News

Clinical Pearls: Management of Sepsis and Septic shock - Updated Recommendations

September 26, 2022
By: Eric Katula

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.

Sepsis is a life-threatening medical condition that, when severe, can lead to acute organ dysfunction, tissue damage, septic shock, and even death20. It affects neonatal, pediatric, and adult patients worldwide20.  According to statistics Canada, one out of eighteen deaths in Canada is due to sepsis1, and it is among the leading cause of death in Intensive Care Unit (ICU) patients20. Most cases of sepsis are caused by bacterial infections, but it can also be caused by fungal infections, traumatic injuries, or viral infections such as COVID-1921.

The cost of sepsis is substantial as treatment often involves complex therapies and lengthy stays in the intensive care units22. Patients with sepsis are two to three times more likely to be readmitted into the hospital compared to patients with other medical conditions such as heart failure or COPD22. Additionally, the development of sepsis may be linked with other illnesses such as pneumonia22. Prevention and early management of sepsis saves healthcare costs as it reduces the number of patients readmitted into hospitals and intensive care units; This helps to increase beds for critically ill patients such as those with severe Covid-19. 

Pharmacists' Role in Sepsis Management

Pharmacists play a crucial role as members of multidisciplinary teams involved in the treatment of sepsis. Various studies have shown the impacts of pharmacists in sepsis management by decreasing the time to administration of antibiotics, ensuring the appropriate selection of antibiotics, improving adherence to medications, lowering health care costs, and decreasing patient mortality2-4.  Additionally, pharmacists are involved in preventing sepsis by monitoring patients, following up on sepsis survivors post-discharge, conducting medication reconciliation, developing guidelines for risk assessment, and educating healthcare providers, patients and the general public about sepsis prevention. These activities reduce health care costs by decreasing the number of sepsis survivors who get re-hospitalized for preventable diseases12. In some health care institutions, pharmacists are members of rapid response teams that assess patients who may require ICU care and prevent ICU admissions by identifying sepsis early and providing appropriate treatment24.   
     
An observational study conducted by Kayvan Moussavi et al. found that an emergency department found that pharmacists significantly decreased the time to antimicrobial administration to patients with sepsis, severe sepsis, or septic shock19. The presence of a pharmacist was also found to increase the number of patients who received appropriate antimicrobials within the timeline recommended by Surviving Sepsis Campaign (SSC) guidelines12,19. Decreasing time to antimicrobial administration is important as each hour of delay in antibiotic administration is associated with a 7.6% decrease in survival12,19. Patients who receive antimicrobials after shock recognition have a significant increase in mortality19. Therefore, incorporating a pharmacist on a multidisciplinary team provides additional value to treating patients with sepsis.  

Updated Surviving Sepsis Guidelines

To guide health care providers in making appropriate and evidence-based decisions when treating patients with sepsis, the international guideline, Surviving Sepsis Campaign, for treating sepsis was updated in 2021. This article aims to briefly highlight some recommendations and changes from the 2016 guidelines for managing infections and hemodynamic changes in adult patients with sepsis. Though all the changes and recommendations in the 2021 guideline are important, this article will highlight the changes most relevant to hospital pharmacists.

Infections
Bacterial infections are the most common causes of sepsis4. Sepsis can also be caused by fungal, parasitic, or viral infections. Hospital pharmacists are valuable members of sepsis response teams and improve adherence to early goal-oriented therapy such as administration of appropriate antimicrobials. Numerous studies have concluded that the presence of a pharmacist on a trained team of health care professionals who are educated in early recognition, diagnosis, and treatment of sepsis, has a significant impact on the time to antimicrobial administration3-7.  Also, clinical pharmacists monitor and adjust dosage regimens based on pharmacologic responses and biological fluid and tissue drug concentrations in conjunction with clinical signs and symptoms or other biochemical variables. They recommend measurements of drug concentrations in bodily fluids or tissues to facilitate the evaluation of dosage regimens14,15, 23, 25

Refer to Table 1 for changes and recommendations made in the 2021 Surviving Sepsis Campaign8 deemed most relevant to hospital pharmacist:

Table 1

It is crucial to rapidly assess patients at risk of developing sepsis. If antimicrobials are indicated, administer them within 3 hours; If the patient is at high risk of MRSA, administer antibiotics with MRSA coverage; and if the patient is at high risk of fungal infection, use empiric antifungal therapy.

Hemodynamic Management and Additional Therapies
Cardiovascular alterations resulting from sepsis and septic shock include myocardial depression, hypovolemia, and systemic vasodilation. These alterations lead to tissue hypoperfusion, which in turn lead to organ failures16. Early interventions to improve oxygen delivery body organs and tissues improve outcome, but continuing hemodynamic support is often required12,16. Table 2 highlights some changes and recommendations most relevant to hospital pharmacists. 

Table 2



Rather than delaying initiation of vasopressors until a central venous access is secured, the guideline suggests starting vasopressors peripherally to restore mean arterial pressure. Additionally, the guidelines recommend administering IV corticosteroids in patients requiring vasopressors. Lastly, do not administer IV vitamin C to patients with sepsis or septic shock. 

Summary

As crucial members of the multidisciplinary teams involved in treating sepsis, pharmacists reduce the time to administration of antibiotics, ensure appropriate selection of antimicrobial or antifungals, and improve patient adherence to medications; these activities contribute to decreasing health care costs, and patient mortality2-4.  Pharmacists can play a crucial role in facilitating early diagnosis of sepsis by recognizing the signs and symptoms of sepsis and by ensuring rapid treatment of patients at risk of developing sepsis or septic shock2,3,6,12. The highlighted changes and recommendations in this article are aimed at improving the care of adult patients with sepsis and septic shock. For a complete list of changes and recommendations, please review the Surviving Sepsis guidelines.  

References

1. Navaneelan, T., Peters, P., Alam, S. and Phillips, O., 2016. Deaths involving sepsis in Canada. [online] Www150.statcan.gc.ca. Available at: <https://www150.statcan.gc.ca/n1/pub/82-624-x/2016001/article/14308-eng.htm> [Accessed 8 September 2022].
2. Cavanaugh JB Jr, Sullivan JB, East N, Nodzon JN. Importance of Pharmacy Involvement in the Treatment of Sepsis. Hosp Pharm. 2017;52(3):191-197. doi:10.1310/hpj5203-191
3. Moussavi K, Nikitenko V. Pharmacist impact on time to antibiotic administration in patients with sepsis in an ED. Am J Emerg Med. 2016;34(11):2117-2121. doi:10.1016/j.ajem.2016.07.031
4. Sarani B, Brenner SR, Gabel B, et al. Improving sepsis care through systems change: the impact of a medical emergency team. Jt Comm J Qual Patient Saf. 2008;34(3):179-125. doi:10.1016/s1553-7250(08)34021-5
5. Tarabichi Y, Cheng A, Bar-Shain D, et al. Improving Timeliness of Antibiotic Administration Using a Provider and Pharmacist Facing Sepsis Early Warning System in the Emergency Department Setting: A Randomized Controlled Quality Improvement Initiative. Crit Care Med. 2022;50(3):418-427. doi:10.1097/CCM.0000000000005267
6. Gawrys GW, Tun K, Jackson CB, et al. The impact of rapid diagnostic testing, surveillance software, and clinical pharmacist staffing at a large community hospital in the management of Gram-negative bloodstream infections. Diagn Microbiol Infect Dis. 2020;98(1):115084. doi:10.1016/j.diagmicrobio.2020.115084
7. MacLaren R, Bond CA, Martin SJ, Fike D. Clinical and economic outcomes of involving pharmacists in the direct care of critically ill patients with infections. Crit Care Med. 2008;36(12):3184-3189. doi:10.1097/CCM.0b013e31818f2269
8. Gaieski DF, Edwards JM, Kallan MJ, Carr BG. Benchmarking the incidence and mortality of severe sepsis in the United States. Crit Care Med. 2013;41(5):1167-1174. doi:10.1097/CCM.0b013e31827c09f8
9. Peltan ID, Brown SM, Bledsoe JR, et al. ED Door-to-Antibiotic Time and Long-term Mortality in Sepsis. Chest. 2019;155(5):938-946. doi:10.1016/j.chest.2019.02.008
10. Alam N, Oskam E, Stassen PM, et al. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. Lancet Respir Med. 2018;6(1):40-50. doi:10.1016/S2213-2600(17)30469-1
11. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43(3):304-377. doi:10.1007/s00134-017-4683-6
12. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-1247. doi:10.1007/s00134-021-06506-y
13. Seymour CW, Gesten F, Prescott HC, et al. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. N Engl J Med. 2017;376(23):2235-2244. doi:10.1056/NEJMoa1703058
14. Callejo-Torre F, Eiros Bouza JM, Olaechea Astigarraga P, et al. Risk factors for methicillin-resistant Staphylococcus aureus colonisation or infection in intensive care units and their reliability for predicting MRSA on ICU admission. Infez Med. 2016;24(3):201-209.
15. Timsit JF, Azoulay E, Schwebel C, et al. Empirical Micafungin Treatment and Survival Without Invasive Fungal Infection in Adults With ICU-Acquired Sepsis, Candida Colonization, and Multiple Organ Failure: The EMPIRICUS Randomized Clinical Trial. JAMA. 2016;316(15):1555-1564. doi:10.1001/jama.2016.14655
16. De Backer, D. Hemodynamic management of septic shock. Curr Infect Dis Rep 8, 366–372 (2006). https://doi.org/10.1007/s11908-006-0047-z
17. Rochwerg B, Alhazzani W, Sindi A, et al. Fluid resuscitation in sepsis: a systematic review and network meta-analysis. Ann Intern Med. 2014;161(5):347-355. doi:10.7326/M14-0178
18. Rygård SL, Butler E, Granholm A, et al. Low-dose corticosteroids for adult patients with septic shock: a systematic review with meta-analysis and trial sequential analysis. Intensive Care Med. 2018;44(7):1003-1016. doi:10.1007/s00134-018-5197-6
19. Moussavi K, Nikitenko V. Pharmacist impact on time to antibiotic administration in patients with sepsis in an ED. Am J Emerg Med. 2016;34(11):2117-2121. doi:10.1016/j.ajem.2016.07.031
20. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315(8): 801-10.
21. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): U.S. Department of Health and Human Services. Sepsis: clinical information; 2020. Available from: https://www.cdc.gov/sepsis/clinicaltools/index.html
22. Hajj J, Blaine N, Salavaci J, Jacoby D. The “centrality of sepsis”: a review on incidence, mortality, and cost of care. Healthcare (Basel) [Internet]. Available from: https://www.mdpi.com/2227-9032/6/3/90/htm
23. Garau J, Bassetti M. Role of pharmacists in antimicrobial stewardship programmes. Int J Clin Pharm. 2018;40(5):948-52.
24. Sarani B, Brenner SR, Gabel B, et al. Improving sepsis care through systems change: the impact of a medical emergency team. Jt Comm J Qual Patient Saf. 2008;34(3):179-125. doi:10.1016/s1553-7250(08)34021-5
25. ASHP statement on the pharmacist's role in antimicrobial stewardship and infection prevention and control. Am J Health Syst Pharm. 2010;67(7):575-577. doi:10.2146/sp100001

 

Latest News

September 26, 2022
Clinical Pearls: Management of Sepsis and Septic shock - Updated Recommendations

APOthecary Heroes Contest

Sept. 26, 2022

Pharmacy professionals play a critical role in improving patient health going above and beyond in their day-to-day for the well-being of Canadians. To honour all that they do, Apotex Inc., Canada’s largest producer of generic drugs, launched season two of its APOthecary Heroes Contest – Canada’s Pharmacy Awards Program dedicated to showcasing the positive impact of pharmacy professionals to our communities and Canada’s healthcare system. Open to any Canadian – including consumers, patients, other pharmacy professionals, and healthcare professionals – this contest recognizes all that pharmacy professionals do to support patients and advance the pharmacy practice. 

