Canadian Society Of Hospital Pharmacists Research Articles

The COVID conversations: A content analysis of Canadian pharmacy organizations' communication of pharmacists' roles and services during the COVID-19 pandemic.

The COVID-19 pandemic presented a unique challenge for pharmacists as they navigated information scarcity on the frontlines while being identified as information experts. Alberta pharmacists looked to their professional organizations for direction regarding what their roles should be in a crisis. The objective of this study was to explore pharmacists' roles and services and how they were communicated by pharmacy organizations during the first year of the COVID-19 pandemic. The study used a conventional content analysis method to explore the online communication of relevant pharmacy organizations for Alberta pharmacists. Five organization websites (National Association of Pharmacy Regulatory Authorities, Canadian Pharmacists Association [CPhA], Canadian Society of Hospital Pharmacists [CSHP], Alberta College of Pharmacy [ACP] and the Alberta Pharmacists' Association [RxA]) were examined to identify and catalogue publicly accessible documents that communicated pharmacists' roles and services during the first year of the pandemic for Alberta pharmacists. A total of 92 documents were collected from CPhA (60), CSHP (2), ACP (26) and RxA (4). While most documents communicated information about pharmacists' roles in public health, patient care and drug and personal protective equipment supply, more than one-third of the documents (32/92, 34.8%) required contextual information to interpret the communication. There was an observed shift in the communication after the first 6 months, becoming more direct in its messaging and context. These pharmacy organizations communicated information for pharmacists' roles and services to provide direction and guidance in the ever-changing context of the COVID-19 pandemic for Alberta pharmacists. Their communication became clearer and more direct as the pandemic progressed, requiring less inference to understand the intended message.

A survey of Saskatchewan family physicians, psychiatrists and pharmacists assessing barriers in lithium use

Lithium is a popular mood stabilizer. Anecdotally, it is an underutilized medication in primary care. We conducted a survey of family physicians (FPs), pharmacists and psychiatrists in Saskatchewan to examine attitudes towards and knowledge of lithium use in bipolar disorder (BD). FPs, psychiatrists and pharmacists within Saskatchewan were contacted via email addresses provided by the Saskatchewan Medical Association, Pharmacy Association of Saskatchewan and Canadian Society of Hospital Pharmacists – Saskatchewan Branch and a link to an online survey provided. Responses were obtained from 209 participants – 30 psychiatrists, 103 FPs and 76 pharmacists. Lithium was considered a specialist medication by 63.11% of FPs and 70% of psychiatrists. Lithium was the first choice for maintenance treatment of BD by 31.03% of psychiatrists and 13.68% of FPs, atypical antipsychotics being preferred by both (37.93 and 44.21%, respectively). 72% of the FPs were hesitant to initiate lithium and yet 73.79% felt comfortable monitoring patients already on it. FPs hesitancy could be related to a lack of knowledge in initiating or adjusting lithium doses (53.9%), how the medication works (28.7%), need for blood tests (34.95%), concern about suicidal ideas (11.5%) and the feeling of needing more education on prescribing lithium (79%). 33.69% of FPs were unsure about reference lithium levels or did not use it for monitoring. Limited by small sample size, we observed significant apprehensions about prescribing lithium in this study, more should done in encouraging its use in BD management.

Pharmacy Distribution, Clinical, and Management Services: A Survey of Small Hospitals in Canada Supported by Telepharmacy Services.

