“North Star” goals toward an ideal integrated behavioral health and ambulatory care setting Tips, resources, and real-world examples of how others are doing it What not to do, or the pitfalls to avoid when integrating behavioral health An interactive integration self-assessment checklist with immediate feedback linked to guidance Access to the Academy Community, an online forum for peer-topeer networking and sharing

Agency for Healthcare Research and Quality (AHRQ)

The literature contains robust evidence on the positive impact of antimicrobial stewardship programs (ASP) in the inpatient setting. With national policies shifting toward provisions of quality health care, the impetus to expand ASP services becomes an important strategy for institutions. However data on stewardship initiatives in other settings are less characterized. For organizations with an established ASP team, it is rational to consider expanding these services to the emergency department (ED). The ED serves as an interface between the inpatient and community settings. It is often the first place where patients present for medical care, including for common infections. Challenges inherent to the fast-paced nature of the environment must be recognized for successful ASP implementation in the ED. Based on the current literature, a combination of strategies for initiating ASP services in the ED will be described. Furthermore, common scenarios and management approaches are proposed for respiratory tract, skin and soft tissue, and urinary tract infections. Expansion of ASP services across the health care continuum may improve patient outcomes with a potential associated decrease in health care costs while preventing adverse effects including the development of antibiotic resistance.

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Antimicrobial Stewardship in the Emergency Department.

Pharmacists have a long history of helping Canadians with minor ailments. This often has involved management with over-the-counter medications. If pharmacists felt that the best care required something more robust, they would refer the patient to a physician. In hopes of improving the care of such ailments, Canadian provinces have granted pharmacists the option of selecting medications traditionally under physician control. This review examines the Canadian perspective on pharmacists prescribing for minor ailments and the evidence of value for these programs. It might provide guidance for other jurisdictions contemplating such a move.

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Pharmacist-led minor ailment programs: a Canadian perspective.

Objective. To measure changes in interprofessional competencies among pharmacy and medical students following a half-day event focusing on interprofessional learning. Methods. There were 118 pharmacy students and 28 medical students who participated in the Healthcare Interprofessional Education Day (HIPED) which consisted of three stations (communication, patient interviewing, and prescribing) in which pharmacy and medical students had to work collaboratively. The standardized Interprofessional Collaborative Competency Attainment Survey (ICCAS) was used to evaluate the effectiveness of the program. Results. There were 133 surveys completed for a response rate of 91%. All 20 items measured by the ICCAS showed a significant improvement. The strongest effect sizes were in the collaboration, roles & responsibilities, and collaborative practice/family-centered approach categories. The least robust effects were in the conflict management/resolution category. Conclusion. The HIPED activity was an effective IPE experience. The strong and consistent improvement in all ICCAS scores suggest a framework for pharmacy and medical school training to move from siloed educational experiences to synergistic learning opportunities.

Evaluation of a Unique Interprofessional Education Program Involving Medical and Pharmacy Students

Background/Objective: To improve antimicrobial utilization, development and implementation of antimicrobial stewardship programs in the emergency department (ED) has been recommended The primary objective of this review was to characterize antimicrobial stewardship (AMS) in the ED and to identify interventions that improve patient outcomes or process of care and/or reduce consequences of antimicrobial use Methods: This study was completed as a systematic review The following databases were searched from inception through November, 2016: MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Scopus, and Web of Science Randomized controlled trials, nonrandomized controlled trials, controlled and uncontrolled before-and-after studies, interrupted time series studies, and repeated-measures studies evaluating AMS interventions in the ED were included in the review Studies published in languages other than English were excluded Results: A total of 43 studies meeting inclusion criteria 

A Systematic Review of Antimicrobial Stewardship Interventions in the Emergency Department