As a Canadian-owned, Canadian-based company, Apotex has supported pharmacy success through multiple initiatives, services, and resources for close to 50 years. They value the strides taken by pharmacy professionals in putting patients first and remain committed to supporting them as valued partners. “Apotex has always been supportive of the pharmacy profession including through their APOthecary Heroes Contest. What drew me to apply for the award was the ability to donate $2500 to a charity of choice. For a pharmacist that works hard to support the community this award was an opportunity to help out even more! How can you beat that?” said Darren Murphy, Northway Pharmacy Broadway & Readymeds, Winnipeg MB, and APOthecary Hero 2021.   

Apotex greatly appreciates the critical front-line support pharmacy professionals provide to Canadian patients every day whose contributions over the years, particularly during the pandemic, have been and continue to be immeasurable. Through this contest, Apotex wants to raise awareness on the efforts made by pharmacy professionals to continuously impact patient lives positively – and encourage Canadians to express their gratitude. 

“We know that Canadians from coast-to-coast value the advice and support of their neighborhood pharmacy professional,” said Jordan Berman, Vice President, Global Corporate Affairs, Transformation & Strategy, Apotex Inc. “We also know that pharmacy professionals have taken on an increasing volume of healthcare responsibilities over the past few years in particular, and this awards program is one way to highlight to their endless contributions,” he adds. 

The awards program calls for nominations of any pharmacy professional – including a pharmacist, pharmacy educator, technician or student – who go above and beyond, overcoming challenges and hurdles

All nominations are assessed on the following:
 
  • The extent to which the nominee's pharmacy involvement impacts patient health
  • Activities undertaken to support pharmacy practice
  • Outstanding effort for patients, their community and/or pharmacy practice

There will be up to 10 winners with one winner per province/territory. You can self-nominate, and any Canadian resident of legal age of majority can nominate a Canadian Pharmacy Professional of their choice. The winning pharmacy professionals are each awarded:

  • A $2,500 CAD donation to a registered charity of their choice that aligns with the Apotex Giving Philosophy of improving access, increasing affordability, and fostering innovation
  • An article written highlighting the winners both internally at Apotex and externally in a national pharmacy publication
  • Social media recognition across all Apotex channels

Learn more about the awards program here. For program rules, click here.

Nominate yourself or a colleague to be the next APOthecary Hero today! Program closes on October 12, 2022. For any questions you have, contact apothecaryheroes@apotex.com.

 

Latest News

September 26, 2022
APOthecary Heroes Contest

Latest News

Notice of the 2022 AGM and Special Resolutions

August 26, 2022

 

NOTICE OF MEETING

The Annual General Meeting of the Canadian Society of Hospital Pharmacists will be held on Sunday, October 30 from 1:30-2:30 pm EDT in-person at the Sheraton Four Points Hotel in Gatineau, Quebec and virtually via zoom.

Attending in person?
We'll register you at the door. 

Attending virtually via Zoom?


A meeting link will be sent closer to the AGM date along with your status (member, supporter, observer) and any background documents will be accessible prior to this date.

Pre-registration is required by Thursday, October 27, 2022, 23:59 ET.

NOTICE OF SPECIAL RESOLUTIONS


According to CSHP’s By-law 14.8.2, notice in writing of any proposed changes in the bylaws of CSHP to be presented at the AGM must be circulated to the members 60 days before the meeting. 
 
The CSHP Board of Directors recommend that the Members approve the special resolutions set out below: 


THAT the Members adopt the Articles of Amendment in the form approved by the directors; and 


THAT the Members adopt the revised By-Law No. 1 in the form approved by the directors. 

The Articles of Amendment and the revised By-law No. 1 can be downloaded by clicking through the links.   

SUMMARY OF CHANGES

CSHP is required to submit any changes to it Articles to Industry Canada in the form of “Articles of Amendment.”  Download the “blackline text” which shows the changes. The major change is the reduction of the minimum number of Board directors from 16 to 13. 

The changes to CSHP By-law No. 1 can be downloaded in this blackline version which compares the revised version with the current version. The majority of changes are to align with the Not-For-Profit Corporations Act under which the Society operates and to simplify the bylaw so it is more straight-forward and easily understood. 

CSHP members are welcome to submit any comments on the proposed amendments to Jody Ciufo, Chief Executive Officer, at jciufo@cshp.ca by September 30, 2022.

 

August 26, 2022
Notice of the 2022 AGM and Special Resolutions

Latest News

Call for Members: Awards Committee

August 18, 2022
 

Join the Awards Committee! We are looking for broad geographical representation from our members. The Committee administers CSHP’s annual awards program, including reviewing submissions and selecting winners.  

We’re also involved in planning awards presentations, developing criteria for new awards, and promoting the program to the membership.

Term of appointment for committee members:
2 years, option of 1 additional 2-year term, 4 years maximum 

Candidate criteria

    • Candidates must be able to commit to a minimum of 4 meetings per year. Meetings are scheduled in 3-hour time blocks; however, the meetings do not generally last the full 3-hours. Meetings are held virtually on the Zoom platform. 
    • An additional time commitment is required for reviewing award submissions. This review is generally performed independently, so that results can be shared at meetings. Candidates should also schedule time to consult with the Committee Chair as necessary to become familiar with the position.

Instructions for applicants:

Please submit the following documents by the deadline date: 

  • Copy of your curriculum vitae 

  • One-page statement describing your interest in volunteering for this position 
     
    Submit the above noted documents to the CSHP office by e-mail to Robyn Rockwell , Membership and Awards Administrator.  
     
    For more information on the role of committee member, please contact Rumi McGloin , Chair, Awards Committee. 
     
    Deadline date for applications: September 30, 2022 

     

  • August 18, 2022
    Call for members: Awards Committee

    Clinical Pearls: Pulmonary Hypertension

    August 16, 2022
    By Jessica Sheard

    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

    Pulmonary hypertension (PH) is an uncommon, yet serious disease that significantly impacts those who are diagnosed. Once an individual is diagnosed with pulmonary hypertension, their mortality rate increases seven-fold, regardless of the classification or severity of PH at diagnosis1. The prevalence of PH globally is 1% but increases to 10% in those over the age of 651. The Pulmonary Hypertension Association estimates that there are between 5,000 and 10,000 patients, of all ages, genders, and backgrounds, living with PH in Canada2. Although there has been significant progress to the diagnosis and management of PH in Canada, the prognosis in these patients remains poor, and patients affected still face significant morbidity and mortality1. Pharmacists can play a key role in pulmonary hypertension management by ensuring medication safety, patient adherence, patient and provider education, side effect management, and transitions of care support3.

    There are five classes of PH that are recognized by the World Health Organization (WHO), the Canadian Cardiovascular Society, and the Canadian Thoracic Society1.
     


    It is important for pharmacists in acute care centres to be aware of the differences between the classifications of pulmonary hypertension, as they will guide both chronic medication management in acute pulmonary hypertension, as well as the treatment of acute pulmonary hypertension itself. 

    Available Targeted Therapies in Canada

    There are 10 Health Canada approved targeted therapies for use in pulmonary arterial hypertension. These medications target three mechanisms that are known to cause PAH and its symptoms. Patients diagnosed with PAH often have deficient levels of prostacyclin1. Prostacyclin pathway agents are used in PAH to open blood vessels and improve symptoms of PAH, such as chest pain and shortness of breath4. Pulmonary arterial hypertension is also associated with elevations in endothelin-1, a potent vasoconstrictor1. Endothelin receptor antagonists will reverse the effects of endothelin-1 and help to prevent blood vessels from narrowing1,4. PAH patients will also be deficient in endogenous nitric oxide (NO)1. Two families of medications are used as nitric oxide pathway agents, phosphodiesterase type 5 inhibitors (PDE-5i) and soluble guanylate-cyclase stimulators (sGCs)1.

     

    Acute Management

    Patients hospitalized with acute pulmonary hypertension often experience concomitant right ventricular (RV) failure. RV failure in PH patients can lead to rapid decompensation and cardiogenic shock, that may be irreversible and lead to death5. Patients may present to hospital with either acute onset of chronic PAH, or acute PAH6. Patients with pre-existing PAH are vulnerable to serious illness and death from acute onset PAH6. These patients may have predisposing factors such as COPD, sleep disordered breathing, portopulmonary hypertension, and right heart failure that will exacerbate to acute PAH6. Acute PAH may also occur in patients without prior PAH, due to massive pulmonary embolism (PE), sepsis, or acute lung injury (ALI)6

    Acute management of pulmonary hypertension is first focused on treating triggering factors such as presence of infection, anemia, arrhythmia, PE, or other comorbidities, and administering supportive therapy5,7. Right ventricular dysfunction or failure must be prioritized in PH management through fluid status, managing RV afterload, and by optimizing cardiac output5,6,7. Most cases of RV failure are associated with fluid overload7,8. In these patients, fluid overload should be treated using IV diuretics5,7. However, in some cases hypovolemic patients may require fluid administration7. Reducing RV afterload is one of the most important interventions to reverse RV failure in PH patients7. Therapies used to reduce RV afterload in the acute setting include prostacyclins and other PAH-targeted therapies, as well as inhaled nitric oxide5,7. Epoprostenol, a prostacyclin, is often the drug of choice in PAH with RV failure5. This agent is used initially due to its rapid onset, shorter half-life, titratability, and pronounced reduction in afterload and mortality8. Treprostinil may also be used in place of epoprostenol, however, it is less often used due to its longer half-life5. Once the patient has been stabilized, there may be addition of oral endothelin receptor antagonists or PDE-5 inhibitors with or without withdrawal of the prostacyclin, depending if the patient is experiencing acute PAH or acute on chronic PAH7. Sildenafil’s short half-life and minimal side effects make it useful in critically ill PAH patients5. Nonspecific vasodilators such as calcium channel blockers should not be used in these patients due to profound systemic hypotension7. PAH patients who are critically ill with RV failure must also have cardiac output and systemic blood pressure optimized, while reducing pulmonary vascular resistance. Patients with low cardiac output and hypotension may need treatment with inotropes such as the β1-agonist dobutamine5,7. Vasopressors such as norepinephrine (NE) and vasopressin can be used to optimize systemic blood pressure and perfusion5,7.