The Canadian Society of Hospital Pharmacists' Hospital Pharmacy in Canada Report presents data from pharmacy departments that service hospitals with at least 50 acute care beds. This report provides valuable data on pharmacy distribution, clinical, and management services in relation to hospital size, type, and geographic region. Pharmacy and hospital leadership use these extensive data in identifying baseline, benchmarking current, and planning enhanced pharmacy services. However, for most of Canada's small hospitals, such data remain unknown, and leadership remains uninformed. To gather and analyze data about current pharmacy distribution, clinical, and management services in hospitals with fewer than 50 acute care beds receiving third-party remote pharmacy (telepharmacy) services. In April 2019, pharmacy administrators of hospitals in Ontario, Quebec, and Saskatchewan that had fewer than 50 acute care beds and were using third-party telepharmacy services were invited to complete a comprehensive survey addressing concepts similar to those in the Hospital Pharmacy in Canada Survey. The following data on clinical pharmacy practice were collected: models of care, assignments to patient care programs, pharmacists' activities, performance indicators, and professional evaluation. The description of pharmacy distribution services comprised type of system, technology, location, hours of operation, method of medication order entry and verification, and medication administration records. Details on facilities' parenteral admixture infrastructure, policy for and provision of sterile compounding, and pharmacy department human resources, including composition and staffing ratios, were also collected. Of the 27 hospitals in Ontario, Quebec, and Saskatchewan that were invited to participate, 24 (89%) completed the survey. The median facility size was 19 acute care beds. Previously unavailable in Canada, these quantitative data from small hospitals supported by telepharmacy services provide facts about pharmacy distribution, clinical, and management services to inform hospital and pharmacy leaders. Creation of a survey unique to small hospitals, whether or not they use telepharmacy services, could provide a valuable resource to assist in the benchmarking, planning, and enhancement of pharmacy services in remote and rural communities.

Investing in the Canadian Society of Hospital Pharmacists

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Survey of Pharmacists Regarding the Use of Propofol Infusions in the PICUs in North America

The objective of this survey was to assess the current use of continuous infusion propofol in PICUs across the United States and Canada. A list of institutions with PICU beds/units was identified through the residency directories available on the American Society of Health-Systems Pharmacists (ASHP) and Canadian Society of Hospital Pharmacists (CHSP) Web sites. A REDCap questionnaire was sent to each identified institution's program director via email. An initial reminder email was sent out 2 weeks later and a second reminder email was sent 4 weeks after the initial request. The survey was closed at 6 weeks. A total of 514 emails were sent to residency program directors, and 50 pharmacists responded to the survey. Of the pharmacists that did respond, 27 (54%) reported using propofol while 23 (46%) did not. Of those that did not, 43.5% reported the FDA boxed warning as the primary reason. Thirty-seven percent of respondents using propofol felt comfortable using a maximum infusion rate of 200 mcg/kg/min. Twenty-nine percent, 25%, and 33% of those who responded as using propofol felt comfortable using this agent for a maximum duration of 24, 48, and 72 hours, respectively. The majority of respondents using propofol did not have a case of propofol-related infusion syndrome. Despite the FDA warning, propofol is used as a continuous infusion (with variable limitations) by a majority of pharmacists in North America. Self-reported incidence of propofol-related infusion syndrome (PRIS) remains low.

Documentation in the Patient’s Medical Record by Clinical Pharmacists in a Canadian University Teaching Hospital

In many studies on documentation, the data are self-reported, which makes it difficult to know the actual level of documentation by pharmacists in patients' medical records. The literature assessing documentation by clinical pharmacists in health care centres is limited. To assess the level of documentation in patients' medical records by clinical pharmacists at one large urban hospital. This retrospective observational study included all patients who were followed by a clinical pharmacist during their stay in the Centre hospitalier de l'Université de Montreal between July 1 and October 31, 2016. The primary outcome, the level of documentation in patients' medical records, was categorized as minimal, sufficient, or extensive. The quality of notes and the impact of pharmacy students and residents on documentation were evaluated as secondary outcomes. A total of 779 patient charts from 4 inpatient units were included in the analysis. Of these, 563 (72.3%) were considered to have minimal documentation (at least 1 intervention described in writing), 432 (55.5%) had sufficient documentation (at least 1 note written during the patient's hospitalization), and 81 (10.4%) had extensive documentation (appropriate number of notes in relation to duration of hospitalization). Medication reconciliation performed by pharmacists at the time of admission was documented in 696 (89.3%) of patients' records. The presence of students or residents on a clinical unit was associated with a significant increase in the percentage of charts with at least 1 follow-up note (23.6% [120/508] with students/residents versus 12.5% [34/271] without students/residents; p < 0.001) and the mean number of followup notes (0.59 versus 0.23, respectively; p < 0.001) but had no effect on other variables. Of a total of 777 notes written by a pharmacist, the overall conformity with pre-established criteria was 56.8% (441/777), and conformity was 43.4% (139/320), 75.1% (272/362), and 31.6% (30/95) for admission, follow-up, and discharge notes, respectively. Documentation by clinical pharmacists in patients' medical records could be improved to achieve the stated goal of the American Society of Health-System Pharmacists and the Canadian Society of Hospital Pharmacists, that all significant clinical recommendations or interventions should be documented.