Background: Overuse of fluoroquinolone antibiotics is associated with outbreaks of methicillin-resistant Staphylococcus aureus and of Clostridium difficile–associated diarrhea and increasing resistance in gram-negative organisms. Over the past decade, resistance of Escherichia coli to ciprofloxacin has increased in the Regina Qu’Appelle Health Region. In August 2011, an exploratory audit of the Regina General Hospital (RGH) emergency department showed that 20% of new antibiotic orders were for fluoroquinolones, and 60% of these new fluoroquinolone orders were for ciprofloxacin. It was postulated that ciprofloxacin was predominantly prescribed for outpatients with urinary tract infection. Objective: To develop, implement, and evaluate a best-practice algorithm for the empiric treatment of uncomplicated urinary tract infection in the RGH emergency department, as part of an educational initiative for emergency physicians. Methods: A literature review was conducted and local antibiogram data were analyzed to establish a best-practice algorithm for treatment of uncomplicated urinary tract infection in outpatients seen in the emergency department. A chart review was conducted from January to March 2011 to establish a baseline of empiric antibiotic use. An educational strategy targeting emergency physicians described changes in antibiotic resistance patterns in the health region, principles of antimicrobial stewardship, drivers of resistance, and the results of a literature review of best practice for urinary tract infection in outpatients. A post-intervention audit was conducted from January to March 2012 to determine changes in practice. Results: Comparison of results from the post-intervention audit with baseline data showed that adherence to best practice increased significantly, from 41% (39/96) before the intervention to 66% (50/76) after the intervention (odds ratio [OR] 2.81, 95% confidence interval [CI] 1.51–5.25; p < 0.001). There was also a significant change in overall antibiotic selection (OR 0.25, 95% CI 0.11–0.58; p < 0.001). Further analysis suggested that this significant change was driven by a decrease in use of ciprofloxacin, from 32% (31/96) to 11% (8/76). Conclusion: Creation of a best-practice algorithm and education focused on emergency physicians significantly increased adherence to best practice and optimized antibiotic prescribing for outpatients with uncomplicated urinary tract infection by limiting overuse of fluoroquinolones, primarily ciprofloxacin. RESUME Contexte : L’utilisation abusive d’antibiotiques de la famille des fluoroquinolones est associee a des eclosions de Staphylococcus aureus resistant a la methicilline et de diarrhee provoquee par le Clostridium difficile ainsi qu’a une augmentation de la resistance des bacteries a Gram negatif. Au cours de la derniere decennie, la resistance d’Escherichia coli a la ciprofloxacine a augmente dans la regie regionale de la sante de Regina Qu’Appelle. En aout 2011, une verification preliminaire du service des urgences de l’Hopital general de Regina (HGR) a montre que 20 % des nouvelles ordonnances d’antibiotiques etaient pour des fluoroquinolones et que 60 % de ces ordonnances etaient pour de la ciprofloxacine. On a emis l’hypothese selon laquelle on prescrivait principalement la ciprofloxacine aux patients externes atteints d’une infection urinaire. Objectif : Elaborer, mettre en place et evaluer un algorithme des meilleures pratiques pour le traitement empirique d’infections urinaires non compliquees au service des urgences de l’HGR dans le cadre d’une initiative de formation destinee aux urgentologues. Methodes : Une revue de la litterature a ete menee et les donnees locales d’antibiogrammes ont ete analysees afin de definir un algorithme des meilleures pratiques destine au traitement des infections urinaires non compliquees chez les patients externes rencontres au service des urgences. Une analyse des dossiers medicaux a ete effectuee de janvier a mars 2011 dans le but d’etablir le traitement antibiotique empirique de reference. Une strategie de formation destinee aux urgentologues decrivait : les changements dans les profils de resistance aux antibiotiques au sein de la regie regionale de la sante, les principes d’une gestion responsable des antimicrobiens, ainsi que les facteurs de resistance. Elle contenait aussi une revue de la litterature des meilleures pratiques pour traiter les infections urinaires chez les patients externes. Une verification post-intervention a ete menee de janvier a mars 2012 afin de determiner les changements dans la pratique. Resultats : Une comparaison entre la verification post-intervention et les donnees de reference a montre une augmentation significative de l’observance des meilleures pratiques, qui est passee de 41 % (39/96) avant l’intervention a 66 % (50/76) apres l’intervention (risque relatif approche [RRA] de 2,81, intervalle de confiance [IC] a 95 % de 1,51–5,25; p < 0,001). On a aussi observe un changement significatif dans les habitudes de choix d’antibiotiques (RRA de 0,25, IC a 95 % de 0,11–0,58; p < 0,001). D’apres d’autres analyses, ce changement significatif a ete cause par une baisse de l’utilisation de la ciprofloxacine, qui est passee de 32 % (31/96) a 11 % (8/76). Conclusion : L’elaboration d’un algorithme des meilleures pratiques ainsi qu’une formation destinee aux urgentologues ont permis d’augmenter de maniere significative l’observance des meilleures pratiques. Elles ont aussi permis d’optimiser la prescription d’antibiotiques aux patients externes atteints d’une infection urinaire non compliquee en reduisant l’utilisation abusive des fluoroquinolones, notamment celle de la ciprofloxacine.