    Hypoxemia is common in critically ill patients with pulmonary hypertension. Hypoxemia in these patients may lead to added pulmonary vasoconstriction, and treatment with supplemental oxygen should be initiated with an oxygen saturation of over 90% recommended5. Due to the complex nature of pulmonary hypertension, it is highly recommended to contact a centre of expertise as soon as possible, and to obtain a referral to a pulmonary hypertension centre if possible5,7.

    Medication Considerations

    Initiation of new PAH medications in critically ill patients is complex and should be managed with the help of an experienced PH team, including pharmacists5. It is important not to initiate medications indicated for Group 1 PH, in patients diagnosed with Groups 2-5 PH, as they may worsen symptoms, including precipitation of pulmonary edema in Group 2 PH patients5. However, in most patients admitted to hospital with pre-existing pulmonary hypertension, home treatment should be continued5. Abrupt discontinuation or dose reductions of PAH therapies may result in rapid decompensation and death in hospitalized patients5. PAH medications are considered high-risk and are prone to potentially fatal medication errors9. There are important clinical considerations for when patients are hospitalized while receiving PAH targeted therapy.

    Transitions of Care

    Pharmacists can play a key role the transitions of care for critically ill PH patients, including at hospital discharge. A recent report explored the role of critical care and ambulatory care pharmacists within a multidisciplinary team to improve the transitions of care for pulmonary hypertension patients10. In this program, the critical care pharmacist collected a PAH medication history, information on their home medication specialty pharmacy, and initiated medication access steps for new medications in hospital10. When the patient’s care was transferred to the ambulatory care pharmacist prior to discharge, the ambulatory care pharmacist provided adherence and medication counselling, adverse effect management, contacted the patient’s specialty pharmacy to ensure medication is continued, followed up on medication coverage, and followed up with the patient within 14 days after their discharge to ensure adherence and provide education when needed10.

    Summary

    While the complex and progressive nature of pulmonary hypertension results in significant morbidity and mortality for patients, pharmacists can play an important role in ensuring safe medication management while patients are in hospital. Pharmacists can aid in continuity of care for important PAH targeted therapy medications in hospitalized PAH patients and help to manage medications in both acute PAH and acute on chronic PAH. Pharmacists can also ensure that PAH target therapies are not used in inappropriate patient populations such as Group 2 and 3 PH, where the underlying heart or lung disease should be the focus of management. Finally, pharmacists can provide important education and ensure medication coverage to improve the transitions of care for their PH patients from their hospital admission to their discharge. 

    References

    1. Hirani, N., Brunner, N. W., Kapasi, A., Chandy, G., Rudski, L., Paterson, I., Langleben, D., Mehta, S., &amp; Mielniczuk, L. (2020). Canadian Cardiovascular Society/Canadian Thoracic Society Position Statement on pulmonary hypertension. Canadian Journal of Cardiology, 36(7), 977–992. https://doi.org/10.1016/j.cjca.2019.11.041 
    2. About Pulmonary Hypertension. Pulmonary Hypertension Association. 2021. Retrieved June 23, 2022, from https://phassociation.org/AboutPHA/ 
    3. Macaulay, T. E., Covell, M. B., &amp; Pogue, K. T. 2015. An update on the management of Pulmonary Arterial Hypertension and the pharmacist’s role. Journal of Pharmacy Practice, 29(1), 67–76. https://doi.org/10.1177/0897190015615902
    4. Treatment Options. Pulmonary Hypertension Association of Canada. 2021. Retrieved June 23, 2022, from https://phacanada.ca/For-Physicians/Treatment-Options 
    5. Barnett, C. F., O’Brien, C., &amp; De Marco, T. 2022. Critical Care Management of the patient with pulmonary hypertension. European Heart Journal. Acute Cardiovascular Care, 11(1), 77–83. https://doi.org/10.1093/ehjacc/zuab113 
    6. Hui-li, G. 2011. The Management of Acute Pulmonary Arterial Hypertension. Cardiovascular Therapeutics, 29: 153-175. https://doi-org.cyber.usask.ca/10.1111/j.1755-5922.2009.00095.x
    7. Hoeper, M. M., &amp; Granton, J. 2011. Intensive Care Unit management of patients with severe pulmonary hypertension and right heart failure. American Journal of Respiratory and Critical Care Medicine, 184(10), 1114–1124. https://doi.org/10.1164/rccm.201104-0662ci 
    8. Tilea, I., Varga, A., Georgescu, A.-M., &amp; Grigorescu, B.-L. 2021. Critical Care Management of decompensated right heart failure in Pulmonary Arterial Hypertension Patients – an ongoing approach. The Journal of Critical Care Medicine, 7(3), 170–183. https://doi.org/10.2478/jccm-2021-0020
    9. Barlow, A., Barlow, B., Koyfman, A., Long, B., &amp; Bissell, B. 2021. Pulmonary arterial hypertension in the emergency department: A focus on medication management. The American Journal of Emergency Medicine, 47, 101–108. https://doi.org/10.1016/j.ajem.2021.03.072
    10. Martirosov, A. L., Smith, Z. R., Hencken, L., MacDonald, N. C., Griebe, K., Fantuz, P., Grafton, G., Hegab, S., Ismail, R., Jackson, B., Kelly, B., Miller, M., &amp; Awdish, R. 2020. Improving transitions of care for critically ill adult patients on pulmonary arterial hypertension medications. American Journal of Health-System Pharmacy, 77(12), 958–965. https://doi.org/10.1093/ajhp/zxaa079
     

    Latest News

    August 16, 2022
    Clinical Pearls: Pulmonary Hypertension

    Latest News

    CSHP awards 2022: Call for nominations

    August 15, 2022

    The CSHP Awards Committee invites applications and nominations for the 2022-2023 National Awards Program. The goal of the awards program is to improve patient outcomes by promoting excellence in pharmacy practice throughout hospitals and other collaborative healthcare settings. Awards are presented annually to Pharmacists and Pharmacy Graduates, Pharmacy Technicians, Individual Supporters, and Students in recognition of outstanding commitment and dedication to the patient and profession. The Hospital Pharmacy Student Award is presented to a Student Pharmacist.

    The following awards will be offered this term:

    • Distinguished Service Award
    • Excellence in Pharmacy Practice – Interprofessional Collaboration
    • Excellence in Pharmacy Practice – Leadership
    • Excellence in Pharmacy Practice – Patient Care
    • Hospital Pharmacy Student Award

    This year, the Awards Committee welcomes submissions to the Excellence Awards with a focus on environmental sustainability. Show us how you’re making climate change a priority in your practice. 



    You can nominate an individual or team for an award. Nominations are due by September 30, 2022. Award recipients will be announced in January via email, CSHP’s website, and social media platforms. Awards will be presented in-person at the Together 2023 conference in Banff, Alberta. Learn more about the awards program here .


    Although several national awards have been retired, including the Isabel E. Stauffer Meritorious Service Award, in many cases, equivalent awards are being offered by certain CSHP branches. Check your branch website for available awards and submission deadlines.

    Did you know you can apply to both branch and national award programs? The Awards Committee encourages submissions to both programs in the same year. Even if you have already applied for a branch award, consider nominating yourself, your colleague, or your project for national recognition.

    To read about last year's award winners, click here.

    For more information, please contact:
    Robyn Rockwell
    Membership and Awards Administrator
    Canadian Society of Hospital Pharmacists
    (877) 340-2756 ext. 222
    (613) 909-9964
    rrockwell@cshp.ca

    Thank you awards sponsors





         


       





           

     
    August 15, 2022
    CSHP awards 2022: Call for nominations

    Latest News

    Call for Appraisers for the National Awards Program 2022

    August 15, 2022

     

    CSHP is seeking award appraisers for the 2022 National Awards Program. Award appraisers are critical to the success of CSHP’s National Awards Program -- Your contribution to this process enhances the visibility of excellence in hospital pharmacy practice. To help select this year’s award-winning projects and to help celebrate hospital pharmacy excellence, please consider submitting your name as an appraiser for the National Awards Program.

    We are seeking appraisers with knowledge in the following areas:

    •  Administration/Management
    • Cardiology
    • Computers/Technology
    • Critical Care
    • HIV/AIDS
    • Infectious Diseases
    • Nephrology
    • Oncology
    • Palliative Care
    • Pediatrics
    • Psychiatry
    • None of the above (general appraiser)

    As an appraiser you must hold a professional degree in pharmacy and your CSHP membership dues must be paid for the current year. However, no prior review or research experience is required.

    Where possible, submissions are distributed to those knowledgeable in the subject area and appraisers are asked to judge the projects based on contribution to patient care. Please note that appraisers are still able to submit to the National Awards Program. In this instance, you will be asked to review projects submitted to categories to which you have not applied.

    Projects will be assigned to appraisers in mid-October. You will be asked to review up to three projects during the appraisal period. Award appraisers are asked to volunteer approximately one hour of their time per submission reviewed. This year’s appraisal period will run from October 10-31, 2022.

    For more information, please refer to the Frequently Asked Questions page .

    If you would like to serve as an appraiser, please notify Robyn Rockwell, Membership & Awards Administrator, by September 30, 2022. Please indicate the areas in which you can review and whether you are able to review French submissions.


