Analysis of Real-World Experiences with the Ontario MedsCheck Program

ABSTRACTBackground: The Ontario MedsCheck program was introduced in April 2007, with enhancements to strengthen the program made in October 2016. Previous literature has characterized patients who received the service before the enhancements and described the experiences of community pharmacists and physicians, but the experiences of participants in the enhanced MedsCheck program and those of hospital pharmacists and pharmacy technicians have not been explored.Objectives: This study was designed to describe and compare the demographic and clinical characteristics of patients admitted to Sunnybrook Health Sciences Centre (SHSC) who had received a MedsCheck before and after the program enhancements of 2016. The study also aimed to describe the experiences of patients, hospital pharmacists, and pharmacy technicians with the MedsCheck program.Methods: Chart reviews were completed to identify and characterize patients who had received a MedsCheck and were admitted to SHSC between March and May 2016 (retrospective cohort) and between March and May 2017 (prospective cohort). Patients were interviewed and focus groups were conducted with pharmacy staff to explore their experiences with the MedsCheck program. Results: MedsChecks had been performed for 321 (14.5%) of 2216 patients in the retrospective cohort and 172 (6.8%) of 2547 patients in the prospective cohort, an absolute decline of 7.7% after the 2016 enhancements. Patient characteristics were similar between the 2 cohorts. Patients’ experiences were varied, but because of low enrolment in the interview process (n = 3), it was difficult to identify and summarize common themes. The analysis of focus groups involving pharmacy staff (n = 27 participants) revealed that the benefits of MedsChecks depended on quality and access, and also identified common barriers and oppor -tunities for future enhancements. Conclusions: Patient interviews revealed the features of the program that patients valued. Pharmacy staff identified several benefits and barriers encountered when using MedsChecks. These findings can guide clinicians in optimal application of the current MedsCheck program and can inform subsequent program revisions.RÉSUMÉContexte : En avril 2007, l’Ontario a introduit le programme MedsCheck assorti d’améliorations visant à renforcer le programme élaboré en octobre 2016. La documentation antérieure décrivait l’expérience des patients rece-vant le service ainsi que celle des pharmaciens et des médecins communau-taires avant les améliorations, mais les expériences des participants au programme MedsCheck amélioré ainsi que celles des techniciens en pharmacie et des pharmaciens d’hôpitaux n’avaient toutefois pas été étudiées.Objectifs : Cette étude a été conçue pour décrire et comparer les caractéristiques démographiques et cliniques des patients admis au Sunnybrook Health Sciences Centre (SHSC) qui ont reçu un MedsCheck avant et après les améliorations apportées au programme de 2016. L’étude vise également à décrire les expériences qu’ont faites les patients, les pharmaciens d’hôpitaux et les techniciens en pharmacie avec le programme MedsCheck amélioré.Méthodes : Des examens de graphiques ont permis d’identifier et de caractériser les patients admis au SHSC entre mars et mai 2016 (cohorte rétrospective) et entre mars et mai 2017 (cohorte prospective), ayant reçu un MedsCheck. Les patients ont été interrogés et des groupes de discussion avec le personnel de pharmacie ont été organisés pour étudier les expériences qu’ils ont faites avec le programme MedsCheck. Résultats : Des MedsChecks ont été effectués auprès de 321 patients (14,5 %) sur les 2216 dans la cohorte rétrospective, et de 172 patients (6,8 %) sur les 2547 dans la cohorte prospective : une diminution de 7,7 % après les améliorations apportées en 2016. Les caractéristiques des patients étaient similaires dans les deux cohortes. Les expériences des patients étaient variées, mais la faible inscription au processus d’entretien (n = 3) n’a pas permis de déterminer et de résumer les thèmes communs. L’analyse des groupes de discussion comprenant des membres du personnel de pharmacie (n = 27 participants) a révélé que les avantages du programme MedsChecks dépendaient de la qualité de l’information fournie par le programme et de l’accès à cette information, et elle a aussi permis de cibler les obstacles courants et des possibilités d’améliorations futures.Conclusions : Les entretiens avec les patients ont révélé les caractéristiques du programme que les patients appréciaient. Le personnel de pharmacie a relevé plusieurs avantages et quelques obstacles liés à l’utilisation du programme MedsChecks. Ces résultats peuvent faciliter l’application optimale du programme MedsCheck actuel par les cliniciens et orienter les révisions ultérieures.