Evaluation of Physical Assessment Education for Practising Pharmacists: A Cross-Sectional Survey

Pharmacists are now seeking to incorporate physical assessment (PA) into their practices. This trend prompted the creation, by the British Columbia Branch of the Canadian Society of Hospital Pharmacists, of a 30-h course specifically designed for practising pharmacists. To evaluate pharmacists' knowledge, skills, and confidence in performing PA after completing the course. All course participants were invited to complete 2 anonymous online surveys, immediately and 6 months after course completion. Of the 218 participants, 82 (38%) responded to the survey administered immediately after the course, and 77 (35%) completed this survey in full. About half of the respondents (39/79 [49%]) reported use of PA on a real patient before taking the course. Lack of formal training and lack of comfort were the most frequently selected barriers to performing PA. All respondents (79/79) agreed that the course had improved their knowledge of PA, 96% (76/79) agreed that it had improved their skills, and 90% (71/79) agreed that it had improved their ability to care for patients. In addition, 61% (48/79) and 67% (53/79), respectively, agreed that they felt confident performing PA and intervening with regard to a patient's drug therapy on the basis of physical findings. Thirty-eight (17%) of the course participants completed the 6-month follow-up survey. In that survey, the most frequently selected barrier to performing PA was lack of time. Paired data, available for 23 respondents, showed a significant increase in use of PA on real patients over time (p = 0.013 by χ2 test). However, there was no significant improvement in confidence in performing PA or intervening on a patient's drug therapy on the basis of physical findings (p > 0.05 by 2-sided t test). The primary limitation of this study was potential responder bias. A PA course designed for pharmacists improved participants' self-reported knowledge and skills, as well as self-perceived ability to care for patients. Six months after the course, two-thirds of respondents had used PA in practice. However, there was no improvement in confidence in performing such assessments or using the findings to intervene on a patient's drug therapy.

Myrella Roy, Canadian society executive, to retire at end of year.

After 15 and a half years leading the Canadian Society of Hospital Pharmacists (CSHP), Executive Director Myrella Roy, B.Sc. Pharm., Pharm.D., FCCP, is wrapping up her professional career at the end of December and planning to stay nearly as busy in retirement. She spent 17 years as a hospital pharmacist and clinical manager with the Ottawa Hospital, a large university teaching hospital in Canada’s capital city, before becoming CSHP’s full-time executive. In 2012, ASHP awarded honorary membership to Roy for her sustained contributions to health-system pharmacy practice. She said last month that receiving the award from ASHP “certainly was one of my proudest moments, and I will cherish that forever.” “Dr. Roy has been a wonderful friend and colleague to ASHP for her entire career,” said ASHP Chief Executive Officer Paul W. Abramowitz. “She has done so much to advance pharmacy practice in Canada, including successfully advocating for enhanced prescribing privileges for pharmacists and leading efforts around collaborative practice and patient safety. Myrella is a true leader in our global pharmacy community, and I am confident that she will continue to contribute to efforts to advance pharmacy practice in Canada and around the world.”

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

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

Winds of Change.

