Pharmacy Residency Papers

Permanent URI for this collectionhttps://hdl.handle.net/10012/21569

The Canadian Pharmacy Residency Board requires that pharmacy residents conduct a research project during their residency, and that a report detailing this work be submitted at the conclusion of the residency. Beginning in 2020, papers completed in the course of fulfilling residencies administered by the University of Waterloo School of Pharmacy will be archived in UWSpace, the University of Waterloo’s open access research repository.

Visit the Pharmacy Resident Paper Submission page on the School of Pharmacy's website to submit your residency paper to UWSpace.

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    Clinical Pharmacy Services in Ambulatory Oncology: An Environmental Scan of the Canadian Practice Landscape
    (University of Waterloo, 2023-02-21) Tibensky, Bryanna; Hutton, Lauren; Wentzell, Jason; LeBlanc, Michael; Edwards, Scott; McFarlane, Thomas
    Background: Canadian clinical pharmacy key performance indicators (cpKPIs) have been developed for inpatient hospital practice but are not established for ambulatory oncology. This study represents the first step in developing cpKPIs for ambulatory oncology. Objectives: To describe the current landscape of pharmacy services in ambulatory oncology in Canada and to identify perspectives related to the development and implementation of cpKPIs in this practice setting. Methods: In this national cross-sectional study, a web-based questionnaire was distributed to pharmacists working in ambulatory oncology settings. Potential participants who self-identified as pharmacists practising in an ambulatory oncology setting were eligible. Survey questions focused on participants’ demographic characteristics, oncology pharmacy services provided, metrics captured, and pharmacists’ perceptions of cpKPIs. All data were analyzed using descriptive statistics. Results: A total of 44 responses were received, with most respondents practising in community hospitals in British Columbia, Ontario, and Atlantic Canada. The services most commonly provided were chemotherapy order verification, laboratory monitoring, identification and resolution of drug therapy problems, and counselling on anticancer medications. Twenty-six of the 44 respondents (59%) indicated that performance metrics or patient outcomes were tracked at their respective institutions, with none being universally captured. Overall, 43 (98%) of the respondents favoured the development of cpKPIs for ambulatory oncology practice. Conclusions: Despite growing patient care needs in ambulatory oncology, there is significant heterogeneity in the scope of pharmacy services offered and the outcomes used to qualify their impact within this setting across Canada. This study demonstrates a clear need for national consensus cpKPIs to inform pharmacy resource utilization and patient-centred quality improvement initiatives.
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    Determination of the relationship between vancomycin trough concentrations and the AUC/MIC Dosing
    (University of Waterloo, 2020-07-15) Ing, Nathan; McQueen, Joe; Nadeau, Lynn; Hussein, Abdulkadir A.
    Rationale: The recently revised guidelines for the therapeutic monitoring of vancomycin recommend targeting an AUC/MIC of 400-600 for serious methicillin-resistant Staphylococcus aureus (MRSA) infections. The feasibility of transitioning from trough-based dosing to dosing by AUC/MIC warrants further study as the latter method has been shown to require additional pharmacist training and increased costs secondary to laboratory monitoring and specialty software. Methods: This was a prospective, non-randomized, single-centre trial conducted over eight months. Adult inpatients receiving vancomycin for greater than three days for the treatment of serious MRSA infections were included in the study. The AUC/MIC was calculated using two-point pharmacokinetic equations from peak and trough concentrations. The primary outcome was to determine the relationship between vancomycin trough concentrations and the AUC/MIC. Secondary objectives were to assess the difference in vancomycin doses and rates of acute kidney injury (AKI) between traditional trough-based dosing and AUC/MIC dosing. Results: 234 patients received vancomycin over the study period and 32 patients met the inclusion criteria; 36 sets of vancomycin levels were obtained. Sites of infection included skin and soft tissue (31.2%), bacteremia (21.9%), pneumonia (18.8%), osteomyelitis (15.6%) and miscellaneous (12.5%). Vancomycin trough concentrations of 10.8-16.1 mg/L correlated to an AUC/MIC of 400-600 with 95% probability (r2=0.75). The average total daily doses for trough-based and AUC/MIC dosing were 1590.28 mg and 1281.25 mg, respectively. The mean difference in dose between the two dosing strategies was 309 mg (p=0.179). There were no significant differences in the rates of AKI between trough-based dosing and dosing by AUC/MIC [OR=1.791; 95% CI (0.119,48.048)]. Conclusion: On average, vancomycin trough concentrations of approximately 11-16 mg/L correlated strongly with an AUC/MIC of 400-600, suggesting that adopting the cumbersome and costly strategy of AUC/MIC targeted dosing may be unnecessary, but further study is required. This correlation also suggests that aggressively targeting vancomycin troughs of 15-20 mg/L, as previously recommended, is unwarranted. Average daily doses and rates of AKI did not significantly differ between trough-based dosing and dosing by AUC/MIC.
