The Canadian Bleeding Disorders Registry (CBDR) has become the national registry for comprehensive care and research in hemophilia in Canada with patient, clinical, and research module connectivity. The CBDR has served as a robust resource to inform epidemiology of disease, burden of disease, and disease changes and variation over time as new treatment modalities are introduced. Information on the utilization of blood products to treat hemophilia has and can be retrieved and used by Canadian blood product procurement agencies to inform decision-making for past and future purchases. The successful multistakeholder coordination and alignment achieved over decades with the development and function of the CBDR is an exemplar that could be extended to other rare disease areas.

Coagulation factors used in prophylactic treatment of patients with clotting disorders are associated with significant costs to health care systems. These products have complex pharmacokinetic profiles subject to large inter-individual variation making their efficient use challenging. Prior to this project, pharmacists were not involved as part of the Hemophilia care teams across Canada. The purpose of this pilot project was to determine whether employment of a pharmacist with expertise and a focus on plasma protein and related products including hemophilia treatments, would be an effective strategy to reduce costs associated with clotting factor prophylaxis regimens and identify the pharmacist’s activities associated with this new role. A cost-minimization analysis was conducted to compare the addition of a pharmacist to the care team of the Hemophilia Treatment Centre (HTC) at a pediatric hospital serving 500,000 children and youth. The analysis was performed from the perspective of the formulary manager, Canadian Blood Services, over a 1-year period including 9 months of interventions. The pharmacist performed 18 therapeutic optimizations on 14 patients with moderate to severe hemophilia A or B, and 1 von Willebrand patient, aged 3 to 18 years old. As a result of the pharmacist’s intervention, clotting factor treatment costs extrapolated over one year were reduced by 20.5% for these patients. This represents a net savings of $225K CAD/year, or $12.5K CAD/optimization/year. The addition of a pharmacist to the HTC to manage recombinant and plasma-derived coagulation factors can optimise the treatment plan and significantly reduce the costs of managing patients with hemophilia.

Humanitarian relief operations (HUMRO) represent a nexus between military diplomacy and global health engagement, and may play an increasing role in military operations in the near future. Language barriers between providers and the individuals being assisted are a significant constraint on HUMRO. A literature review was conducted to identify recommendations to address patient-provider language discordance in the international HUMRO context. This was supplemented by a North Atlantic Treaty Organization and US Department of Defense doctrinal review to identify existing best practices for addressing language barriers. Four general themes were identified: (1) print-based aids, (2) information technology, (3) bilingual responders, and (4) the effective use of medical interpreters in the HUMRO setting. Each strategy is reviewed. Informed by expert opinion, we provide concrete leadership and training recommendations for how HUMRO providers might more effectively communicate with patients in a deployed language-discordant context.

Abstract Ongoing provision of pharmaceuticals and medical supplies is of key importance during and following a disaster or other emergency event. An effectively coordinated response involving locally available pharmacy personnel—drawing upon the efforts of licensed pharmacists and unlicensed support staff—can help to mitigate harms and alleviate hardship in a community after emergency events. However, pharmacists and their counterparts generally receive limited training in disaster medicine and emergency preparedness as part of their initial qualifications, even in countries with well-developed professional education programs. Pharmacy efforts have also traditionally focused on medical supply activities, more so than on general emergency preparedness. To facilitate future work between pharmacy personnel on an international level, our team undertook an extensive review of the published literature describing pharmacists’ experiences in responding to or preparing for both natural and manmade disasters. In addition to identifying key activities that must be performed, we have developed a classification scheme for pharmacy personnel. We believe that this framework will enable pharmacy personnel working in diverse practice settings to identify and undertake essential actions that are necessary to ensure an effective emergency response and will promote better collaboration between pharmacy team members during actual disaster situations. (Disaster Med Public Health Preparedness. 2017;11:496–504)