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Factors Influencing Fourth-Year Pharmacy Students’ Decisions to Pursue a Hospital Pharmacy Residency

The Canadian Society of Hospital Pharmacists promotes the recruitment of residency-trained pharmacists for work in hospitals and related health care settings. However, Quebec hospitals are still hiring non-residency trained pharmacists, in part because of a severe shortage of hospital pharmacists. To date, no studies have examined the factors influencing the career choices of fourth-year pharmacy students in Canada. To identify motivating factors and barriers influencing students' decision to pursue a hospital pharmacy residency. All 186 fourth-year students in the Faculty of Pharmacy, Université de Montréal, were invited by e-mail to participate in a validated and institutionally approved survey that was available online between March and May 2014. Of the 138 respondents who returned a completed survey (74% response rate), 36 (26%) planned to apply for a hospital pharmacy residency. Those planning to apply for a residency were older (p = 0.037) and had more hospital work experience (36% versus 3%, p < 0.001) than those not planning to apply. The most important motivators for pursuing a residency were potential gains in knowledge (reported by 88% of respondents, whether or not they were planning to pursue a residency), experience (80%), and self-confidence (62%). The most frequently reported barriers were recognition that a hospital pharmacy residency is a highly demanding program (65%), having work available upon graduation from the undergraduate program (43%), and financial obligations (34%). Hospital experiential rotations influenced, either positively or negatively, 23 (72%) of the 32 students who changed their decision to pursue or not pursue residency training over the course of their studies. The potential gain in knowledge and experience acquired through residency, the fact that it is considered a highly demanding program, and having work available upon graduation from undergraduate studies were the most influential factors in fourth-year pharmacy students' decision of whether to pursue a hospital pharmacy residency.

Opinions of Hospital Pharmacists in Canada Regarding Marijuana for Medical Purposes.

Canada's most recent Marihuana for Medical Purposes Regulations have changed the way in which patients access marijuana. Furthermore, if authorized by the person in charge of the hospital, a pharmacist practising in a hospital may now place orders with licensed producers for dried marijuana for in-hospital use by patients. As use of this product increases, hospital pharmacists may have an increased role in the care of patients who are using marijuana for medical purposes. The primary objective of this study was to determine the opinions of hospital pharmacists in Canada regarding marijuana for medical purposes. The secondary objective was to assess the factors influencing these opinions. An online survey was made available in early 2015 to licensed hospital pharmacists in Canada through individual provincial and territorial pharmacy regulatory bodies, pharmacist associations, hospital pharmacy directors, the Canadian Society of Hospital Pharmacists, and the Association des pharmaciens des établissements de santé du Québec. Responses were based on a 5-point Likert style scale, ranging from "completely agree" to "completely disagree". A total of 769 valid survey responses were received. Among the respondents, 44.6% (333/747) agreed that marijuana is safe, whereas 55.2% (411/745) agreed that it is effective. Only 17.2% (129/748) agreed that they were knowledgeable about marijuana for medical purposes, and about 65% of respondents reported no formal training in this area. Factors that influenced respondents' opinions were age, education, area of clinical practice, province of work, and personal experience. Many Canadian hospital pharmacists agreed that marijuana for medical purposes is safe and effective, yet few considered themselves knowledgeable about this substance, with more than half reporting no formal training on the topic.

Bisphosphonates for Osteoporosis in Patients with Renal Insufficiency: Pharmacists' Practices and Beliefs.