    August 15, 2022
    Call for Appraisers for the National Awards Program 2022

    Latest News

    Resource spotlight: Pulmonary Hypertension

    August 12, 2022

     

    Written by Jessica Sheard

    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


    Pulmonary hypertension (PH) is an uncommon, yet serious and progressive disease that results in significant morbidity and mortality in all patients diagnosed1. This “Resource Spotlight” will provide pharmacists with resources that will help them learn more about pulmonary hypertension, its classifications, and its treatments, and highlights clinical guidelines and information regarding acute management in hospitalized patients. 

    Pulmonary Hypertension Association of Canada

    The Pulmonary Hypertension Association of Canada is a federally registered charitable organization that was created by patients, caregivers, and healthcare providers. The organization provides useful resources and community support for patients with PH and their caregivers, as well as educational resources for healthcare providers. Pharmacists can find a brief overview of available treatments for pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension in Canada 2, and overview of risk factors associated with pulmonary hypertension and signs of symptoms to watch out for in these patients3. When encountering patients with pulmonary hypertension in the hospital, pharmacists may need to provide education and recommendations on their medications, including over the counter (OTC) products. A brief overview of common OTC products that should be avoided in patients with pulmonary hypertension can be found in this resource4.

    Canadian Cardiovascular Society and Canadian Thoracic Society Guidelines

    The Canadian Cardiovascular Society (CCS) and Canadian Thoracic Society (CTS) released an updated position statement on pulmonary hypertension in 20205. This new position statement was created due to the rapid changes in the management of PH since their previous position statement in 2005. In this document, pharmacists can find guidelines on supportive management, targeted therapies for pulmonary arterial hypertension (PAH) available in Canada, treatment strategies, and information on medication access in Canada. The position statement also contains a map of current pulmonary hypertension treatment facilities for reference. 
    The Canadian Cardiovascular Society has developed a webinar6 for healthcare providers to learn about updates in pulmonary hypertension, based on the aforementioned combined position statement from the CCS and CTS. The webinar discusses classification of PH, patient case examples, and management of PH, including general medications, PAH-targeted therapies, and acute management. 

    Current Literature

    Patients with pulmonary arterial hypertension will often be on one or more targeted therapies to improve their symptoms. An article by Barlow et al, 7 provides an overview of the available targeted therapies that are used chronically in PAH patients, with important clinical considerations of these therapies for when patients are presenting to the emergency department.

    Critical care management of the patient with pulmonary hypertension8, published recently in The European Heart Journal provides a great overview of pulmonary hypertension epidemiology, pathophysiology, and a concise overview of patient management in critical care, including PH medication, fluid, and hemodynamic management. 

    A concise clinical review 9 by Hoeper and Granton includes important information on the management of patients with severe pulmonary hypertension and right heart failure. In this article, pharmacists can find information on the pathophysiology and classification of PH, triggering factors of PH and RV failure, as well as important management and monitoring considerations for patients admitted to the ICU. Although published in 2011, this article still contains useful clinical guidance in the Canadian context.


    References

    1. Hirani, N., Brunner, N. W., Kapasi, A., Chandy, G., Rudski, L., Paterson, I., Langleben, D., Mehta, S., &amp; Mielniczuk, L. (2020). Canadian Cardiovascular Society/Canadian Thoracic Society Position Statement on pulmonary hypertension. Canadian Journal of Cardiology, 36(7), 977–992. https://doi.org/10.1016/j.cjca.2019.11.041

    2. Treatment Options. Pulmonary Hypertension Association of Canada. 2021. Retrieved June 23, 2022, from https://phacanada.ca/For-Physicians/Treatment-Options 

    3. Sometimes It’s PH. Pulmonary Hypertension Association of Canada. 2021. Retrieved June 23, 2022, from https://phacanada.ca/For-Physicians/Sometimes-It-s-PH

    4. Managing medications. Resources - Pulmonary Hypertension Association of Canada. Retrieved June 23, 2022, from https://phacanada.ca/Living-with-PH/Resources/Living-with-PH/Managing-medications

    5. Hirani, N., Brunner, N. W., Kapasi, A., Chandy, G., Rudski, L., Paterson, I., Langleben, D., Mehta, S., &amp; Mielniczuk, L. (2020). Canadian Cardiovascular Society/Canadian Thoracic Society Position Statement on pulmonary hypertension. Canadian Journal of Cardiology, 36(7), 977–992. https://doi.org/10.1016/j.cjca.2019.11.041 

    6. Pulmonary hypertension webinar series. Canadian Cardiovascular Society. https://ccs.ca/pulmonary-hypertension-webinar-series/. Published August 27, 2021. Accessed June 23, 2022.

    7. Barlow, A., Barlow, B., Koyfman, A., Long, B., &amp; Bissell, B. 2021. Pulmonary arterial hypertension in the emergency department: A focus on medication management. The American Journal of Emergency Medicine, 47, 101–108. https://doi.org/10.1016/j.ajem.2021.03.072

    8. Barnett, C. F., O’Brien, C., &amp; De Marco, T. 2022. Critical Care Management of the patient with pulmonary hypertension. European Heart Journal. Acute Cardiovascular Care, 11(1), 77–83. https://doi.org/10.1093/ehjacc/zuab113 

    9. Hoeper, M. M., &amp; Granton, J. 2011. Intensive Care Unit management of patients with severe pulmonary hypertension and right heart failure. American Journal of Respiratory and Critical Care Medicine, 184(10), 1114–1124. https://doi.org/10.1164/rccm.201104-0662ci 
     
    August 12, 2022
    Resource spotlight: Pulmonary Hypertension

    Latest News

    Resource spotlight: Clinical resources and creating safe spaces for 2SLGBTQ+ patients

    July 27, 2022

     

    Written by Jessica Sheard

    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

    It is estimated that there are at least 1 million 2SLGBTQ+ people over the age of 15 living in Canada as of 20181, with 1 in 300 people over 15 identifying as either transgender or non-binary2. Although there has been progress for 2SLGBTQ+ inclusivity, patients in this community still face significant healthcare disparities due to societal rejection, stigma, prejudice, and discrimination3. Many 2SLGBTQ+ patients report having negative experiences with the healthcare system and with healthcare providers. Some patients report inappropriate questions or lack of knowledge from their healthcare providers, while other patients report outright refusal of care and discrimination4,5. Negative or discriminatory experiences can result in long-lasting affects for 2SLGBTQ+ patients. Small, honest mistakes can be triggering for patients who have had previous negative experiences, and can lead to emotional responses, or delaying and avoiding receiving future care. In this “Resource Spotlight” pharmacists can learn more about the 2SLGBTQ+ community, how to integrate inclusive strategies into their practice to create safe and welcoming spaces for 2SLGBTQ+ patients, and access clinical guidelines important for transgender patient care. 

    Cultural Competency, Inclusivity, and Safe Space Guidelines

    Health Professionals Advancing LGBTQ Equality (previously known as the Gay & Lesbian Medical Association (GLMA) is the world's largest and oldest association of lesbian, gay, bisexual, transgender, and queer (LGBTQ) healthcare professionals. GLMA was founded in 1981, as the American Association of Physicians for Human Rights, with the mission of ensuring equality in healthcare for 2SLGBTQ+ individuals and healthcare professionals. GLMA has created a three-part webinar series titled “Quality Healthcare for Lesbian, Gay, Bisexual & Transgender People” (GLMA - Cultural Competence) free for anyone to access. The webinar series covers topics to understand healthcare needs of 2SLGBTQ+ people, creating a welcoming and safe environment, and clinical skills for the care of transgender patients. 

    Rainbow Health Ontario (RHO) has created a new online learning platform for healthcare providers called LGBT2SQ Health Connect.  On this platform pharmacists can access the LGBT2SQ Foundations Course, to heighten comfort and competency when providing high quality and inclusive, affirming, welcoming, culturally sensitive care. The course is available for free for healthcare professionals in Ontario, and $50 for those outside of Ontario. Many other courses are available through LGBT2SQ Health Connect, including another useful course called Removing the Barriers: Making your Organization LGBT2SQ friendly, which is offered at scheduled intervals bimonthly. This course explores various strategies for programs and services, policies, and inclusive language, intake forms and signage. The LGBT2SQ Foundations course is a prerequisite for this course, and all others on LGBT2SQ Connect. Course descriptions can be found here (Education & Training | Rainbow Health Ontario). Pharmacists can sign up for an account to access these courses here (Rainbow Health Ontario).

    The University of Toronto Faculty of Medicine has created this (LGBT Infographic Page 1 – Aug 9, 2016 (utoronto.ca)) condensed infographic for healthcare providers. The infographic, through useful information, tips, and creative drawing, is a tool for healthcare professionals to learn about 2SLGBTQ+ terminology and providing inclusive healthcare. 

    This article (LGBTQ cultural competence for pharmacists (pharmacytoday.org)) published by Pharmacy Today and developed by American Pharmacists Association (APhA) as a continuing education home-study, aims to increase 2SLGBTQ+ cultural competence for pharmacists. The activity contains a brief pre-assessment questionnaire, learning material, and 20 question assessment following the readings. Learners will cover topics including foundational concepts about the 2SLGBTQ+ community, 2SLGBTQ+ health disparities relating to physical and mental health, the pharmacist’s role in 2SLGBTQ+ patient care, and creating a welcoming pharmacy environment.

    Mount Sinai Hospital has developed this gender identity policy (General Manual Master Form - Microsoft Word (rainbowhealthontario.ca)) to provide guidelines for the care of trans, intersex, and Two Spirit individuals in the hospital. This policy covers the rights of members of the hospital community, including patients and staff, responsibilities of members of the hospital community, and guidance on policies for managers and employees. Policies surrounding education, bed assignments, washroom access, and intake forms can be found in this document. Although specific to one hospital, this policy manual can be used as an example for hospitals and departments in creating and implementing policy to protect patients of various gender identities. 

    Trans Care BC Resources

    Trans Care BC provides free educational courses on gender diversity for healthcare providers that introduce key terms and concepts as well as basic strategies for creating welcoming and gender-affirming services in both a basic, 30-minute course, and expanded 60-minute course for professionals regularly interacting with gender-diverse individuals. The basic course can be accessed here (Intro to Gender Diversity - LearningHub (phsa.ca)) and expanded course here (Intro to Gender Diversity - Expanded - LearningHub (phsa.ca)), and learners can receive a certificate of completion after signing up for a free account. To bypass the account sign up and complete the courses without receiving a completion certificate, access the basic course here (Intro to Gender Diversity - Overview | Rise 360 (articulate.com)) and expanded course here (Intro to Gender Diversity - Expanded - Overview | Rise 360 (articulate.com)).