BACKGROUND Drug benefits are provided at public expense to all actively serving Canadian Armed Forces (CAF) personnel, with ongoing drug coverage offered by Veterans Affairs Canada (VAC) for selected conditions following termination of employment. Differences in drug coverage between these programs could introduce risks for treatment disruption. OBJECTIVES Work was undertaken to establish a process that would allow systematic comparison of the entire VAC and CAF formularies, and to identify and explain discordant listings in 14 therapeutic categories that pose risk of adverse outcomes with sudden treatment interruption. METHODS Lists of medications were created for each program, including regular benefit and restricted use drugs, using files obtained from the claims processor in January 2015. Products were coded using the Anatomic-Therapeutic-Chemical (ATC) system. Degree of alignment within therapeutic categories was assessed based on the percentage of fifth-level ATCs that were covered in common. Discordantly listed drugs in 14 categories of concern were reviewed to identify similarities in product characteristics. RESULTS A total of 1124 medications were identified in 80 therapeutic categories. Coverage of medications was identical in 11 categories, and overall, almost three-quarters of identified drugs (73.4%, n = 825) were covered in common by both plans. Many discordant listings reflected known differences in the programs' operating procedures. A number of discrepancies were also identified in newer therapeutic categories. CONCLUSIONS There is significant overlap in the medications covered by the CAF and VAC drug benefit programs. Application of the ATC coding system allowed for discrepancies to be readily identified across the entire formulary, and in specific therapeutic categories of concern.

Background In today’s world of government fiscal accountability, there is a growing and persistent requirement for Canadian Forces (CF) publicly funded pharmacies to justify their expenses while at the same time ensuring high-quality health care for their patients. However, no mechanism currently exists by which CF pharmacy managers can determine if they are meeting these objectives. It has been identified that they require a tool with which they can gather the information required effectively and efficiently. The Canadian Forces (CF) Health Services Centre Ottawa is a primary care clinic serving a patient population of approximately 5500. The outpatient pharmacy is integral to the success of meeting the centre’s needs. It is staffed by 4 fulltime pharmacists and 5 technicians and operates between the hours of 7:30 a.m. and 4 p.m., 5 days a week. In the fall of 2009, we identified that the workload measurement system (WMS) being employed at the Ottawa Clinic pharmacy was not meeting the pharmacy’s needs. Despite using the system, pharmacy staff continually expressed concerns of feeling overworked and at times being unable to meet their patients’ needs in a timely manner. Surveys indicated growing discontent among our patient population due to what they felt were unacceptable wait times to receive their prescriptions.1 Our review of the current WMS found no clear explanation of why certain activities were being tracked while others were not. In addition, there was no formal process for the analysis of the data and the understanding of how the measured activities related to performance outcomes. We could not find any literature on existing workload and performance measurement systems for use in a primary care outpatient pharmacy environment. Therefore, we decided that a new system that allowed for ease of use, tracking of pharmacy workload by occupation, assessment of pharmacy performance and ease of modification had to be created. The creation team consisted of the pharmacy manager and a pharmacist from the CF Health Services Group Headquarters. There was strong agreement between the investigators that any system created had to be more than just a WMS and had to provide a method of ensuring that the needs of the Ottawa pharmacy’s 3 main customer groups—patients, prescribers and the Canadian taxpayer—were being met.

ObjectivesComprehension by the patient is often difficult due to varying levels of health literacy, language differences, and cultural variations. The authors worked collaboratively with six First Nation communities to develop pictographic instructions for the labelling of medications that were meaningful and sensitive to First Nation culture.MethodsFocus groups composed of community members and healthcare providers were conducted in six communities. They were presented with current medication labelling pictograms and asked to provide feedback and revisions required to be best understood by members of their community. The redesigned pictograms were then communicated back to the communities through several iterations until agreement was reached.ResultsFocus group discussions identified modifications to pictograms to reduce interpretation errors based on cultural characteristics. The focus groups agreed that the majority of the original pictograms were not culturally adequate so 16 new or modified pictograms were created and validated for use in First Nation communities. This project also discovered that pictograms are not only culture specific but context specific.ConclusionDeveloping culturally and contextually meaningful pictograms can be used as a tool to improve patients' understanding and may help with remembering complex medical instructions and reduce the risk of taking medications incorrectly, thereby contributing to patient safety.