Clinicians often face challenges in deciding how to treat osteoporosis in patients with chronic kidney disease. As background to offering guidance to health care providers, it is important to understand their practices and beliefs. To describe the practices and beliefs of pharmacists regarding use of bisphosphonates for patients with osteoporosis and chronic kidney disease. A cross-sectional survey of pharmacists working in hospitals and related health care settings was conducted. A 34-item online questionnaire was developed consisting of 4 sections: demographic characteristics, practices, beliefs, and comfort level with making decisions about osteoporosis treatment. An e-mail invitation was sent to members of the Canadian Society of Hospital Pharmacists (n = 2499) in November 2012. A total of 367 pharmacists completed the survey. Most of the respondents were women (258 [70%]), had more than 10 years in practice (213 [58%]), and were providing care to 1 or more osteoporosis patients per week (212 [58%]). Over one-third (150 [41%]) stated that they would use a bisphosphonate for patients with creatinine clearance (CrCl) of 15-30 mL/min, but more than half (207 [56%]) stated that they would avoid a bisphosphonate (and recommend another medication) for patients with CrCl below 15 mL/min. Forty-eight percent (176/363) agreed that oral bisphosphonates could be used for patients with renal failure (defined as CrCl < 30 mL/min), so long as dosage adjustments are made. More than half (206/363 [57%]) believed that the adverse effects of oral bisphosphonates increase for patients with renal failure. Respondents expressed a low level of comfort in assessing and initiating osteoporosis treatment for patients with renal failure. Pharmacists had varying beliefs about managing osteoporosis in patients with chronic kidney disease. This study highlights the need for practice tools and targeted education addressing the use of bisphosphonates for these patients.

Learning and networking: utilization of a primary care listserv by pharmacists.

Expanding into new types of practice, such as family health teams, presents challenges for practising pharmacists. The Primary Care Pharmacy Specialty Network (PC-PSN) was established in 2007 to support collaboration among pharmacists working in primary care. The PC-PSN offers to its members a listserv (also referred to as an electronic mailing list) jointly hosted by the Canadian Society of Hospital Pharmacists and the Canadian Pharmacists Association. To characterize PC-PSN membership and participation in the listserv and to examine how the listserv is used by analyzing questions posted, concerns raised, and issues discussed. Qualitative content analysis was used to examine 1 year of archived PC-PSN listserv posts from the year 2010. Two coders used NVivo software to classify the content of posts. Research team members reviewed and discussed the coding reports to confirm themes emerging from the data. Overall, 129 people (52.9% of the 244 listserv members registered at the end of the calendar year) posted to the listserv during the study period. These participants worked in various practice settings, with over half residing in Ontario (68/129 [52.7%]). A total of 623 posts were coded. Agreement between coders, for a sample of posts from 10 users, was acceptable (kappa = 0.78). The listserv was used to share information on a diverse set of topics, to support decision-making and acquire solutions for complex problems, and as a forum for mentorship. The qualitative content analysis of the PC-PSN listserv posts for the year 2010 showed that the listserv was a medium for information-sharing and for providing and receiving support, through mentorship from colleagues. Apparent learning needs included effective question-posing skills and application of evidence to individual patients.

Drug shortages in health care institutions: perspectives in early 2014.

The year 2012 was marked by an unprecedented number of drug shortages in Canada. This crisis was due in particular to the publication, in November 2011, of a warning letter from the US Food and Drug Administration (FDA) to Novartis International AG for its Boucherville plant, which was managed by Sandoz Canada.1,2 Although Sandoz was not the only drug manufacturer with shortages for some products, the wide range of single-source generic parenteral products affected by this crisis led to a high level of uncertainty in the Canadian health care sector. Since the publication of our most recent analysis of the Canadian drug shortage situation,3 the FDA has issued at least one other warning letter, this time to Apotex, a Canadian generic manufacturer.4 In 2012, our research group evaluated the impact of drug shortages in 5 Quebec teaching hospitals and highlighted administrative costs of at least Can$0.5 million to manage these shortages, mainly at the level of individual pharmacies.5 Barthelemy and others6 also published a case study of the management of drug shortages in hospitals, illustrating the challenges for pharmacists and the risks for patients. In response to this crisis, many stakeholders (including the Standing Committee on Health, the Royal College of Physicians and Surgeons of Canada, the Ordre des pharmaciens du Quebec, the Canadian Pharmacists Association, and the group purchasing organization SigmaSante) came together in 2012 and made a set of recommendations to various levels of government, buying groups, supply chains, the pharmaceutical industry, and individual pharmacists.7 Surprisingly, only one-third of the 30 recommendations had been implemented 1 year later.7 In June 2013, a Member of Parliament from the New Democratic Party of Canada proposed a private member’s bill on the mandatory disclosure of drug shortages in Canada,8 but this bill was defeated at second reading in February 2014. In September 2013, Health Canada published a drug-shortage protocol and tool kit, based on the work of the Multi-Stakeholder Steering Committee on Drug Shortages.9 In its Appendix B, the protocol establishes a guide for drug-shortage notification and communication and lists the key relevant fields to be completed by drug manufacturers in the Canadian drug shortage database (www.drugshortages.ca). Pharmacists and various stakeholders, such as the Canadian Society of Hospital Pharmacists and group purchasing organizations, found this database to be incomplete and requested the addition of key data (e.g., number of similar commercialized products, links to other relevant information sources). Disappointingly, it took more than 24 months after initial consultations for these key data to be added as fields on the website for complete update by the manufacturers. Before then, these key data were available only on a website known as “FridayPM”. The FridayPM website, a voluntary, pharmacistinitiated tool launched in early 2011, was closed in August 2014, as drug manufacturers are now allowed by some group purchasing organizations to declare their drug shortages only on the Canad ian drug shortage platform.