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Urinary Tract Infections: Leading Initiatives in Selecting Empiric Outpatient Treatment (UTILISE)

Student-run primary health care clinics (SRPHCCs) are prevalent in the United States and have reported benefits not only by providing medical care for underserved patients but also by acting as a valuable learning experience for medical students.1 There are currently 7 SRPHCCs in Canada.2 The Community Health Initiative by University Students (CHIUS) in Vancouver, British Columbia, was the first to open its doors in April 2000. Subsequently, 6 additional SRPHCCs have opened in Alberta, Saskatchewan, Manitoba and Ontario.2 These Canadian student-run primary health care clinics offer medical services that are similar to those available in typical family doctors’ offices; however, most patients of the SRPHCCs seek care on a walk-in basis, in contrast to appointment-based encounters. What makes these SRPHCCs unique (in addition to the fact that they are operated by students) is that they use a collaborative, interprofessional approach and that patients can access a wide variety of educational and social services at the clinics, not exclusively medical care.

The purpose of this article is to describe the function of interprofessional SRPHCCs in Canada and to discuss potential benefits of the model for educating undergraduate pharmacy students.

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Interprofessional student-run primary health care clinics: Educational experiences for pharmacy students.

Switching prescribed medications to over- or behind-the-counter status is considered an option to improve accessibility to treatment while insuring appropriate and safe use. For example, in the UK, omeprazole and simvastatin have already been granted over-the-counter (OTC) status, while omeprazole has nonprescription status in the USA.


KEY POINTS


Pharmacists in Canada do not support the deregulation of simvastatin or omeprazole and only moderately support an OTC switch for fluticasone.


The complexity of disease and drug management was listed as the main barrier to OTC switch.


Additional training was perceived as a facilitator of OTC switch.


Other issues included access to laboratory test results, liability issues and loss of drug plan coverage





POINTS CLES


Les pharmaciens ne sont pas en faveur de la dereglementation de la simvastatine ou de l'omeprazole et ne sont que moderement en faveur de la mise en vente libre du fluticasone.


La complexite de la maladie et de la prise en charge pharmaceutique a ete citee comme principal motif d'opposition a la mise en vente libre.


On estime qu'une formation supplementaire serait necessaire pour faciliter le reclassement du produit parmi les medicaments en vente libre.


Parmi les autres questions soulevees, mentionnons l'acces aux resultats d'analyses de laboratoire, les questions de responsabilite et le retrait du regime d'assurance-medicaments.




In Canada, switching prescribed medications to OTC status (Schedule II) can have major implications for pharmacists. The level of care required to ensure safe selection and use may be quite significant. To date, few reports in Canada have dealt with pharmacists' readiness to expand practice in this area. Indeed, some concern has been expressed over the ability of pharmacists to engage in more patient assessment.1

In this paper, we explore pharmacists' readiness for switching simvastatin, omeprazole and fluticasone to Schedule II status. We also identify the barriers and facilitators for such a switch.

Results of a national survey on OTC medicines, Part 2: Do pharmacists support switching prescription agents to over-the-counter status?