Administration of drugs through enteral feeding tubes can be a simple way by which infants and children can receive medications, but it introduces concerns about potential blockage of the tube. The risk of feeding tubes becoming blocked is greater with small-diameter feeding tubes and low flush volumes.Tube blockage is disruptive to patient care, and replacing tubes can be uncomfortable for the children. Patients with enteral feeding tubes may require acid suppression with proton pump inhibitors (PPIs). Previous studies have assessed the delivery of a single PPI dose through feeding tubes, with delivery of esomeprazole typically being less labour-intensive and more complete than delivery of omeprazole and lansoprazole. However, these studies did not evaluate the potential for blockage with repeated administration of PPIs. This is a real concern, as the tubes may be in place for up to several months. A new sachet formulation of esomeprazole (Nexium), developed for people who have difficulty swallowing capsules, can be administered by enteral feeding tube. With the small diameter of the esomeprazole pellets and the formation of a viscous suspension after reconstitution, this formulation was designed to remain stable in solution and to prevent clogging within enteral tubes. The objective of our in vitro study was to evaluate the potential for clogging (and the resulting change in feeding flow rate) with repeated delivery of 10-mg esomeprazole sachet as suspension through the smalldiameter enteral feeding tubes used at the Children’s Hospital of Eastern Ontario and to assess the use of these tubes to deliver the suspension. Three different types of enteral feeding tubes, each of a different size, were tested: size 6 French Pedi-Tube (Kendall, Mansfield, Massachusetts), size 8.5 French Dawson-Mueller drainage catheter (Cook Canada Inc, Stouffville, Ontario), and size 10 French urological catheter (Bard Canada Inc, Mississauga, Ontario). Four tubes of each type were tested, for a total of 12 tubes. Each tube received a continuous feed of Enfamil A+ formula (Mead Johnson Nutrition, Ottawa, Ontario) at 25 mL/h for 7 consecutive days, with an average of 2 h downtime per day for maintenance and drug administration. For each tube, the formula was delivered by a Kangaroo ePump (Kendall; total of 12 pumps), by means of the pump’s compatible 500-mL feed bag set. Each tube was positioned vertically and emptied into its own graduated bottle. For each tube type, 3 of the 4 tubes received the drug suspension; the fourth tube received water as a control. Every 12 h the pumps were halted to allow measurement of volumes delivered, replenishment of formula, and administration of the esomeprazole suspensions. With the pumps on hold, the volume that had been fed through each tube was measured (using the respective graduated bottle) and recorded. The predicted volume fed, as displayed on each pump, was also recorded. The exterior of each tube was rinsed with warm water. The feed remaining in the bag sets was discarded, and the feed bags were rinsed with hot water and refilled with 310 mL of formula. The 10-mg esomeprazole sachets were mixed according to manufacturer’s guidelines in 15 mL sterile water. The tubes were disconnected from the feed lines one at a time, and the drug suspension or placebo was delivered with a 30-mL syringe. The drug infusion time was the same for each tube (4 or 5 s). The additional flush of 15 mL advised by the manufacturer’s guidelines was not used, so as to simulate drug administration for a patient with volume restriction. Each tube received a 5-mL flush with sterile water before and after delivery of drug or placebo. After drug administration, the tube was reconnected and the pump restarted. The stop, start, and drug administration times were recorded individually for each pump or tube. Blockage of the 12 enteral feeding tubes was assessed by measurement of the feed flow rate. Average flow rates were calculated according to the volume delivered for a 12-h period. A change in the calculated feed flow rate was considered significant if it was outside the ±10% operating range. The pumps had the capacity to sound an alert when a blockage occurred. If this happened, the tube was removed and was not replaced. The bag set was restarted and run for a short period (30 min) to confirm that the blockage was in the tube and not the bag set. On the sixth day of continuous feeding with twice-daily drug administration, one complete block occurred immediately after administration of the 11th dose of esomeprazole into 1 of the 3 size 6 French tubes receiving the drug suspension. There was no observable change in the feed flow rate leading up to the blockage in this tube. The only indication of a potential blockage occurred during the final drug administration, when it was more difficult than usual (i.e., more pressure on the syringe was required) to administer the drug through the tube. No blockages occurred in any of the other tubes, and there were no observable changes in feed rates in any of the 3 tube types tested. Administration of the viscous suspension through the size 6 French tubes required significant pressure on the syringe. Using the dual-port design on these tubes to deliver the drug suspension without detaching the tube resulted in backflow of drug into the feed bag set. When the tube was detached from the bag set to prevent backflow during drug administration, minor leaks from the dual port occurred. On the basis of the data from this study, we conclude that the potential for blockage exists when esomeprazole sachet as suspension is delivered through size 6 French feeding tubes. However, there were no changes in feed flow rates until complete failure (blockage) of the feeding tube occurred. The other tubes tested showed no signs of blockage or changes in feed flow rate.

