Author(s)

Fabrizia Negrini, Giorgia Vella

Why was it done?

The aims of this project were firstly to optimize the content of the stock (choice of medicines and quantity) so that it is suitable for various potential events of different nature that may occur in the region. The second aim was to optimize the management processes in order to reduce costs.

What was done?

To manage extraordinary events (short-lasting phenomenon without contamination) in a region with 1.5 million inhabitants, the hospital pharmacy, in collaboration with a major acute Hospital, manages a designated stock containing medication that may be required during unplanned emergencies.

How was it done?

To achieve these two aims, the first step was to define which major events are possible and most likely to occur in the region. To do this we utilized a risk-based analysis of all disasters and emergencies relevant in the area that was performed by an external company that specializes in developing risk management projects in the context of civil protection1. Based on the identified events, we determined which types of injuries were more likely to occur. The medicine stock was subsequently updated and a process for minimizing the management cost was defined.

What has been achieved?

The hazards that were identified as being of particular importance for the analyzed region are likely to mainly result in blunt, perforating, and burn injuries. In collaboration with the Hospital, a list of 61 different medicines used to treat these types of injuries was established. In order to reduce costs, only drugs which were part of the main stock of the pharmacy were chosen. In this way, it is possible to exchange products with a longer shelf life from the main stock 6 months before expiring and use them without having to discard them.

What next?

In case of extraordinary events in a restricted region, the major acute hospital has an increased need for certain medicines. It is task of the hospital pharmacy to always be ready to supply them with such medicines. This is only possible if the probable emergency scenarios are well understood, and the stock and management processes are well-defined and communicated at all levels.

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Author(s)

SALIM HADAD

Why was it done?

It remains that new solutions to increasing the safety of handling Solid Dosage Form hazardous drugs have to be developed. Conceptually, through operating in a closed system, CSTDs should significantly reduce the risks to pharmacists and nurses There are two main drawbacks of the known solutions:
1. The crushing and dilution of the solid dosage form medicine is done with an open vessel to the environment, such as a porcelain crater, which may cause the work environment to be contaminated with carcinogenic or teratogenic substances, that could expose and endanger the medical staff to hazardous substances in the course of their duties as providers of medical care.
2. The tools available today are reusable, requiring a thorough cleaning process between different materials (drugs), which can lead to cross-contamination between different doses of drugs, which are crushed one after the other with the same instrument.

What was done?

CSTD – for oral dosage form new device of its kind, combines the act of crushing the various drugs, dissolve in liquid and give to a patient who cannot swallow for various reasons, that mechanically prohibits the transfer of environmental contaminants into the system and the escape of hazardous drug or vapor concentrations outside the system.

How was it done?

We designed the device with 3D software (solid wark). It consists of a number of functional parts. The main ones are: a 20 ml barrel, a top part of which is a piston with a bottom basket loaded with the solid medicine; this part is sealed as a barrel from above. With the help of mechanical rotation, the drug breaks down into small particles that fall into the inner space of the barrel. Adding the liquid through a fluid port disposed on the bottom barrel which it is completely sealed. The removal of the liquid drug through a unique adapter which at its end is adapted to the gastric tube or oral administration to the patient,

What has been achieved?

1. The complete process of crushing and liquefying of the solid drugs is carried out under sealed conditions to the immediate environment and without fear of exposure to residues of toxic substances to the medical caregiver. 2. A one-time use system saves complex cleaning process. 3. There is no risk of cross-contamination between different drugs. 4. Saving personal protective equipment such as gloves, masks, lab coats clean rooms, etc. which is necessary for protection and for the safety of the caregiver team.

What next?

Applied research will be carried out by pharmacists and nurses to test the efficiency of the new device (as a basic prototype). These experiments will take various non-cytotoxic pills, will be dummy operations, in which the crushing and liquefying will be performed, and the solution or suspension will be transferred through the gastric tube, according to an approved research protocol.

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Author(s)

EDURNE FERNANDEZ DE GAMARRA MARTINEZ, NÚRIA PI SALA, RAQUEL AGUILAR SALMERON, ANTONI BROTO SUMALLA, MILAGROS GARCÍA-PELÁEZ, LIDIA MARTINEZ SÁNCHEZ, SANTIAGO NOGUÉ XARAU

Why was it done?

Antidotes are drugs used in emergency situations. Some of them often present availability issues due to shortages, high cost, complex acquisition (foreign drugs’ importation) or short validity periods. This tool was implemented in July 2015 to improve the availability of antidotes.