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    Evaluation of a microlearning module on hypertension in Canada
    (University of Waterloo, 2023-02-20) Waked, Khrystine; Nagge, Jeff; Grindrod, Kelly
    Objectives: To use a microlearning platform to evaluate pharmacists’ knowledge and behaviour related to hypertension. Methods: Pharmacy 5in5 is an online microlearning platform designed to help pharmacy professionals develop skills and acquire a deeper understanding of a variety of clinical and professional practice topics. Each topic includes a fact-based quiz, six case-based quizzes, six reflection questions, animated videos, infographics and flash cards. In April 2019, a hypertension module was released to engage pharmacists in managing hypertension and improving current practice behaviours. The module was developed using Canadian and American hypertension guidelines, landmark trials, and tertiary drug resources. The hypertension module was accessible on the Pharmacy5in5 website. Preliminary data were collected over 8 weeks between April-June 2019. User performance was analyzed with a binomial regression model. Results: Overall, 600 users accessed the Pharmacy 5in5 platform in the first two months, 81% of which were in Ontario. Licensed pharmacists performed significantly better than other registered users (β = −0.56, t (3362) =−2.15, p = 0.03), with users working in hospitals performing the best. The quiz resulting in the highest average focused on proper techniques for home blood pressure monitoring (mean score of 87%; SD 17%), while the quiz resulting in the lowest average focused on choosing medication therapy (mean score of 59%; SD 22%). In the reflection questions for behaviour in the last three months, 68% of users reported counselling a patient on home blood pressure monitoring and 62% had educated patients on their blood pressure targets, but only 18% had contacted a prescriber to optimize pharmacotherapy. Conclusion: The Pharmacy5in5 hypertension module is an engaging method of continuing education which can be used to rapidly reach many healthcare professionals in a short time. More education is needed to support pharmacists in working with prescribers to proactively optimize hypertension therapy.
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    Impact of short-acting vs. long-acting antipsychotic use on time in seclusion on a forensic assessment unit: a retrospective chart review
    (University of Waterloo, 2025-02-21) Vij, Sumani
    Background: Seclusion, a strategy used to manage aggressive behavior in patients posing safety risks, can result in prolonged hospitalization and trauma. Antipsychotics, used to treat major mental illnesses including schizophrenia and bipolar disorder, are available as long-acting (LA) and short-acting (SA) formulations, with evidence suggesting LA antipsychotics may improve patient outcomes such as reducing hospitalizations and decreasing aggression, which is primarily driven by an increase in medication adherence. Objective & Methods: This retrospective chart review evaluated the impact of SA versus LA antipsychotics on seclusion duration in adult patients at the Southwest Centre for Forensic Mental Health Care (Ontario, Canada) between April 1, 2017, and December 31, 2023. Results: Of 83 patients (60 in the SA cohort, 23 in the LA cohort), no significant difference was found in seclusion time for SA compared to LA antipsychotics (2.7 hours, 95% CI: -67.8, 62.5, p > 0.05). Mood stabilizer use was associated with longer seclusion (SA: 112.7 hours, LA: 215.3 hours, p < 0.05), but no difference was observed with anxiolytics. Conclusion: Clinicians should consider individual patient needs and treatment contexts when prescribing antipsychotics. Further research is warranted to investigate broader patient outcomes and the implications of antipsychotic formulations in forensic mental health
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    A Quality Assurance Evaluation of Hydromorphone Adverse Events Post-Implementation of a Safety Initiative
    (University of Waterloo, 2019-08) Purivatra, Elsa; Haluk-McMahon, Charlene; El-Masri, Maher; Yrigoyen-Dacruz, Lidia; Duronio, Antoinette
    Purpose: Hydromorphone is a potent opioid that may lead to respiratory and central nervous system depression prompting naloxone use. The primary objective of this study was to evaluate whether a safety initiative implemented at Windsor Regional Hospital involving interchanging hydromorphone intravenous or subcutaneous doses of 1 mg or greater to low dose (0.5 mg) in opioid naïve, medical and surgical patients was associated with naloxone events. The secondary objective was to assess whether there was a compromise in patient pain control with the low dose. Methods: We conducted a retrospective, multicenter, observational study of medical and surgical opioid-naïve patients admitted to Windsor Regional Hospital who received intravenous or subcutaneous hydromorphone within an eighteen-month timeframe. To determine if there is an association between naloxone events and implementation of the safety initiative, we compared patients who experienced a naloxone event (cases) with patients who did not experience a naloxone event (controls) in approximately 1:4 ratio. Efficacy outcomes assessed changes in patient pain control before and after interchange policy implementation (i.e. need for increase in dose, frequency or additional analgesics). Results: Of the 4343 patients who received hydromorphone, 143 opioid naïve patients were included in the final analysis. Of the 27 patients who experienced a naloxone event, 0% of patients were interchanged. In contrast, of the 116 patients who did not experience a naloxone event, 52% were interchanged (OR = 0, 95% 0 to 0.13, p<0.01). There were no significant differences in terms of patient pain control before and after interchange policy implementation. Conclusions: The pharmacist-led safety initiative of interchanging all opioid naïve patients to low dose hydromorphone was not associated with naloxone events and did not compromise patient pain control.