Why pharmacists should care about the marketing of unhealthy foods: Increasing our role in public health policy / Pourquoi les pharmaciens devraient-ils s’intéresser à la promotion des aliments néfastes pour la santé? Contribuons davantage aux politiques en matière de santé publique

As highly accessible health professionals, pharmacists have a unique opportunity to offer advice and care to patients across a variety of settings and therapeutic areas. Traditionally, pharmacists’ activities have focused on the care of individual patients, but recent scope of practice expansions, such as the administration of vaccines, highlight our profession’s ability to participate in larger public health initiatives. Research has also suggested that pharmacists view public health activities as important and as part of their role in addition to medication management activities.1 Indeed, the Blueprint for Pharmacy includes a statement calling on pharmacists to “empower patients in decision-making about their health, and play a prominent role in health promotion, disease prevention and chronic disease management.”2 Similarly, CSHP 2015 (an initiative from the Canadian Society of Hospital Pharmacists) calls for an “increase [in] the extent to which pharmacy departments in hospitals and related healthcare settings engage in public health initiatives on behalf of their communities.”3 Patients have also been shown to view pharmacists as respected providers of public health advice.1

“You’re Off to Great Places!”

JCPH – Vol. 66, n 4 – juillet–aout 2013 272 Throughout my career, the Canadian Society of Hospital Pharmacists (CSHP) has been a constant companion. I got involved with CSHP upon completing my residency and participated actively at the Branch level, holding several positions on Council. Over the past few years, I have been fortunate to become more involved at the National level, serving as the CSHP representative on the Canadian Council on Continuing Education in Pharmacy and, more recently, as the British Columbia Branch delegate to National Council. The dedicated volunteers who put in tireless hours to make CSHP and the profession better certainly exemplify the sentiments expressed in the Margaret Mead quote above. So where does this long and winding road that I have travelled now lead? I look forward to my term on the CSHP Executive and especially to working with dedicated staff in the CSHP office and the talented individuals at the branch level. I will finish with another quote from Dr Seuss: “You’re off to Great Places! Today is your day! Your mountain is waiting. So ... get on your way!”