BACKGROUNDTo reduce the risk of medication errors in paediatric patients, the Canadian Council on Health Services Accreditation endorsed the standardization and limiting of drug concentrations available within an organization.METHODSStandard concentrations (SCs) were implemented in the emergency department, operating room and paediatric intensive care unit at the Children's Hospital of Eastern Ontario in Ottawa, Ontario. The change in practice involved addressing concerns raised during stakeholder consultations, developing a computer program, and educating and testing staff in the new method. The software for SC selection and infusion rate calculation featured redundant inputs, a 'deviation' column comparing the prescribed and infused doses, and a printout of patient information that also facilitated dose verification back-calculation.RESULTSThe major barrier to acceptance of SCs was possible fluid overload in lower weight patients. Thus, infusions received by 48 successive infants in the paediatric intensive care unit were compared with theoretical SC infusions. Volumes were not significantly increased, and there was no trend toward proportionally larger volumes in lower weight patients. Medication error reporting was very low before implementation, and SC errors remained low; new online reporting led to higher reporting of other errors after implementation. A survey indicated excellent staff acceptance and beliefs that patient safety and continuity of care were improved.INTERPRETATIONSCs were successfully instituted with computer support, in lieu of 'smart pumps,' across multiple critical care units in a paediatric institution. The initial program is being expanded to 40 continuous infusion drugs, plus paediatric advanced life support bolus medications.

C P J / R P C • N O V E M B E R / D E C E M B E R 2 0 0 7 • V O L 1 4 0 , N O 6 In the last decade, claims have been made regarding the efficacy of vitamin D for different indications. Data from various trials suggest that vitamin D is associated with a lower risk of multiple sclerosis, cardiovascular disease, diabetes, cancer, and osteoporosis. Sources of vitamin D include dairy products and supplements; however, the primary supply for humans results from the conversion of 7-dehydrocholesterol through photosynthesis in the skin. Due to reduced sun exposure, the elderly population in the northern hemisphere have the highest risk for vitamin D deficiency. The elderly are also at higher risk for osteoporosis and cancer. The Society of Obstetricians and Gynaecologists of Canada (SOGC) Canadian Consensus Conference on Menopause, 2006 Update, recommends 800 IU of vitamin D per day as adjunct therapy for patients taking medication to prevent osteoporotic fractures, while new information (2007) from the Canadian Cancer Society suggests a daily dose of 1000 IU during the fall and winter months for all adults and year-round for adults at higher risk for lower vitamin D levels (e.g., individuals who are older, have dark skin, or less frequent sun exposure). On the other hand, Health Canada continues to recommend a daily supplement of vitamin D 400 IU for people over the age of 50. Until consistent recommendations are made, pharmacists may question whether older patients should receive higher doses of vitamin D to decrease their risk of both osteoporotic fractures and cancer. This article reviews the mechanism of action of vitamin D in osteoporosis and in cancer prevention, and summarizes the evidence for the efficacy of vitamin D in both of these indications (Table 1).