What was done?

A virtual network was designed in order to have a tool that allows pharmacy departments to locate antidotes: to know in which centres they are stocked, how much there is of each drug and when it would expire. It also facilitates communication between centres and loan movements in case they are required.

How was it done?

A web-based application was developed (www.redantidotos.org). It includes a public site with general information, an updated antidotes guide and a section where non-urgent toxicological consultations could be submitted. In addition, there is a private site (accessed through username and password) where each pharmacy department might introduce the stock they have of 18 selected antidotes (anti-digoxin antibodies, anti-vipera serum, botulism antitoxin, dantrolene, deferoxamine, defibrotide, dimercaprol, calcium disodium edetate, ethanol, fomepizole, glucagon, glucarpidase, hydroxocobalamin, idarucizumab, pralidoxime, physostigmine, silibinin and uridine triacetate). Each Hospital has two key users: a ‘farmatox’ (pharmacy department) and an ‘urgetox’ (emergency department). Their participation has been crucial for the success of the project.

What has been achieved?

Currently there are 63 Spanish hospitals included in the Antidotes Network. It has been used 49 times to locate an antidote that was needed and to request a loan between centres. Thirteen antidotes were involved in these movements. The most requested drugs have been anti-vipera serum (10/49), glucagon (6/49), anti-digoxin antibodies (5/49), botulism antitoxin (5/49) and fomepizol (5/49). Additionally, recommendations were published about stock availability and use of antidotes according to hospital complexity (Emergencias 2016;28:45-54).

What next?

The network was first implemented in Catalonia and now the project is being extended to other Spanish regions (currently it has been implemented in three out of 17 regions). We aim to continue improving communication between professionals involved in intoxication management, sharing knowledge and improving the care we offer to our patients.

Author(s)

Roisin O’Hare, Andrew Dawson, Natasha Beattie, Eva McRory, Jayne Agnew, Sara Laird, Tracey Boyce, Victoria McConville

Why was it done?

In November 2016, regional funding was provided to all of the Trusts in order to improve medicines reconciliation rates within 24 hours of admission. The weekend clinical pharmacy service to the emergency department was established from 1st December 2016.
The aim of this project was to examine the impact of a clinical pharmacist led weekend service on to the Emergency Department in xxxxxxx.
Objectives
To determine the number of medication histories and medicines reconciliation completed within 24hrs of patient admission
To evaluate the type and signficance of pharmacy interventions identified
To record the number of medications prescribed by the pharmacist.

What was done?

A pharmacy service to optimise medicines use and pharmaceutical care for patients in the emergency department at the weekend was established.

How was it done?

We conducted a literature review on the existing clinical pharmacy services to ED. We used an Agile methodology. We established a core stakeholder group to develop a vision and a plan for the project. We used an Agile methodology with Plan Do Study Act (PDSA) with weekly ‘scrums’ and 6-8 weekly sprint meetings. We developed a data collection form to collate quantitative data; including the number of; patients reviewed by the pharmacy team, medication histories completed, medicines reconciliation completed within 24hrs of admission, pharmacist interventions, medications prescribed by the pharmacist.

What has been achieved?

We demonstrated an increase in the number of patients reviewed per day since December (average of 10) to June (average of 12). We increased the Medicines Reconciliation rate in the ED in xxxxxxx within 24hrs of admission from 0% in Nov 2016 to ~60% in Dec 2016 and ~80% in August 2017. The Pharmacy Team made on average 4.5 interventions (range 3-6) per patient reviewed (an average of 45 interventions per day). Prescribing by pharmacists demonstrated an increase in the number of medications prescribed per patient; December (0) and August (4).

What next?

The pharmacist interventions directly improved patient safety and care. Staff in the ED have anecdotally praised the service to the Pharmacy Team and have increasingly accessed the knowledge of the pharmacist at the weekend to address medication-related problems. We believe that we shaped an approach to clinical pharmacy practice in the ED which could be shared across the Trust and further across the country.
References:
1. Medicines Optimisation, the safe and effective use of medicines. Available from: http://www.nice.org.uk/guidance/ng5 Accessed on 13th October 2017.
2. Eadon H. Assessing the quality of ward pharmacists’ interventions. Int J Pharm Practice. 1992;1:145–7.
Acknowledgements:
We would like to acknowledge the work of the entire clinical pharmacy and clinical pharmacy technician staff at xxxxxxx who provide this service to the ED at the weekend and who tirelessly collected the data for this project.

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