The Conundrum of Clinical Practice Guidelines

Clinical practice guidelines (CPGs) have been defined by the Institute of Medicine as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances”. The purported benefits of CPGs include improving patient outcomes, standardizing practice by ensuring a certain minimal level of care and discouraging non-evidence-based care, improving consistency and efficiency, highlighting knowledge gaps, stimulating professional discussions, and lowering the cost of care. However, whether such benefits are realized in actual practice is not clearly documented in the literature. Notwithstanding these potential benefits, implementation of CPGs is a complex and labour-intensive process, and a recent large-scale cluster randomized controlled trial found that multifaceted and comprehensive knowledge translation interventions reaching up to 96% of the targeted audience in a variety of intensive care units resulted in an increase of only 8% over 2 years in concordance with a set of evidence-based guideline recommendations for ventilator-associated pneumonia. At the same time, clinicians have voiced several concerns about CPGs, including poor uptake of guidelines by practitioners, their potential to replace clinical judgment and to impede teaching and curiosity, and their inappropriate use for legal and insurance coverage purposes. In this issue of the Canadian Journal of Hospital Pharmacy (CJHP), the Point Counterpoint question asks whether clinical practitioners, as part of institutional or accreditation standards, should be required to document rationale when they choose to not adhere to widely accepted clinical practice guidelines. The authors on both sides present many valid lines of reasoning to support their cases. One of the points raised, relating to the degree to which guidelines are actually evidence-based, merits further discussion. In fact, I believe that the evidentiary basis of guidelines is fundamental, as evidence-based medicine is considered the standard for current practice in the health sciences, and is certainly something we clinical pharmacists all try very hard to instill in our students, fellow practitioners, and even administrators. So, before consideration of whether it should be mandatory for practitioners to cite their rationale for deviation from CPGs, it must be asked whether the guidelines themselves have been developed using rigorous method ologies and thus whether they are valid for use in guiding practice. The answer is, at least to me, somewhat unexpected. First, numerous validated tools exist for critically appraising CPGs. One such tool, the AGREE (Appraisal of Guidelines for Research and Evaluation) tool, is in fact the one used by the Canadian Society of Hospital Pharmacists when the Society is asked to endorse any externally developed CPG. Yet appraisal of CPGs with a validated tool is not routinely part of pharmacy curricula, nor are there any publications focusing on critical appraisal of CPGs similar to what exists for randomized controlled trials (e.g., ACP Journal Club, published by the American College of Physicians). In one study, when CPG appraisal tools were used to critically appraise existing guidelines in intensive care, the mean quality scores were at best 50%! The problem is not unique to critical care and has been confirmed in many other areas of medicine. Fortunately, the quality of CPGs is improving over time. In addition, other efforts such as the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system for recommendations and a proposed framework for standardization of reporting are welcome improvements to increase the quality of CPGs. The GRADE system for recommendations is particularly valuable, given that patients’ perspective, quality of life, and cost-effectiveness are all considered in arriving at the final strength of recommendations. This is particularly useful in areas such as geriatrics, where practitioners sometimes need to appropriately deviate from guideline recommendations according to patient-related factors. Finally, the Institute of Medicine has recently published its own standards for developing trustworthy CPGs. Given the widespread nature of CPGs and their potential to be used in formal documentation with legal implications, as illustrated by the debate in this issue of the CJHP, I would

Drug Shortages: The Survey Says . . .

My daughter is graduating from high school and has completed her university application. She will be enter ing a pre-pharmacy program and is thinking about a career in hospital pharmacy, so perhaps the apple really doesn’t fall too far from the tree. I recall the upheaval that her starting school a dozen years ago created in our family. Every year, she became involved in more scholastic and extracurricular activities. As the associated parental work increased, our ability to accomplish the tasks also grew, in part because we gave up other activities. In many ways, the Canadian drug shortage situation has had the same effect on pharmacists. The Canadian Society of Hospital Pharmacists (CSHP) recently joined the Canadian Pharmacists Association and the Canadian Medical Association in surveying members about drug shortages and releasing a statement about the results to the media. 1 If you missed it on your local news broadcast, don’t feel bad: media pick-up of the story was limited and so was the interest of our politicians. Perhaps what was missing from the story was the aspect of potential patient harm. The diligent and timely mitigation of drug shortages by hospital and community pharmacists and by physicians has resulted in many positive patient outcomes, but these tend not to make great news stories. Survey results indicated that up to 20% of patients have been affected by shortages. The top 3 impacts for patients were delayed access to needed medication, use of a less effective medication or formulation, and increased risk of adverse effects. Hospital pharmacists who responded to the survey indicated that patients experienced delays in acquiring their medications, additional cost associated with alternative medications, and confusion related to changes in medication or formulation. Of 215 hospital pharmacists who responded, more than half reported trouble sourcing a medication for a patient during their most recent shift, and almost two-thirds indicated difficulty getting a medication in the previous week. Hospital pharma cists’ strategies to mitigate the effects of drug shortages included communication within the pharmacy, hospital, and health region; rationing or restricting the use of existing supplies; obtaining medications from another source; compounding

