Background: Optimization of HFrEF GDMT should occur within 3 - 6 months of diagnosis.
Objectives: We sought to determine the impact of a novel approach to optimization with a prescribing pharmacist / nurse compared to specialty heart failure clinic (HFC) care.
Methods: Med-OpS, a quality improvement initiative, aimed to create a structured approach to optimization including frequent follow-up and self-care teaching. The pharmacist supported the nurse with case review and prescribing. Med-OpS was embedded within the HFC and was physician referral based. Clinics occurred weekly via telephone and Med-OpS discharge occurred at ≥ 3 months once optimized.
A retrospective chart review was conducted including all patients in Med-OpS (n = 52) and 148 new patients from the HFC (3:1). The primary objective was to compare the proportion of patients optimized on GDMT within 6 months. We also compared utilization, the Heart Failure Collaboratory Score (HFC-Score), and the number of clinical encounters.
Results: The groups were similar at baseline, with a median age of 63 years and 23% female. At 6 months, Med-OpS optimized 80.8% compared to 37.2% of patients in usual care (p = 0.0043). More patients in Med-OpS were on quadruple therapy (67.3% vs 39.6%; p = 0.00056), and increased their HFC-Score (2.42 vs 1.68 points; p = 0.0366), but required more frequent encounters (9.73 vs 2.99).
Conclusions: A focused prescribing pharmacist / nurse approach was associated with greater optimization of GDMT in patients with HFrEF within a specialty clinic and should be considered as a strategy for medication optimization.
The Sunnybrook Odette Cancer Centre Oral Anticancer Medication (OAM) Program
Christine Peragine and Victoria Bugaj
Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario
Background: Increased availability of oral anticancer medications (OAMs) created a paradigm shift in oncology that introduced new challenges to treatment access, placed additional burden on the patient and prescriber to coordinate care, and increased risk for medication non-adherence and severe toxicity. Recognizing the emergent issues associated with OAM therapies, the Sunnybrook Odette Cancer Centre Pharmacy created an innovative program to optimize the clinical, and technical, medication-related support needed by OAM patients and prescribers
Objectives: OAM Program goals include: (1) coordinating timely and continuous OAM access; (2) improving OAM safety and effectiveness; (3) providing OAM information and education to patients, staff, and trainees; and (4) creating new knowledge on OAM-related practices, processes, and outcomes.
Methods: Dedicated pharmacy technicians liaise with prescribers, drug access navigators, and patient support programs to proactively resolve funding issues and facilitate timely medication access. Oncology pharmacists clinically verify each OAM order, perform drug-interaction analyses, and provide tailored education to optimize drug safety and adherence. The OAM Team has developed a variety of clinical tools to guide OAM management and ensures protocolized telephone follow-up for over 60 OAM agents.
Results: The OAM Team has enhanced the care of 3007 Oncology patients since 2015 (1108 currently active). Patients of the OAM Program report high rates of satisfaction, excellent rates of medication adherence and reduced rates of grade 3-4 drug toxicities. OAM Program services optimize OAM distribution efficiency, improve patients’ ability to self-manage OAMs, and reduce the risk of severe side effects and unplanned breaks in therapy.
Conclusions: The OAM Program minimizes time-to-access OAM therapy, maximizes time on OAM therapy, and optimizes patient and prescriber convenience. The Program was identified as a Leading Practice in Cancer Care by Accreditation Canada in 2017 and is considered the gold standard / best-practice for OAM care among local oncology professionals.
Medication Assessment Centre Interprofessional Opioid Pain Service (MAC iOPS):
A Novel Approach to Chronic Pain Management
Derek Jorgenson, Katelyn Halpape, Eric Landry, Taylor Raiche, Amy Wiebe
University of Saskatchewan, Medication Assessment Centre, Saskatoon
Background: One in five Canadians experience chronic pain. Saskatchewan residents have limited access to interdisciplinary chronic pain management. The Medication Assessment Centre Interprofessional Opioid Pain Service (MAC iOPS) was created to fill this gap.
Objectives: To develop, implement, and evaluate an interdisciplinary, pharmacist-led, chronic pain clinic.
Methods: The program development and implementation included securing funding, hiring health professionals, creating a care model, and patient recruitment. Initial program evaluation includes retrospective chart audit and survey of patients and their healthcare professionals.