    Trans Care BC has very useful practice tools that can be used by pharmacists and pharmacy departments to assess their current practices and implement strategies to improve patient care for gender-diverse patients. This short reference (Gender-Affirming_Patient_Care_In_a_Hospital_Setting.pdf (phsa.ca)) provides tips for healthcare workers in hospitals to ensure they are providing gender-affirming care to their patients. The reference provides guidance on pronouns, referring to patients, and name verification with example scripts, and guidance on transferring care, washroom access for patients, and times of greater vulnerability for this population. Pharmacists can reflect on their knowledge, approach to gender diverse patients, personal comfort, and patient engagement using this personal reflection tool (Service_Provider_Reflection_Tool.pdf (phsa.ca)). Pharmacists can also use this tool to reflect on their approach to advocacy and allyship for their gender-diverse patients, their organizational supports, and to create time-based goals to improve their patient care. 

    This tool (20_Care_Strategies.pdf (phsa.ca)) can be used by pharmacists and pharmacy departments to find strategies that will increase and improve access to care for gender-diverse patients. The practice tool includes 20 strategies, 10 which are organizational and program specific, and 10 that are service provider and staff specific. Strategies can be marked based on relevance to the organization, a level can be given based on current practices, and targeted goals can be created to meet the strategy guidelines. This organizational assessment tool (Organizational_Assessment_Tool.pdf (phsa.ca)) can also be used by pharmacy departments and hospitals to help develop an approach to offering more inclusive and gender-affirming care. It can be used on its own, or in combination with the Service Provider Reflection Tool. Sections for assessment include education, visibility and outreach materials, programming, forms and charts, waiting rooms, referral services, rooming, and hospital policies for providing gender-affirming care and protecting gender-diverse patients from discrimination. 

    Clinical Guidelines

    Sherbourne Health and Rainbow Health Ontario developed clinical guidelines for gender-affirming primary care for trans and non-binary patients. This Canadian guideline (Guidelines for Gender-Affirming Primary Care with Trans and Non-Binary Patients (rainbowhealthontario.ca)) provides a brief framework for providing gender-affirming care to trans and non-binary patients, a useful list of other transgender health guidelines, and clinical guidance surrounding hormone therapies in transgender patients. Within the clinical guidelines for hormone therapies, pharmacists can find convenient tables for formulations and dosing, and monitoring parameters, including bloodwork and time to onset of expected effects from hormone therapy. Pharmacists can also find tables outlining precautions for both feminizing and masculinizing medications, with guidance to minimize associated risks. 

    This Standards of Care (SOC) clinical guideline (SOC V7_English.pdf (wpath.org)) was created by the World Association for Transgender Health (WPATH). This organization has been creating Standards of Care for transgender and gender diverse patients since 1979. The SOC document is intended to provide clinical guidance for healthcare professionals to maximize the overall health, psychological well-being, and self-fulfillment of transgender and gender diverse patients. Guidelines on primary care, gynecologic and urologic care, reproductive options such as sperm and oocyte preservation, voice and communication therapy, mental health services, and hormonal and surgical treatments can be found within the SOC. It is important to note that most of the research that has guided this document comes from a North American and Western European perspective. 

    Research Surrounding Hormone Therapy in Transgender Patients

    Many transgender patients will choose to initiate hormone therapy to achieve characteristics of their gender, which may result in clinical considerations for healthcare providers while they are in hospital. This meta-analysis and meta-regression study (Frontiers | Risk of Venous Thromboembolism in Transgender People Undergoing Hormone Feminizing Therapy: A Prevalence Meta-Analysis and Meta-Regression Study | Endocrinology (frontiersin.org)) identifies the prevalence of VTE in transgender patients on feminizing hormone therapy. This review (Perioperative Transgender Hormone Management: Avoiding Venou... : Plastic and Reconstructive Surgery (lww.com)) discusses the evidence and recommendations surrounding the management of feminizing hormones for patients in the perioperative period. 

    Two Spirit Resources

    The National Collaborating Centre for Indigenous Health is an organization established by the Government of Canada, funded by the Public Health Agency of Canada (PHAC), and hosted by the University of Northern BC. The organization was established to support Indigenous health equity. This webinar (NCCIH - National Collaborating Centre for Indigenous Health > Home > NCCIH PUBLICATIONS) is an introduction to Two-Spirit people and their health. An accompanying document, and suggested pre-reading for the webinar, on Two-Spirit health can be accessed here: An Introduction to the Health of Two-Spirit People: Historical, contemporary and emergent issues (ccnsa-nccah.ca).

    This (Indigenous gender diversity: creating culturally relevant and gender-affirming services - LearningHub (phsa.ca)) free, three-hour course was created by Trans Care BC in collaboration with gender diverse Indigenous and Two-Spirit community members. It is intended to increase awareness, knowledge, and skills for people working in healthcare settings to ensure culturally relevant and gender-affirming services for gender diverse Indigenous people. 

    There is an Inclusive Healthcare Community (QID - Community Page)) that can be found on QID. This community contains resources for pharmacists and can be used as a space to ask questions or share resources surrounding care for 2SLGBTQ+ patients and other marginalized patients. 
     
    References 
    1. A statistical portrait of Canada’s LGBTQ2+ communities. Statistics Canada; 2021 June 15 [cited 2022 June 2] Available from: https://www150.statcan.gc.ca/n1/en/daily-quotidien/210615/dq210615a-eng.pdf?st=LSJc4Y2w
    2. Canada is the first country to provide census data on transgender and non-binary people. Statistics Canada; 2022 Apr 27 [cited 2022 June 2] Available from: https://www150.statcan.gc.ca/n1/en/daily-quotidien/220427/dq220427b-eng.pdf?st=CgjeOryJ
    3. LGBTQ2 Health in Canada: Study brief for the Standing Committee on Health [Internet]. Rainbow Health Ontario. 2019. Available from: https://www.ourcommons.ca/Content/Committee/421/HESA/Brief/BR10445304/br-external/RainbowHealthOntario-revised-e.pdf
    4. Transgender-Affirming Hospital Policies [Internet]. Human Rights Campaign Foundation. 2016. Available from: https://assets2.hrc.org/files/assets/resources/TransAffirming-HospitalPolicies-2016.pdf?_ga=2.13740471.1667924262.1652800445-840857854.1652800445
    5. Bauer GR, Scheim AI, Deutsch MB, Massarella C. Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: Results from a respondent-driven sampling survey. Annals of Emergency Medicine. 2014;63(6):713-720.  https://doi.org/10.1016/j.annemergmed.2013.09.027.
    July 27, 2022
    Resource spotlight: Clinical resources and creating safe spaces for 2SLGBTQ+ patients

    Clinical Pearls: Student reflection on AFPC’s Indigenous History Month Information Series

    July 15, 2022
    By Jessica Sheard


    For this year’s Indigenous History Month, the Association of Faculties of Pharmacy of Canada’s Truth & Reconciliation Special Interest Group held a series of educational webinars. These sessions, presented by pharmacists Dr. Jaris Swidrovich and Amber Ruben, discussed important terminology tips as well as how to create a meaningful territorial acknowledgment.  Although these information sessions were not developed to address clinical issues, much of what was discussed can be applied to hospital pharmacy practice to provide culturally competent and sensitive care to Indigenous patients. 

    Medicine vs. medication

    One terminology tip shared that would be relevant and useful to hospital pharmacists was the difference between the terms medicine and medication. In our healthcare system, based on principles of Western medicine, the words medication and medicine are often used interchangeably. However, in the information sessions I learned that these words could have different meanings for Indigenous People. Dr. Swidrovich explained that the word medication can carry the context of being manufactured, whereas in the Indigenous health context the word medicine can encompass something that is in its natural state, or a natural item such as a plant or herb. This can be an important communication component when collecting medication histories from patients in the hospital. Asking each patient specifically about whether they use traditional medicines can help pharmacy staff gain a complete medication history while providing culturally aware care. Adding this simple, but important, question can encourage Indigenous patients to share their complete medicine and health history. 

    Two-Spirit individuals

    During the information session, Dr. Swidrovich went into detail about Two-Spirit individuals and their importance in Indigenous communities. Having previously only briefly learned about Two-Spirit individuals, I appreciated the ability to learn more about these individuals, especially the importance of their roles in Indigenous communities. During this discussion, I learned that prior to colonization, Two-Spirit individuals held very important roles in their tribes, including medicine people, chiefs, caregivers, protectors, and knowledge keepers. I also learned that what it means to be Two-Spirit can vary between Indigenous communities and individuals. Indigenous communities embraced their people for having a range of gender identities and sexual orientations, and Two-Spirit people were loved and accepted as being unique individuals. I found this to be an important detail in the context of providing culturally competent care, as we can learn and integrate practices of culturally competent care through both an Indigenous health lens and a 2SLGBTQ+ lens. With both Pride Month and Indigenous History Month occurring together in June, we can reflect on providing gender-affirming, culturally aware care to Two-Spirit individuals by learning the histories of colonialism and residential schools, and their effects on Two-Spirit individuals.

    Territorial acknowledgements

    As it becomes more common that territorial acknowledgments are made before meetings, events, and presentations, it was useful to learn about the importance of making these intentional and meaningful. I learned through these sessions that although it is positive that territorial acknowledgments are becoming more common, the most important part of a territorial or land acknowledgment is the learning and reflection that occurs before drafting it. Delivering a land or territorial acknowledgment is intended as a small step toward Truth and Reconciliation, which requires education and reflection on the histories of Indigenous Peoples prior to colonization, as well as on the continued ramifications of colonization, residential schools, racism and discrimination faced by Indigenous Peoples living in Canada. I learned the importance of research when preparing a territorial acknowledgment, to determine which nations had previously and are currently living on that land, whether a treaty exists, or if you are residing on unceded land. The term unceded in terms of territorial acknowledgement and general learning is an important point of reflection. I learned in the information series that the term unceded, when referring to areas of land without treaty, means that the land had never reached an agreement between settlers and Indigenous People, and as such the land remains stolen. Although it is still appropriate to use the word unceded when describing an area, or to include it in land acknowledgements, it is important to reflect on the histories behind the unceded territory. Reflecting on the interpretations of treaties between settlers and First Nations Peoples is another important aspect I have learned about drafting territorial acknowledgements. It is important to realize that treaties were thought by the First Nations People to be an agreement of hunting and fishing rights, education, health, money for necessities, housing, sharing the land, and maintaining their spiritual and cultural beliefs. It is also important to realize that treaties were conducted in English. As Amber Ruben had described during her session, treaties that do exist are still not being lived up to in many ways, including continued health disparities faced by Indigenous People, and a continued lack of clean drinking water on many reserves.

