www.uptodate.com  
  11. Bistervels IM, Buchmüller A, Wiegers HMG, et al. Intermediate-dose versus low-dose low-molecular-weight heparin in pregnant and post-partum women with a history of venous thromboembolism (Highlow study): an open-label, multicentre, randomised, controlled trial. Lancet. 2022;400(10365):1777-1787. doi:10.1016/S0140-6736(22)02128-6 
  12. Haché J, Bonsu KO, Chitsike R, Nguyen H, Young S. Assessment of a Pharmacist-Led Direct Oral Anticoagulant Monitoring Clinic. Canadian journal of hospital pharmacy. 2021;74(1):7-14. doi:10.4212/CJHP.V74I1.3035 
  13. Ogilvie M, Nissen L, Kyle G, Hale A. An evaluation of a collaborative pharmacist prescribing model compared to the usual medical prescribing model in the emergency department. Research in social and administrative pharmacy. 2022;18(10):3744-3750. doi:10.1016/j.sapharm.2022.05.005 
     

Latest News

January 16, 2023
Clinical Pearls: Venous Thromboembolism in Pregnancy

Latest News

Call for applications: CSHP Foundation Board Pharmacy Technician Trustee 

January 11, 2023

 

Call for applications

The CSHP Foundation Board is seeking applications for a Pharmacy Technician Trustee (new position)

Selection Criteria:

  • CSHP Member (Pharmacy Technician – an individual who is licensed by or registered with a provincial college of pharmacists/pharmacy or in the province of Quebec, comparable education and/or experience).
  • Demonstrated interest in programs that advance the practice of pharmacy and patient care in hospitals and other collaborative healthcare settings and support the mission and vision of the CSHP Foundation.
  • No conflict of interest with the work of the Foundation.

Pharmacy Technician Trustee Term: 3 years (option to renew once, 6 years total).

CSHP Foundation Pharmacist, Pharmacy Technician, Industry and Public Trustees are voting members of the Foundation Board. This is your opportunity to become directly involved in the work of the CSHP Foundation.
 
Are you interested? Information on CSHP Foundation Board Member responsibilities and application forms are available on the Foundation’s website at  https://cshp-scph.ca/foundation-board-member-recruitment

For additional information on position responsibilities and commitments, contact Michael LeBlanc, Chair, CSHP Foundation Board Trustees, at michael.leblanc@horizonnb.ca.

Completed application forms and other required documents should be submitted electronically to Rosemary Pantalone at rpantalone@cshp.ca.

 

Deadline Date for Applications is March 24, 2023  

The CSHP Foundation supports research and educational programs that advance pharmacy practice and patient care in hospitals and other collaborative healthcare settings. The Foundation raises funds that are used to: promote research, advance pharmaceutical science and programs of pharmaceutical education.

January 11, 2023
Call for applications: CSHP Foundation Board Pharmacy Technician Trustee

Latest News

Resource spotlight: Precepting tools

January 3, 2023

 

Written by Eric Katula

This article was written and researched by a CSHP student member for Interactions, our biweekly newsletter. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the student to select topics that are of interest and utility to both the student and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at practice@cshp.ca

 

Background

A crucial part of pharmacy education is experiential learning, which gives students and interns the chance to apply their vast knowledge to real-world situations while being directed by pharmacists with relevant expertise. Being a preceptor is a difficult and crucial job that aids in
preparing graduates for the expanding complexity of the health care system, varied modes of care delivery, navigating the diversity and ambiguity of clients, and the quickening pace of technological advancements. This article aims to highlight tools and resources that can aid in facilitating preceptors' important roles. 

University of Alberta
The faculty of pharmacy and pharmaceutical sciences at the University of Alberta has a preceptor guide that contains answers to any questions preceptors may have about student placements. The guide provides a range of information and suggestions regardless of the student’s year. Among other resources, the faculty offers a checklist for new preceptors, a policies and procedures manual for PharmD students, a guide to teaching clinical problem solving, complete training modules for preceptors, and a document outlining novel models of precepting. Also, the Alberta Health Services has a free preceptor module to help enhance preceptors’ skills. 

Dalhousie University
Dalhousie University offers a free preceptor eLearning course, available to students and instructors at the university, that provides both refresher modules and comprehensive preceptor practice information. The course highlights preceptor roles, teaching methods and styles, providing feedback and evaluation, and interprofessional learning. 

University of Saskatchewan
The university has resources and tools for new and seasoned preceptors that can help guide them through student mentorship. The university has a one-page document outlining the reasons to become a preceptor, how to be an effective preceptor, the roles of a preceptor, and Saskatchewan Health Information Resources and Partnership (SHIRP), a health information resource. 

Western University
The Preceptor Education Program is an online interprofessional program that has eight interactive learning modules. The program is free and available to the public. The modules include downloadable resources, learning exercises, video case scenarios and references. Learning is self-directed and the modules can be completed in any order. The learning modules will help preceptors to prepare for their roles, help students develop learning objectives, resolving conflicts, foster clinical reasoning, and learn how to provide effective feedback

American Society of Hospital Pharmacists
The ASHP offers its active members resources to help mentor and educate students in real world settings to fulfill experiential learning objectives. Their resources can serve as guidance as preceptors develop the most effective methods to teach and mentor students and residents. Such resources include a generational learning document that outlined tips to offering feedback to students of different generations, residency specific resources, student-specific resources, and a preceptor’s playbook that includes nine modules designed to enhance the skills of pharmacy preceptors. 

Suggested Reading Materials

Below are links to reading materials that outline current research on improving preceptors' abilities to guide students throughout their rotations. The studies and articles contain practical ways to implement the suggestions into practice.
 
  • Biagioli FE, Chappelle K. How to be an efficient and effective preceptor. Fam Pract Manag. 2010;17(3):18-21. This paper is a tool for preceptors to aid in pharmacy students' development of professionalism. The article defines professionalism, describes it in the context of contemporary pharmacy practice, discusses the professional socialization process of students, and suggests strategies for preceptors to facilitate improvement in professionalism among students during experiential training.

The following studies and articles introduce preceptors to the clinical reasoning and problem solving. The teaching strategies offered in the articles are aimed at facilitating the preceptor role in helping students develop their own clinical reasoning. 

January 03, 2023
Resource spotlight: Precepting Tools

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