Background Canadians are the second-highest users of opioids in the world, and the rate of opioid-related death in Canada has been increasing dramatically. The Public Health Agency of Canada recently reported that over 4000 people died of opioid-related overdoses in 2017. In an effort to reduce opioid-related harm, the Canadian Guideline for Opioids in Chronic Non-Cancer Pain recommends that health professionals meet regularly with patients who are prescribed chronic opioids to develop treatment plans to taper opioid doses, maximize use of nonopioid pain medications, provide education to minimize opioid risk and offer frequent followup. This recommendation is challenging to implement because it is time-consuming and resource intensive. Consequently, this service is often offered in interprofessional chronic pain clinics in Canada, where wait lists can be long. Some regions, such as Saskatchewan, do not even have such clinics. Pharmacists are reported to be among the most underused health professionals in North America, and the US Department of Health recently noted that they are uniquely positioned to help in a more substantive way to address the opioid crisis. In 2019, an article was published that proposes a framework to help pharmacists implement opioid guideline recommendations into practice. Unfortunately, studies evaluating the impact of pharmacist interventions, targeting opioid use in chronic noncancer pain, are limited. One retrospective chart audit evaluated 148 patients taking opioids for chronic noncancer pain in a Veterans Health clinic in California. Pharmacists working in the clinic developed a telephone assessment service that included a monthly call to patients taking opioids. This study found that opioid prescriptions were changed in 32% of patients, and over half of the pharmacists’ recommendations were to reduce doses. A Belgian study evaluated the impact of a multidisciplinary pain team, which included a pharmacist, on analgesic utilization in 93 patients with chronic noncancer pain. This study found that 53% of patients had a medication change implemented after being assessed by the pharmacist. Another study that assessed the impact of a pharmacist-led chronic pain clinic in the United States found improvements in chronic pain scores and reduced overall health expenditures among 564 patients who attended the clinic. Pharmacist-led medication assessment programs are available as publicly funded services in 8 of the 10 Canadian provinces; however, none specifically include opioid use or chronic pain in the eligibility criteria. Since these programs focus on medication optimization and patient education, it is conceivable that they could be leveraged to focus on patients who are prescribed chronic opioids to reduce the risk of unintentional overdose and death. There is significant research published regarding the benefits of pharmacist-led medication assessment programs. Studies have found that the service can improve quality of life, medication appropriateness, patient knowledge, chronic disease management, patient satisfaction and medication cost; however, there were no published studies identified that evaluated the impact of a contemporary pharmacist-led medication assessment program on opioid utilization. The aim of this study was to determine the impact of a publicly funded, Canadian pharmacist-led medication assessment program on opioid utilization among ambulatory patients with chronic noncancer pain.

/pdf/impact-of-pharmacist-led-medication-assessments-on-opioid-ypdpw8735t.pdf

Impact of pharmacist-led medication assessments on opioid utilization.

Background The Medication Assessment Center is a faculty and student run patient care clinic located within the pharmacy school at the University of Saskatchewan (Canada). It was created as a novel experiential education site for pharmacy students and to provide clinical pharmacist services for complex patients who have trouble accessing services elsewhere. Objective To determine if the clinical services provided by faculty and students at the Medication Assessment Center are valuable to patients who are referred to the program. Setting The Medication Assessment Center, which is faculty and student run patient care clinic. Method Convergent mixed methods design comprised of a retrospective patient chart audit and a paper based patient experience survey. All patients who attended at least one appointment at the Medication Assessment Center between March 1, 2014 and July 31, 2015 were included in the chart audit. All new patients who were referred between April 1, 2015 and October 26, 2015 were included in the survey. Main outcome measures Recommendations made by the pharmacist and patient experience survey indicators. Results 173 patients were included in the chart audit, which found that patients were elderly (64.8 years), highly medically complex (13.8 medications and 6.5 diagnoses each), and had a large number of recommendations made by the pharmacist to adjust drug therapy (6.2 per patient). 121 questionnaires were mailed to patients with a response rate of 66.9 % (n = 81). The survey found high levels of support and satisfaction for the program, including more than half of patients (59.2 %) who reported that their health had improved as a result of the Medication Assessment Center. Conclusion The patient care and experiential education program offered by the Medication Assessment Center provides a valuable service to patients who are referred to the clinic.

Eric Landry

Papers

Urinary Tract Infections: Leading Initiatives in Selecting Empiric Outpatient Treatment (UTILISE)

Interprofessional student-run primary health care clinics: Educational experiences for pharmacy students.

Results of a national survey on OTC medicines, Part 2: Do pharmacists support switching prescription agents to over-the-counter status?

Impact of pharmacist-led medication assessments on opioid utilization.

A mixed methods evaluation of a patient care clinic located within a pharmacy school.