    In her information session, Amber Ruben clarified the difference between land and territorial acknowledgments. Land acknowledgements are statements that are focused on the physical land, land use, or spiritual connection to the land. Often, land acknowledgements express thanks or connectedness of the event, workplace, meeting, or ceremony to the land on which the events are taking place. Territorial acknowledgments differ in that they recognize and pay respect to the First Nations, Inuit, and Métis people and their traditional and current geographical territories on which we all work and live upon. An associated treaty or treaties are often included in territorial acknowledgments. During these sessions I learned that aside from your own reflection prior to drafting a land or territorial acknowledgment, it is appropriate to ask Indigenous People for guidance on delivering the acknowledgement, depending on the event or meeting taking place. However, it is also important not to  impose more responsibility and emotional or academic labour these same individuals. As non-Indigenous people, we are in a position of privilege to be learning and reflecting on Indigenous history and current contexts and are responsible to become educated ourselves. 

    Summary and resources

    This information series was a great opportunity to learn and reflect for Indigenous History Month. There were many important points, tips, and contexts to be learned, but the above reflection were areas that stood out to me most in the context of providing patient care and the practice of giving territorial acknowledgements. I encourage pharmacists to reflect on their own knowledge and biases in providing care to Indigenous patients, not only during Indigenous History Month in June each year, but regularly and consistently. Indigenous education resources from the Association of Faculties of Pharmacy of Canada can be found here (Indigenous Educational Resources | AFPC). 
     

    Latest News

    July 15, 2022
    Clinical Pearls: Student reflection on AFPC’s Indigenous History Month Information Series

    CSHP opportunities to connect and give back

    June 22, 2022

    Getting involved in the Society

    For you, what does the road to a fulfilling hospital pharmacy career look like? Many have found rewarding connections in the opportunities available to them as an active CSHP member. Here's a look at a few places you can get involved today.

    Residency Roadmap reviewer or interviewer
    Call for Curriculum Vitae Reviewers, Letter of Intent Reviewers and Mock Interviewers
         
    Canadian Journal of Hospital Pharmacy reviewer
    Learn about the reviewer process and how to become a reviewer
         
    Pharmacy Specialty Network Chair
    It's more than just monitoring posts. Learn about this network role.
         
    CSHP Foundation Board Pharmacist Trustee
    CSHP Foundation Pharmacist, 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.
         
    CSHP Foundation Grant Committee member
    The Committee reviews submissions for CSHP Foundation education grants and provides recommendations to the Foundation Board.
         
    Branch events
    Visit your local branch site to find more opportunities to connect.
         
    CSHP Fellow
    Becoming a CSHP Fellow is not only wonderful recognition but also a chance to share your experience with others along the way.
         


    Latest News

    June 22, 2022
    CSHP opportunities to connect and give back

    Latest News

    Call for Residency Roadmap reviewers and interviewers 2022

    June 21, 2022

    Call for Curriculum Vitae, Letter of Intent Reviewers and Mock Interviewers

     

    The Canadian Society of Hospital Pharmacists (CSHP) is relaunching the Pharmacy Residency Application Roadmap Program  this year. The program is designed for prospective pharmacy residency candidates to provide them with additional knowledge and experience needed to competitively apply for Year 1 and Year 2 pharmacy residency programs. The program will consist of both didactic (online modules) and practical (CV/essay review and mock interviews).

    We are looking for CSHP members who were previous pharmacy residents or coordinators not currently actively involved in the interview and selection process of pharmacy residency programs (to avoid conflict of interest) to conduct CV/essay reviews and mock interviews.

    Mock interviewer/CV reviewer and LOI reviewer participation requirements: 

    • CSHP member
    • Not currently active in a pharmacy residency program selection process
    • Email practice@cshp.ca by Friday July 8, 2022 with your Curriculum Vitae
    • Each mock interviewer/CV & LOI reviewer will perform 12 mock interviews and 12 CV&LOI reviews
    • Review Module 3: Writing CV/Cover Letter/Letter of Intents AND Module 5:  Residency Interview Preparation
    • Attend a one-hour training session for the CV and Letter of Intent and Mock Interview at a mutually agreed upon date and time
    • Be available on the weekend of October 15/16 to conduct a “live” virtual mock interview 
    June 21, 2022
    Call for Residency Roadmap reviewers and interviewers

    Latest News

    Call for Applications

    June 21, 2022

    The CSHP Foundation Board is seeking applications for a Pharmacist Trustee

     

    Selection Criteria:

    • CSHP Member (individuals with a professional degree in pharmacy).
    • Demonstrated interest in research and/or education programs that advance the practice of pharmacy and patient care in hospitals and other collaborative healthcare settings.
    • No conflict of interest with the work of the Foundation.

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

    CSHP Foundation Pharmacist, 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 Heather Kertland, Chair, CSHP Foundation Board Trustees, at heather.kertland@unityhealth.to

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

    Deadline Date for Applications is September 30, 2022  

    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.

    June 21, 2022
    Call for applications: CSHP Foundation Board Pharmacist Trustee

    Latest News

    Announcing the Availability of Education Grants in 2022

    June 20, 2022



    The CSHP Foundation is now accepting applications for education grants in the following categories:

    • Thematic Conferences Development: organization of a targeted group that will focus on issues in pharmacy practice and/or education.
    • Educational Programs or Materials Development for Pharmacists: development of resources for pharmacists with a focus on optimizing pharmacotherapy

    Two education grants, maximum $5,000 each have been allotted for 2022.

    Eligible education proposals will reflect CSHP members’ innovative approaches to identifying or developing opportunities for professional education, dialogue and knowledge transfer for pharmacists. The ultimate goal of each program will be to advance pharmacy practice and patient care in hospitals and other collaborative healthcare settings.

    Education Grant Applicant Criteria
    The principal applicant must be a CSHP Member, Member-in-Training, or Student Supporter and have been a CSHP member for at least 12 months at the time of the grant application.  Only one grant application may be submitted each year, and the principal applicant may only be awarded a grant every two years. See Criteria and Submission Checklist for further criteria.

    Full details on the education grant program and the application process are available on the CSHP Foundation website at: https://cshp-scph.ca/foundation-education-grants

    Submissions for the Education Grants require the following components:
    1. Criteria and Submissions Checklist (checklist document on Foundation website)
    2. Title page (see Checklist document for details on what the title page should contain)
    3. Written proposal (see Checklist document for details on what the written proposal should contain)
    4. Grant Budget and Justification (budget template on Foundation website)
    5. Curriculum vitae of the Principal Applicant
    6. Letter(s) of support from applicant’s employer(s).

    Additional information is also available on the CSHP Foundation website:

    • Criteria for Evaluation of Submissions
    • Education Grant Program Description

    APPLY: To apply for a 2022 Education Grant, please submit all application documents in PDF format to 
    Rosemary Pantalone electronically at rpantalone@cshp.ca
    QUESTIONS: Please direct inquiries to Rosemary at the above-noted e-mail address.
    DEADLINE DATE: Submissions must be received by October 14, 2022.

    Grant decisions will be announced in January 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.

    June 20, 2022
    Announcing the Availability of Education Grants in 2022

    Latest News

    Announcing the opening of the 2022 Research Grant Competition

    June 20, 2022



    The CSHP Foundation is pleased to announce the opening of the 2022 Research Grant Competition. The Foundation is committed to supporting CSHP members in research that advances pharmacy practice and patient care in hospitals and other collaborative healthcare settings. It also encourages grant recipients to present and publish their findings thereby raising the profile of quality research being conducted by CSHP members. 

    Two grants of $10,000 each have been allocated to the current competition. The CSHP Research Committee will adjudicate eligible submissions based on established criteria and make recommendations for funding to the Board. Novice researchers are also encouraged to apply (see definition of novice re-searchers in the Criteria and Submissions Check List).

    Full details on the Research Grant program and the application process are available on the Foundation website at  https://cshp-scph.ca/foundation-research-grants

    Submissions require the following components:
    1. Criteria and Submissions Check List (template found on Foundation website
    2. Research Proposal
    3. Budget and Justification (template found on Foundation website)
    4. Completed Signature Page (template found on Foundation website)
    5. Proof of Institutional Review Committee/Research Ethics Board Submission
    6. CV of the applicant and each investigator

    Additional information is also available on the CSHP Foundation’s website: 

    • Criteria for Evaluation of Submissions
    • Research Committee Grant Review Process
    • How to Get Started with a Research Grant Project

    APPLY: To apply for a 2022 Research Grant, please submit all application documents to Rosemary Pantalone electronically  rpantalone@cshp.ca  Applications must include components 1-5 in one PDF file and item 6 (i.e., CVs) in a separate PDF file.
    QUESTIONS: Please direct inquiries to the CSHP Research Grant Committee Chair, Marisa Battistella at
    Marisa.Battistella@uhn.ca
    DEADLINE DATE: Submissions must be received by October 14, 2022.

    Grant decisions will be announced in January 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.

    June 20, 2022
    Announcing the opening of the 2022 Research Grant Competition

    Latest News

    Hospital Pharmacy in Canada Survey Report available fall 2022

    June 20, 2022



    Get ready for the publication of the 2020/21 Hospital Pharmacy in Canada Survey Report this fall. Survey Board members have reviewed, analyzed and interpreted the many data elements, trend tables and comments from hospital pharmacies across the country. Over the summer, the work turns to final editing, translation and production to prepare the results for release. Ongoing issues with COVID and new technical challenges bumped the expected release from June by a few months. 

    New this year, the Survey collected information on the impact of the COVID pandemic on hospital pharmacy services. As well, for the first time the inclusion of facilities with less than 50 acute care beds will provide a first look at small hospitals in Canada and offer baseline data for this new group of respondents. As in previous editions, the 2020/21 HPC Survey Report will provide comparison of the aggregate results based on province; hospital size; teaching versus non-teaching hospitals, and pediatric patients. 

    We are grateful for the support of our corporate sponsors, Pfizer Canada, Pharmascience/Pendopharm, and Baxter Canada. Their funding covers such technical production as survey programming, French translation, publication, and copyediting. As always, the editorial direction, content, survey design, analysis and interpretation are the sole responsibility of the respected pharmacy leaders on our affiliated HPC Survey Board.