Results: MAC iOPS was established, with federal funding, as an interdisciplinary chronic pain service in March 2020. The team includes four pharmacists, one chronic pain physician, one physical therapist, and two social workers. MAC iOPS is available to all Saskatchewan residents and services are delivered virtually or in-person. MAC iOPS differs from traditional interdisciplinary teams in that pharmacists lead the team. MAC iOPS does not prescribe but works with the patient’s existing prescriber to implement treatment plans. Chart audit results (n=79) found reductions in mean daily morphine equivalents of 37mg and improved Brief Pain Inventory scores of 1.3 points. Eleven patients were provided take home naloxone kits. Patient surveys (n=17) indicated that 65% of patients had improved overall health status and 94% were satisfied with their care. The health professional surveys (n=16) revealed that 100% would recommend MAC iOPS to colleagues and 69% were more confident managing chronic pain after working with MAC iOPS.
Conclusions: MAC iOPS has improved access to interdisciplinary chronic pain management in Saskatchewan, resulting in improved overall self-reported health status of chronic pain patients, reduced opioid intake, and expanded access to take home naloxone. The service has been well received by patients and health professionals.
Improving Decision-Making in Empiric Antibiotic Selection (IDEAS)
Marion Elligsen
Sunnybrook Health Sciences Centre, Toronto
Background : Timely initiation of adequate antibiotics has been associated improved patient outcomes. However, selecting adequate empiric antibiotics is difficult due to rising resistance rates and the competing desire to apply antimicrobial stewardship principles.
Objectives : The objective of this project was to develop, implement and evaluated two interventions to optimize empiric antibiotics using prospective audit and feedback.
Methods : The interventions included providing suggestions to prescribers at two points in the empiric period: (1) prior to availability of any culture results, empiric therapy was altered to ensure concordance with prior cultures that have predictive relevance for future infection; and (2) when Gram-negative bacteremia was identified, previously derived and validated multivariable models were used to recommend the most narrow-spectrum adequate antibiotic. The interventions were evaluated simultaneously using a quasi-experimental design comparing two 9-month periods (pre and post-intervention) at Sunnybrook Health Sciences Centre, Toronto, Ontario.
Results : The first intervention increased the proportion of patients that received concordant therapy from 73% (72/99) in the control group to 88% (76/86) in the intervention group (p=0.01). The median time to concordant therapy was significantly shorter in the intervention group (25 vs 55 hrs; p<0.001). The median duration of unnecessary vancomycin therapy was reduced by 1.1 days (95% CI 0.5 – 1.6 days, p<0.001).
The second intervention increased the proportion of patients who were on the most narrow-spectrum adequate therapy at the time of culture finalization from 44% (88/201) in the control group to 55% (100/182) in the intervention group ( p=0.04). Time to adequate therapy was similar in the intervention and control groups (5 vs 4 hours; p=0.95)
Conclusions : Together, these interventions demonstrated that systematic decision support interventions can simultaneously improve the adequacy of empiric antibiotic coverage while decreasing overall use of broad-spectrum empiric agents.
Radiology Exam and Postoperative/Post-Sedation Breastfeeding: Internal Initiatives and Information Documents
Nathalie Gagnon
CISSS de l’Outaouais, Gatineau Hospital, Gatineau, QC
Background: During breastfeeding, tests and procedures requiring contrast media, anesthetics and analgesics may be prescribed. Too often, the tendency is still to tell women they have to pump and throw away their milk, even though this is rarely necessary. In addition, the information being provided is generally inconsistent between departments or healthcare professionals.
Objectives: Review the literature on drugs used in radiology, examination room or operating room in breastfeeding context. Develop a protocol or procedure. Provide written information.
Methods: An internet search was conducted for such documents, but nothing was found. Phone calls to other CISSS, including those holding a “Baby Friendly Initiative” accreditation, were done; none of them had a protocol or procedure in place. Reference books, literature reviews and specialized databases were consulted.
Results: The use of these drugs in these contexts is a one-time event. They are rapidly eliminated from the plasma compartment, the amount likely to pass into the milk is generally very low with an unlikely digestive absorption in the infant. A resumption of breastfeeding is possible as soon as the patient is in a stable state and has regained a level of alertness authorizing her to stand up.
Conclusions: The procedure “Radiology exam in breastfeeding patient” has been in place since January 2017, while the medical protocol “Postoperative/post-sedation breastfeeding” has been in force since November 2018. The drugs involved are compatible with breastfeeding. The challenge is to widely disseminate these initiatives for the benefit of lactating patients and the children they breastfeed.