P137: Automation of follow-up microbiology culture results in patients discharged from the emergency department

Introduction: At Sunnybrook Health Sciences Centres Emergency Department (ED), delays occurred in reporting positive microbiology culture results of patients discharged from the ED. Follow-up of culture results was driven by a manual paper based process that was inefficient and resulted in a one to three day delay in reporting results. The previous system was time consuming, labour intensive and prone to human error. Timely reporting of microbiology culture results is important to ensuring that patients receive optimal care. The aim is that >80% of positive microbiology culture results of patients discharged from Sunnybrook Health Sciences Centre ED will be followed-up within 24 hours of results being available from the lab. Methods: Outcome Measure Percentage of positive culture results followed up within 24 hours Process Measure Time from availability of culture results from lab to completion of patient follow-up Balancing Measure Number of positive culture results not displayed in ED server Change Idea Electronically push positive culture results to an ED server that is periodically checked daily and acted upon. An electronic interface was created to capture positive results from the microbiology lab in real time. Results: There was a 45 hour reduction in the mean time to complete a patients follow-up of culture results (59 hours pre vs. 14 hours post, p=0.03). We surpassed our aim of >80% follow-up within 24 hours. Conclusion: A significant reduction to completing a patients follow-up of microbiology culture results was achieved by automating the availability of results and eliminating the manual process previously used in relaying results from the microbiology lab to ED. This new process has the following benefits: 1) Improves timely reporting of culture results to patients, that may require initiation or change in antibiotics 2) Enhanced patient safety due to elimination of human error 3) Decreased workload due to elimination of batching of results and data entry 4) Entire process is streamlined, since only positive culture results are transmitted for follow-up.

Toxic Epidermal Necrolysis Spectrum Management at Sunnybrook Health Sciences Centre: Our Multidisciplinary Approach After Review of the Current Evidence

Toxic epidermal necrolysis spectrum (TENS) is a rare yet severe adverse drug reaction associated with a high mortality rate. Beyond supportive care, there is still no established therapy for TENS, although recent meta-analyses and UK guideline recommendations have attempted to offer a review of relevant literature on this difficult topic. As most directed treatments lack clear consensual evidence, care centres often resort to establishing their own strategies. As Canada’s largest adult burn centre and the provincial reference centre for most burn patients in Ontario, our team at the Ross Tilley Burn Centre, in collaboration with the Department of Dermatology at Sunnybrook Health Sciences Centre, Toronto, Canada, has managed over 60 confirmed cases of TENS over the past 2 decades. We would like to share our management, experience, and present our treatment protocol that we recently established by a collaborative multidisciplinary team approach to help guide treatment of these complex patients not only in Canada but worldwide.

How Well IsHelicobacter pyloriTreated in Usual Practice?