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    Risk and Benefit of Warfarin for Primary Prevention in Atrial Fibrillation Patients on Hemodialysis: A Retrospective Pilot Study
    (University of Waterloo, 2020-07-17) Panic, Gea; McNorton, Kelly; Yrigoyen-Dacruz, Lidia; Duronio, Antoinette
    Background Despite increased awareness and advocacy regarding the opioid epidemic, data from Health Quality Ontario (HQO) shows steady prescribing of opioids with concerning trends toward prescribing more potent opioids. The creation of a quality standard for Opioid Prescribing in Acute Pain provides opportunity for organizations to assess whether they are meeting best practice recommendations. Objective To examine opioid prescribing patterns for patients presenting to the emergency department (ED) and to assess opioid prescribing at discharge in comparison to HQO quality standards. Methods This retrospective, observational study examined adults presenting to two ED sites within in a multi-site community teaching hospital. Patients prescribed intravenous (IV)/intramuscular (IM)/subcutaneous (SC) morphine, hydromorphone, and fentanyl were included. Patients were excluded if intubated, palliative or end-of-life, being treated for overdose, multi-fracture trauma, or admitted for inpatient treatment. Results Opioids were administered to 200 patients, with 12 patients receiving two different opioids (n=212). The most common opioid was morphine (79.7%), route was intravenous (92.9%), and frequency was as a one-time dose (46.2%). Common indications included abdominal pain (32%), trauma (11%), and renal/biliary colic (10.5%). A median parenteral morphine equivalent (MEQ) of 5 mg (IQR, 4-6.67 mg) was given, with 33.5% of patients receiving concurrent non-opioid pain management. Patients who received hydromorphone (OR 6.37), were prescribed as needed (OR 2.32), scheduled (OR 30.81) or repeated doses (OR 3.95), and had an indication of migraine or headache (OR 8.92) were more likely to receive higher doses. At discharge, one in four patients received an opioid prescription, most commonly for acetaminophen/oxycodone 325/5 mg (46%) or acetaminophen/caffeine/codeine 300/15/30 mg (36%) with a median duration of 3.1 days. Conclusion In summary, our organization showed reassuring prescribing patterns, meeting HQO quality standards for dose and duration of discharge prescription.
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    Risk and Benefit of Warfarin for Primary Prevention in Atrial Fibrillation Patients on Hemodialysis: A Retrospective Pilot Study
    (University of Waterloo, 2019-07) Andrei, Alexandra; Hussein, Abdulkadir A.; Zagar, Joseph; Soong, Derrick
    Rationale: Although warfarin is an established anticoagulation therapy for prevention of ischemic strokes in patients with atrial fibrillation, studies reporting INR values with correlation to warfarin efficacy and safety outcomes in patients on hemodialysis with atrial fibrillation are scarce. The purpose of this study was provide additional information to aid in optimizing future clinical anticoagulation decisions for patients with atrial fibrillation on hemodialysis. Methods: A retrospective cohort study was conducted from April 2011 to January 2019 at a regional kidney dialysis centre in southwestern Ontario, Canada. The primary objective of this study was to correlate achieved INR measurements with the efficacy and safety of warfarin anticoagulation. Results: A total of 286 patients were reviewed and 25 patients were included. No ischemic strokes were reported and six bleeding episodes occurred. The mean INR of the 25 patients was 2.4 (SD±0.47) with an average follow up of 336 days. Using a Cox Proportional Hazards Model, univariate correlations between risk of bleeding and baseline characteristics were examined and no statistically significant correlations were found. Conclusion: Patients on hemodialysis with atrial fibrillation may have a higher bleeding rate while on warfarin despite having therapeutic IN Rs. This may be attributed to the small sample size, duration of observation and factors such as intra-dialysis heparin use and uremic platelet dysfunction. Therefore, initiating warfarin for primary prevention in this patient population requires a careful assessment of bleeding risk factors. Further studies are warranted.