    June 20, 2022
    Hospital Pharmacy in Canada Survey Report available fall 2022

    Latest News

    Monkeypox: Canadian outbreak update

    June 16, 2022

     

    Background

    Monkeypox is a rare viral disease caused by monkeypox virus (genus orthopox), related to, but distinct from smallpox and cowpox1. This virus is usually found in central and western Africa, with two genetically distinct clades1. The West African clade has limited human-to-human transmission, and case fatality of 1%, where the Congo Basin clade is associated with human-to-human transmission, with a case fatality reported at 10%1. On May 13, 2022, the United Kingdom (UK) notified the WHO about the presence of the West African clade of the virus in the UK, and on May 19, 2022, the Public Health Agency of Canada confirmed the first two human cases of monkeypox in Canada1.

    Transmission

    Risk of community spread of monkeypox remains very low and is limited to close, direct contact with infected persons, animals, or objects2. Person to person spread may occur through contact with skin lesions, blood, bodily fluids, and mucosal surfaces2. Transmission may also occur by contact with non-intact skin or scabs, indirect contact with clothing or linens used by an infected person, or close contact with respiratory tract secretions of a person with monkeypox1. Sexual transmission has not been previously known as a mode of transmission, however, close direct contact with sexual partners infected with monkeypox can result in transmission of the virus1. Asymptomatic spread of monkeypox is extremely uncommon2. It is unknown at this time if airborne transmission of monkeypox occurs, however, with evidence of smallpox airborne transmission, there is still concern that monkeypox may be transmitted by the airborne route1.

    Symptoms and Management

    Symptoms of monkeypox are generally mild and infected patients will recover on their own after approximately four weeks3. The incubation period of monkeypox is typically 6-13 days; however, patients can develop symptoms in a range of 5-21 days after exposure to the virus3. Monkeypox infection occurs in two stages of illness, lasting between 2-4 weeks3. In the first stage of illness, patients will develop fever, chills, swollen lymph nodes, headache, muscle, joint, and back pain, and exhaustion3. The second stage of illness usually occurs between 1-3 days after the occurrence of fever3. Patients will develop a rash that often starts on the face and extremities, mouth, or genitals3. This rash will last between 14-28 days and will resolve when scabs will form and eventually fall off3. Most cases of monkeypox are mild and self-limiting, however some severe cases may occur. Treatment for monkeypox is mainly supportive care, there are no established treatments at this time3.

    Infection Prevention and Control

    Although airborne transmission of monkeypox is currently unknown, healthcare settings should implement droplet, contact, and airborne precautions for suspect, probable, and confirmed cases of monkeypox until more information on transmission is known1. Precautions should be used with all patients presenting with fever and a vesicular, pustular rash1. Patients with known or suspected monkeypox should practice hand hygiene, wear a medical mask, and have their skin lesions covered with a gown, clothing, bedsheets, or bandages1. Infected patients should be isolated in an airborne infection isolation room (AIIR), or a single room with the door closed1. When providing care to patients with suspected or confirmed monkeypox, healthcare providers should wear a fitted N95 mask, gown, gloves, and eye protection1. All PPE worn while in contact with the patient must be discarded after each contact1. It should be assumed that the patient is contagious until scab crusts fall off and new skin is formed (approximately 3-4 weeks)1.

    Canadian Outbreak Update

    As of June 10, 2022, at 11:00 am EDT Canada has reported 112 cases of monkeypox4. Provinces reporting cases include British Columbia (1 case), Alberta (4 cases), Ontario (9 cases), and Quebec (98 cases)4. Other countries where monkeypox is non-endemic have been reporting cases. The WHO provides global updates on their website, found here (Multi-country monkeypox outbreak in non-endemic countries (who.int)). Canada’s Chief Public Health Officer has been working in close contact with provincial and territorial Chief Medical Officers, while Canada’s National Microbiology Laboratory is performing diagnostic testing and whole genome sequencing of the monkeypox virus4.
    Canadian monkeypox outbreak updates can be found here (Monkeypox: Outbreak update - Canada.ca), with updates provided each week on Tuesdays and Thursdays. 

    References

    1. Public Health Agency of Canada. Government of Canada. Interim guidance on infection prevention and control for suspect, probable or confirmed monkeypox within healthcare settings. Canada.ca. https://www.canada.ca/en/public-health/services/diseases/monkeypox/health-professionals/interim-guidance-infection-prevention-control-healthcare-settings.html. Published June 1, 2022. Accessed June 10, 2022.
    2. Public Health Agency of Canada. Government of Canada. Monkeypox: Risks. Canada.ca. https://www.canada.ca/en/public-health/services/diseases/monkeypox/risks.html. Published June 1, 2022. Accessed June 10, 2022.
    3. Public Health Agency of Canada. Government of Canada. Monkeypox: Symptoms and management. Canada.ca. https://www.canada.ca/en/public-health/services/diseases/monkeypox/symptoms-management.html. Published June 8, 2022. Accessed June 10, 2022. 
    4. Public Health Agency of Canada. Government of Canada. Monkeypox: Outbreak update. Canada.ca. https://www.canada.ca/en/public-health/services/diseases/monkeypox.html. Published June 9, 2022. Accessed June 10, 2022. 
       
    June 16, 2022
    Monkeypox: Canadian outbreak update

    Latest News

    SPIKEVAX Government of Canada health professional risk communication 

    June 16, 2022
     

    The Government of Canada has released important information for healthcare providers regarding a new presentation of Moderna’s SPIKEVAX COVID-19 vaccine. A new presentation of the SPIKEVAX vaccine was approved by Health Canada on June 1, 2022. The new presentation has a concentration of 0.10mg/mL in a 2.5mL multidose vial with a royal blue cap. The original presentation of this vaccine has a concentration of 0.20mg/mL in a 5mL multidose vial with a red cap. It is important for pharmacists to be aware that there are now two presentations of the SPIKEVAX vaccine available in Canada and the volume required for primary series and booster dosing will be different depending on the presentation used. 

    Pharmacists must also be aware that the new 0.10mg/mL presentation is NOT intended for preparation of the 100mcg dose. Patient populations requiring the 100mcg dose include adults 18 years of age or older for their primary series, and children 12 to 17 years of age for their primary series. These specific populations must have their dose prepared using the original 0.20mg/mL presentation. Children ages 6 to 11 years old requiring a 50mcg dose for their primary series can have their dose prepared from either the 0.10mg/mL or 0.20mg/mL presentation. Adults 18 years of age or older requiring a 50mcg booster dose can have their dose prepared from either the 0.10mg/mL or 0.2mg/mL presentation. 

    Healthcare providers are also advised that there is important Canadian-specific information absent from the vial and carton labels, and current vials and cartons contain English only labels, due to providing rapid access to the new SPIKEVAX presentation. However, Canadian-specific labelling information can be accessed here (Canada | SPIKEVAX™ Information (modernacovid19global.com)) and Canadian product monograph for SPIKEVAX in English and French can be found in Canada’s Drug Product Database. 

    The full Government of Canada health professional risk communication can be accessed here:

    Distribution of a New Presentation of SPIKEVAX (elasomeran) COVID-19 Vaccine (0.10 mg/mL in 2.5 mL multidose vial) with English-only Vial and Carton Labels - Canada.ca

     
    June 16, 2022
    SPIKEVAX GoC health professional risk communication

    Clinical pearls: Clinical considerations and creating safe spaces for 2SLGBTQ+ patients

    June 15, 2022
    By Jessica Sheard

    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

    The 2SLGBTQ+ community represents a significant portion of the Canadian population.  The most recent data reported from Statistics Canada estimates the Canadian 2SLGBTQ+ population 15 years of age or older to be over 1 million as of 20181. A more recent statistic provided by Statistics Canada reports that in May 2021, 1 in 300 people over the age of 15 identify as being transgender or non-binary2. Although self-disclosure of belonging to the 2SLGBTQ+ community is increasing due to more inclusivity, 2SLGBTQ+ patients still face significant healthcare disparities. Healthcare disparities experienced by 2SLGBTQ+ people are not inherent to their identities, but rather from societal rejection, stigma, prejudice, and discrimination3,4. When accessing healthcare, 2SLGBTQ+ people have reported experiencing discrimination, including healthcare providers using harsh or abusive language, asking inappropriate questions not pertaining to care, providers refusing to touch them or using excessive precautions, or refusing to provide care completely5.  Transgender people who have received healthcare also report overhearing jokes, slurs, and mockery from staff in health care settings5. While receiving care, 2SLGBTQ+ patients report their healthcare provider admitting to their lack of knowledge in providing 2SLGBTQ+ healthcare and having to teach their provider about their own care4,6. An Ontario study found that 54% of transgender patients had to teach their provider “some” or “a lot” about trans issues, with 52% of transgender patients having a negative experience when presenting to the emergency department or their provider not knowing enough to provide care7. Similarly, another Canadian study from Vancouver Island found that 63% of transgender patients had to teach their provider about trans issues8. Negative experiences such as these can have a long-lasting impact on 2SLGBTQ+ patients. Even small, honest mistakes can be triggering for patients who have had previous negative experiences with the healthcare system and may create an emotional response4 and cause some 2SLGBTQ+ patients to delay care or avoid services all together9.

    How Hospital Pharmacists Can Help Create Inclusive, Safe Spaces for 2SLGBTQ+ Patients

    Pharmacists are in a unique position to help 2SLGBTQ+ patients feel comfortable and safe during their interactions in hospital. Several communication strategies can be incorporated into pharmacists’ clinical practice to enhance relationships with 2SLGBTQ+ patients and create a more inclusive space10:

    • Asking every patient their pronouns or how they would like to be addressed, and offering their own pronouns
    • Using the patient’s pronouns when charting, documenting, or speaking of the patient; referring to the patient by first name only; and/or not using pronouns at all
    • Refraining from using gendered terms when addressing patients, such as sir or ma’am
    • Offering sincere apologies when mistakes to names and pronouns are made
    • Asking questions only relevant to providing care
    Pharmacists can be leaders in the hospital and pharmacy departments by creating an environment of accountability by politely correcting colleagues if mistakes are made to names or pronouns, and if insensitive comments are made by staff or others4

    Pharmacy departments can advocate for transgender patients by ensuring access to hormone therapies while in hospital to allow for continuity of care5. Many transgender patients require gender affirming personal items such as makeup or clothing to feel comfortable. Pharmacists may also advocate for the allowance of these items for easy access while transgender patients are in hospital5.