BACKGROUND:Helicobacter pyloriis a WHO class I carcinogen also associated with nonmalignant gastrointestinal diseases. Effective treatment exists, and all persons infected withH pylorishould receive treatment. However, data regarding the rates of treatment prescription in clinical practice are lacking.OBJECTIVE: To determine the rates ofH pyloritreatment in usual practice.METHODS: Patients with histological evidence ofH pyloriinfection between January 1, 2007, and December 31, 2007, at Sunnybrook Health Sciences Centre (Toronto, Ontario) were identified. Charts were reviewed to determine the rates ofH pyloritreatment and confirmation of eradication, when indicated. Questionnaires were subsequently sent to endoscopists of patients identified as not having received treatment to determine the reasons for lack of treatment.RESULTS: A total of 102 patients wereH pyloripositive and were appropriate candidates for treatment, of whom 58 (57%) were male and 78 (76%) were outpatients, with 92 (90%) receiving eradication therapy. When indicated, 15 of 22 (68%) patients received confirmation of eradication, 13 of 18 (72%) patients underwent repeat endoscopy and 86% received complete therapy. Outpatients were more likely to receive eradication therapy (OR 10.3 [95% CI 2.6 to 40.4]; P=0.001) and complete therapy (OR 13.2 [95% CI 3.8 to 45.7]; P=0.0001) compared with inpatients. Having a follow-up appointment resulted in higher treatment rates (OR 12.0 [95% CI 3.0 to 47.5]; P=0.001).CONCLUSION: During the time period studied, adequate rates ofH pyloritreatment were achieved in outpatients and patients who had formal follow-up at Sunnybrook Health Sciences Centre. However, some aspects of care remain suboptimal including treatment of inpatients and care following treatment. Additional studies are required to identify strategies to improve the care of patients infected withH pylori.

Characteristics and Outcomes of Patients Receiving Massive Transfusions at a Tertiary Care Centre

Abstract 4412 Purpose: To determine the characteristics and outcomes of patients who had been massively transfused at a university affiliated trauma centre. Method: Consecutive patients who received ≥ 10 RBC units in ≤ 24 hours at Sunnybrook Health Sciences Centre and Women's College Hospital from January 2007 to December 2008 were identified. Demographic and outcome data were extracted through the blood bank database and retrospective chart analysis. Result: 6,326 patients were transfused a total of 19,845 RBC units in 2007 and 2008 at Sunnybrook Health Sciences Centre and Women's College Hospital. 134 consecutive massive transfusions among 131 patients were identified. Patients who were massively transfused received a total of 2,284 RBC units, represented 2.1% of the total number of patients transfused and used 11.5% of the total RBC units transfused. Their median age was 66 years and 63% were men. 50% survived to discharge. Of those who survived, 50% were discharged home, 41 % were discharged to a rehabilitation facility, and 9% was discharged to another acute care facility. A single patient had poor neurological function and was ventilator dependent at discharge. The median number of units transfused in ≤ 24 hrs among patients who received massive transfusions was 18.5 RBC units, 2 pools of platelets, 8 FFP and 8 cryoprecipitate. At our institution, 1 pool of platelet equals 4 individual platelets or a single apheresis platelet. Recombinant Factor 7a was utilized in 19% of the massive transfusions. Median length of stay in hospital was 17 days. Median time to death (TTD) from the massive transfusion event was 1 day. Overall survival (OS) among patients who were transfused 10–19 units (n=107), 20–29 (n=16), ≥30 (n=11) RBC units in ≤ 24 hours were: 56%, 31%, and 55% respectively. Indications and overall survival for massive transfusion were: trauma (49%, OS 51%, TTD 0 days), cardiac surgery (22%, OS 41%, TTD 12 days), oncologic surgery (12%, OS 63%, TTD 12 days), vascular surgery (6%,OS 50%, TTD 8.5 days), GI bleed (3%, OS 50%, TTD 18 days) and other (8%, OS 55%, TTD 19 days). Conclusion: Patients who have been massively transfused (≥10 RBC units in ≤ 24 hours) use a disproportionate amount of blood products. Trauma, cardiac and oncologic surgeries are the most common indications for massive transfusion at Sunnybrook Health Sciences Centre and Women's College Hospital. All causes of massive transfusion had similar mortality of approximately 50% and the majority of the survivors were discharged home or to rehabilitation with preserved neurological function. Transfusions of ≥ 30 RBC units in 24 hours were not associated with worse survival outcomes. A noticeable difference between the groups was in trauma where death occurred within hours of admission, while the majority of deaths for other causes occurred between 8 and 18 days later. These findings suggest that bleeding may have been directly responsible for most trauma deaths, while complications related to bleeding may have caused the late deaths observed in the other groups. Measures for defining medical futility, other than volume of blood products transfused, need to be sought. Disclosures: No relevant conflicts of interest to declare.