What Will It Take? The Quest to Achieve Indexing by the National Library of Medicine

To become indexed in MEDLINE has been a goal of the Canadian Journal of Hospital Pharmacy (CJHP) for as long as those of us on the Editorial Board can remember. We believe that the benefits of achieving indexing in MEDLINE are enormous. First, indexing will provide more exposure for the work of authors who publish in the CJHP. That is, authors’ articles will be more widely disseminated and more readily available to other clinicians and scientists around the world, who can then incorporate this new knowledge into their practice or build on the published work. Second, indexing will lead to more high-quality submissions. I have heard from more than a few of my academic colleagues who work in a “publish or perish” environment that they do not submit papers to the CJHP because “it is not indexed”. Once we achieve indexing status, however, authors will receive more recognition, more citations, and higher impact for their published papers and therefore will be more likely to submit their high-quality work to CJHP. Third, indexing is expected to improve the value of the Journal not only for authors but also for readers, subscribers, advertisers, and its owner, the Canadian Society of Hospital Pharmacists (CSHP), for all the reasons described above. If you have searched PubMed recently, you may have noticed that you are already able to retrieve citations of articles published in the CJHP. This is because the Journal was successful in its 2010 application for archiving in PubMed Central (PMC), the US National Institutes of Health’s free digital archive of biomedical and life sciences journal literature (www.ncbi.nlm.nih.gov/pmc/). PMC is part of the larger PubMed service, which also includes MEDLINE, the primary international online bibliographic citation database of biomedical and life sciences journal literature. PubMed now includes a link to the material that CJHP has available on the PMC site. This is great news, but PMC archiving is only one step toward indexing. That is, at the PubMed site, CJHP citations are denoted as “PubMed – in process” or “PubMed”. Only after the CJHP is indexed by the National Library of Medicine (NLM) will it say “PubMed – indexed for MEDLINE”. Currently, about 5000 journal titles are indexed in MEDLINE. The Director of the NLM decides whether or not to index a journal, on the basis of considerations of both scientific quality and policy. Specifically, the NLM’s Literature Selection Technical Review Committee (LSTRC) reviews and assesses the quality of journals, while NLM’s Board of Regents determines the mix of types of journals to be indexed, according to considerations of program relevance. In fact, our Journal was indexed in MEDLINE over the period 1975 to 1997. While the specific reasons for halting our indexing are unknown, the NLM has been known to drop currently indexed journals to accommodate new ones. In 2004, the CJHP submitted an application for indexing that was unsuccessful. Although we would have been allowed to reapply after a minimum of 3 years, the Editorial Board believed it best to hold off until we were more confident of success. As such, we have been “beefing up” the Journal, while carefully examining the NLM’s criteria for indexing and scrutinizing what it took for other journals to achieve indexing status. I would like to take this opportunity to describe some of the additional changes we are planning for the CJHP and to explain why we are advocating these changes and why we believe we can be successful in our effort to achieve indexing status. In planning for our next application for indexing (in early 2015), we have adopted the following primary goals: (1) to improve the CJHP’s scope and coverage, making the Journal more internationally relevant; (2) to continue improving the quality of the CJHP’s review articles, clinical research papers, case reports, and editorials; (3) to further improve the LSTRC’s perception of the strength and credibility of the CJHP’s Editorial Board and the Journal’s editorial independence; (4) to