    Training surrounding 2SLGBTQ+ experiences and healthcare needs has been largely lacking in medical training6,11. To provide a safe and inclusive healthcare environment for these patients, all staff must receive training in 2SLGBTQ+ health disparities and inclusive communication12. 2SLGBTQ+ affirmative training should be provided during onboarding and at regular intervals, and educational resources should be made available to staff at all times13. Training and cultural competency for 2SLGBTQ+ health increases knowledge, attitudes, self-efficacy, and intentions of providers11. Although each individual pharmacist and staff member can be responsible for their own knowledge and learning regarding 2SLGBTQ+ health, leadership should be engaged to create an inclusive environment for all patients. Senior management should be actively engaged to set the tone for creating an inclusive space and scheduling training on 2SLGBTQ+ health12

    Clinical Considerations for 2SLGBTQ+ Patients:

    Hospital pharmacists may need to consider factors for laboratory monitoring and risk assessment in 2SLGBTQ+ patients while they are in hospital, particularly for transgender patients. It is important that pharmacists be familiar with clinical guidelines and laboratory monitoring for transgender patients on hormone therapies14. However, gender-specific “normal” values can be challenging to interpret in transgender patients on hormone therapy14,15. A small study compared laboratory values of transgender women to both cis women and cis men. This study found that the trans women’s reference ranges for hemoglobin, hematocrit, and LDL more closely resembled that of cis women, while the reference ranges for ALP, potassium, and creatinine more closely resembled that of cis men14,15.

    Kidney function of transgender patients is another complex area in which pharmacists may need to navigate for dosing considerations. A review of four studies assessing transgender patients’ serum laboratory values demonstrated that these more closely reflected the patients’ gender identity, rather than their gender assigned at birth16. The authors recommend assessing renal function by using creatinine clearance and ideal body weight for the patient’s gender identity16. However, creatinine clearance may not be a reliable measure in transgender patients because this value is dependent on age, race, muscle mass, diet, and drugs16. A 24-hour urine creatinine collection may be used to assess renal function with a value independent of sex or muscle mass16.

    A metanalysis and an Endocrine Society review found significant elevations in TG and LDL and decreases in HDL in trans men on testosterone17. However, the clinical outcomes of these findings have been debatable, and overall evidence of CV outcomes was insufficient to allow for conclusion17. A transient increase in liver enzymes can occur occasionally in trans men on testosterone17. However, the elevations spontaneously resolve, unless another cause is present17.

    Risk of VTE has been a concern for trans women on estrogen therapy, especially in the first year of initiation. However, many of the studies on trans women using estrogen therapy were using ethinyl estradiol, known to carry a higher risk of thrombogenic events than estadiol17. Age over 40, sedentary lifestyle or obesity, smoking, or underlying thermophilic disorders can increase risk17. A meta-analysis and meta-regression study found the overall prevalence of VTE in trans women to be 2%, with large heterogeneity18. Prevalence of VTE increased to 3% in patients who were 37.5 years of age or older, while risk was reduced to 0% in patients younger than 37.5 years of age18. Duration of therapy more than 53 months was found to have VTE prevalence of 1%, whereas prevalence was found to be 0% in less than 53 month duration of therapy18. Management of VTE risk in hospitalized transgender women remains controversial. In the perioperative period, some surgeons advocate for estrogen therapy discontinuation 2-6 weeks prior to surgery, with resumption of therapy when ambulation is reliable19,20. However, discontinuation of hormone therapy may result in emotional and physiological effects in these patients, including exacerbation of gender dysphoria19,20. Current Endocrine Society clinical practice guidelines recommend collaboration between the prescribing physician and surgeon surrounding perioperative hormone management, including informed consent discussions with the patient20. VTE prophylaxis should still be considered in transgender women where indicated, particularly in patients in their first year of estrogen therapy or with risk factors such as smoking21. In patients undergoing surgery under general anesthesia with operation times over 60 minutes and Caprini Score between 3-6, postoperative use of low-molecular-weight heparin or unfractionated heparin should be considered21.

    References

    1. A statistical portrait of Canada’s LGBTQ2+ communities. Statistics Canada; 2021 June 15 [cited 2022 June 2] Available from: https://www150.statcan.gc.ca/n1/en/daily-quotidien/210615/dq210615a-eng.pdf?st=LSJc4Y2w
    2. Canada is the first country to provide census data on transgender and non-binary people. Statistics Canada; 2022 Apr 27 [cited 2022 June 2] Available from: https://www150.statcan.gc.ca/n1/en/daily-quotidien/220427/dq220427b-eng.pdf?st=CgjeOryJ
    3. LGBTQ2 Health in Canada: Study brief for the Standing Committee on Health [Internet]. Rainbow Health Ontario. 2019. Available from: https://www.ourcommons.ca/Content/Committee/421/HESA/Brief/BR10445304/br-external/RainbowHealthOntario-revised-e.pdf
    4. Providing Inclusive Services and Care for LGBT People [Internet]. National LGBT Health Education Center. 2016. Available from: https://www.lgbtqiahealtheducation.org/wp-content/uploads/Providing-Inclusive-Services-and-Care-for-LGBT-People.pdf
    5. Transgender-Affirming Hospital Policies [Internet]. Human Rights Campaign Foundation. 2016. Available from: https://assets2.hrc.org/files/assets/resources/TransAffirming-HospitalPolicies-2016.pdf?_ga=2.13740471.1667924262.1652800445-840857854.1652800445
    6. Literature Review to Support Health Service Planning for Transgender People [Internet]. The Canadian Professional Association for Transgender Health. 2015. Available from: https://cpath.ca/wp-content/uploads/2015/10/Trans-lit-review-supporting-service-planning-final.pdf
    7. Bauer GR, Scheim AI, Deutsch MB, Massarella C. Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: Results from a respondent-driven sampling survey. Annals of Emergency Medicine. 2014;63(6):713-720.  https://doi.org/10.1016/j.annemergmed.2013.09.027.
    8. Heinz M, MacFarlane D. Island lives: a trans community needs assessment for Vancouver Island. SAGE Open. 2013 Sep 16;3(3):2158244013503836.
    9. Mitra S, Globerman J. Rapid response: Facilitators and barriers to health care for lesbian, gay and bisexual (LGB) people [Internet]. Rapid Response Service. 2014. Available from: https://www.ohtn.on.ca/Pages/Knowledge-Exchange/Rapid-Responses/Documents/RR79.pdf
    10. Schwindt, R. LGBTQ cultural competence for pharmacists. Pharmacy Today. 2020. Available from: https://www.pharmacytoday.org/action/showPdf?pii=S1042-0991%2820%2930876-8
    11. Bhoten B, Burkhalter JE, Joo R, Mujawar I, Bruner D, Scout NFN, et al. Impact of an LGBTQ cultural competence training program for providers on knowledge, attitudes, self-efficacy and intensions. Journal of Homosexuality. 2022;69(6):1030-1041. https://doi.org/10.1080/00918369.2021.1901505
    12. Ten Strategies for Creating Inclusive Health Care Environments for LGBTQIA+ People [Internet]. National LGBT Health Education Center. 2021. Available from: https://www.lgbtqiahealtheducation.org/wp-content/uploads/2021/05/Ten-Strategies-for-Creating-Inclusive-Health-Care-Environments-for-LGBTQIA-People-Brief.pdf
    13. Providing Inclusive Care and Services for the Transgender and Gender Diverse Community: A Pharmacy Resource Guide [Internet]. Human Rights Campaign Foundation. 2021. Available from: https://hrc-prod-requests.s3-us-west-2.amazonaws.com/Transgender-Pharmacy-Resource-Guide.pdf
    14. Roberts TK, Kraft CS, French D, Ji W, Wu AHB, Tangpricha V, et al. Interpreting laboratory results in transgender patients on hormone therapy. The American Journal of Medicine. 2014;127(2):159-162. https://doi.org/10.1016/j.amjmed.2013.10.009
    15. Redfern JS, Jann MW. The evolving role of pharmacists in transgender health care. Transgender Health. 2019;4(1):118-130. DOI: 10.1089/trgh.2018.0038
    16. Jue JS, Alameddine M. Assessment of renal function in transgender patients. American Journal of Health-System Pharmacy. 2020 Sep 15;77(18):1460-1.
    17. Bourns A. Guidelines for gender-affirming primary care with trans and non-binary patients [Internet]. Rainbow Health Ontario. 2019. Available from: https://www.rainbowhealthontario.ca/wp-content/uploads/2021/06/Guidelines-FINAL-4TH-EDITION-c.pdf
    18. Totaro M, Palazzi S, Castellini C, Parisi A, D;Amato F, Tienforti D et al. Risk of venous thromboembolism in transgender people undergoing hormone feminizing therapy: a prevalence meta-analysis and meta-regression study. Frontiers in Endocrinology. 2021. https://doi.org/10.3389/fendo.2021.741866
    19. Tollinche LE, Walters CB, Radix A, Long M, Galante L, Garner Z, et al. The perioperative care of the transgender patient. Anesth Analg. 2018; 127(2);359-366. doi:10.1213/ANE.0000000000003371.
    20. Honstscharuk R, Alba B, Manno C, Pine E, Deutsch MB, Coon D, et al. Perioperative transgender hormone management: Avoiding venous thromboembolism and other complications. Plastic and Reconstructive Surgery. 2021;147(4):1008-1017. doi: 10.1097/PRS.0000000000007786
    21. Lennie Y, Leareng K, Evered L. Perioperative considerations for transgender women undergoing routine surgery: a narrative review. British Journal of Anaesthesia. 2020;124(6);702-711. https://doi.org/10.1016/j.bja.2020.01.024

    Latest News

    June 15, 2022
    Clinical pearls: Clinical considerations and creating safe spaces for 2SLGBTQ+ patients

    Latest News

    Fellows Recognition Committee accepting applications for Fellow status - 2022

    June 03, 2022

    CSHP Fellow status is a peer recognition that is conferred upon CSHP members who have demonstrated noteworthy, sustained service in CSHP and excellence in pharmacy practice in a hospital or other collaborative healthcare settings.

    The Fellows Recognition Committee is currently inviting qualified candidates to apply to be considered for Fellow status.

    If you wish to apply to the program, please consult the program overview  and criteria .

    Applicants are encouraged to perform a self-assessment and consult with a colleague who has recently been conferred with Fellow status before deciding to complete and submit an application. Please take note that the application process takes time. Interested candidates are encouraged to begin filling out the Fellows Application Form well in advance of the deadline. All requests for information and completed applications are strictly confidential.   

    Any questions can be forwarded to Pamela Saunders by email at fellows@cshp.ca

    The application deadline is August 2, 2022.

    June 06, 2022
    Fellows Recognition Committee accepting applications for Fellow status 2022

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